It’s now officially summertime, but people have been hitting the pools and beaches for weeks in many parts of the nation. In fact it has been well into the 90’s for over two month here in Baton Rouge, which is what I blame for the early exit of LSU from the College World Series. Our boys just weren’t used to that cold and dry northern weather.

Not surprisingly, the media has already been busy reporting on some of the many tragic drowning incidents that have occurred thus far, and Facebook profiles have been full of commentary from worried parents. And, as usual, there are businesses offering infant and toddler swimming lessons costing hundreds and even thousands of dollars per course, some of which come with claims of decreasing the risk of drowning in the young participants.

At what age can a child begin swimming lessons? According to Jan Emler of Emler Swim School, teaching a child to swim can start “As soon as the umbilical cord falls off.” Emler, like more reputable proponents of infant and toddler swimming programs, doesn’t actually put newborns into swimming pools for lessons (I’ll leave water birthing enthusiasts out of this discussion). For the most part these programs only cover bath time activities to help younger babies grow comfortable being in the water. Truly teaching infants and toddlers behaviors aimed at reducing the likelihood of drowning in the event of falling into a body of water doesn’t usually start until 6 months of age. There are exceptions.

But when should these lessons start, are they safe and do they work? Or do they actually put children at risk of injury and the parent at risk of having a false sense of security? Until their updated 2010 policy statement on the prevention of drowning, the American Academy of Pediatrics came down firmly against initiating swimming lessons in children less than 4 years of age for a number of very good reasons. Why did they soften their stance and does their change of opinion support the claims that are being made by infant and toddler swimming programs?  First some background information.

An Overview of Drowning

What is drowning?

The most widely accepted definition of drowning, determined during a 2002 international Utstein-style consensus conference in Amsterdam, is “the process of experiencing respiratory impairment from submersion/immersion in liquid.” This definition, as well as recommendations by the World Congress on Drowning and the WHO to avoid confusing terminology such as “near-drowning”, “wet”, “dry”, “silent”, or “secondary drowning”, has helped to make discussion and collection of data more consistent and reliable. They recommend categorizing drowning outcomes as death, no injury, or with injury (moderately disabled, severely disabled, vegetative state/coma and brain death). Determination of disability is primarily based on cognitive impairment but does take into account involvement of other organ systems. In 2010, the American Heart Association endorsed this approach as well.

How does drowning affect the body?

If you happen to have a phobia about drowning, you may want to skip this section as it will make clear why the process is so terrifying. All drowning incidents involve a liquid, usually water, invading at least the opening into the airway and leading to an inability to breathe air. Injuries are usually preceded by the onset of panic and loss of normal rhythmic breathing patterns. We hold our breaths as long as possible but eventually develop air hunger and are overcome by involuntary reflex attempts at breathing.

As the liquid enters the opening to the airway in the mouth and throat, the musculature reacts quickly to keep water out of the lungs by an intense spasm despite respiratory effort increasing dramatically. Often large amounts of liquid are swallowed. Oxygen levels in the blood continue to drop and carbon dioxide levels rise, leading to increasing acidity of the blood. (And we all know that people with acidic blood are at high risk for cancer, poor immune function and the dreaded Low T.) Eventually the muscle spasm will relax and water will be actively taken into the lungs in varying amounts.

During this process, no gas exchange is taking place in the lungs. This means that decreasing amounts of oxygen will be delivered to vital organs like the brain and heart. Water in the lungs adds insult to injury by causing increased blood pressure in the pulmonary blood vessels and abnormal shunting of blood. The worsening acidosis and hypoxia (lack of oxygen) can cause fatal heart arrhythmias, renal failure, and clotting abnormalities, but cerebral hypoxia is the primary means of disability and death.

How does drowning impact children?

By far the most common causes of death in young children are unintentional injuries. And of these fatal injuries, drowning is the most common culprit in children aged 1 to 4 years. It is the second-most common cause of injury related death overall through 18 years of life, killing about a thousand kids each year in the United States.

But it isn’t just fatal outcomes that make drowning injuries such a scourge in pediatrics. For every fatality there are many more nonfatal drowning injuries that are seen in emergency departments each year, of which many require hospitalization and about 5-10% lead to long-term disabilities caused by damage to the central nervous system. Caring for severely disabled children is often a significant emotional strain on parents, the result of which can be devastating for the family unit. Least of the many well-recognized negative aspects of pediatric drowning in my opinion, but important nonetheless, is the monetary cost. The lifetime expense of caring for pediatric drowning victims runs up a bill of roughly 3 billion dollars each year.

Which kids drown?

