POLICY STATEMENT Organizational Principles to Guide and Define the Child Health

Care System and/or Improve the Health of all Children

Prevention of Drowning
Sarah 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 ON
INJURY, VIOLENCE, AND POISON PREVENTION

Drowning is a leading cause of injury-related death in children. In 2017, abstract

drowning claimed the lives of almost 1000 US children younger than 20 years.
A number of strategies are available to prevent these tragedies. As educators
a
College of Medicine, The Ohio State University and Nationwide
and advocates, pediatricians can play an important role in the prevention of Children’s Hospital, Columbus, Ohio; bSchool of Medicine, University of
drowning. Washington and Seattle Children’s Hospital, Seattle, Washington; cUS
Public Health Service, Rockville, Maryland; dChildren’s Hospital of San
Antonio, San Antonio, Texas; eBaylor College of Medicine and fTexas
Children’s Hospital, Houston, Texas; gOregon Health and Science
University and Doernbecher Children’s Hospital, Portland, Oregon; and
h
College of Medicine, University of Arizona and Phoenix Children’s
BACKGROUND Hospital, Phoenix, Arizona
Drowning is the leading cause of injury death in US children 1 to 4 years of Dr Denny led the authorship group; Drs Quan, Gilchrist, McCallin, Yusuf,
age and the third leading cause of unintentional injury death among US and Shenoi contributed sections; Dr Hoffman provided significant early
children and adolescents 5 to 19 years of age.1 In 2017, drowning claimed review; Dr Weiss authored the previous policy statement that formed
the basis of this document; and all authors approved the final
the lives of almost 1000 US children. Fortunately, childhood unintentional manuscript as submitted.
drowning fatality rates have decreased steadily from 2.68 per 100 000 in This document is copyrighted and is property of the American
1985 to 1.11 per 100 000 in 2017. Rates of drowning death vary with age, Academy of Pediatrics and its Board of Directors. All authors have filed
conflict of interest statements with the American Academy of
sex, and race and/or ethnicity, with toddlers and male adolescents at highest Pediatrics. Any conflicts have been resolved through a process
risk. After 1 year of age, male children of all ages are at greater risk of approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
drowning than female children. Overall, African American children have the involvement in the development of the content of this publication.
highest drowning fatality rates, followed in order by American Indian and/or
Policy statements from the American Academy of Pediatrics benefit
Alaskan native, white, Asian American and/or Pacific Islander, and Hispanic from expertise and resources of liaisons and internal (AAP) and
children. For the period 2013–2017, the highest drowning death rates were external reviewers. However, policy statements from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
seen in white male children 0 to 4 years of age (3.44 per 100 000), American organizations or government agencies that they represent.
Indian and/or Alaskan native children (3.58), and African American male
The guidance in this statement does not indicate an exclusive course
adolescents 15 to 19 years of age (4.06 per 100 000).1 of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
Drowning is also a significant source of morbidity for children. In 2017,
All policy statements from the American Academy of Pediatrics
an estimated 8700 children younger than 20 years of age visited automatically expire 5 years after publication unless reaffirmed,
a hospital emergency department for a drowning event, and 25% of revised, or retired at or before that time.
those children were hospitalized or transferred for further care.1 Most DOI: https://doi.org/10.1542/peds.2019-0850
victims of nonfatal drowning recover fully with no neurologic deficits, but
Address correspondence to Sarah A. Denny, MD, FAAP. E-mail: sarah.
severe long-term neurologic deficits are seen with extended submersion [email protected]
times (.6 minutes), prolonged resuscitation efforts, and lack of early
bystander-initiated cardiopulmonary resuscitation (CPR).2–4 To cite: Denny SA, Quan L, Gilchrist J, et al. AAP COUNCIL
The American Academy of Pediatrics issues this revised policy statement ON INJURY, VIOLENCE, AND POISON PREVENTION. Prevention
because of new information and research regarding (1) populations at of Drowning. Pediatrics. 2019;143(5):e20190850

