POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

Prevention of DrowningSarah A. Denny, MD, FAAP,a Linda Quan, MD, FAAP,b Julie Gilchrist, MD, FAAP,c Tracy McCallin, MD, FAAP,d,e

Rohit Shenoi, MD, FAAP,e,f Shabana Yusuf, MD, Med, FAAP,e,f Benjamin Hoffman, MD, FAAP,g Jeffrey Weiss, MD, FAAP,h COUNCIL ONINJURY, VIOLENCE, AND POISON PREVENTION

abstractDrowning is a leading cause of injury-related death in children. In 2017,drowning claimed the lives of almost 1000 US children younger than 20 years.A number of strategies are available to prevent these tragedies. As educatorsand advocates, pediatricians can play an important role in the prevention ofdrowning.

BACKGROUND

Drowning is the leading cause of injury death in US children 1 to 4 years ofage and the third leading cause of unintentional injury death among USchildren and adolescents 5 to 19 years of age.1 In 2017, drowning claimedthe lives of almost 1000 US children. Fortunately, childhood unintentionaldrowning fatality rates have decreased steadily from 2.68 per 100000 in1985 to 1.11 per 100000 in 2017. Rates of drowning death vary with age,sex, and race and/or ethnicity, with toddlers and male adolescents at highestrisk. After 1 year of age, male children of all ages are at greater risk ofdrowning than female children. Overall, African American children have thehighest drowning fatality rates, followed in order by American Indian and/orAlaskan native, white, Asian American and/or Pacific Islander, and Hispanicchildren. For the period 2013–2017, the highest drowning death rates wereseen in white male children 0 to 4 years of age (3.44 per 100000), AmericanIndian and/or Alaskan native children 0 through 4 years (3.58), and AfricanAmerican male adolescents 15 to 19 years of age (4.06 per 100000).1

Drowning is also a significant source of morbidity for children. In 2017,an estimated 8700 children younger than 20 years of age visiteda hospital emergency department for a drowning event, and 25% ofthose children were hospitalized or transferred for further care.1 Mostvictims of nonfatal drowning recover fully with no neurologic deficits, butsevere long-term neurologic deficits are seen with extended submersiontimes (.6 minutes), prolonged resuscitation efforts, and lack of earlybystander-initiated cardiopulmonary resuscitation (CPR).2–4

The American Academy of Pediatrics issues this revised policy statementbecause of new information and research regarding (1) populations at

aCollege of Medicine, The Ohio State University and NationwideChildren’s Hospital, Columbus, Ohio; bSchool of Medicine, University ofWashington and Seattle Children’s Hospital, Seattle, Washington; cUSPublic Health Service, Rockville, Maryland; dChildren’s Hospital of SanAntonio, San Antonio, Texas; eBaylor College of Medicine and fTexasChildren’s Hospital, Houston, Texas; gOregon Health and ScienceUniversity and Doernbecher Children’s Hospital, Portland, Oregon; andhCollege of Medicine, University of Arizona and Phoenix Children’sHospital, Phoenix, Arizona

Dr Denny led the authorship group; Drs Quan, Gilchrist, McCallin, Yusuf,and Shenoi contributed sections; Dr Hoffman provided significant earlyreview; Dr Weiss authored the previous policy statement that formedthe basis of this document; and all authors approved the finalmanuscript as submitted.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DOI: https://doi.org/10.1542/peds.2019-0850

Address correspondence to Sarah A. Denny, MD, FAAP. E-mail: sarah.denny@nationwidechildrens.org

To cite: Denny SA, Quan L, Gilchrist J, et al. AAP COUNCILON INJURY, VIOLENCE, AND POISON PREVENTION. Preventionof Drowning. Pediatrics. 2019;143(5):e20190850

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increased risk, (2) racial andsociodemographic disparities indrowning rates, (3) watercompetency (water-safety knowledgeand attitudes, basic swim skills, andresponse to a swimmer in trouble),5,6

(4) when children are in and aroundwater (the need for close, constant,attentive, and capable adultsupervision and life jacket use inchildren and adults), (5) whenchildren are not expected to bearound water (the importance ofphysical barriers to preventdrowning), and (6) the drowningchain of survival and importance ofbystander CPR (Table 1).