Drowning related injury and death occurs across the pediatric spectrum but it is an entity that does discriminate to a certain degree. Young children, for instance, are considerably more likely to die compared to kids over the age of 4 years. Another way in which drowning discriminates is based on ethnicity. Although white children of all ages drown more often than any other ethnicity in the United States when looking at total numbers, black and Hispanic children have a much higher rate of drowning (1.95 versus 1.29 deaths per 100,000). In fact, the group at highest risk for drowning are black teenagers (over 4 deaths per 100,000) with white toddlers a not-too-close runner up.

There are a variety of proposed explanations regarding why minorities, in particular black children, are at such increased risk of drowning. Many black families place less emphasis on swimming as a desirable life skill, often because of a paradoxical parental fear of their child drowning. Other cultural and socioeconomic factors such as lack of access to or awareness of affordable lessons are also at play. Parents of black children are also more likely to be unable to swim themselves.

A tragic 2010 drowning incident that occurred in Shreveport, LA illustrates these concerns perfectly. 6 black teenagers drowned in the Red River when they accidentally went from waist deep water into a deeper area with a stronger current. Their parents watched helplessly. Nobody present at the scene could swim.

Where and when do children drown?

Geographically, children that live in states that experience longer and more intense summers are at higher risk. The reason for this is obvious, or at least should be. More obvious at least than the reason why ice cream consumption correlates with drowning but isn’t causally related, even if consumed less than an hour before heading back into the water. Longer and more frequent access to water is the key, and kids eat more ice cream in the summer. If you really are worried about your child drowning, move to New England. That is not the reason I’m moving there, however. I just really like lobsters and drinking out of bubblers instead of water fountains.

Younger children are much more likely to drown in bath tubs and swimming pools but have been known to drown in almost any larger containers of water including toilets, buckets, fish tanks and fountains. Even deep puddles can be dangerous. Younger children, particularly toddlers that have gained mobility through cruising/walking, have large heads and little bodies. They also have poor balance, coordination and strength. This is why you will never see a 15-month-old on an Olympic gymnastics team. They are also curious. This is a recipe for disaster if poor supervision is added to the volatile mix, and it very often is.

Older kids, mostly boys once into the 5 years of age and older group, increasingly tend to drown in open water as they age. Teenage victims are most likely to both drown in a lake, river, or ocean and to be drunk while doing so. When looking at the impact of ethnicity on drowning location, white children overall tend to drown more in backyard pools while black children are more likely to drown in public or hotel pools.

Why do children drown?

The single most important factor in pediatric drowning is the level of supervision. There are other potentially important issues like swimming ability (we’ll get to that shortly), intoxication, use of personal flotation devices (not water wings!) and medical conditions like seizure disorders, but even a seizing teenager who can’t swim and just polished off a liter of MD 20/20 would be very unlikely to drown if a sober adult is there watching closely. Although he would probably just tell you how embarrassing you are. I can’t wait for my kids to be teenagers. But despite most people being aware of the importance of proper supervision, there are frequently lapses that occur. Many drowning injuries, both fatal and nonfatal, occur when a parent or caregiver leaves the scene for only a brief period and sometimes even when they are within a few feet of the child but aren’t paying close attention. We recommend never being more than an arms length away when watching young children.

Swimming Ability and the Role of Swimming Lessons in Pediatric Drowning

Before delving into the nuances of this topic, let me be completely clear about one thing: there is absolutely no such thing as “drown-proof” young child, or any age child for that matter, regardless of their ability to swim or initiate any learned safety maneuvers. The Titanic could sink and, if they have access to a large enough body of liquid, any child can drown. The only thing that comes close to perfect prevention is direct and unwavering observation by a competent adult.

So does swimming instruction decrease the risk of drowning? This question isn’t exactly on par with whether or not parachute use prevents “death and major trauma related to gravitational challenge.” Common sense would seem to tell us that of course there must be a decrease in the risk of drowning as the ability to swim increases, and for what it is worth I believe it myself. But common sense, as we all know, often steers us in the wrong direction. Intuition on the other hand…

In older swimmers, the relationship is the most plausible but remains unproven because of a dearth of good evidence. Better swimmers likely spend more time in and around water and may take risks a less proficient swimmer wouldn’t, so it isn’t entirely implausible that there may actually be an increased risk of an incident. Also, as I attempted to make clear earlier, swimming proficiency certainly doesn’t remove the risk of drowning entirely. In one study, 16% of victims of drowning fatalities were reported to be average or strong swimmers. Remember, a majority of adolescents who drown are in open water and many are intoxicated.