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PEDIATRICS Volume 143, number 5, May 2019:e20190850 FROM THE AMERICAN ACADEMY OF PEDIATRICS
increased risk, (2) racial and POPULATIONS WITH INCREASED contributing to 30% to 70% of
sociodemographic disparities in DROWNING RISK recreational water deaths among US
drowning rates, (3) water Certain populations, because of adolescents and adults.13
competency (water-safety knowledge behavior, skill, environment, or
and attitudes, basic swim skills, and underlying medical condition, are at
response to a swimmer in trouble),5,6
UNDERLYING MEDICAL CONDITIONS
increased risk of drowning.
(4) when children are in and around Epilepsy
water (the need for close, constant, Toddlers Drowning is the most common cause
attentive, and capable adult
For the period 2013–2017, the of death from unintentional injury for
supervision and life jacket use in
highest rate of drowning occurred in people with epilepsy,14 and children
children and adults), (5) when
the 0- to 4-year age group (2.19 per with epilepsy are at greater risk of
children are not expected to be
100 000 population), with children 12 drowning, both in bathtubs and in
around water (the importance of
to 36 months of age being at highest swimming pools.15 The relative risk
physical barriers to prevent
risk (3.31). Most infants drown in of fatal and nonfatal drowning in
drowning), and (6) the drowning
bathtubs and buckets, whereas the patients with epilepsy varies greatly
chain of survival and importance of
majority of preschool-aged children but is 7.5- to 10-fold higher than that
bystander CPR (Table 1).
drown in swimming pools.8 The in children without seizures15,16 and
primary problem for this young age varies with age, severity of illness,
CLASSIFICATION OF DROWNING degree of exposure to water, and level
group is lack of barriers to prevent
In 2002, the World Congress on unanticipated, unsupervised access to of supervision.15–17 Parents and
Drowning and the World Health water, including in swimming pools, caregivers of children with active
Organization revised the definition of hot tubs and spas, bathtubs, natural epilepsy should provide direct
drowning to “the process of bodies of water, and standing water supervision around water at all times,
experiencing respiratory impairment in homes (buckets, tubs, and toilets). including swimming pools and
from submersion/immersion in The Consumer Product Safety bathtubs. Whenever possible,
liquid.” Drowning outcomes are Commission (CPSC) found that 69% children with epilepsy should shower
classified as “death,” “no morbidity,” of children younger than 5 years of instead of bathe17 and swim only at
or “morbidity” (further divided into age were not expected to be at or in locations where there is a lifeguard.
“moderately disabled,” “severely the pool at the time of a drowning Children with poorly controlled
disabled,” “vegetative state/coma,” incident.9 epilepsy should have a discussion
and “brain death”). The drowning with their neurologist or pediatrician
process is a continuum that can be Adolescents before any swim activity.
interrupted by rescue at any point in
Adolescents (15–19 years of age)
that process, with varying sequelae Autism
have the second highest fatal
from no symptoms to death. Terms Children with autism spectrum
drowning rate. In this age group, just
such as wet, dry, secondary, active, disorder (ASD) are also at increased
less than three-quarters of all
near, passive, and silent drowning risk of drowning,18 especially those
drownings occur in natural water
should not be used. The 2002 revised younger than 15 years of age18 and
settings, and this age group makes up
definition and classification is more those with greater degrees of
half of childhood drownings in
consistent with other medical intellectual disability.19 Wandering is
natural water.10 In 2016, Safe Kids
conditions and injuries and should the most commonly reported
Worldwide reported that the natural
help in drowning surveillance and behavior leading to drowning,
water fatal drowning rate for
collection of more reliable and accounting for nearly 74% of fatal
adolescents 15 to 17 years old was
comprehensive epidemiological drowning incidents among children
more than 3 times higher than that
information.7 with autism.20
for children 5 to 9 years old and twice
TABLE 1 Top Tips for Pediatricians the rate for children younger than
5 years of age.11 The increased risk Cardiac Arrhythmias
Assess all children for drowning risk on the
basis of risk and age and prioritize for fatal drowning in adolescents can Exertion while swimming can trigger
evidence-based strategies: be attributed to multiple factors, arrhythmia among individuals with
- barriers; including overestimation of skills, long QT syndrome.21 Although the
- supervision; underestimation of dangerous condition is rare and such cases
- swim lessons; situations, engaging in high-risk and represent a small percentage of
- life jackets; and impulsive behaviors, and substance drownings, long QT syndrome, as well
- CPR.
use.12 Alcohol is a leading risk factor, as Brugada syndrome and

