Protecting Your Child from Accidental Drowning

It Can't Happen to My Child
Drowning is a major cause of accidental childhood death worldwide. In the United States, it is second only to motor vehicle deaths as a major cause of unintentional death among people under the age of 20. The number of drownings in most states exceeds the total number of deaths from poisonings, fires, and bicycle injuries. Drowning rates are highest in the western United States; in some western states, such as California and Alaska, it is the major cause of pediatric injury death. This is a very lethal injury, as 50% of pediatric submersion victims die, placing it among the highest percentage of all reported injuries. Up to 50% of all drowning victims are declared dead at the submersion site and never receive medical care.

What Ages Are at Risk?
In every country studied, drowning rates are the highest among children younger than five years and second highest among 15- to 19-year-olds. Nevada and Florida have some of the highest reported drowning rates in the world. Over the past two decades, drowning rates have decreased among all but those younger than five years of age. As with all injuries, males predominate. Boys are two to 10 times more likely to drown than are girls. The drowning rate in boys peaks at age two, and again at age 16 to 18. The second peak in boys is primarily attributed to the three "D’s"—drinking, drugs, and dares. Alcohol and/or illicit drug use are a contributing factor in 40% to 50% of all adolescent drownings.

Where and When Do These Accidents Occur?
Forty-two percent of near-drownings occur in swimming pools, and up to 10% of near-drownings occur in the bathtub. Submersions among infants younger than one year old usually occur in bathtubs where they have been left unattended. One- to four-year-olds typically fall into swimming pools. In the northwestern United States, preschoolers are more likely to fall into lakes or rivers than into swimming pools; in inner cities, five-gallon buckets may be more common risk sites. Oftentimes these tragedies occurred when children were left unsupervised, or during a period of parental vulnerability, such as when a parent is exhausted or alone. In toddlers, drowning rates are highest at noon and 6 p.m., when their care takers are likely to become preoccupied with other concerns. Adolescents, eager and able to get to large, unsupervised, often-hazardous waters, are usually swimming or boating in natural bodies of open water when they drown. Overall, drowning rates are highest on Friday through Sunday, presumably as a result of drinking and/or boating on those days. Epilepsy increases the risk 13-fold for both a submersion event and death from the submersion event. In fact, drowning is the most likely cause of unintentional death in this population.

Alcohol and Water Don't Mix!
Consumption of alcohol clearly increases the risk of drowning. This fact is underscored by the finding of positive blood alcohol levels in 10% to 50% of adolescent drownings. Alcohol use is most likely in male, suicidal, boat or motor vehicle­related, and off-season drownings. Although it adversely affects judgment and has multiple physiologic effects upon the body, alcohol’s lethality may lie in its ability to induce or promote abnormal heart rhythms, which cause sudden cardiac arrest in submersion victims. What Actually Occurs During Submersion? The injury of submersion is hypoxia (lack of adequate oxygenation of the blood). An estimated 10% to 20% of drownings are "dry," with immediate laryngospasm (involuntary closure of the throat muscles) as the body attempts to prevent aspiration of water. Unfortunately, the mechanism attempting to keep water out of the lungs also interferes with the ability to breathe. Water plays a limited role once the victim can no longer breathe. Water washes out surfactant, a substance that allows our lungs to inflate easily and fully. Once this occurs, the smaller airways of the lungs collapse, further reducing the ability to breathe. Lack of oxygen lasting one to three minutes can shut down key organ systems, especially the brain and the heart. The victim loses consciousness, and the heart develops arrhythmias, leading to cardiac arrest. CPR may be successful if accomplished within a few minutes; but although the heart muscle may resume function, the brain may not. The most common and dreaded event following a severe drowning is the swelling of brain tissue resulting from damage caused by lack of oxygen during the submersion event. This usually develops six to 12 hours after the injury. Most pediatric drowning deaths in the hospital are due to cerebral rather than pulmonary causes, but all are due to damage secondary to lack of oxygen. Hypothermia (drop to below normal body temperature) can be an additional injury. Children are at increased risk because they have relatively large surface area, predisposing them to rapid heat loss in cool waters. Other injuries depend on the mechanism of the submersion. Diving or a fall from a height is associated with cervical spine injury.

