Drowning — Interventions

Please note that this section contains my personal notes from my readings on this topic.

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In this section:

• Adult Supervision
• Pool Fencing
• Pool Covers
• Pool Alarms
• Lifeguards
• CPR Training
• Swimming and Water-Survival Training
• PFDs

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The below are notes from “Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.

In the Haddon matrix of injury prevention, safety interventions are aimed at changing the environment, the individual at risk, or the agent of injury (in this case, water). For drowning prevention, the environment and the individual are the prime targets. Experts generally recommend that multiple “layers of protection” be used to prevent drowning, because no single strategy is likely to prevent all submersion deaths and injuries. Such layers might include environmental changes such as adult supervision, pool fencing, pool covers, water-entry alarms, lifeguards, and CPR training. Additional prevention layers focused on the individual would include strategies such as swimming and survival skills training and use of PFDs. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Studies from the late 1990s revealed that pediatricians report that they were not adequately taught about drowning prevention during their residency training and that few of them counseled parents about this topic.^54,55 There have been no recent publications regarding the current status of drowning-prevention counseling by physicians and no research about whether such an intervention is effective in decreasing drowning rates. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Adult Supervision
Close supervision of young children around any body of water is an essential preventive strategy, but inevitable lapses make supervision alone insufficient.^15,33 Because young children who fall into water often make no noise and are hard to see below the water surface, proper care of a young nonswimmer requires the supervising adult to be within an arm’s length and provide “touch supervision.” To stress the importance of supervision, some communities have distributed “designated water watcher” badges as part of their drowning-prevention campaigns. While wearing the badge, the adult “water watcher” is responsible for pool safety and is expected not to engage in any distracting activities. The efficacy of such programs still needs evaluation. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Pool Fencing
Pool fencing is an important prevention strategy for decreasing the risk of drowning in swimming pools when children are not supposed to have access to the water. Compared with no fencing, installation of 4-sided fencing that isolates the pool from the house and yard has been shown to decrease the number of pool-immersion injuries among young children by more than 50%.^56–58 One Cochrane collaboration meta-analysis of available studies revealed the OR for drowning in a fenced versus an unfenced pool to be 0.27 (95% CI: 0.16–0.47). In this analysis, pool isolation fencing was revealed to be superior to property-perimeter fencing (OR: 0.17 [95% CI: 0.07–0.44]).⁵⁸ A study from Australia revealed that the risk of a child drowning in a pool with perimeter fencing was almost twice that seen in pools with an isolation fence (incidence rate ratio: 1.78 [95% CI: 1.40–1.79]).^{59 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Unfortunately, laws and ordinances regarding pool fencing may have dangerous loopholes. Perimeter fencing with self-locking or alarming doors between the house and pool area are often considered acceptable, and in some locales, pool covers can substitute for a fence. Often, the fence law pertains only to new pool construction or to homes in which a young child is actually living at the time of the pool installation. Furthermore, in the United States, pool fences are rarely inspected, and ordinances are often not enforced. A recent study from Australia revealed that government inspections raised the rate of compliance with pool-fencing laws from approximately 50% to 97%.^{60 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Children’s ability to climb fences varies with the type of fence. In 1 study, chain-link fences were easily scaled by children, whereas ornamental iron-bar fences proved more difficult to climb.⁶¹ Fences should be at least 4 ft high, and no opening under the fence should be more than 4 in (some building codes require a 5-ft fence and a maximum fence-to-ground distance of only 2 in). Vertical members of the fence should be less than 4 in apart to keep a child from squeezing through them, and there should be no footholds or handholds that could help a young child climb the fence. The fence should not prevent a clear view of the pool. Gates should be self-closing and self-latching, and the latch should be placed at least 54 in above the bottom of the gate. The gate should open away from the pool and should be checked often to ensure that it is in good working order. Pool gate alarms may provide additional protection, but no research exists on their efficacy. Detailed guidelines for safety barriers for home pools are available online from the CPSC,⁶² but homeowners must also be aware of local laws and building codes regarding pool-fence construction. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Pool Covers
Retractable pool covers and pool nets capable of holding the weight of a child have been advertised as effective barriers for drowning prevention. Because these covers must be removed and replaced each time the pool is used, they are not likely to be used appropriately and consistently. Because there has been no scientific study regarding the efficacy of pool covers, they cannot be recommended as a substitute for isolation fencing. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Some types of pool covers actually present a hazard for children. In 1980, the CPSC issued a warning about solar pool covers that are designed to keep the water warm and minimize pool chemical and water evaporation. When children try to walk on these thin sheets of plastic, they can fall into the water and drown while entangled in the cover or hidden from view.^{63 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Pool Alarms
The CPSC has evaluated the performance of surface, subsurface, and wristband pool alarms.⁶⁴ Several of these alarms functioned properly and were thought to provide some protection against drowning; however, the report concluded that alarms “should not be relied on as a substitute for supervision or a barrier completely surrounding the pool.” No study results have demonstrated whether pool alarms prevent drowning. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Lifeguards
Although no formal scientific study has quantified the value of lifeguards, anecdotal reports indicate that drowning rates are lower when lifeguards are present.⁶⁵ The US Lifesaving Association has reported that only 20 of the 109 beach drowning deaths occurred on guarded beaches in 2007.⁶⁶ In addition to rescue efforts, lifeguards serve to make beaches safer by monitoring the aquatic environment, enforcing rules and regulations, and educating beachgoers about safety and injury prevention. Those who choose to swim in natural bodies of water or other sites accessible to the public should swim in designated swim areas with lifeguards present. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