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2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
catecholaminergic polymorphic include water-safety awareness, basic these water-survival skills, usually
ventricular tachycardia, should be swim skills, and the ability to learned in a pool, is affected by the
considered as a possible cause for recognize and respond to a swimmer aquatic environment (water
unexplained submersion injuries in trouble. Swim lessons and swim temperature, water depth, water
among proficient swimmers in low- skills alone cannot prevent drowning. movement, clothing, and distance),
risk settings.22 Learning to swim needs to be seen as and demonstration of skills in 1
a component of water competency aquatic environment may not transfer
that also includes knowledge and to another. There is tremendous
SOCIODEMOGRAPHIC FACTORS
awareness of local hazards and/or variability among swim lessons, and
There continue to be significant racial risks and of one’s own limitations; not every program will be right for
and socioeconomic disparities in how to wear a life jacket (previously each child. Parents and caregivers
drowning rates among children. For referred to as “wearable personal should investigate options for swim
many, cultural beliefs and traditions flotation device”); and ability to lessons in their community before
may prevent children from recognize and respond to a swimmer enrollment to make sure that the
swimming.23,24 Furthermore, for in distress, call for help, and perform program meets their needs and the
some religious and ethnic groups, safe rescue and CPR.5 needs of the child. High-quality swim
single-sex aquatic settings are lessons provide more experiential
required,25 and clothing that protects Evidence reveals that many children training, including swimming in
modesty according to religious norms older than 1 year will benefit from clothes, in life jackets, falling in, and
may not be allowed in some pools. swim lessons.28 Swim lessons are practicing self-rescue. Achieving basic
Socioeconomically, the multiple swim increasingly available for a wide water-competency swim skills
lessons required to achieve basic range of children, including those requires multiple lessons, and
water competency can be costly or with various health conditions and acquisition of water competency is
difficult given limited access and disabilities such as ASD. A parent or a protracted process that involves
transportation. Moreover, decreased caregiver’s decision about when to learning in conjunction with
municipal funding for swimming initiate swim lessons must be developmental maturation. There is
pools, for swimming programs, and individualized on the basis of a need for a broad and coordinated
for lifeguards has limited access to a variety of factors, including comfort research agenda to address not only
swim lessons and safe water with being in water, health status, the efficacy of swim lessons for
recreational sites for many emotional maturity, and physical and children age 1 to 4 years but also the
communities. cognitive limitations. Although swim many components of water
lessons provide 1 layer of protection competency for the child and parent
These barriers may be surmounted
from drowning, swim lessons do not or caregiver.
through community-based programs
“drown proof” a child, and parents
targeting high-risk groups by
must continue to provide barriers to
providing free or low-cost swim
prevent unintended access when not DROWNING-PREVENTION STRATEGIES
lessons, developing special programs
in the water and closely supervise The Haddon Matrix paradigm for
to address cultural concerns as well
children when in and around water. injury prevention is used to identify
as developing swim lessons for youth
with developmental disabilities, In contrast, infants younger than interventions aimed at changing the
changing pool policies to meet the 1 year are developmentally unable to environment, the individual at risk,
needs of specific communities, using learn the complex movements, such and/or the agent of injury (in this
culturally and linguistically as breathing, necessary to swim. They case, water).31 Experts generally
appropriate instructors to deliver may manifest reflexive swimming recommend that multiple “layers of
swim lessons, and working with both movement under the water but protection” be used to prevent
health care and faith communities to cannot effectively raise their heads to drowning because it is unlikely that
refer patients and their families to breathe.29 There is no evidence to any single strategy will prevent
swim programs.25–27 suggest that infant swimming drowning deaths and injuries. The
programs for those younger than Haddon Matrix (Table 2) reveals
1 year are beneficial. examples of interventions before the
WATER COMPETENCY, SWIM LESSONS, drowning event, during the drowning
AND SWIM SKILLS Basic swim skills include ability to event, and after the drowning event
Water competency is the ability to enter the water, surface, turn around, at the levels of the individual,
anticipate, avoid, and survive propel oneself for at least 25 yards, environment, and policy. Five major
common drowning situations.6 The float on or tread water, and exit the interventions are evidence based: 4-
components of water competency water.30 Importantly, performance of sided pool fencing, life jackets, swim

