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Preparing for Summer: Drowning Prevention Guidelines

With the approaching warmer summer weather, comes the joy of swimming and long lazy afternoons by the pool! However, drowning remains the second-leading cause of unintentional injury-related death in children from 1 to 19 years of age, so it warrants a few moments of consideration to be sure we are doing all we can to safeguard our children. The American Academy of Pediatrics released an updated report on the Prevention of Drowning last summer (7/1/10), and some of the new guidelines have received a bit of media attention, particularly the guidelines related to swim lessons in toddlers and young children. There is quite a lot of excellent information in the report, so I will summarize some of the main points here.

In thinking about drowning prevention, it helps to know who exactly is at the greatest risk. The highest rate of drowning is in the 0- to 4-year age group, with a second peak in adolescence. Boys are at greater risk than girls at all ages after 1yr. In fact, up to 12 years of age, drowning rates are approximately double for boys compared to girls, but in teenagers, the rate is an impressive 10x higher for boys. This is likely attributable to higher risk-taking behaviors, greater exposure to aquatic environments, and in adolescents, greater alcohol use. In regard to location of drowning deaths, 47% occur in fresh bodies of water (rivers, creeks, lakes, ponds, canals, quarries), 23% in artificial pools, 9% in the home (bathtubs, buckets), and 4% in salt water. The vast majority of infant drowning deaths (78%) occur in bathtubs and buckets. Above-ground inflatable or portable pools have become a more frequent source of drowning in recent years, as they have become less expensive and, therefore, more commonplace. They are rarely fenced in, and because they contain large amounts of water, they are left filled for weeks or months. Additionally, the soft sides of some models make it easy for children to lean over and fall in. And children can be amazingly nimble when they really want something. In a study of above-ground pools, children between 42 and 54mo of age were shown to be able to climb into a pool with a 48in wall, even if the ladder was removed.

Swimming pools may be fun, but they can be terrifying when it comes to toddlers and young children. Every pediatrician, including me, has at least one story of a young patient lost to drowning. It’s not something you ever forget. Young children can drown in 30-60 seconds, and when they drown, there is no splashing or screaming. It’s silent, and it’s fast. It scares me enough that my routine advice to swimming pool-owning families who have toddlers/young children is simply not to fill up the pool until the children are older and able to swim well. And I can honestly say that if any of my children’s grandparents or other relatives had a pool at their home, my children would never be allowed to be there without my husband or me. Swimming pools are serious business. However, there are definitely some steps families can take to make their pools and children safer for summer swimming:

1. All swimming pools must have a 4-sided fence that isolates the pool from the house and yard. This step alone has been shown to decrease pool-immersion injuries among young children by more than 50%. The fence should be at least 4ft high, with no opening under the fence more than 4in from the ground. Vertical members of the fence should be less than 4in apart to prevent children from squeezing through, and there should be no footholds or handholds that could help a child climb the fence. The fence should not obstruct the view of the pool. Gates must be self-closing and self-latching, and the latch should be placed at least 54in above the bottom of the gate. The gate should open away from the pool. The importance of an intact fence and functional gates cannot be overemphasized.

2. Pool gate alarms and retractable pool covers can provide additional layers of protection, but there is no research about their effectiveness so they should not replace any of the recommendations in #1.

3. All parents and caregivers should be trained in infant/child CPR. Immediate resuscitation, even before the arrival of emergency medical service providers, is associated with a significantly better outcome for children with submersion injury.

4. Continuous, eye-contact, adult supervision is imperative anytime children are around water. In fact, the vast majority of drownings don’t occur in the absence of supervision, but rather during momentary lapses in supervision, such as when the caregiver is distracted by socializing, talking on the phone, texting, reading, caring for other children, etc.

5. Teach children that they should never play anywhere near pool or spa drains. Body entrapment and hair entanglement can occur. All pools and spas should be equipped with drain covers, unblockable drains, and safety vacuum-release systems.

6. In regard to swim lessons, interestingly, studies regarding the association of swimming ability and the risk of drowning are not conclusive. In fact, there is no clear evidence that drowning rates are higher in poor swimmers. It is probable that increased swimming proficiency may actually serve to increase drowning rates due to increased exposure to water situations. The AAP’s previous stance was that children should not begin formal swimming lessons until at least age 4. This was due to lack of research showing benefit for swim lessons at younger ages, concern that caregivers would become overly-confident in their child’s ability to “swim” and would thereby increase swimming exposure, and that young children might become comfortable enough in the water that they would be more likely to seek out and enter the water without supervision. Recently, however, there have been a couple of studies that have shown that swimming lessons in children 1 to 4 years of age may reduce drowning risk, prompting the Academy to soften its stance. While the Academy still does not recommend swim lessons for children under age 4, it does note that “the evidence no longer supports an advisory against” them. However, as you consider this, it is also pertinent to note that swimming lessons have potential for some ill effects for young children, including increased asthma risk due to chlorine exposure, increased gastrointestintal tract infections, hypothermia, and low sodium due to excessive swallowing of water. Also of note, there is no published data supporting anecdotal claims that teaching a baby to roll over and float is sufficient to prevent drowning. In fact, there are no studies showing benefit to swim lessons under age 1, and the AAP does not recommend these. In regard to lesson techniques for young children, the studies that are available thus far don’t support any particular type of teaching technique, which makes it challenging to know what to look for. General recommendations for children under age 3 include: 1) direct parent involvement and supervision, 2) one-on-one teaching, 3) warm water to help avoid hypothermia, and 4) limited submersions to help decrease ingestion of water (excessive water intake can disrupt electrolytes and cause seizures in young children).

So, while swimming is great fun, excellent exercise, and a rite of summer, we must be diligent to take all possible precautions and must never let our guard down — even for a moment — when our children are in a swimming or water environment. This is truly a situation where lives can change dramatically in under a minute. Have fun, but please do be careful around the water!

Michelle Bennett, M.D., F.A.A.P.
Pediatric & Adolescent Associates

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