In children ages 1 to 4 years the benefit of swimming ability and instruction, regardless of whether or not it specifically includes emergency maneuvers like rolling onto the back and floating/kicking for the pool edge, is less clear. Pediatricians have had a number of very plausible concerns and until recently there was a complete lack of any good data to work with. Also, there was data to support the fear that parents of young children enrolled in swimming programs might develop a false sense of security and increase the likelihood of poor supervision. Or that those children who have taken part in such a program may be less fearful of water and more likely to attempt to swim while not being observed.

As I stated earlier, for years the AAP came down firmly against swimming instruction under age 4 years, citing a lack of neurological maturity, but relaxed their position in 2010 based on a few new studies that showed a possible benefit. These studies were small and I believe should be considered preliminary. They probably should be interpreted as showing that there doesn’t appear to be any increased risk rather than conclusively showing that there is great benefit. And they don’t address which type of instruction might work best or whether the apparent small decrease in drowning risk is because of improved supervision, as many programs teach general water safety, rather than any new skill the child might have learned.

The current AAP statement includes language to the effect that the evidence, as weak as it is, does not support prohibition nor does it support a blanket recommendation in favor of swimming lessons in this age group. It depends on the child’s readiness and that must be determined by the caregiver and physician. The AAP still strongly discourages programs dedicated to infants less than 1 year of age because there is no evidence whatsoever of decreased risk of drowning.

The American Red Cross Advisory Council on First Aid, Aquatics, Safety and Preparedness agrees with the AAP but pushes the age up to 2 years. They specifically disagree with claims that instruction in back floating prevents drowning in very young children. This issue has required addressing by pediatricians and water safety experts because there are a large number of programs specifically targeting infants down to 6 months. Check out the first video on this site and see if it nauseates you as much as it did me.

Again, there is no evidence that this actually saves lives. What dramatic anecdotes like this rely on is a normal reflex seen in aquatic mammals (and penguins), including humans to a lesser degree, known as the diving reflex. When the face of an infant is exposed to cold water, the heart slows down and blood is shifted away from the peripheral muscles to conserve oxygen for the brain and heart, and they typically hold their breath. The reflex is much stronger in the young, and allows for prolonged submersion under water, something useful for whales but less so for human infants.

This can’t be taught, despite what some programs claim. Physicians, however, can sometimes take advantage of this reflex to treat a condition called supraventricular tachycardia but it does have risk. A bag of ice water to the face might correct a heart rate of 250 secondary to SVT but in children with long QT syndrome, a cardiac rhythm problem that predisposes to sudden death, the diving reflex can trigger a fatal arrhythmia. Thankfully this is a very rare occurrence.

Another aspect of exposing young infants to submersion is spasm of the respiratory muscles when the oral cavity and upper airway is hit with cold water. This non-painful reflex does typically prevent aspiration of water into the lungs for brief periods but it does not prevent the swallowing of large amounts of water, which is common. For this reason, diluting the level of sodium in the blood is a potentially deadly outcome in infants submerged in water several times in a short period of time. Some programs are aware of this risk and claim to limit the number of submersions per session in infants.

The cold water required for the diving reflex to kick in also predisposes young infants to hypothermia. Additionally, exposure to pools is a risk for gut and respiratory infections as well as respiratory illness caused by the chemicals used to treat the water. These risks are not extreme, but taking into account the complete lack of any evidence of benefit, I believe that the AAP and other safety organizations are right to frown upon these programs and focus on educating adults on proper supervision and water/boating safety.

What can you do to prevent pediatric drowning?

There are steps to take even if you don’t personally have children. Most importantly, never leave a child under your care alone while they are in or around enough water to drown in, even for a few seconds. If you happen upon one while looking for sea glass, be a good citizen. Avoid distractions and don’t rely on other children to alert you in case of trouble.

Putting an appropriate fence around your home pool is a proven means of decreasing the risk of pediatric drowning. It must provide a complete barrier separating the pool from the house and yard. It should have a self-latching gate and be difficult to climb or squeeze through but not obstruct the view of the pool. Pool covers on the other hand have not been proven to be an adequate substitution for proper fencing and some are dangerous because a child can become entangled. The same goes for pool alarms.

Avoid, if possible, allowing younger children to swim in areas where a lifeguard is not present if you can’t be a good observer and learn CPR. Learn to swim and, yes, make sure your kids know how to swim. If you want to start them after age 1, that is an individual decision but discuss it with their doctor. Definitely start lessons once they are 4 years of age. All young children, and all children on a boat, should wear a lifejacket-type personal flotation device. Make sure that pool drains have appropriate covers to avoid a child becoming entrapped or entangled under the water. Talk to your older kids about pool safety, especially avoiding alcohol while swimming or boating, and don’t drink and supervise yourself. Oh, and always wear sunscreen.

For a more complete breakdown of water safety, check out this handout from the AAP.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.