Tailored guidance for families key to prevention of drowning: updated policy

Spending time with family and friends on vacation was an annual tradition for the Hughes family. A group of physicians and their families shared a beach house and spent the days swimming, crab hunting and making memories. Nicole Hughes, aware of the dangers of water, always put her 3-year-old son, Levi, in a life jacket when he was around water. As Nicole was getting the kitchen cleaned up at their beach house one day, Levi slipped out and made his way to the pool. He was found face down in the pool just moments after asking his mom for a snack. Despite lifesaving efforts, Levi died later that night.

Drowning is the leading cause of injury death in U.S. children ages 1-4 years and the third leading cause of unintentional injury death in children and adolescents ages 5-19 years, according to the Centers for Disease Control and Prevention (CDC). It is important for pediatricians to address drowning risk for their patients, based on their age, special health care needs and geographic location, by providing anticipatory guidance and resources regarding effective ways to prevent drowning.

The revised AAP policy statement Prevention of Drowning provides guidance and recommendations on best practices to help pediatricians work with their families and communities to decrease the risk of drowning. The policy, from the Council on Injury, Violence and Poison Prevention, is available at https://doi.org/10.1542/peds.2019-0850 and will be published in the May issue of Pediatrics.

Essential precautions

Anyone can drown, and it only takes seconds. Infants are most likely to drown in bathtubs or buckets, and preschoolers are most likely to drown in swimming pools. Many of these deaths occur when the child gets unanticipated access to water.

Preventing drowning deaths involves many layers. Adequate supervision, described as close, constant and attentive supervision of young children around any water, is a primary and essential preventive strategy. However, when children are not expected to be around water, this level of supervision is not always possible or realistic.

To prevented unanticipated access to water, barriers must be in place. Four-sided fencing with a locking gate that isolates the pool from the house has been shown to prevent more that 50% of swimming pool deaths in children. Door alarms, pool alarms and rigid pool covers are other less-studied prevention strategies.

Swim lessons, including for children 1-4 years, have been shown to decrease the risk of drowning in some children, but parents need to understand that swim lessons cannot “drown proof” any child, and supervision and barriers remain essential.

Role of health care professionals, parents

Pediatricians can play a critical role in drowning prevention by providing tailored anticipatory guidance to families as well as engaging with their community to adopt proven drowning prevention policies and strategies. Pediatricians need to become familiar with drowning risk for children with special health care needs, including epilepsy and autism spectrum disorder, and counsel families appropriately. They also must recognize the socioeconomic, racial and ethnic disparities in drowning risk and work to mitigate those.

Parents must understand the critical role they play in water safety, including supervision, enrollment in swim lessons, requiring and modeling life jacket use, having effective barriers in place and being able to recognize a child in distress and take appropriate action, including CPR.

Health care providers can advocate for passage and enforcement of four-sided fencing policies. They can work with communities to establish or enhance programs that loan life jackets or provide swim lessons that are accessible, affordable and culturally and linguistically appropriate to children and adolescents, especially those at increased risk of drowning.

Key recommendations

• Parents and caregivers should be advised to never — even for a moment — leave young children alone or in the care of another young child while in or near bathtubs, pools, spas, wading pools, irrigation ditches, ponds or other open standing water.
• Parents and caregivers must be aware of drowning risks associated with hazards in the home, including infant bath seats, toilets and containers filled with water.
• Supervision of children in and around the water must be close, constant and attentive.
• Families should install a four-sided fence that separates the pool from the house and the rest of the yard with a self-closing, self-latching gate.
• Parents, caregivers and pool owners should learn CPR and keep a telephone and equipment approved by the U.S. Coast Guard (e.g., life buoys, life jackets and a reach tool, such as a shepherd’s crook) near pools.
• Children and parents need to learn to swim. Basic water competency swim skills include ability to enter the water, surface, turn around, propel oneself for at least 25 yards and then exit the water.
• All children and adolescents should be required to wear U.S. Coast Guard-approved life jackets whenever they are in or on watercraft, and all adults should wear life jackets when boating to model safe behavior and to facilitate their ability to help their child in case of emergency. Small children and nonswimmers should wear life jackets when they are near water and when swimming.

Dr. Denny, the lead author of the policy statement, is a member of the AAP Council on Injury, Violence and Poison Prevention Executive Committee.