CLASSIFICATION OF DROWNING

In 2002, the World Congress onDrowning and the World HealthOrganization revised the definition ofdrowning to “the process ofexperiencing respiratory impairmentfrom submersion/immersion inliquid.” Drowning outcomes areclassified as “death,” “no morbidity,”or “morbidity” (further divided into“moderately disabled,” “severelydisabled,” “vegetative state/coma,”and “brain death”). The drowningprocess is a continuum that can beinterrupted by rescue at any point inthat process, with varying sequelaefrom no symptoms to death. Termssuch as wet, dry, secondary, active,near, passive, and silent drowningshould not be used. The 2002 reviseddefinition and classification is moreconsistent with other medicalconditions and injuries and shouldhelp in drowning surveillance andcollection of more reliable andcomprehensive epidemiologicalinformation.7

POPULATIONS WITH INCREASEDDROWNING RISK

Certain populations, because ofbehavior, skill, environment, orunderlying medical condition, are atincreased risk of drowning.

Toddlers

For the period 2013–2017, thehighest rate of drowning occurred inthe 0- to 4-year age group (2.19 per100 000 population), with children 12to 36 months of age being at highestrisk (3.31). Most infants drown inbathtubs and buckets, whereas themajority of preschool-aged childrendrown in swimming pools.8 Theprimary problem for this young agegroup is lack of barriers to preventunanticipated, unsupervised access towater, including in swimming pools,hot tubs and spas, bathtubs, naturalbodies of water, and standing waterin homes (buckets, tubs, and toilets).The Consumer Product SafetyCommission (CPSC) found that 69%of children younger than 5 years ofage were not expected to be at or inthe pool at the time of a drowningincident.9

Adolescents

Adolescents (15–19 years of age)have the second highest fataldrowning rate. In this age group, justless than three-quarters of alldrownings occur in natural watersettings, and this age group makes uphalf of childhood drownings innatural water.10 In 2016, Safe KidsWorldwide reported that the naturalwater fatal drowning rate foradolescents 15 to 17 years old wasmore than 3 times higher than thatfor children 5 to 9 years old and twicethe rate for children younger than5 years of age.11 The increased riskfor fatal drowning in adolescents canbe attributed to multiple factors,including overestimation of skills,underestimation of dangeroussituations, engaging in high-risk andimpulsive behaviors, and substanceuse.12 Alcohol is a leading risk factor,

contributing to 30% to 70% ofrecreational water deaths among USadolescents and adults.13

UNDERLYING MEDICAL CONDITIONS

Epilepsy

Drowning is the most common causeof death from unintentional injury forpeople with epilepsy,14 and childrenwith epilepsy are at greater risk ofdrowning, both in bathtubs and inswimming pools.15 The relative riskof fatal and nonfatal drowning inpatients with epilepsy varies greatlybut is 7.5- to 10-fold higher than thatin children without seizures15,16 andvaries with age, severity of illness,degree of exposure to water, and levelof supervision.15–17 Parents andcaregivers of children with activeepilepsy should provide directsupervision around water at all times,including swimming pools andbathtubs. Whenever possible,children with epilepsy should showerinstead of bathe17 and swim only atlocations where there is a lifeguard.Children with poorly controlledepilepsy should have a discussionwith their neurologist or pediatricianbefore any swim activity.

Autism

Children with autism spectrumdisorder (ASD) are also at increasedrisk of drowning,18 especially thoseyounger than 15 years of age18 andthose with greater degrees ofintellectual disability.19 Wandering isthe most commonly reportedbehavior leading to drowning,accounting for nearly 74% of fataldrowning incidents among childrenwith autism.20

Cardiac Arrhythmias

Exertion while swimming can triggerarrhythmia among individuals withlong QT syndrome.21 Although thecondition is rare and such casesrepresent a small percentage ofdrownings, long QT syndrome, as wellas Brugada syndrome and

TABLE 1 Top Tips for Pediatricians

Assess all children for drowning risk on thebasis of risk and age and prioritizeevidence-based strategies:

- barriers;- supervision;- swim lessons;- life jackets; and- CPR.

