Pediatric drowning fatality rates declined from 1999 to 2019 but have since started to rise, according to an updated policy statement published by the American Academy of Pediatrics (AAP). Racial and ethnic disparities in deadly pediatric drowning rates have widened and urban/rural disparities persist. Drowning is the leading cause of death in the US for children aged 1-4 years.

Medical conditions may sharply increase odds of drowning, the authors wrote, led by Rohit P. Shenoi, MD, with the Department of Pediatrics at Baylor College of Medicine in Houston, on behalf of AAP’s Council on Injury, Violence, and Poison Prevention. For example, epilepsy is a comorbidity in 4.1% of drowning fatalities among 0- to 14-year-olds compared with 0.7%-1.7% among the general population.

Drowning risk in children and adolescents with autism spectrum disorder (ASD) is three times higher than in those without ASD and the risk in children with ASD is highest from ages 0 to 4 years. “Fatal drowning often occurs when a child with ASD wanders into a body of water,” stated the authors, writing in the paper published on June 15 in Pediatrics. 

Guidance for Pediatricians

When counseling families, the AAP statement advises, pediatricians should:

• Identify children at higher drowning risk because of age, comorbidities (such as epilepsy, autism), exposure (including access to a private pool), or the family’s lack of aquatic experience.
• Warn families about high-risk settings, such as unanticipated access to water; parties near water; and lack of a supervisor or lifeguard.
• Promote cardiopulmonary resuscitation (CPR) and safe rescue training for adolescents, parents, and grandparents.
• Recommend aquatic experiences for infants with a parent and swimming lessons for children after their first birthday. Encourage water competency for the entire family.
• If family has a pool, emphasize the need for a four-sided fence with a self-closing, self-latching gate.
• Encourage life jacket use.
• Encourage and support families of children with disabilities to seek out swimming or water recreation programs and access to facilities.

A full list of the recommendations is available with the statement.

Racial Disparities Persist

The policy statement noted racial disparities persist in drowning rates. For swimming pools, fatal drowning rates for White toddlers are higher than for non-White toddlers. However, after age 5 years, Black children were more than 5.5 times likely to die from drowning in swimming pools than White children of similar age.

Pediatrician Gary Kirkilas, DO, at Phoenix Children’s Hospital in Phoenix, who was not part of the statement work group, told Medscape Medical News that a strength of this AAP statement is that it emphasizes a layered approach and that more than one precaution is needed to keep children safe in water. He said he talks with children and families about drowning prevention at the yearly well-visit from 0 to 6 years.

One of the most important things pediatricians can communicate in drowning prevention is that there must be a qualified “pool boss” watching children, Kirkilas said, adding that that person must be an adult, able to swim, no more than an arm’s length away from the water, and ideally, trained in CPR.

Another point to stress is the devastation a momentary lapse can cause, he said. In some tragic cases, he said, the “pool boss” reported going inside to grab their phone. “I say to my patients’ parents, ‘If you walk away for that 4 or 5 minutes, imagine a child under the water holding their breath for 4-5 minutes. Most people can hold their breath for about 30-45 seconds.’”

He also said he tells families it’s a misconception that there will be yelling and flailing if someone is drowning. “A lot of times it happens silently,” he said. “Someone grabs a mouthful of water, gags, and goes under.”

Authors and Kirkilas reported having no relevant financial relationships.

Marcia Frellick is an independent, Chicago-based healthcare journalist and a regular contributor to Medscape.