About four months ago, I was reading to my four-year-old when I received a text message from one of my close friends from residency. It was a short message. Eleanor, the two-year-old daughter of another pediatrician friend, was dead. Her mom had taken her older sister to a riding lesson and Ellie was home with her brother, twin sister, and dad. Our friend’s husband had left the twins eating a snack and watching cartoons in the living room while he went to the bathroom. He was gone for only a few minutes. When he came back, Eleanor was missing. He searched all over the house first and when he couldn’t find her, he went to the back yard. He found her face down in their backyard pool. The pool in question was surrounded by a four-sided fence with a self-latching gate, but the gate had been propped open. They found out later it had been accidentally left that way by the pool maintenance worker. EMS was called, and Ellie was coded all the way to the emergency department. By the time our friend arrived at her child’s bedside, she knew her baby was gone. She asked them to stop resuscitation efforts.
When my local medical society’s magazine editor asked for someone to write an article on drowning prevention for the summer issue, it occurred to me that I had something to say on the matter. I asked Eleanor’s mommy if it would be alright for me to include her story and her answer was an enthusiastic “yes”. Maybe if we make more parents aware of how and when drowning actually happens, there could be fewer stories like hers.
First, Some Definitions
The way we talk to patients and the public in general about drowning matters. If we are going to educate effectively and reduce confusion about drowning, it’s important that we use consistent and accurate terms. In 2014 the American Red Cross released a statement asking medical professionals to use only accepted medical definitions of drowning and terms in its publications as well as its communication with patients. These are as follows:
- Drowning is defined as the process of experiencing respiratory impairment from submersion or immersion in liquid.
- Drowning has three potential outcomes:
- Fatal drowning
- Nonfatal drowning with injury or illness
- Nonfatal drowning without injury or illness
The terms “near-drowning”, “dry drowning”, and “secondary drowning” are not accepted medical terms and can be confusing to the lay public. These terms have grown out of the common understanding that drowning always results in death, but we know this is not the case. The problem with these terms is that they can cause both inadequate and excessive worry in the minds of parents. They may assume that a child who has had a submersion event and has persistent symptoms does not need medical care because they don’t recognize that the child has had a drowning event. Conversely, they may worry that their asymptomatic child may suddenly die in their sleep after swimming from “dry drowning”, causing undue stress and avoidance of water altogether.
“Near-drowning” has historically been used to refer to drowning events that do not result in death, but newer terms are clearer. “Dry-drowning” has been used to refer to cases of fatal drowning in which no liquid was discovered in the lungs at autopsy. This pathologic finding is actually not uncommon as death is typically caused by hypoxic brain injury resulting from disruption of the surfactant layer in the lungs. Such disruption can occur when only a very small volume of liquid enters the lungs, less than 2ml/kg of body weight. This can translate to less than an ounce for an average sized toddler. Using the term “dry drowning” further contributes to the false understanding that water literally fills up the lungs of drowning victims. We need parents to understand that drowning can occur in shallow water and small vessels such as bathtubs, buckets and even toilets.
Use of the term “secondary drowning” perpetuates the myth that asymptomatic children may develop symptoms of drowning and even suddenly die hours or even days after swimming. This just simply doesn’t happen. It’s not a real thing, despite myths that pervade social media every summer. You may have heard the story last summer of a toddler in Texas who died suddenly days after playing in a water-filled ditch. He was initially misidentified by his family as a case of “secondary drowning” but on autopsy was found to have perished from cardiomyopathy. We know that children who have submersion/immersion event in water and who experience drowning will exhibit symptoms within 4-6 hours of the event. These symptoms include persistent cough, foaming at the mouth, persistent vomiting, confusion or other abnormal behavior. If patients do exhibit these symptoms within a few hours after an event, they should be advised to seek immediate medical attention. If these symptoms develop more than 8 hours after an event, other etiologies should be considered such as spontaneous pneumothorax, chemical pneumonitis, infectious pneumonia, head injury, asthma, cardiac pathology, chest trauma, etc.
How Big Is the Problem?
Over the last decade there have been an average of 13,000 emergency department visits for drowning each year. About 3,500 per year were fatal drowning events. In the United States, drowning volleys between the first and second leading cause of unintentional injury and death in the pediatric age group from year to year. In Arizona, California, Florida, and Texas drowning is consistently the leading cause of death in children across the board. These are preventable deaths. Particularly in our state, we need to do better.
Frequently Overlooked Risks
Everyone knows that children can drown in lakes, rivers, oceans and swimming pools but the sad reality is that children die each year from drownings involving washing machines, bathtubs, buckets, drainage ditches, and toilets as well. The vast majority of these deaths occur in children ages 12 to 36 months and can be traced to a lack of supervision. Parents may not think of these other bodies of water as drowning hazards and thus may not take steps to adequately supervise their young toddlers around them.
Another all-too-common source of danger are pool drains. Without proper safety filters or other devices, swimmer’s hair or other body parts may be sucked in and entrapped. Thus, swimmers are unable to surface and can drown. Federal legislation requires safety devices to be installed in all public pools and spas, but these laws do not apply to private home pools. This is something we should be discussing with our patients who have pools in their yards.
Soft-sided and inflatable above ground pools are a third source of danger for small children. Because these pools are considered portable, laws about fencing often do not apply to them, even though they can hold thousands of gallons of water and remain filled for months at a time. Because their sides are flexible, it is easy for small children to fall in head first while leaning over the edge.