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catecholaminergic polymorphicventricular tachycardia, should beconsidered as a possible cause forunexplained submersion injuriesamong proficient swimmers in low-risk settings.22

SOCIODEMOGRAPHIC FACTORS

There continue to be significant racialand socioeconomic disparities indrowning rates among children. Formany, cultural beliefs and traditionsmay prevent children fromswimming.23,24 Furthermore, forsome religious and ethnic groups,single-sex aquatic settings arerequired,25 and clothing that protectsmodesty according to religious normsmay not be allowed in some pools.Socioeconomically, the multiple swimlessons required to achieve basicwater competency can be costly ordifficult given limited access andtransportation. Moreover, decreasedmunicipal funding for swimmingpools, for swimming programs, andfor lifeguards has limited access toswim lessons and safe waterrecreational sites for manycommunities.

These barriers may be surmountedthrough community-based programstargeting high-risk groups byproviding free or low-cost swimlessons, developing special programsto address cultural concerns as wellas developing swim lessons for youthwith developmental disabilities,changing pool policies to meet theneeds of specific communities, usingculturally and linguisticallyappropriate instructors to deliverswim lessons, and working with bothhealth care and faith communities torefer patients and their families toswim programs.25–27

WATER COMPETENCY, SWIM LESSONS,AND SWIM SKILLS

Water competency is the ability toanticipate, avoid, and survivecommon drowning situations.6 Thecomponents of water competency

include water-safety awareness, basicswim skills, and the ability torecognize and respond to a swimmerin trouble. Swim lessons and swimskills alone cannot prevent drowning.Learning to swim needs to be seen asa component of water competencythat also includes knowledge andawareness of local hazards and/orrisks and of one’s own limitations;how to wear a life jacket (previouslyreferred to as “wearable personalflotation device”); and ability torecognize and respond to a swimmerin distress, call for help, and performsafe rescue and CPR.5

Evidence reveals that many childrenolder than 1 year will benefit fromswim lessons.28 Swim lessons areincreasingly available for a widerange of children, including thosewith various health conditions anddisabilities such as ASD. A parent orcaregiver’s decision about when toinitiate swim lessons must beindividualized on the basis ofa variety of factors, including comfortwith being in water, health status,emotional maturity, and physical andcognitive limitations. Although swimlessons provide 1 layer of protectionfrom drowning, swim lessons do not“drown proof” a child, and parentsmust continue to provide barriers toprevent unintended access when notin the water and closely supervisechildren when in and around water.

In contrast, infants younger than1 year are developmentally unable tolearn the complex movements, suchas breathing, necessary to swim. Theymay manifest reflexive swimmingmovement under the water butcannot effectively raise their heads tobreathe.29 There is no evidence tosuggest that infant swimmingprograms for those younger than1 year are beneficial.

Basic swim skills include ability toenter the water, surface, turn around,propel oneself for at least 25 yards,float on or tread water, and exit thewater.30 Importantly, performance of

these water-survival skills, usuallylearned in a pool, is affected by theaquatic environment (watertemperature, water depth, watermovement, clothing, and distance),and demonstration of skills in 1aquatic environment may not transferto another. There is tremendousvariability among swim lessons, andnot every program will be right foreach child. Parents and caregiversshould investigate options for swimlessons in their community beforeenrollment to make sure that theprogram meets their needs and theneeds of the child. High-quality swimlessons provide more experientialtraining, including swimming inclothes, in life jackets, falling in, andpracticing self-rescue. Achieving basicwater-competency swim skillsrequires multiple lessons, andacquisition of water competency isa protracted process that involveslearning in conjunction withdevelopmental maturation. There isa need for a broad and coordinatedresearch agenda to address not onlythe efficacy of swim lessons forchildren age 1 to 4 years but also themany components of watercompetency for the child and parentor caregiver.

DROWNING-PREVENTION STRATEGIES

The Haddon Matrix paradigm forinjury prevention is used to identifyinterventions aimed at changing theenvironment, the individual at risk,and/or the agent of injury (in thiscase, water).31 Experts generallyrecommend that multiple “layers ofprotection” be used to preventdrowning because it is unlikely thatany single strategy will preventdrowning deaths and injuries. TheHaddon Matrix (Table 2) revealsexamples of interventions before thedrowning event, during the drowningevent, and after the drowning eventat the levels of the individual,environment, and policy. Five majorinterventions are evidence based: 4-sided pool fencing, life jackets, swim

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lessons, supervision, and lifeguards(with descending levels of evidence).

