Submersion injuries, which include drowning and near-drowning incidents, continue to be a serious problem in pediatrics. Drowning is defined as death within 24 hours of a submersion incident. Near drowning is defined as survival for at least 24 hours following a submersion.
This article promotes the concept that submersion injuries represent a serious epidemic in pediatrics. It pertains only to warm water drownings, defined as immersion in water with a temperature greater than 200C. The epidemiology, pathophysiology, and prevention of drowning and near drowning are discussed.
In the United States, drowning and near drowning are the second leading cause of accidental deaths in children.1 Among all causes of death in children, only motor vehicle accidents and cancer surpass submersion incidents.2 Six thousand children are hospitalized and 2,000 children die each year due to drowning and near-drowning incidents. One-third of all survivors will suffer severe, irreversible, anoxic brain injury, often leaving them in a persistent vegetative state.3 Stated differently, roughly 40 children die, 115 are hospitalized, and 12 suffer severe brain damage each week in the United States as a result of submersion injuries. If one considers that submersion injuries are clustered during the late spring and summer months, these statistics become even more staggering. Submersion injuries represent an epidemic with significant morbidity and mortality.
Similar to any epidemic, submersion injuries place a financial strain on society. Each year $450 to $650 million are spent as a result of drowning and near drowning.3 More than $100,000 are spent annually for each child who sustains neurologic injuries from submersion injuries.3
The two groups at highest risk for submersion injuries are infants and toddlers and adolescent boys. Infants and toddlers from birth to 4 years old account for 40% to 50% of all submersion injuries in the United States.1 Adolescent boys between 10 and 18 years old account for 15% to 20% of all drowning and near-drowning incidents.1
The sources of water in childhood submersion injuries are shown in the table. Contrary to what many believe, 98% of drowning and neardrowning incidents occur in freshwater, whereas 1% to 2% occur in salt water. These statistics hold true even in towns, cities, states, and other communities located by the ocean. Of the various sources of freshwater, 50% of drowning and near-drowning incidents in the United States occur in private swimming pools, most often involving a child of the family that owns the pool. More than 75% of incidents occur in bodies of water that are part of the victim's home environment.
Relative Contribution of Various Submersion Media to Drowning Accidents
Figure. Postulated sequence of events during a submersion injury.
Child maltreatment and neglect are highly associated with drowning and near-drowning injuries. Lack of adult supervision of infants and toddlers around bodies of water, especially pools and bathtubs, often leads to submersion incidents.1'4,5 Bathtub drownings and near drownings are connected with child maltreatment, and this form of submersion injury is often intentionally inflicted.6,7
Much of the risk-taking behavior of adolescent boys that leads to submersion injuries occurs while they are under the influence of alcohol or illicit drugs.8 Many pool diving, boating, scuba diving, surfing, and water skiing accidents are the result of substance abuse. Submersion injuries involving infants and toddlers frequently implicate an adult caregiver who was under the influence of drugs or alcohol at a time when he or she should have been watching the victim in a pool or bathtub.57
The common enologie agent responsible for all physiologic derangements in any sort of submersion injury is anoxia.9 The figure illustrates the postulated sequence of events during a submersion injury. The process often begins with a brief accidental submersion in a liquid environment. Following submersion, water is introduced into the back of the oropharynx and larynx, which sets off a choking response and laryngospasm. Laryngospasm represents the first anoxic insult during the submersion sequence. As a result of this anoxic insult, the victim loses consciousness and becomes submerged, and further anoxia ensues.
Once the victim is underwater, one of two scenarios occurs. In 80% to 90% of submersion injuries, muscular relaxation occurs and the laryngospasm abates. As the glottis opens and the unconscious victim breathes, water is aspirated into the lungs. This is known as "wet drowning." In the remaining 10% to 20%, muscular relaxation does not occur. The victim remains unconscious and anoxia continues, but the laryngospasm persubmersion injuries.3132 They found that the PRISM system accurately distinguished emergency department patients who would survive neurologically intact from those who would die or suffer severe neurologic impairment. However, it could not accurately make such distinctions for patients already admitted to the pediatric intensive care unit.31 Therefore, despite various attempts to predict outcome in patients with submersion injuries, there is no foolproof method to distinguish those patients who will survive a submersion injury with intact brain function from those who will die or survive with severe neurologic injury.
How should health care providers approach an epidemic where it is impossible to treat the major cause of the morbidity and mortality (ie, anoxic brain injury) and to predict which patients will benefit from aggressive therapies as opposed to which will either die or be left in a vegetative state? The most effective approach is to use the same strategies that have been proven successful in other epidemics. These strategies attempt to optimize the benefits of prevention, education, and community and political involvement.