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PEDIATRICS Volume 143, number 5, May 2019 3
lessons, supervision, and lifeguards drowning are discussed in detail in parental supervision is emphasized,39
(with descending levels of evidence). the accompanying technical report and a study in Bangladesh revealed
(available online soon). that adult supervision, in addition to
Installation of 4-sided fencing (at the physical barrier of playpens,
least 4 ft tall) with self-closing and Inadequate supervision is often cited significantly reduced the risk of
self-latching gates that completely as a contributing factor for childhood drowning in children ages 1 to
isolates the pool from the house and drowning, especially for younger 5 years.27 Supervision should include
yard is the most studied and effective children.11,37,38 Adequate being capable of recognizing and
drowning-prevention strategy for the supervision, described as close, responding appropriately to a child in
young child, preventing more than constant, and attentive supervision of distress. Supervision is critical for
50% of swimming-pool drownings of young children in or around any safety in children with ASD and other
young children.32,33 Life jackets are water, is a primary and absolutely disabilities. The National Autism
now also well proven to prevent essential preventive strategy.27 For Association’s Big Red Safety Box40
drowning fatalities. Some data reveal beginning swimmers, adequate contains information for parents,
that swim lessons may lower supervision is “touch supervision,” in schools, and first responders and
drowning rates among children,27 which the supervising adult is within suggests a safety plan in public places
including those 1 to 4 years of age.28 arm’s reach of the child so he or she where there is a handoff of
Lifeguards and CPR training also can pull the child out of the water if supervision so that children with ASD
appear to be effective.2,4,34–36 the child’s head becomes submerged and other disabilities do not
However, data regarding the value of under water. Evaluated interventions wander off.
other potential preventive strategies, shown to increase the quality of
such as pool covers and pool alarms, supervision include swim lessons in Although supervision is an essential
are lacking. Interventions to prevent which the need for continued layer 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, and Install 4-sided fencing that Swim where lifeguards are Mandate 4-sided residential
attentive supervision of isolates the pool from present pool fencing
children and poor the house and yard
swimmers
Clear handoff supervision Install self-closing and Attend to warning signage Mandate life jacket wear
responsibilities latching gates
Develop water competency, Wear life jackets Swim at designated swim sites Adopt the Model Aquatic Health
including water-safety Code
knowledge, basic swim
skills, and ability to
recognize and respond to
a swimmer in trouble
Evaluate preexisting health Install compliant pool drains Remove toys from pools when Increase availability of
condition not in use to reduce lifeguards
temptation for children to
enter the pool
Know how to choose and fit Install door locks Empty water buckets and Increase access to affordable
a life jacket wading pools and culturally compatible
swim lessons
Avoid substance use Enclosures for open bodies — Close high-risk waters during
of water high-risk times
Know the water’s hazards, Promote life jacket–loaner — Develop designated open-water
conditions programs swim sites
Swim at a designated swim site Role model life jacket use by — Enforce boating under the
adults influence laws
Learn CPR Make rescue devices — —
available 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 system
After 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-based
interventions. AED, automated external defibrillator.