Installation of 4-sided fencing (atleast 4 ft tall) with self-closing andself-latching gates that completelyisolates the pool from the house andyard is the most studied and effectivedrowning-prevention strategy for theyoung child, preventing more than50% of swimming-pool drownings ofyoung children.32,33 Life jackets arenow also well proven to preventdrowning fatalities. Some data revealthat swim lessons may lowerdrowning rates among children,27

including those 1 to 4 years of age.28

Lifeguards and CPR training alsoappear to be effective.2,4,34–36

However, data regarding the value ofother potential preventive strategies,such as pool covers and pool alarms,are lacking. Interventions to prevent

drowning are discussed in detail inthe accompanying technical report(available online soon).

Inadequate supervision is often citedas a contributing factor for childhooddrowning, especially for youngerchildren.11,37,38 Adequatesupervision, described as close,constant, and attentive supervision ofyoung children in or around anywater, is a primary and absolutelyessential preventive strategy.27 Forbeginning swimmers, adequatesupervision is “touch supervision,” inwhich the supervising adult is withinarm’s reach of the child so he or shecan pull the child out of the water ifthe child’s head becomes submergedunder water. Evaluated interventionsshown to increase the quality ofsupervision include swim lessons inwhich the need for continued

parental supervision is emphasized,39

and a study in Bangladesh revealedthat adult supervision, in addition tothe physical barrier of playpens,significantly reduced the risk ofdrowning in children ages 1 to5 years.27 Supervision should includebeing capable of recognizing andresponding appropriately to a child indistress. Supervision is critical forsafety in children with ASD and otherdisabilities. The National AutismAssociation’s Big Red Safety Box40

contains information for parents,schools, and first responders andsuggests a safety plan in public placeswhere there is a handoff ofsupervision so that children with ASDand other disabilities do notwander off.

Although supervision is an essentiallayer of protection when children are

TABLE 2 Haddon Matrix for Drowning-Prevention Strategies

Personal Equipment Physical Environment Social Environment

Before the event Provide close, constant, andattentive supervision ofchildren and poorswimmers

Install 4-sided fencing thatisolates the pool fromthe house and yard

Swim where lifeguards arepresent

Mandate 4-sided residentialpool fencing

Clear handoff supervisionresponsibilities

Install self-closing andlatching gates

Attend to warning signage Mandate life jacket wear

Develop water competency,including water-safetyknowledge, basic swimskills, and ability torecognize and respond toa swimmer in trouble

Wear life jackets Swim at designated swim sites Adopt the Model Aquatic HealthCode

Evaluate preexisting healthcondition

Install compliant pool drains Remove toys from pools whennot in use to reducetemptation for children toenter the pool

Increase availability oflifeguards

Know how to choose and fita life jacket

Install door locks Empty water buckets andwading pools

Increase access to affordableand culturally compatibleswim lessons

Avoid substance use Enclosures for open bodiesof water

— Close high-risk waters duringhigh-risk times

Know the water’s hazards,conditions

Promote life jacket–loanerprograms

— Develop designated open-waterswim sites

Swim at a designated swim site Role model life jacket use byadults

— Enforce boating under theinfluence laws

Learn CPR Make rescue devicesavailable at swim sites

— —

Take a boater education course Phone access to call for help — —

— Ensure functional watercraft — —

Event Water-survival skills Rescue device available — EMS systemAfter the event Early bystander CPR AED — Advanced medical care

Bystander response Rescue equipment — —

The Model Aquatic Health Code provides guidelines and standards for equipment, for staffing and training, and for monitoring swimming pools. Bold indicates the most evidence-basedinterventions. AED, automated external defibrillator.

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expected to be in or around the water,barriers must be in place to preventunintended access of children towater during nonswim times.Drowning is silent and only takesa minute. Those children with highestdrowning risk are 12 to 36 months ofage. Developmentally, they arecurious and lack the judgement orawareness of the dangers of water, sobarriers, such as 4-sided fencing anddoor locks, are critical in preventingaccess when the caregiver isdistracted by other children, mealpreparation, etc.