Of all preventive strategies, placing proper fences around pools is most effective. Proper pool fencing has been shown to lower the rate of submersion injuries by 50% to 80% in communities using such measures.33 A properly constructed pool fence should be freestanding and four sided and should completely surround the pool. The fence should be at least 5 feet high and should separate the pool from the house whose property the pool is on. The fence should have no spaces or openings greater than 4 inches in width, and should be self-closing and self-locking.34
Three-sided fences with a fourth side that is a wall of the pool owner's house are not an adequate barrier. These fences will prevent neighborhood children from accessing the pool, but not the children who live in the house. Children who live in households where a pool is present are most likely to suffer a submersion injury in a pool.4 Likewise, barriers such as pool covers and pool alarms are not acceptable substitutes for a properly constructed pool fence.
As in any epidemic, education is an extremely effective tool. Health care providers must take an active role in teaching methods of prevention of submersion injuries, the importance of complying with such methods, and identification and avoidance of behaviors and activities that increase the risk of drowning. They must make conversations regarding drowning and near drowning and the dangers of drug and alcohol use in relation to submersion injuries an integral part of anticipatory guidance during regular well-child office and clinic visits. Parents who own swimming pools must be made aware that a properly constructed pool fence is the only way to provide adequate protection for their children. Adult caregivers must be alerted to the importance of constant supervision of children around bodies of water. Parents, guardians, and baby-sitters must be taught to never leave a child unattended for even the briefest period around pools, bathtubs, or any source of water. Although teaching children to swim is important, parents must be made aware that teaching swimming or drowning prevention methods to children is not an adequate substitution for vigilant adult monitoring around pools. Likewise, floatation devices for children are not a substitute for adult supervision. Owners of pools should also be urged to become certified in cardiopulmonary resuscitation. Caregivers must also be made aware of the added dangers of indulging in alcohol or mindaltering drugs when supervising children in water. Drinking alcohol while watching a child in a pool or bathtub should be equated to driving under the influence of alcohol.35
Health care providers must also educate their patients on issues of drowning and near drowning. Children should be taught to swim only when an adult supervisor is present. Adolescent patients must be made aware of the dangers of indulging in alcohol or mind-altering drugs when swimming or participating in other waterrelated activities.35
Unfortunately, as with other child safety issues, lack of education is not the only reason for a lack of compliance with measures to prevent drowning and near drowning. Long after the public was made aware of the lifesaving value of child safety products such as car seats, window bars, and smoke detectors, laws were required to mandate their implementation. The same situation holds true for the prevention of drowning and near drowning. Wintemute and Wright reported that although pool owners were aware of the importance of proper pool fencing, 65% still refused to install proper barriers around their pools. Fifty percent of pool owners refused to obtain training in cardiopulmonary resuscitation, although they knew the importance of such training.36
Health care providers, therefore, must become politically active in their communities. They must advocate for local, state, and federal legislation mandating proper pool fencing around all residential pools.35 In most communities in the United States, laws regarding pool fencing are inadequate. Most of these laws contain exemptions. Some apply only to newly constructed pools; others exempt households without young children.37 Laws requiring pool fences to have the characteristics described above are virtually nonexistent in the United States. Health care providers must also advocate for laws that mandate cardiopulmonary resuscitation training for all pool owners. Such laws do not exist at a widespread level in the United States.35
Local, state, and federal health departments must increase and improve methods of surveillance for the drowning and near-drowning epidemic. More information is needed regarding epidemiologic aspects of submersion injuries, including ages, locations, and outcomes of victims, environmental and behavioral factors, and rescue and preventive strategies.35
Submersion injuries represent a serious pediatric epidemic in the United States with a significant morbidity and mortality. Anoxia is the major underlying etiology for the pathophysiology encountered in drowning and near drowning. Anoxic brain injury continues to be one of the most significant problems in submersion injuries. Because there are no effective methods to treat the complications of this injury, an increasing number of submersion injury victims are surviving with severe, irreversible brain damage. Also, there are no foolproof methods to accurately predict the prognosis of many victims. Preventive measures appear to be the most effective weapon in combating the drowning and near-drowning epidemic.
1. Orlowski JP. Drowning, near-drowning, and ice- water drowning. JAMA. 1988;260:390-391.
2. Cavalier S. Drownings, In: U.S. Consumer Product Safety Commission and National Spa and Pool Institute. National Pool and Spa Safety Conference. Washington, DC: U.S. Consumer Product Safety Commission; 1985:9-12.
3. Zamula WW. Social Costs of Drownings and NearDrownings From Submersion Accidents Occurring to Children Under Five in Residential Swimming Pools. Washington, DC: Directorate for Economic Analysis, U.S. Consumer Product Safety Commission; 1987.
4. Levin DL, Morriss FC, Toro LO, Brink LW, Turner GR. Drowning and near-drowning. Pediatr Clin North Am. 1993;40:321-336.
5. Kemp A, Sibert JR. Drowning and near drowning in children in the United Kingdom: lessons for prevention. BMJ. 1992;304:1143-1146.