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4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
expected to be in or around the water, (EMS) personnel, is the most effective 3. Whenever infants and toddlers
barriers must be in place to prevent means to improve outcomes in the (or noncompetent swimmers)
unintended access of children to event of a drowning incident.2,3 are in or around water,
water during nonswim times. Prompt initiation of bystander CPR, a supervising adult with swim
Drowning is silent and only takes with a focus on airway and rescue skills should be within an arm’s
a minute. Those children with highest breathing before compressions43 and length, providing constant touch
drowning risk are 12 to 36 months of activation of prehospital advanced supervision. Even with older
age. Developmentally, they are cardiac life support for the pediatric children and better swimmers,
curious and lack the judgement or submersion victim, have the greatest the eyes and attention of the
awareness of the dangers of water, so impact on survival and prognosis.4,44 supervising adult should still be
barriers, such as 4-sided fencing and Current guidelines recommend that constantly focused on the child.
door locks, are critical in preventing drowning victims who require any This “water watcher” should not
access when the caregiver is form of resuscitation (including only be engaged in other distracting
distracted by other children, meal rescue breaths) be transported to the activities that can compromise
preparation, etc. emergency department for evaluation this attention, including using the
and monitoring, even if they appear telephone (eg, texting),
The Model Aquatic Health Code,41
alert with effective cardiopulmonary socializing, tending chores, or
developed by the Centers for Disease
function at the scene.43 drinking alcohol, and there needs
Control and Prevention (CDC), is
based on science and best practices to to be a clear handoff of
help guide policy makers and aquatic responsibility from one water
PREVENTION OF DROWNING watcher to the next. Supervision
leaders on pool and spa safety. The RECOMMENDATIONS
Model Aquatic Health Code provides must be close, constant, and
guidelines and standards for Parents and Caregivers attentive. In case of an
equipment, for staffing and training, emergency, the supervising adult
1. Parents and caregivers should
and for monitoring swimming pools. must be able to recognize a child
never (even for a moment) leave
Similar attention and effort are in distress, safely perform
young children alone or in the
needed for open-water swim sites. a rescue, initiate CPR, and call for
care of another child while in or
near bathtubs, pools, spas, or help. Parents need to recognize
wading pools and when near that lifeguards are only 1 layer of
DROWNING CHAIN OF SURVIVAL protection, and children in and
irrigation ditches, ponds, or other
The drowning chain of survival near the water require constant
open standing water.
(Fig 1) refers to a series of steps that, caregiver supervision, even if
when enacted, attempt to reduce 2. Parents and caregivers must be
a lifeguard is present.
mortality associated with drowning. aware of drowning risks
associated with hazards in 4. To prevent unintended access,
The steps of the chain are as follows: families should install a 4-ft, 4-
(1) prevent drowning, (2) recognize the home.
sided isolation fence that
distress, (3) provide flotation, (4) • Infant bath seats can tip over, separates the pool from the
remove from water, and (5) provide and children can slip out of house and the rest of the yard
care as needed. The chain starts with them and drown in even a few with a self-closing, self-latching
prevention, the most important and inches of water in the bathtub. gate. Detailed guidelines for
effective step to reducing morbidity Infants should always be with safety barriers for home pools
and mortality from drowning.42 an adult when sitting in a bath are available online from the
Rescue and resuscitation of seat in a bathtub.45
CPSC.46 Families of children with
a drowning victim must occur within • Water should be emptied from ASD or other disabilities who are
minutes to save lives and reduce containers, such as pails and at risk for wandering off should
morbidity in nonfatal drownings and buckets, immediately after use. identify local hazards and work
underscores the critically time-
• To prevent drowning in toilets, with the community on pool
sensitive role of the parent or
young children should not be fencing and mitigation of
supervising adult.
left alone in the bathroom, and hazards.
toilet locks may be helpful. 5. Although data are lacking,
IMPORTANCE OF BYSTANDER CPR • Parents and caregivers should families may consider
Immediate resuscitation at the prevent unsupervised access to supplemental pool alarms and
submersion site, even before the the bathroom, swimming pool, weight-bearing pool covers as
arrival of emergency medical services or open water. additional layers of protection;

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PEDIATRICS Volume 143, number 5, May 2019 5
FIGURE 1
Drowning 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.)

