Evidence Based Strategies for Common Clinical Questions

Turning the Tide: Preventive Measures to Address Childhood Drowning

Author: Maria Newmaster, MD | Pediatric Resident

Column Editor: Kathleen Berg, MD | Co-Director, Department of Evidence Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine 

With warming temperatures and abundant sunshine, this is an ideal time for pediatricians to remind families about water safety. Despite numerous strategies aimed at prevention, drowning remains the leading cause of injury-related death in children 1-4 years of age and the third leading cause of injury-related death in children 5-19 years of age.¹ Males account for 70%-80% of fatal drownings.² In addition to a peak incidence in toddlers ages 1-4, there is a second peak in adolescent males ages 15-19, which is attributed to overestimation of swimming ability, increased risk-taking behavior, peer pressure and substance use.

A recently updated policy statement by the American Academy of Pediatrics regarding drowning prevention reflects new insight into racial and socioeconomic disparities in drowning rates. Recent trends reveal that drowning rates are highest in Black populations (1.79 per 100,000), with the lowest rates observed in White (1.06 per 100,000) and Hispanic (0.82 per 100,000) populations.¹ These disparities among race and ethnicity are attributable to inadequate resources for early swim training and insufficient municipal funding for pools and lifeguards.³ Approximately 57.5% of Black youth report being unable to swim or uncomfortable near water.¹ Other at-risk populations include children with epilepsy, autism spectrum disorder or cardiac arrhythmias.¹

Up to 90% of drowning events occur during periods of inadequate supervision, with the most cited reasons for poor supervision being alcohol impairment or distraction by phones or acquaintances.¹ Up to 75% of victims were out of direct supervision for less than five minutes at the time of a submersion incident.² Appropriate supervisory behavior has three key components: proximity, attention and continuity. Parents should employ “touch supervision” by remaining within an arm’s reach of young children near the water.

The physical environment is also a vital component of drowning prevention. Evidence supports the need for physical boundaries including fencing and self-closing locked gates, which have been shown to decrease submersion injuries by more than 50%.^1,4 Additional measures include presence of lifeguards (when used in conjunction with but not replaced by parental supervision), life jacket use including role-modeling by adults, and appropriate pool drain covers to prevent entrapment and entanglement. In contrast, covers over pools are less effective as they provide a false sense of security and may actually risk entangling or hiding a drowning victim.

Water competency via swim lessons and water survival training is an important aspect of drowning prevention, especially in open water settings where other physical measures are impractical. Recent guidelines from the American Academy of Pediatrics support swim lessons for children over the age of 1, to be adjusted based on an individual child’s developmental status or any underlying medical concerns.^1,2 Swim lessons should focus on basic swim skills necessary for water survival. It is important to note that swim lessons may cause a false sense of security, as parents may believe that their child is better equipped to be near water and thus requires less supervision. Therefore, a child’s swim lessons should be accompanied by parental training to emphasize the importance of parental supervision and ability to assess their child’s swim skills.⁵

These measures of prevention are the most important steps in reducing fatal drownings. However, in the event of a drowning, immediate resuscitation with CPR by a bystander is the intervention associated with the highest rates of survival and best prognosis. Additional predictors of positive outcomes include submersion time of less than six minutes and EMS response time of less than 10 minutes.²

Pediatricians should advise patients and caregivers about methods to improve water safety and encourage CPR training. Adolescents, especially males, should receive specific counseling on the risk of alcohol or drug use during water activities. Pediatricians should also partner with their communities, advocating for preventive measures and proper water training to mitigate the risk of drowning in children. High-quality and culturally sensitive community-based programs can support disproportionally affected populations, addressing the health disparities highlighted by drowning rates. Additional resources for families regarding drowning prevention are available at www.cdc.gov/drowning.  

References:

1. Denny SA, Quan L, Gilchrist J, et al. Prevention of drowning. Pediatrics. 2019;143(5):e20190850. doi:10.1542/peds.2019-0850
2. McCallin TE, Morgan M, Hart MLI, Yusuf S. Epidemiology, prevention, and sequelae of drowning. Pediatr Rev. 2021;42(3):123-132. doi:10.1542/pir.2019-0150
3. Willcox-Pidgeon SM, Franklin RC, Leggat PA, Devine S. Identifying a gap in drowning prevention: high-risk populations. Inj Prev. 2020;26(3):279-288. doi:10.1136/injuryprev-2019-043432
4. How to Plan for the Unexpected: Preventing Child Drownings. U.S. Consumer Product Safety Commission; 2021. Publication No. 359. Accessed April 27, 2021. https://www.cpsc.gov/PageFiles/122207/359.pdf
5. Sandomierski MC, Morrongiello BA, Colwell SR. S.A.F.E.R. near water: an intervention targeting parent beliefs about children’s water safety. J Pediatr Psychol. 2019;44(9):1034-1045. doi:10.1093/jpepsy/jsz042