The Model Aquatic Health Code,41

developed by the Centers for DiseaseControl and Prevention (CDC), isbased on science and best practices tohelp guide policy makers and aquaticleaders on pool and spa safety. TheModel Aquatic Health Code providesguidelines and standards forequipment, for staffing and training,and for monitoring swimming pools.Similar attention and effort areneeded for open-water swim sites.

DROWNING CHAIN OF SURVIVAL

The drowning chain of survival(Fig 1) refers to a series of steps that,when enacted, attempt to reducemortality associated with drowning.The steps of the chain are as follows:(1) prevent drowning, (2) recognizedistress, (3) provide flotation, (4)remove from water, and (5) providecare as needed. The chain starts withprevention, the most important andeffective step to reducing morbidityand mortality from drowning.42

Rescue and resuscitation ofa drowning victim must occur withinminutes to save lives and reducemorbidity in nonfatal drownings andunderscores the critically time-sensitive role of the parent orsupervising adult.

IMPORTANCE OF BYSTANDER CPR

Immediate resuscitation at thesubmersion site, even before thearrival of emergency medical services

(EMS) personnel, is the most effectivemeans to improve outcomes in theevent of a drowning incident.2,3

Prompt initiation of bystander CPR,with a focus on airway and rescuebreathing before compressions43 andactivation of prehospital advancedcardiac life support for the pediatricsubmersion victim, have the greatestimpact on survival and prognosis.4,44

Current guidelines recommend thatdrowning victims who require anyform of resuscitation (including onlyrescue breaths) be transported to theemergency department for evaluationand monitoring, even if they appearalert with effective cardiopulmonaryfunction at the scene.43

PREVENTION OF DROWNINGRECOMMENDATIONS

Parents and Caregivers

1. Parents and caregivers shouldnever (even for a moment) leaveyoung children alone or in thecare of another child while in ornear bathtubs, pools, spas, orwading pools and when nearirrigation ditches, ponds, or otheropen standing water.

2. Parents and caregivers must beaware of drowning risksassociated with hazards inthe home.

• Infant bath seats can tip over,and children can slip out ofthem and drown in even a fewinches of water in the bathtub.Infants should always be withan adult when sitting in a bathseat in a bathtub.45

• Water should be emptied fromcontainers, such as pails andbuckets, immediately after use.

• To prevent drowning in toilets,young children should not beleft alone in the bathroom, andtoilet locks may be helpful.

• Parents and caregivers shouldprevent unsupervised access tothe bathroom, swimming pool,or open water.

3. Whenever infants and toddlers(or noncompetent swimmers)are in or around water,a supervising adult with swimskills should be within an arm’slength, providing constant touchsupervision. Even with olderchildren and better swimmers,the eyes and attention of thesupervising adult should still beconstantly focused on the child.This “water watcher” should notbe engaged in other distractingactivities that can compromisethis attention, including using thetelephone (eg, texting),socializing, tending chores, ordrinking alcohol, and there needsto be a clear handoff ofresponsibility from one waterwatcher to the next. Supervisionmust be close, constant, andattentive. In case of anemergency, the supervising adultmust be able to recognize a childin distress, safely performa rescue, initiate CPR, and call forhelp. Parents need to recognizethat lifeguards are only 1 layer ofprotection, and children in andnear the water require constantcaregiver supervision, even ifa lifeguard is present.

4. To prevent unintended access,families should install a 4-ft, 4-sided isolation fence thatseparates the pool from thehouse and the rest of the yardwith a self-closing, self-latchinggate. Detailed guidelines forsafety barriers for home poolsare available online from theCPSC.46 Families of children withASD or other disabilities who areat risk for wandering off shouldidentify local hazards and workwith the community on poolfencing and mitigation ofhazards.

5. Although data are lacking,families may considersupplemental pool alarms andweight-bearing pool covers asadditional layers of protection;

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however, neither alarms nor poolcovers are a substitute foradequate fencing and adultsupervision. Importantly, sometypes of pool covers, such as thinplastic solar covers, should notbe used as a means of protectionbecause they might increase riskof drowning.

