A reader contacted me to remind us that September is National Baby Safety Month. And while there are many threats to this vulnerable population, the No. 1 cause of death in children between the ages of 1 and 4 years old, continues to remain the same: drowning. It is the second-most common cause of injury-related death overall through 18 years of life, killing about 1,000 kids each year in the United States.
What is drowning?
In a Science-based Medicine.org article, “Infant and Toddler Swimming programs: Are they safe and effective?,” Clay Jones explains that drowning is “the process of experiencing respiratory impairment from being in or under in liquid.” Drowning outcomes can be categorized as death, no injury, or with disabling injury — such as vegetative state or brain death. Determination of disability is primarily based the amount of brain damage incurred from the lack of oxygen.
Drowning doesn’t always look like a struggle. Many times there is no yelling or arm waving. It is painfully silent. Dr. Graham Snyder, engineer and emergency room physician, says that if adults don’t know what to look for, they can miss the signs. He explains how drowning can look like a game, the child is rhythmically bobbing up and down, until they don’t come up again.
When water invades the opening of the airway it causes an inability to breathe air. Instinctively, victims hold their breaths until they are desperate (air hunger). At some point, they are overcome by an involuntary reflex need to inhale. But instead of air entering the mouth and throat, water enters —which causes muscles to spasm and close in an attempt to prevent liquid from entering the lungs. As a result, oxygen levels in the blood drop and carbon dioxide levels rise, leading to increasing acidity of the blood. Eventually the muscle spasm stops and water enters the lungs.
With decreasing amounts of oxygen, along with building acid levels, brain injury or brain death occur, along with abnormal and fatal heart rhythms.
Clay shares that for every drowning fatality there are many more nonfatal drowning injuries, many of which require hospitalization and long-term disabilities caused by hypoxic (insufficient oxygen) brain damage.
Which kids drown?
According to the U.S. Centers for Disease Control and Prevention (CDC), children ages 1 to 4 have the highest drowning rates. Drowning is responsible for more deaths in this age range than any other cause except birth defects and most often occur in home swimming pools.
The fatal unintentional drowning rate for minorities — specifically African Americans — is significantly higher than that of whites across all ages. In a four year study, the disparity was most pronounced in swimming pools where African American children 5-19 drowned at rates 5.5 times higher than those of whites. It was greatest among those 11-12 years old, where African Americans drowned in swimming pools at rates 10 times those of whites.
Contributing factors to this disparity in drowning rates were thought to be related to access to swimming pools and the desire to learn how to swim. The researcher noted that if drowning rates could be determined by actual participation in water-related activities, the disparity in minorities’ drowning rates compared to whites would be much greater.
Where, when and how do children drown?
The CDC found that most young children who drowned in pools were last seen in the home, had been out of sight less than five minutes, and were in the care of one or both parents at home at the time.
A study by the Consumer Product Safety Commission (CPSC) investigated the deaths of children under 5 in Arizona, California and Florida who had drowned in home swimming pools and looked at who was in charge of supervision at the time of drowning:
▪ 69% of the accidents occurred while one or both parents were responsible for supervision;
▪ 10% were adults other than the parents;
▪ 14% were sitters;
▪ 7% were siblings.
Summer is the deadliest month for drowning. Children who live in areas with longer and more intense summers are at higher risk because they are more likely to participate in water activities. While younger children have high rates of bathtub and pool drownings, children have also been known to drown in any large container of water, such as toilets, kiddie pools or large buckets.
Why do children drown?
The single most important factor in childhood drowning is the level of supervision. Even if a non-swimmer fell into the pool with a vigilant adult around, the child would be unlikely to drown. Many drowning injuries, both fatal and nonfatal, occur when a parent or caregiver leaves the scene for a brief period and sometimes even when they are within a few feet of the child but aren’t paying close attention.
Carolina Buia, in her Newsweek article “Technology to End Childhood Drowning,” says much of the risk stems from children swimming when they shouldn’t. In a 2010 University of Memphis study commissioned by the USA Swimming Foundation, more than half of the kids sampled in six urban cities reported little to low swimming ability yet they are in the pools.
While many countries like the United Kingdom and Bangladesh require swimming lessons as part of their public school curriculum, in the U.S. the burden falls on local recreational centers, national organizations (American Red Cross and USA Swimming), and parents.
The impact of swim lessons
The only thing that comes close to perfect prevention is direct and unwavering observation by a competent adult. So what is the role of knowing how to swim in decreasing the risk of drowning? Francesco Pia, renowned drowning-prevention expert, says nothing can replace lessons. He shares a study in JAMA Pediatrics that showed that for many children, lessons reduced the risk of drowning by 88%.