6. Nixon J, Pearn J. Non-accidental immersion in the bath: another extension to the syndrome of child abuse and neglect. Child Abuse Negl. 1977;1:445-448.
7. Pearn JH, Nixon J. An analysis of the causes of freshwater immersion accidents involving children. Accia Anal Prev. 1979;11:173-178.
8. U.S. Consumer Product Safety Commission and National Spa and Pool Institute. National Pool and Spa Safety Conference: Final Report. Washington, DC: U.S. Consumer Product Safety Commission; May 14, 1985:1-48.
9. Orlowski JP, Abulleil MM, Phillips JM. Effects of tonicities of saline solutions on pulmonary injury in drowning. Crit Care Med. 1987;15:126-130.
10. Modell JH, Gaub M, Moya F, Vestal B, Swarz H. Physiologic effects of near drowning with chlorinated fresh water, distilled water and isotonic saline. Anesthesiology. 1966;27:33-41.
11. Karch SB. Pathology of the heart in drowning. Arch Pathol Lab Med. 1985;109:176-178.
12. Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med. 1989;18:1044-1049.
13. Pearn J. Pathophysiology of drowning. Med J Ausi. 1985;142:586-588.
14. Grausz H, Amend WJ Jr, Earley LE. Acute renal failure complicating submersion in sea water. JAMA. 1971;217:207-209.
15. Ports TA, Deuel TF. Intravascular coagulation in freshwater submersion: report of three cases. Ann intern Med. 1977;87:60-61.
16. Peterson B. Morbidity of childhood near-drowning. Pediatrics. 1977;59:364-370.
17. Pearn JH, Bart RD Jr, Yamaoka R. Neurologic sequelae after childhood near-drowning: a total population study from Hawaii. Pediatrics. 1979;64:187-191.
18. Conn AW, Edmonds JF, Barker GA. Near-drowning in cold fresh water: current treatment regimen. Canadian Anaesthetists' Society Journal. 1978;25:259-265.
19. Sarnaik AP, Preston G, Lieh-Lai M, Eisenbrey AB. Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med. 1985;13:224-227.
20. Bohn DJ, Biggar D, Smith CR, Conn AW, Barker GA. Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Crii Care Med. 1986;14:529-534.
21. Biggart MJ, Bohn DJ. Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children. J Pediatr. 1990;117:179-183.
22. Lavelle JM, Shaw KN. Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated? Crit Care Med. 1993;21:368-373.
23. Haun SE, Dean JM, Kirsch JR, Ackerman AD, Rogers MC. Theories of brain resuscitation. In: Rogers MC, ed. Textbook of Pediatric Intensive Care Medicine. Baltimore: Williams & Wilkins; 1992:698-732.
24. Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics. 1992;90:909-913.
25. Quan L, Wentz KR, Gore EJ, Copass MK. Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics. 1990;86:586-593.
26. Orlowski JP. Prognostic factors in pediatric cases of drowning and near-drowning. Journal of the American College of Emergency Physicians. 1979;8:176-179.
27. Dean JM, Kaufman ND. Prognostic indicators in pediatric near-drowning: the Glasgow coma scale. Crit Care Med. 1981;9:536-539.
28. Jacobsen WK, Mason LJ, Briggs BA, Schneider S, Thompson JC Correlation of spontaneous respiration and neurologic damage in near-drowning. Crit Care Med. 1983;11:487-489.
29. Nussbaum E, Galant SP. Intracranial pressure monitoring as a guide to prognosis in the nearly drowned, severely comatose child. / Pediatr. 1983;102:215-218.
30. Romano C, Brown T, Frewen TC. Assessment of pediatric near-drowning victims: is there a role for cranial CT? Pediatr Radiol. 1993;23:261-263.
31. Zuckerman GB, Gregory PM, Santos-Damiani SM. Predictors of death and neurologic impairment in pediatric submersion injuries: the Pediatric Risk of Mortality Score. Arch Pediatr Adolesc Med. 1998;152:134-140.
32. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med. 1988;16:1110-1116.
33. Pearn J, Nixon J. Prevention of childhood drowning accidents. Med J Aust. 1977;23:616-618.
34. Frisby ML, Hill JH. A community's response to childhood drownings: a model for accident prevention. Crit Care Nurs Clin North Am. 1991;3:373-379.
35. American Academy of Pediatrics Committee on Injury and Poison Prevention. Drowning in infants, children, and adolescents. Pediatrics. 1993;92:292-294.
36. Wintemute GJ, Wright MA. Swimming pool owners' opinions of strategies for prevention of drowning. Pediatrics. 1990;85:63-69.
37. Wintemute GJ, Drake C, Wright M. Immersion events in residential swimming pools: evidence for an experience effect. Am J Dis Child. 1991;145:1200-1203.
Relative Contribution of Various Submersion Media to Drowning Accidents