however, neither alarms nor pool Parents should be reminded that fences with closed gates in good
covers are a substitute for swim lessons will not drown working order, and ensure that
adequate fencing and adult proof a child of any age. It is supervision will be consistent
supervision. Importantly, some critical that swim instructors with the preceding
types of pool covers, such as thin stress this message as well as the recommendations.
plastic solar covers, should not need for constant supervision 10. All children and adolescents
be used as a means of protection around water. Swim ability must should be required to wear US
because they might increase risk be considered as only 1 part of Coast Guard–approved life
of drowning. water competence and jackets whenever they are in or
6. Parents, caregivers, and pool a multilayered protection plan on watercraft, and all adults
owners should learn CPR and that involves effective pool should wear life jackets when
keep a telephone and rescue barriers; close, constant, and boating to model safe behavior
equipment approved by the US attentive supervision; life jacket and to facilitate their ability to
Coast Guard (eg, life buoys, life use; training in CPR and the use help their child in case of
jackets, and a reach tool such as of an automated external emergency. Small children and
a shepherd’s crook) poolside. defibrillator; and lifeguards. nonswimmers should wear life
Older children and adolescents Children need to be taught never jackets when they are near water
should learn CPR. to swim alone and never to swim and when swimming. Parents
without adult supervision. and caregivers should ensure
7. Children and parents should
learn to swim and learn water- 8. Parents should monitor their that any life jacket is approved by
safety skills. Because children child’s progress during swim the US Coast Guard because
develop at different rates, not all lessons and continue their many do not meet safety
children will be ready to learn to lessons at least until basic water requirements. Information about
swim at exactly the same age. competence is achieved. Basic fitting and choosing US Coast
There is evidence that swim swim skills include ability to Guard–approved life jackets is
lessons may reduce the risk of enter the water, surface, turn available at the US Coast Guard
drowning, including for those 1 around, propel oneself for at least Web site.47 Parents should not
to 4 years of age. A parent’s 25 yards, float on or tread water, use air-filled swimming aids
decision about starting swim and exit the water. (such as inflatable arm bands,
lessons or water-survival skills 9. Any time a young child visits neck rings, or “floaties”) in place
training at an early age must be a home or business where access of life jackets. These aids can
individualized on the basis of the to water exists (eg, pool, hot tub, deflate and are not designed to
child’s frequency of exposure to open water), parents and/or keep swimmers safe.
water, emotional maturity, guardians should carefully assess 11. Jumping or diving into water can
physical and cognitive the premises to ensure that basic result in devastating spinal
limitations, and health concerns barriers are in place, such as injury. Parents and children
related to swimming pools. sliding door locks and pool should know the depth of the

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6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
 water and the location of poorly controlled seizures should “near drowning”) when speaking
underwater hazards before discuss water safety with their to families and the media to avoid
jumping or diving or permitting physician before swim activities. confusion and misconceptions
children to jump or dive. The first 3. Counseling parents and associated with the other terms
entry into any body of water adolescents about water safety previously used. There has been
should be feet first. provides an opportunity to stress much misinformation circulated in
12. When selecting an open body of the problems related to alcohol recent years regarding dry
water in which their children will and drug use during any activity. drowning and secondary
swim, parents should select sites Specifically, the discussion should drowning.49 Pediatricians should
with lifeguards and designated include a warning about the educate caregivers that dry and
areas for swimming. Even for the increased drowning risk that secondary drowning are not
strongest of swimmers, it is results when alcohol or illicit medically accurate terms.
important to consider weather, drugs are used when swimming or Pediatricians can address
tides, waves, and water currents boating. Because male adolescents parental concerns by providing
in selecting a safe location for have high risk of water-based reassurance that nonfatal or fatal
recreational swimming. injuries, they warrant extra drownings do not occur at a later
Swimmers should know what to counseling. time in patients with no previous
do in case of rip currents: swim symptoms.
4. Pediatricians should help facilitate
where there is a lifeguard, and if a conversation between caregivers 3. Pediatricians should partner with
caught in a rip current, remain and their children about levels of community groups to increase
calm and either swim out of the water competency to decrease the access to life jackets through life
rip current parallel to the shore frequency of children or parents jacket–loaner programs at
(do not try to swim against the overestimating swimming skills swimming and boating sites.
current) or tread water until and equipping older children with 4. Pediatricians should work with
safely out of the current and able the ability to make informed community partners to provide
to return to shore or signal for decisions when not in the access to programs that develop
help.48 presence of their parent or water-competency swim skills for
13. Parents and children should guardian. all children, especially those from
recognize drowning risks in cold 5. Pediatricians should support the low-income and diverse families
seasons. Children should refrain inclusion of CPR training in high and those with developmental
from walking, skating, or riding school health classes. disabilities. Pediatricians can
on weak or thawing ice on any identify and support programs to
body of water. increase the access to high-quality,
COMMUNITY INTERVENTIONS AND culturally sensitive, and affordable
Pediatricians ADVOCACY OPPORTUNITIES programs.26
1. Pediatricians should know the
Pediatricians Pool Operators
leading causes of drowning in
their location so they can 1. Pediatricians should work with 1. Community pools should have
appropriately tailor their legislators and serve as a voice certified lifeguards with current
prevention guidance to caregivers. for children to pass policy that CPR certification.
Pediatricians can provide specific decreases the risk of drowning, 2. Pool owners and operators should
targeted messages by age, sex, including, but not limited to, adopt the Model Aquatic Health
high risk of drowning, and policy on fencing, boating, life Code to ensure that best practices
geographical location. jackets, safety of aquatic are being used to keep the pool
2. Children with special health care environments, boating under the and spa environment safe.
needs should have tailored influence, and EMS systems. 3. Owners of private pools and spas
anticipatory guidance related to Pediatricians should partner with and managers of public pools
drowning risks. Children with public health and policy leaders to should be made aware of
epilepsy, ASD, and cardiac address the issue of childhood entrapment and/or entanglement
arrhythmias are at particular risk. drowning by implementing risks and of the laws mandating
When swimming or taking a bath, effective evidence-based drain covers and filter pump
children of any age with epilepsy interventions. equipment needed to prevent
should be supervised closely by an 2. Pediatricians should use the term these injuries that primarily
adult at all times.15 Children with “nonfatal drowning” (rather than involve children.50,51