CPR Training
Immediate resuscitation at the site of a submersion incident, even before the arrival of emergency medical services personnel, is an important means of secondary prevention and is associated with a significantly better outcome for children with submersion injury.^2,3 For this reason, all parents and caregivers should be trained in infant/child CPR. Initial resuscitative efforts for a drowning victim should include rescue breathing as well as chest compressions when signs of circulation are absent. “Hands-only” CPR is not appropriate for drowning victims. The Heimlich maneuver is not recommended to expel water from the lungs, because positive pressure ventilation by mouth or mask will accomplish adequate oxygenation.⁶⁷ Additional CPR information and courses for parents and caregivers is available through the American Heart Association and the American Red Cross. Education for health care professionals on resuscitation of pediatric patients is available through American Academy of Pediatrics programs Pediatric Advanced Life Support (PALS) and Pediatric Education for Prehospital Professionals (PEPP). ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Swimming Instruction and Water-Survival Training
All children should eventually learn to swim. In the past, the position of the American Academy of Pediatrics has been that children are not “developmentally ready” for formal swimming lessons until after their fourth birthday.⁶⁸ This policy was based on (1) the lack of data needed to determine if infant and toddler aquatic programs increase or decrease the likelihood of drowning, (2) concerns that such programs would cause parents to develop a false sense of security and lead them to provide inadequate supervision around water, and (3) evidence that starting swimming lessons at a very young age does not result in earlier development of proficient swimming skills.^69,70 In addition, there was concern that swimming programs might reduce a child’s fear of water and unwittingly encourage him or her to enter the water without supervision. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Concern about parents developing a false sense of security is well founded. Compared with controls, parents of small children who were enrolled in swimming lessons were more likely to endorse the statements “swimming lessons are the best way to prevent drowning,” “toddlers can learn to save themselves if they fall into water,” and “it is better to develop swimming ability rather than rely on adult supervision.”⁷¹ In a follow-up study, when they were given a targeted educational program to reverse misconceptions about toddler water safety, parents of children in a toddler swim program were more likely to agree that their child required more, not less, supervision. These parents were also more likely to disagree that swimming lessons were the best way to prevent drowning.⁷² The authors suggested that “swim schools can provide a valuable opportunity to address parental misconceptions about toddler water safety.” ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

By 4 years of age, most children can learn basic aquatic locomotion, and by 5 or 6 years of age, most of them can master the front crawl.^69,70 The more important question for this report relates to when a child can learn water skills needed to prevent a drowning. Results of research from Asher et al,⁴⁰ Yang et al,⁴¹ and Brenner et al⁴² have indicated that some drowning-prevention skills can be learned between 1 and 4 years of age. It should be stressed, however, that these were relatively small studies that had outcomes with wide CIs. Although there is anecdotal evidence that even some small infants can successfully learn water-survival skills, there are currently no published scientific studies to indicate that such training results in the “drown-proofing” claimed by some advocates. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