Yet lessons will not make your child drown-proof. In a study involving older swimmers, 16% of victims of drowning fatalities were reported to be average or strong swimmers. A majority of adolescents who drown are in open water caught up in rip tides, and many are intoxicated.
In contrast, children ages 1 to 4 years do benefit from swim instruction and the ability to swim. Although the American Academy of Pediatrics (AAP) was initially against swimming instruction in kids under 4 years, the position changed 2010 after some studies showed a relationship between early lessons and a decrease risk of drowning. However, the AAP, as well as the Red Cross, does not recommend submerging infants (children under 1) or exposing them to formal swim programs due to the number of risks (ingesting too much water, an inability to maintain body temperatures in cool pool water) without documented survival benefit.
While there are numerous programs available that offer learn to swim and roll and float survival methods, neither the AAP nor Red Cross support submerging infants or teaching back floating as a means to prevent drowning. Infants instinctively hold their breath when under water, but this reflex fades by about 6 months. At this age, parent/infant swim classes are a form of enjoyment and bonding and should not be considered a water safety program.
Despite the fact that vigilant supervision and common sense prevails, parents are always on the hunt for new gadgets and safety devices. There are piercing open-door alarms on house doors that lead to the outside, underwater motion swimming pool alarms, drone-aided lifeguard towers and radio-frequency wearable sensors (SEAL SwimSafe necklace, iSwimband headband) that sound when the device is submerged for more than a preset number of seconds. In supervised settings, technology can also contribute to a relaxed sense of supervision on the part of parents and lifeguards.
The main factors that affect drowning risk in children are lack of swimming ability, lack of barriers to prevent unsupervised water access, lack of close supervision while swimming, location and failure to wear life jackets while boating.
Rita Goldberg, former British national swimmer and founder of the British Swim School, believes that all very young children can and should be taught survival skills at a very young age. Her book, I Love to Swim, encourages parents to teach kids to swim. She elaborates on some the top ways to avoid drowning:
▪ Learn to swim: Research has shown that participation in formal swimming lessons can reduce the risk of drowning among children aged 1 to 4 years. Teach children water safety and swimming skills as early as possible so they have the best chance to survive a water accident.
▪ Adult supervision: Drowning can happen quickly and quietly anywhere there is water and even in the presence of lifeguards. During social gatherings, appoint a designated watcher to monitor children or anywhere near pools. Always maintain visual contact. Use the buddy system when necessary.
▪ Don’t depend on floaties or inflatable toys: Parents should be fully aware that flotation devices are not a substitute for supervision. They provide nothing but a false sense of security.
▪ Be prepared: Keep rescue equipment poolside. Don’t wait for the paramedics to arrive because you will lose valuable lifesaving seconds. Knowing CPR ahead of time can save lives.
▪ Protect the pool space: The pool should be surrounded by a fence that is at least 4 feet tall and should have self -closing and self-latching gates with latches that are out of the reach of young children. The fence should completely isolate the pool from the house. A four-sided isolation fence (separating the pool area from the house and yard) reduces a child’s risk of drowning 83% compared to three-sided property-line fencing.
▪ Wear life jackets when boating: In 2010, the U.S. Coast Guard received reports for 4,604 boating incidents; Most (72%) boating deaths that occurred during 2010 were caused by drowning, with 88% of victims not wearing life jackets.
The U.S. Swim School Association compiled a basic safety guideline for parents to evaluate their children at the start of the summer pool season. Kids should be able to:
▪ Flip and float. Any time a child enters a body of water unexpectedly, he or she should know to first reach the surface, then flip onto his or her back and float until help arrives.
▪ Find the side. If your child accidentally falls into a pool, he or she should know how to swim to the side and either pull themselves out of the water or move along the wall to the stairs where they can safely exit.
▪ Pass a clothes test. Children might be successful swimmers in their goggles and swimsuit, but if you have a backyard pool, there could be a situation where your child falls into the pool fully clothed. To help your children know how to react and judge their skill level in a situation like this effectively, under your supervision, have them jump into the pool with clothes on and swim to the side.
▪ Take a lap. If you have a backyard pool, it is a good idea to test your child at the end of the summer to make sure your child can swim a full lap of the pool. This will inform you if your child can swim far enough to reach the side or a step to exit the pool no matter where he or she falls in.
Laurie Futterman ARNP is a former Heart Transplant Coordinator at Jackson Memorial Medical Center. She now chairs the science department and teaches gifted middle school science at David Lawrence Jr. K-8 Center. She has three children and lives in North Miami.