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PEDIATRICS Volume 143, number 5, May 2019 7
Policy Makers 7. Because we lack a robust evidence other barriers, drain covers, and
1. Policy makers should pass base, a coordinated research CPR. It also includes information
legislation or building codes to agenda must be established to about the Virginia Graeme Baker
mandate 4-sided isolation pool inform future policy, and federal Pool and Spa Safety Act and a list
fencing for new and existing funding should be secured to of manufacturers of approved
residential pools at the local and advance this research. drain covers and safety vacuum
state level. Local governments release systems. The publications
should inspect and strictly section contains safety-barrier
enforce pool fencing requirements
APPENDIX: RESOURCES FOR guidelines for home pools and
PEDIATRICIANS AND FAMILIES a family education brochure about
because this has been shown to
be effective in reducing 1. The American Academy of preventing childhood drowning.
drowning.52 Pediatrics Web site (http://www. Specific information on fencing
aap.org) contains educational can be found online.46
2. Policy makers should work with
materials for parents from the The 5. The US Coast Guard Web site
recreation and boating agencies to
Injury Prevention Program about (http://www.uscgboating.org/)
support legislation mandating that
home water hazards for young contains detailed information and
life jackets be worn by adolescents
children, life jackets and life tip sheets about life jackets, vessel
and by caregivers of children when
preservers, pool safety, and water safety checks, approved online
boating.53 When adults model
safety for school-aged children. It boating-safety courses, and beach
appropriate behavior by wearing
also has links to water-safety safety. It also has links to sites
life jackets, children and
information from the CPSC, the with information about safety and
adolescents are more likely to do
CDC, and Safe Kids Worldwide. boating regulations as well as links
so as well.53
2. The Safe Kids Worldwide Web to statistics, research, and surveys
3. States and communities should
site55 contains information about about boating and boating crashes
pass legislation and adopt
pools and hot tubs, drain covers and injury. Specific information on
regulations to establish basic
and safety vacuum release systems the right-fit life jacket can be found
safety requirements for natural
to prevent entrapment, and safety online.47
swimming areas and public and
checklists (in English and Spanish) 6. The American Heart Association
private recreational facilities (eg,
about pools, spas, open-water Web site57 contains information
mandating the presence of
swimming and boating, and home on CPR courses for the community
certified lifeguards in designated
water safety. It also has links to and health professionals.
swimming areas).54
a national research study about
4. States and communities should 7. The National Autism Association
pool and spa safety. It has some
enforce laws that prohibit alcohol Web site40 contains many
nice materials for children,
and other drug use by all resources for families of children
including boating-safety coloring
watercraft occupants, not just with ASD, including a Family
pages. One can download a color
operators. Wandering Emergency Plan,
water watcher badge from
this site. MedicAlert tools, wireless window
5. State and local EMS personnel,
and door alarms, and many other
medical examiners, health 3. The CDC Web site (http://www. helpful tools to keep children safe.
departments, and child- cdc.gov) contains a water-related
death–review teams should use injuries factsheet, CDC research 8. The Water Safety USA Web site
consistent systematic reporting of and information on water safety (https://www.watersafetyusa.org/
information on the circumstances and water-related illnesses and ) contains information on water
of drowning events. Periodic injuries, and a link to the Web- competency, water watchers, and
review of these data is critical in based Injury Statistics Query and water safety.
the development of drowning- Report System. The CDC Childhood
prevention strategies appropriate Injury Report contains state- LEAD AUTHORS
for the geographic area. specific information about
Sarah A. Denny, MD, FAAP
6. Local governmental agencies drowning and other injuries.56 Linda Quan, MD, FAAP
should adopt the Model Aquatic 4. The CPSC Web site (https://www. CAPT Julie Gilchrist, MD, FAAP
Health Code for swimming pools, Tracy McCallin, MD, FAAP
poolsafely.gov/) has pool-safely
Rohit Shenoi, MD, FAAP
with better inspection and materials for parents, Shabana Yusuf, MD, MEd, FAAP
enforcement of swimming-pool grandparents, and caregivers, Benjamin Hoffman, MD, FAAP
safety standards.41 including supervision, fencing and Jeffrey Weiss, MD, FAAP