6. Parents, caregivers, and poolowners should learn CPR andkeep a telephone and rescueequipment approved by the USCoast Guard (eg, life buoys, lifejackets, and a reach tool such asa shepherd’s crook) poolside.Older children and adolescentsshould learn CPR.

7. Children and parents shouldlearn to swim and learn water-safety skills. Because childrendevelop at different rates, not allchildren will be ready to learn toswim at exactly the same age.There is evidence that swimlessons may reduce the risk ofdrowning, including for those 1to 4 years of age. A parent’sdecision about starting swimlessons or water-survival skillstraining at an early age must beindividualized on the basis of thechild’s frequency of exposure towater, emotional maturity,physical and cognitivelimitations, and health concernsrelated to swimming pools.

Parents should be reminded thatswim lessons will not drownproof a child of any age. It iscritical that swim instructorsstress this message as well as theneed for constant supervisionaround water. Swim ability mustbe considered as only 1 part ofwater competence anda multilayered protection planthat involves effective poolbarriers; close, constant, andattentive supervision; life jacketuse; training in CPR and the useof an automated externaldefibrillator; and lifeguards.Children need to be taught neverto swim alone and never to swimwithout adult supervision.

8. Parents should monitor theirchild’s progress during swimlessons and continue theirlessons at least until basic watercompetence is achieved. Basicswim skills include ability toenter the water, surface, turnaround, propel oneself for at least25 yards, float on or tread water,and exit the water.

9. Any time a young child visitsa home or business where accessto water exists (eg, pool, hot tub,open water), parents and/orguardians should carefully assessthe premises to ensure that basicbarriers are in place, such assliding door locks and pool

fences with closed gates in goodworking order, and ensure thatsupervision will be consistentwith the precedingrecommendations.

10. All children and adolescentsshould be required to wear USCoast Guard–approved lifejackets whenever they are in oron watercraft, and all adultsshould wear life jackets whenboating to model safe behaviorand to facilitate their ability tohelp their child in case ofemergency. Small children andnonswimmers should wear lifejackets when they are near waterand when swimming. Parentsand caregivers should ensurethat any life jacket is approved bythe US Coast Guard becausemany do not meet safetyrequirements. Information aboutfitting and choosing US CoastGuard–approved life jackets isavailable at the US Coast GuardWeb site.47 Parents should notuse air-filled swimming aids(such as inflatable arm bands,neck rings, or “floaties”) in placeof life jackets. These aids candeflate and are not designed tokeep swimmers safe.

11. Jumping or diving into water canresult in devastating spinalinjury. Parents and childrenshould know the depth of the

FIGURE 1Drowning chain of survival. (Reprinted with permission from Szpilman D, Webber J, Quan L, et al. Creating a drowning chain of survival. Resuscitation.2014;85[9]:1151.)

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water and the location ofunderwater hazards beforejumping or diving or permittingchildren to jump or dive. The firstentry into any body of watershould be feet first.

12. When selecting an open body ofwater in which their children willswim, parents should select siteswith lifeguards and designatedareas for swimming. Even for thestrongest of swimmers, it isimportant to consider weather,tides, waves, and water currentsin selecting a safe location forrecreational swimming.Swimmers should know what todo in case of rip currents: swimwhere there is a lifeguard, and ifcaught in a rip current, remaincalm and either swim out of therip current parallel to the shore(do not try to swim against thecurrent) or tread water untilsafely out of the current and ableto return to shore or signal forhelp.48

13. Parents and children shouldrecognize drowning risks in coldseasons. Children should refrainfrom walking, skating, or ridingon weak or thawing ice on anybody of water.

Pediatricians

1. Pediatricians should know theleading causes of drowning intheir location so they canappropriately tailor theirprevention guidance to caregivers.Pediatricians can provide specifictargeted messages by age, sex,high risk of drowning, andgeographical location.

2. Children with special health careneeds should have tailoredanticipatory guidance related todrowning risks. Children withepilepsy, ASD, and cardiacarrhythmias are at particular risk.When swimming or taking a bath,children of any age with epilepsyshould be supervised closely by anadult at all times.15 Children with

poorly controlled seizures shoulddiscuss water safety with theirphysician before swim activities.