The American Red Cross Advisory Council on First Aid, Aquatics, Safety and Preparedness recently published an extensive scientific review regarding minimum age for swimming lessons. They concluded that the “limited empirical research evidence does not support prohibiting early aquatic experiences at any specific age.” In their report, the council stated that “children between the ages of 2 and 4 years can optionally start swim lessons for the purpose of building aquatic readiness and water acclimation on an individual basis.”⁷³ Although the council recognized that there may be some drowning-prevention benefit to swim lessons before 4 years of age, they indicated that “there is absolutely no published evidence to support anecdotal claims” that “rolling over and floating are sufficient to prevent drowning.” ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Although early instruction may be beneficial, there are some concerns about aquatic programs in this young age group. These concerns include the risk of gastrointestinal tract infections, dermatitis, and acute respiratory illness that can result from exposure to infectious agents and pool chemicals. Hyponatremia from drinking pool water and hypothermia have also been reported. Generally, medical problems from swimming are rare, treatable, and preventable events.^74,75 The World Aquatic Infants and Children Network has published guidelines for the operation of aquatic programs for children younger than 3 years. The guidelines address (1) required parental involvement, (2) a fun atmosphere with 1-on-1 teaching, (3) qualified teachers, (4) warm water to prevent hypothermia, (5) maintenance of water purity, and (6) a limited number of submersions to prevent water ingestion and hyponatremia.^{76 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

Recent articles have been published and suggest a link between infant exposure to chlorination byproducts in swimming pools and damage to respiratory epithelium, resulting in a predisposition to asthma and bronchitis.^77–79 In 1 of these studies, asthma was more likely in infants of atopic mothers.⁷⁹ In another study, atopic adolescents exposed to chlorinated pools were more likely to have hay fever, asthma, cough, and shortness of breath than were atopic adolescents who swam in pools disinfected by a copper-silver method.^{80 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

The AAP continues to support swimming lessons for children 4 years old and older without physical or developmental disabilities. In light of new research that has revealed that swim instruction for children 1 to 4 years of age may decrease drowning,^41,42 it is reasonable for the AAP to relax its policy regarding the age at which children should start learning water-survival skills. The evidence no longer supports an advisory against early aquatic experience and swim lessons for children of any specific age. However, the current evidence is insufficient to support a recommendation that all 1- to 4-year-old children receive swim lessons. Clearly, more research is needed to determine which types of swim instruction and water-survival skills training are most effective in preventing drowning in young children of various ages. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

A parent’s decision about the age at which to teach water-survival skills or initiate swimming lessons must be individualized on the basis of a variety of factors such as frequency of exposure to water, health concerns, emotional maturity, and physical limitations. Some parents may feel that the benefits of infant or toddler water programs outweigh any possible dangers. Once again, it must be stressed that even advanced swimming skills will not always prevent drowning and that swimming lessons must be considered only within the context of multilayered protection with effective pool barriers and constant, capable supervision. ^{(“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}

PFDs
The use of an approved PFD, although not well evaluated, seems likely to decrease drowning morbidity and mortality.^81,82 US Coast Guard boating statistics from 2008 indicate that only 9% of 510 drowning-death victims (all ages) were wearing a PFD.⁵¹ Successful educational and life-jacket–loaner programs designed to increase PFD use have been reported,^83,84 and in the past 10 years, the Coast Guard reported a slight improvement in PFD use in children younger than 18 years from 56% to 65% nationally.⁸⁵ It is important to recognize that air-filled swimming aids (such as inflatable arm bands) are toys that can deflate and should not be used in place of PFDs. Information about infant and child PFDs for a variety of aquatic situations is available online from the US Coast Guard.^{86 (“Prevention of Drowning”; PEDIATRICS Vol. 126 No. 1 July 2010, pp. e253-e262.  Published online May 24, 2010.)}