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8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
COUNCIL ON INJURY, VIOLENCE, AND Jonathan D. Midgett, PhD – Consumer Product prevention and policy and for her
POISON PREVENTION, 2018–2019 Safety Commission commitment to the American
Bethany Miller, MSW, Med – Health Resources
Benjamin Hoffman, MD, FAAP, Chairperson Academy of Pediatrics.
and Services Administration
Phyllis F. Agran, MD, MPH, FAAP
Alexander W. (Sandy) Sinclair – National
Sarah A. Denny, MD, FAAP
Highway Traffic Safety Administration
Michael Hirsh, MD, FAAP
Richard Stanwick, MD, FAAP – Canadian
Brian Johnston, MD, MPH, FAAP
Pediatric Society
Lois K. Lee, MD, MPH, FAAP ABBREVIATIONS
Kathy Monroe, MD, FAAP
STAFF ASD: autism spectrum disorder
Judy Schaechter, MD, MBA, FAAP
Milton Tenenbein, MD, FAAP Bonnie Kozial CDC: Centers for Disease Control
Mark R. Zonfrillo, MD, MSCE, FAAP and Prevention
Kyran Quinlan, MD, MPH, FAAP, Immediate ACKNOWLEDGMENT CPR: cardiopulmonary
Past Chairperson
We write this article in memory of resuscitation
LIAISONS our friend and colleague, Ruth CPSC: Consumer Product Safety
Lynne Janecek Haverkos, MD, MPH, FAAP – Brenner, MD, FAAP, and in Commission
National Institute of Child Health and Human appreciation for her significant EMS: emergency medical services
Development contributions to the field of drowning

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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PEDIATRICS Volume 143, number 5, May 2019 11
 Prevention of Drowning
Sarah A. Denny, Linda Quan, Julie Gilchrist, Tracy McCallin, Rohit Shenoi, Shabana
Yusuf, Benjamin Hoffman, Jeffrey Weiss and COUNCIL ON INJURY, VIOLENCE,
AND POISON PREVENTION
Pediatrics originally published online March 15, 2019; originally published online
March 15, 2019;

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 Prevention of Drowning
Sarah A. Denny, Linda Quan, Julie Gilchrist, Tracy McCallin, Rohit Shenoi, Shabana
Yusuf, Benjamin Hoffman, Jeffrey Weiss and COUNCIL ON INJURY, VIOLENCE,
AND POISON PREVENTION
Pediatrics originally published online March 15, 2019; originally published online
March 15, 2019;

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