Definition/Introduction

Drowning is the leading cause of injury-related death in children. Drowning is defined as the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are defined as “death,” “no morbidity” or “morbidity.” It is important to note that the terms “wet,” “dry,” “active,” “passive,” “silent,” “secondary” drowning and near-drowning are no longer be used. More than half of the drowning deaths of children 0 to 4 years old occurred in swimming pools. There are risks involved whether it is a portable, inflatable, permanent in-ground, or personal home pool, or a hot tub or a public pool in a residential area or at a hotel.[1]

Issues of Concern

Guidelines that should be provided to parents and caregivers of children should be as follows:

• Parents and caregivers should never leave a young child alone near a swimming pool or any body of water. Caregivers should always be within arm’s length of a young child while supervising them near water. [2]When caring for an older child, distractions of the caregiver should be at a minimum. This includes talking, backyard chores, reading, or consuming alcohol.[3]
• It is important that if a child is in daycare away from home, parents inquire about exposure to water and backyard pools. The American Academy of Pediatrics has a policy statement with recommended ratios of caregivers and that states have their regulations about what is allowable. The caregivers must know how to swim, know how to perform CPR, and can call for help.[1]
• Parents who have a home pool should be counseled on fence safety. Fences are the most effective and proven way to prevent the drowning of young children. Fences should be at least 4 feet high. They should surround the pool, in a separate enclosure separating the pool from the house and the rest of the yard. The fences should not be chain-link as this is easy to climb. They should lack any footholds, handholds, or be near any lawn furniture that could be easily climbed. The fencing material should also be easy to see through. The vertical slats should have no more than 4 inches of space between them, and there should be no greater than 4 inches from the ground to the fence. The gate should be at least 54 inches off of the ground and out of child’s reach. The gate should be self-closing and self-latching and should open outward. When not in use, the pool fence gate should be locked.[1]
• Pool alarms are also available and to be considered supplemental to a pool fence. There has been some noted benefit of the pool water surface alarms that provide some function against drowning, but it should never be considered a substitute for a fence surrounding the pool.[2]
• Pool covers have also been advertised to be useful in the prevention of swimming pool drowning. These have not been well studied. Because pool covers require removal and replacement after each use, they are not likely to be consistently used and are not a safe replacement for a fence. The top of pool covers should always be drained of standing, as a child could still drown in 2 inches of water. Additionally, some pool covers such as the solar-warming covers, actually provide a danger, as a child could try to walk on them and become entangled in the cover and be hidden from view.[1]
• CPR training is recommended to all those who plan on being a caregiver to a child. This is especially crucial to those watching children play near water. Initial rescue efforts should include rescue breathing and chest compressions. Heimlich maneuver is not recommended.[1]
• Personal floatation devices have been shown to decrease the morbidity and mortality associated with drowning. It is important to recognize that personal floatation devices only include life safety vests. Inflatable armbands do not substitute for PFDs as they can easily deflate.[1]
• Swim lessons can provide children with some skills that would allow them to be safer in the water. There have been some studies that children enrolled in swim lessons from 12-42 months of age were able to develop water safety skills necessary to survive a fall into a home swimming pool, for example, recovering after being dropped in 2 feet of water, kicking to propel themselves, and getting to the side of a pool after falling in. These results are controversial, as the American Academy of Pediatrics (AAP) does not want swimming lessons in this age group to take the place of supervision and fencing. The AAP does support swimming lessons in the age 4 and above as these children have the motor and cognitive ability to propel themselves in water appropriately.[2]
• Drain entrapment has also become a serious health risk in home swimming pools. These reports of entrapment usually involve a child playing near an open drain, having their hair caught in an open drain, or sitting on an open drain and becoming trapped. These can be prevented by the use of drain covers, safety vacuum release systems, filter pumps with multiple drains. Only 12% to 15% of home pool owners currently have these safety features on their swimming pools.[2] Fortunately, in 2007 the United States Federal Government ensured that all public pools have these safety devices in place.[1][2]

There are many concerning misconceptions about home pool safety, including above-ground pools, inflatable pools, and infant swim lessons.

Recently, there has been an increase in the popularity of inflatable or portable large above ground swimming pools. These are typically between 18 to 48 inches deep, and some require filtration equipment. Many owners of these pools do not consider fencing to be necessary given the height of the pool. However, the pools with the soft-siding are a risk for a child leaning against the pool and falling in head first. Additionally, it has been shown that a child between 42 and 54 months of age can climb into a pool with a 48-inch wall, even with the ladder removed. Parents and caregivers should be made aware of these risks.[1]

Infant swim lessons have controversially been shown on the internet as a way to prevent babies from drowning. Social media has provided a means of spreading videos of infants being submerged in water and then being able to recover and float on their back. These videos are concerning as they can give parents a false sense of security of the safety of their baby. There has been no scientific research to support that rolling over and floating on their back would prevent an infant from drowning.[1]

Clinical Significance

Drowning leads to 372,000 deaths annually worldwide and severe morbidity secondary to asphyxiation or aspiration. A total of 12,529 weighted patients presented to emergency departments (ED) or submersion injury in 2013 yielding a rate of 9.29 per 100,000 ED visits.[4]

End Organ Effects of Drowning

Fluid aspiration results in varying degrees of hypoxemia, and the water can wash out surfactant, effectively producing pulmonary edema and acute respiratory distress syndrome (ARDS). The hypoxemia causes anoxic brain injury and neuronal damage. In non-fatal drownings, arrhythmias can be seen secondary to hypoxemia. Sinus tachycardia, sinus bradycardia, and atrial fibrillation are the most common arrhythmias seen in this setting. Metabolic and respiratory acidosis is often seen initially in nonfatal drowning patients.[5]

Management

Upon presentation to the emergency department, resuscitative efforts should be made. In those patients who do not require intubation, supplemental oxygen should be applied. If necessary, positive pressure ventilation should be applied. A trauma evaluation should be performed when necessary and appropriate imaging studies should be considered.

Diving and jumping into pools provides an additional risk. Caregivers should always advise no running on a pool deck, and no jumping or diving where the depth of the water is unknown. One-third of diving injuries occur in swimming pools. This risk is especially high in above-ground pools. Patients who participate in competitive diving also put themselves at risk. A diver from a 10-meter board hits the water at a 64-kilometer-per-hour speed. Without proper training and supervision, this could cause significant injury.[6]