3. Counseling parents andadolescents about water safetyprovides an opportunity to stressthe problems related to alcoholand drug use during any activity.Specifically, the discussion shouldinclude a warning about theincreased drowning risk thatresults when alcohol or illicitdrugs are used when swimming orboating. Because male adolescentshave high risk of water-basedinjuries, they warrant extracounseling.

4. Pediatricians should help facilitatea conversation between caregiversand their children about levels ofwater competency to decrease thefrequency of children or parentsoverestimating swimming skillsand equipping older children withthe ability to make informeddecisions when not in thepresence of their parent orguardian.

5. Pediatricians should support theinclusion of CPR training in highschool health classes.

COMMUNITY INTERVENTIONS ANDADVOCACY OPPORTUNITIES

Pediatricians

1. Pediatricians should work withlegislators and serve as a voicefor children to pass policy thatdecreases the risk of drowning,including, but not limited to,policy on fencing, boating, lifejackets, safety of aquaticenvironments, boating under theinfluence, and EMS systems.Pediatricians should partner withpublic health and policy leaders toaddress the issue of childhooddrowning by implementingeffective evidence-basedinterventions.

2. Pediatricians should use the term“nonfatal drowning” (rather than

“near drowning”) when speakingto families and the media to avoidconfusion and misconceptionsassociated with the other termspreviously used. There has beenmuch misinformation circulated inrecent years regarding drydrowning and secondarydrowning.49 Pediatricians shouldeducate caregivers that dry andsecondary drowning are notmedically accurate terms.Pediatricians can addressparental concerns by providingreassurance that nonfatal or fataldrownings do not occur at a latertime in patients with no previoussymptoms.

3. Pediatricians should partner withcommunity groups to increaseaccess to life jackets through lifejacket–loaner programs atswimming and boating sites.

4. Pediatricians should work withcommunity partners to provideaccess to programs that developwater-competency swim skills forall children, especially those fromlow-income and diverse familiesand those with developmentaldisabilities. Pediatricians canidentify and support programs toincrease the access to high-quality,culturally sensitive, and affordableprograms.26

Pool Operators

1. Community pools should havecertified lifeguards with currentCPR certification.

2. Pool owners and operators shouldadopt the Model Aquatic HealthCode to ensure that best practicesare being used to keep the pooland spa environment safe.

3. Owners of private pools and spasand managers of public poolsshould be made aware ofentrapment and/or entanglementrisks and of the laws mandatingdrain covers and filter pumpequipment needed to preventthese injuries that primarilyinvolve children.50,51

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Policy Makers

1. Policy makers should passlegislation or building codes tomandate 4-sided isolation poolfencing for new and existingresidential pools at the local andstate level. Local governmentsshould inspect and strictlyenforce pool fencing requirementsbecause this has been shown tobe effective in reducingdrowning.52

2. Policy makers should work withrecreation and boating agencies tosupport legislation mandating thatlife jackets be worn by adolescentsand by caregivers of children whenboating.53 When adults modelappropriate behavior by wearinglife jackets, children andadolescents are more likely to doso as well.53

3. States and communities shouldpass legislation and adoptregulations to establish basicsafety requirements for naturalswimming areas and public andprivate recreational facilities (eg,mandating the presence ofcertified lifeguards in designatedswimming areas).54

4. States and communities shouldenforce laws that prohibit alcoholand other drug use by allwatercraft occupants, not justoperators.

5. State and local EMS personnel,medical examiners, healthdepartments, and child-death–review teams should useconsistent systematic reporting ofinformation on the circumstancesof drowning events. Periodicreview of these data is critical inthe development of drowning-prevention strategies appropriatefor the geographic area.

6. Local governmental agenciesshould adopt the Model AquaticHealth Code for swimming pools,with better inspection andenforcement of swimming-poolsafety standards.41

7. Because we lack a robust evidencebase, a coordinated researchagenda must be established toinform future policy, and federalfunding should be secured toadvance this research.

APPENDIX: RESOURCES FORPEDIATRICIANS AND FAMILIES

1. The American Academy ofPediatrics Web site (http://www.aap.org) contains educationalmaterials for parents from the TheInjury Prevention Program abouthome water hazards for youngchildren, life jackets and lifepreservers, pool safety, and watersafety for school-aged children. Italso has links to water-safetyinformation from the CPSC, theCDC, and Safe Kids Worldwide.