Large flotation devices used in pools (e.g. rafts, kayaks, killer whales, what have you) must be used with extreme caution and should be removed from the water once family play time is over. Even children who have had formal swimming lessons and “know how to swim” can become trapped underneath them, become confused and panicked. Drowning can occur very quickly, and adults present may not realize a child is missing until it is too late.
Evidence Based Prevention Measures
Here’s the bottom line. These are the pearls of advice we should be giving to our patients and to the public at large, the measures we should be talking to our legislators about when we have the opportunity.
- Fences – Texas state law requires that all pools, both public and residential, be enclosed by a 4-sided fence that is at least 4 feet tall, that has no gaps wider than 4 inches, that cannot be easily climbed, and that is self-latching with a locking mechanism. Said locking mechanism must be located on the upper quarter of the gate. This is quite effective for keeping neighborhood children from wandering into the pool area but may not keep children who live in the home away from the water. Thus, the American Academy of Pediatrics (AAP) recommends that residential pools be completely enclosed by a 4-sided fence that separates the pool from the house. Most small children who drown in their own family pools were last seen inside the house before being found in the water. I tell parents all the time – toddlers are sneaky. They can open doors you think they can’t. They can climb things you think they can’t. They can move faster than you think and have much poorer judgement that you would have imagined. Home pools need to be separated from the house and the rest of the yard by a proper fence. Texas state law does require alarms on doors and windows that open into the pool area in homes that do not have a fence in place, but there is strong evidence that fences are far more effective than these alarms.
- Rigid pool covers or alarms may decrease the risk of drowning for small children, but they do not replace a proper fence. Soft pool covers are absolutely NOT recommended, as children may slip through at the edge and then become trapped underneath them.
- Toys or other attractions should not be left in the pool area when it is not in use. Such objects can lure young unsupervised children to the pool area. Care givers should make sure that everything is picked up at the end of each and every swimming session. In that same vein, patio furniture, storage boxes, etc. should not be placed near the pool fence as these objects may used by small children to climb over the fence.
- Small children and other non-swimmers are encouraged to wear a life vest when playing in the water and all times when riding on boats. Inflatable floating devices should not be relied upon to protect children from drowning as children can slip out of them too easily or they may become deflated while being used.
- Previously the AAP has recommended against swimming lessons for children under 4 or 5 years as there was not adequate data to support the idea that younger children are capable of learning these skills. There was also concern in the past that enrolling children under 4 in swimming lessons might create a false sense of security and cause parents to be less vigilant with their children when near water. There was also concern that small children might become more bold around water without adequate skills to prevent drowning. While it is still generally understood that younger children cannot be taught to “swim” (i.e. specific strokes, breathing techniques, etc.) there is newer data suggesting that risk of drowning may yet be lowered by formal swimming lessons. There is not yet an official recommendation from the AAP for universal swimming lessons for children aged 12 months to 4 years of age, but I relay to my patients that there is some benefit. There is not currently data to support survival swimming lessons for infants, however. While parents may wish to participate in these lessons for enjoyment, it should be emphasized that infants and toddlers cannot be “drowning proofed” and that lessons are not a substitute for proper supervision. Once again, drowning prevention comes down to layers of protection (you’ll see this phrase a lot in this piece). Swimming lessons are one of these layers.
- Speaking of supervision, this is the single most important preventive measure care givers can take to protect children from drowning. Children should be watched constantly when near the water, not just in the water. Remember that most small children who drown do so when they were not expected to be in the water. Pool parties can be particularly dangerous because adults will often distract one another and may be consuming alcohol. Pool owners should be encouraged to hire certified life guards if they are hosting a party, especially if young children will be invited. If no life guard is present, there should be designated child watchers. I myself do not send my children to pools or the beach with other adults unless I know there will be certified life guards. Care givers should make sure that toddlers and older children who have not had formal lessons are kept within arm’s reach, a practice known as “touch supervision”.
- Older children and teenagers who ARE good swimmers should still be supervised by adults. Horse play, risk taking behaviors, showing off and alcohol use can put even strong swimmers at risk for drowning. Older children should be counseled about these risks, as well as their parents.
Finally, it is important to emphasize the idea of layers of protection. Have I said that enough, yet? No one intervention will protect all children from all drowning hazards. It is paramount to implement ALL the above protective measures to keep our kids safe.
Not long after I completed this article, as I was waiting for it to go to print, I was heartbroken to hear of another old friend who had lost a child to drowning. His name is Levi and he was three years old. You can read about him in my previous post, “Levi’s Legacy” and I hope you will. Please disseminate this information. Help Eleanor’s and Levi’s moms in their efforts to increase awareness and protect other people’s children.
- Hawkins, Sempsrott, Schmidt. “Drowning in a Sea of Misinformation”. Emergency Medicine News. June 16, 2017.
- “Drowning Prevention Speaking Points”. AAP Advocacy Practice Guidelines – Working With the Media. www.aap.org
- Agran. “Patterns of Drowning in Young Children”. Abstract Presentation, AAP National Conference and Exhibition – Boston, 2017.
- “AAP Gives Updated Advice on Drowning Prevention”. AAP Press Release. 2010
- Brenner. Taneja. Haynie et al. “Association Between Swimming Lessons and Drowning in Childhood: A Case Control Study”. Archives of Pediatric Adolescent Medicine. 2009;163(3):203-210