Won't I Know if My Child Is in Trouble?
Contrary to popular belief, the pediatric submersion is usually silent. A parent may leave the bathroom door open, falsely believing that any problem in the bathtub will be heard. Onlookers may believe that the child is just pretending to have trouble in the water. Parents may have an unrealistic expectation of the child. Surprising is the ability of toddlers to drown in only inches of water because simple measures such as standing or sitting up are beyond their problem-solving skills.

What Is the Usual Outcome for Submersion Injury?
The outcome for submersion injury usually goes only one of two ways: victims either survive neurologically intact or die. Investigations indicate that some normal survivors may have learning deficits. Survival with severe neurologic sequelae occurs in only 11% of those who suffer submersion injury. However, drowning is the second leading cause of brain death in pediatric intensive care units and causes the worst neurologic outcomes. Near-drowning victims whose outcome is bad are devastated with the inability to control and move their limbs normally, no self-help skills, and estimated medical care costs of $100,000 per year. Intact survival is associated with submersion durations of fewer than five minutes. The likelihood of a bad outcome increases with longer submersion durations and approaches 100% at greater than 25 minutes in non-icy waters. Cardiac arrest decreases the likelihood for survival, as almost all submersion victims who present to the emergency department in cardiac arrest as a result of the event will die. The sooner the patients become alert, the more likely they will survive intact. Almost all patients who are alert in the field or emergency department will survive; if they do not have spontaneous, purposeful movements by 24 hours postsubmersion, they will have severe neurologic deficits or die.

How Can I Protect My Child?
Prevention is the most important link in the chain of survival! Most drowning prevention has focused on the preschooler who falls into swimming pools. The number of residential swimming pools has increased from 10,000 in 1950 to 3.4 million in-ground pools and 3.2 million above-ground pool today. Sixty to ninety percent of drownings in children less than five years old occur in residential swimming pools. Nearly two-thirds of these drownings occur in the child’s home pool. An additional third occur in relatives’ or neighbors’ pools. In most cases, the child has been left unsupervised for less than five minutes. Currently, only 15% of in-ground pools in the U.S. are adequately fenced. Most building codes only require three-sided fencing of residential swimming pools, with the house serving as the fourth side of the perimeter. This situation puts the child at risk by allowing direct access to the pool from the house. Where county ordinances have required four-sided fencing, the number of submersion incidents has decreased by half. Adding self-closing latches to all gates offers an added measure of protection. Use of life vests seems an obvious preventive intervention for all age groups around water, including toddlers playing around pools or open water, boaters, and even poor swimmers. Improving swimming ability with swim lessons makes sense but has not been proven effective. It is commendable to teach one’s children over three years of age to swim, but parents need to be aware that even children who can swim are not "drown-proof." Other conditions such as cold water, swift water current, loss of consciousness, or hypothermia may negate the usefulness of swimming skills. Although swimming buys time to rescue, a life vest buys more time. Changing our culture so it views mixing alcohol and water-related activities as dangerous instead of fun should also be a goal. Drowning among children and adolescents with seizure disorders can be prevented only with the awareness and vigilance of the both the individuals at risk and their parents. Changing their bathing patterns to include showering, avoid bathtubs, and encourage swimming only in supervised settings are the key messages. Parents should take it upon themselves to learn CPR and keep these skills current. Early intervention can often be the difference between life and death. Swimming should be regarded as a fun summertime activity that can be enjoyed by the entire family if simple but effective safety measures and practices are always performed. Water, as with any powerful force, can be safe, useful, and enjoyable, if treated with the respect it deserves.

-- Dr. David A. Bowlin Jr., M.D. Resident Instructor, Internal Medicine/Pediatrics