2. The Safe Kids Worldwide Website55 contains information aboutpools and hot tubs, drain coversand safety vacuum release systemsto prevent entrapment, and safetychecklists (in English and Spanish)about pools, spas, open-waterswimming and boating, and homewater safety. It also has links toa national research study aboutpool and spa safety. It has somenice materials for children,including boating-safety coloringpages. One can download a colorwater watcher badge fromthis site.

3. The CDC Web site (http://www.cdc.gov) contains a water-relatedinjuries factsheet, CDC researchand information on water safetyand water-related illnesses andinjuries, and a link to the Web-based Injury Statistics Query andReport System. The CDC ChildhoodInjury Report contains state-specific information aboutdrowning and other injuries.56

4. The CPSC Web site (https://www.poolsafely.gov/) has pool-safelymaterials for parents,grandparents, and caregivers,including supervision, fencing and

other barriers, drain covers, andCPR. It also includes informationabout the Virginia Graeme BakerPool and Spa Safety Act and a listof manufacturers of approveddrain covers and safety vacuumrelease systems. The publicationssection contains safety-barrierguidelines for home pools anda family education brochure aboutpreventing childhood drowning.Specific information on fencingcan be found online.46

5. The US Coast Guard Web site(http://www.uscgboating.org/)contains detailed information andtip sheets about life jackets, vesselsafety checks, approved onlineboating-safety courses, and beachsafety. It also has links to siteswith information about safety andboating regulations as well as linksto statistics, research, and surveysabout boating and boating crashesand injury. Specific information onthe right-fit life jacket can be foundonline.47

6. The American Heart AssociationWeb site57 contains informationon CPR courses for the communityand health professionals.

7. The National Autism AssociationWeb site40 contains manyresources for families of childrenwith ASD, including a FamilyWandering Emergency Plan,MedicAlert tools, wireless windowand door alarms, and many otherhelpful tools to keep children safe.

8. The Water Safety USA Web site(https://www.watersafetyusa.org/) contains information on watercompetency, water watchers, andwater safety.

LEAD AUTHORS

Sarah A. Denny, MD, FAAPLinda Quan, MD, FAAPCAPT Julie Gilchrist, MD, FAAPTracy McCallin, MD, FAAPRohit Shenoi, MD, FAAPShabana Yusuf, MD, MEd, FAAPBenjamin Hoffman, MD, FAAPJeffrey Weiss, MD, FAAP

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COUNCIL ON INJURY, VIOLENCE, ANDPOISON PREVENTION, 2018–2019

Benjamin Hoffman, MD, FAAP, ChairpersonPhyllis F. Agran, MD, MPH, FAAPSarah A. Denny, MD, FAAPMichael Hirsh, MD, FAAPBrian Johnston, MD, MPH, FAAPLois K. Lee, MD, MPH, FAAPKathy Monroe, MD, FAAPJudy Schaechter, MD, MBA, FAAPMilton Tenenbein, MD, FAAPMark R. Zonfrillo, MD, MSCE, FAAPKyran Quinlan, MD, MPH, FAAP, ImmediatePast Chairperson

LIAISONS

Lynne Janecek Haverkos, MD, MPH, FAAP –National Institute of Child Health and HumanDevelopment

Jonathan D. Midgett, PhD – Consumer ProductSafety CommissionBethany Miller, MSW, Med – Health Resourcesand Services AdministrationAlexander W. (Sandy) Sinclair – NationalHighway Traffic Safety AdministrationRichard Stanwick, MD, FAAP – CanadianPediatric Society

STAFF

Bonnie Kozial

ACKNOWLEDGMENT

We write this article in memory ofour friend and colleague, RuthBrenner, MD, FAAP, and inappreciation for her significantcontributions to the field of drowning

prevention and policy and for hercommitment to the AmericanAcademy of Pediatrics.

ABBREVIATIONS

ASD: autism spectrum disorderCDC: Centers for Disease Control

and PreventionCPR: cardiopulmonary

resuscitationCPSC: Consumer Product Safety

CommissionEMS: emergency medical services

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: Dr Quan has provided expert witness testimony in a drowning case in 2018; the other authors have indicated they have no

potential conflicts of interest to disclose.

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