Keeping Kids Safe in and Around the Water: New AAP Guidelines Texas Medicine July 2019


Working in the pediatric emergency department (ED) is not always an easy task. It can be physically and psychologically stressful but also incredibly rewarding at times. No matter how long we have worked in this setting, it never gets easier to treat victims of drowning. 

Every year we treat these patients, those who have been on the front lines like we have will understand that one child who has drowned is one too many. As providers and advocates for children, it is not enough to treat a child after a drowning incident – we must work to prevent these tragedies from happening in the first place. Our independent experiences at Texas Children’s Hospital in Houston and the Children’s Hospital of San Antonio have shaped each of our careers with a passion for drowning prevention.

Drowning is the leading cause of death in children 1-4 years of age, and is the second leading cause of death in children under 14. The highest-risk ages for drowning are toddlers followed by adolescents. From 2013–2017, U.S. Centers for Disease Control and Prevention (CDC) statistics showed that most fatal drownings occurred in the 0-4 years age group (2.19 per 100,000 population), with children 12 to 36 months of age being at highest risk (3.31 per 100,000).

The Consumer Product Safety Commission has found that 69% of children younger than 5 were not expected to be at or in the pool at the time of a drowning incident. This was highlighted by two fatal drowning incidents last summer when Olympic skier Bode Miller’s 19-month-old daughter Emmy and Tennessee mother Nicole Hughes’ 3-year-old son Levi both slipped out of a residence unnoticed and tragically drowned in the backyard pool. Although supervision is an essential layer of protection when children are expected to be in or around the water, barriers such as four-sided pool isolation fencing (at least 4 feet tall) with self-closing and self-latching gates that completely isolate the pool from the house, must be in place to prevent children’s unintended access to water during non-swim times. Developmentally, toddlers and preschoolers are curious and lack the judgement and awareness of the dangers of water. By the time a caregiver realizes the child is gone, it is often too late.

In the March 2019 issue of Pediatrics, the American Academy of Pediatrics (AAP) published a revised policy statement on “Prevention of Drowning,” which we co-authored. This statement revised the 2010 version based on new evidence in the areas of: populations at increased risk of drowning; racial and sociodemographic disparities in drowning rates; water competency and water safety skills as a means to prevent drowning; the need for adult supervision when children are in and around the water; the importance of physical barriers to prevent drowning; life jacket use in children and adults; the drowning chain of survival; and the importance of bystander CPR.

AAP recommends assessing all children for drowning based on risk factors, and prioritizing the evidence-based strategies including barriers to water (especially pool fencing), supervision of children in and around water, swim lessons to obtain water competency skills, wearing life jackets, and CPR training. No single strategy will “drown-proof” a child, and there must be a multi-layered protection plan in place against drowning. For infants, always supervise when bathing, and do not leave them in the care of an older child. Children can drown in less than 1 minute in 2 inches of water or less: the time it takes for a caregiver to answer the door, check on dinner, or get a towel. In May 2019, an 11-month-old girl from Phoenix drowned in the toilet of her family home, highlighting that these tragedies can occur with even a small amount of water. Adults should provide “touch supervision” within arm’s reach of children in or near the water by designating a water watcher who will remain free from distraction. Supervision must be close, constant, and attentive.

AAP also recommends swim lessons beginning at 1 year of age, including focus on water competency skills that may decrease the risk of drowning in conjunction with other strategies. The decision of when to initiate swim lessons must be individualized based on the child’s comfort with being in water, overall health status, developmental stage, emotional maturity, and physical and cognitive limitations of the child. The AAP policy statement advises that infants younger than 1 year are developmentally unable to learn the complex movements, such as breathing, necessary to swim. Though infants may manifest reflexive swimming movement under the water, they cannot effectively lift their heads to breathe, and hence swimming programs for these children are not beneficial.

Additional strategies to prevent drowning are using U.S. Coast Guard-approved life jackets when boating and for non-swimmers in or near water, and swimming at sites with lifeguards, especially for open water recreation. AAP also recommends CPR training, and highlights primary and secondary prevention of drowning through the drowning chain of survival – a series of steps to reduce mortality, namely: prevent drowning, recognize distress, provide flotation, rescue from water, and provide CPR to improve outcomes.

AAP also advises physicians work with legislators on passing policy that will decrease the risk of drowning. We are uniquely poised for such roles as trusted advocates for children. Such policies include pool fencing and barrier requirements for new and existing residential pools, mandating use of life jackets, providing safe aquatic environments, boating regulations, coordination of EMS systems, and partnering with community organizations to encourage CPR classes and improve access to swimming lessons – especially for high-risk populations.

Finally, physicians should remove myths about “dry drowning” and reassure caregivers that nonfatal or fatal drownings do not occur at a later time in patients with no prior symptoms. Complications from a submersion happen within a few hours of the event and do not occur days after a suspected drowning incident.

Tracy McCallin, MD, is assistant professor of pediatrics at Children’s Hospital of San Antonio. Shabana Yusuf, MD, is associate professor of pediatrics at Texas Children's Hospital in Houston. Both facilities are affiliated with Baylor College of Medicine. 



 Tex Med. 2019;115(7):6-7 
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Last Updated On

August 02, 2019

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