In one of my earliest posts for SBM, I wrote about a leading cause of death and severe neurologic injury in the pediatric population: drowning. In particular, I discussed the promotion of infant (< 12 months of age) swimming programs despite a complete lack of evidence in support of their effectiveness in preventing drowning. I also discussed the latest AAP policy statement on drowning prevention.
That was eight years ago. In the interim, people have continued to drown at terrifying rates. In the United States, there are 11 fatal drownings every day and twice as many nonfatal drownings, meaning that thousands of people die or suffer long-term disability every year. When it comes to kids, drowning kills more toddlers (1-4 years) than anything except for birth defects and is the third most common cause at 9% of unintentional deaths in children aged 5 to 19 years behind car accidents (60%) and drug poisoning (13%). Drowning is just as big of a problem worldwide. And though there have been improvements in these statistics, particularly when compared to the 1980s, these have stalled in recent years.
I recently happened upon some of the same advertising for infant swimming lessons that I discussed back in 2013. Current ads and program websites are making the same claims of drowning prevention that I saw back then and had described as implausible, unproven, and potentially dangerous. Here is an example from Infant Swimming Resource, “the global leader” in “survival swimming lessons for infants”:
ISR’s core conviction is that the child is the most important part of a drowning prevention strategy and our over 300,000 ISR graduates and 800 documented survival stories are proof that children can save themselves. Children are curious, capable, and have an uncanny ability to overcome obstacles like pool fences; at ISR we take that ability and teach them skills to potentially save themselves if they find themselves in the water alone.
Putting the onus of drowning prevention on an infant is more than a bit ridiculous. To be fair, ISR does discuss other means of drowning prevention such as parental supervision and proper fencing around pools, but they frequently call them unreliable. And even if they didn’t downplay the role of those interventions, paying lip service to them doesn’t make it okay to make claims about their swimming lessons that aren’t backed by evidence.
Of course, they say that the proof is in the many documented survival stories that they have received. I went back through several years of their blog and found none that involved a child less than a year of age. Some don’t even involve use of any specific ISR techniques and just come down to luck or the assumption that a child might have used an ISR technique if they had actually fallen into a pool. Poor supervision, however, is a consistent theme in the anecdotes that I was able to find. I am not aware of any published research showing a benefit.
But have I missed something? Was research published during the past 8 years that found these programs can save lives? Has the AAP changed their tune on infant swimming lessons for drowning prevention? A quick search did bring to my attention that there was a major policy statement update in 2019 that I hadn’t seen yet. With an open mind, I dove/dived back into the topic.
The pathophysiology of drowning
Drowning is defined as “The process of experiencing respiratory impairment from submersion/immersion in liquid”. Terms such as “near-drowning”, “wet”, “dry”, “silent”, or “secondary drowning” are inaccurate and confusing, and should be avoided. Drowning outcomes include death, no injury, or with injury (moderately disabled, severely disabled, vegetative state/coma, and brain death). Disability is primarily based on the degree of cognitive impairment.
The drowning process during complete submersion is complex and terrifying. As liquid occludes the opening into the airway and prevents breathing, panic ensues and breath is voluntarily held. Air hunger inevitably wins out and you are overcome by involuntary reflex attempts at breathing, allowing liquid to enter the mouth and throat. A powerful spasm of the muscles surrounding the upper airway occurs which prevents the liquid from entering the lungs despite the desperate involuntary attempts to breathe. Large amounts of liquid are often swallowed at this point.
As this is going on, blood oxygen levels are dropping while carbon dioxide levels simultaneously rise, leading to metabolic and respiratory acidosis. Eventually the muscles of the upper airway relax and allow the liquid into the lungs, rendering them incapable of gas exchange. Starved of oxygen, vital organs such as the brain and heart will be damaged. Pulmonary hypertension, worsening acidosis and lack of oxygen result in fatal heart arrhythmias, kidney failure, and abnormal clotting, but lack of oxygen to the brain is the primary cause of disability and death.
Pediatric drowning 101
As I mentioned above, drowning kills a lot of kids every year and children under the age of 4 years are especially at risk. And while white children of all ages drown in larger total numbers than other ethnic groups in the United States, a higher percentage of black and brown children suffer fatal drowning injuries. Black teenagers specifically are the group most at risk, followed by white toddlers.
Largely due to social and cultural factors, children from ethnic minority groups are more likely to drown because they are less likely to know how to swim. Their parents are also less likely to have acquired this skill and tend to place less emphasis on swimming than white parents in general. This almost certainly has roots in historical (and current) systemic societal racism, but it is a complex problem with multiple factors at play.
When it comes to where kids drown, the answer is also complex. Geographically speaking, there are more drownings in regions with higher temperatures over longer periods of time. More time in or around pools or natural bodies of water means more drownings. But curious toddlers also drown in bath tubs, fountains, buckets of water, and even deep puddles because of a combination of increased mobility, bodies with disproportionately heavy heads, and poor coordination and strength.
Older children are more likely to drown in natural bodies of water such as lakes, rivers, and oceans. Alcohol intoxication, or really any illicit or prescribed drug that impairs judgement and/or coordination, is also more likely to play a role. Home swimming pools are more likely to be involved when white kids drown while black children are more likely to die in public or hotel pools. The most important factor involved in almost all pediatric drownings, however, is an absence of supervision. But even the most attentive caregivers are only human, and mistakes are often made that allow unsupervised young children access to bodies of water. So it’s understandable that many caregivers might seek out a way to reduce their child’s risk.
What about those swimming lessons?
General water safety education that might go along with swimming lessons is almost certainly beneficial, especially when it involves caregivers of young children and older swimmers that are more likely to be on their own. But what about the specific techniques learned by the children themselves? What about skills like treading water, turning to float on the back (a common focus in infant lessons), and instruction on the basic strokes? Does this prevent drowning?
Although there is some plausible nuance, swimming lessons do decrease the overall risk of drowning in older children and there is evidence to back this up, although this isn’t something that can ethically be studied using a prospective trial where some children are not allowed to learn how to swim. But it is possible, on an individual basis, that increased confidence in one’s own swimming ability might lead to more risky behaviors. This might also simply result in more chances for an accident to happen in a body of water. Neither is a reason to avoid swim lessons for older children, however.
But what about toddlers? One of the main points of my 2013 post was that the AAP had done a bit of an about face on lessons for children aged 1 to 4 years in their 2010 policy statement. They went from strongly recommending against them to stating that they haven’t been proven to prevent drowning but at least probably don’t make it more likely to happen. There was some evidence for decreased risk in that age group at that time but it wasn’t clear if that was because of any specific skill learned by the child or because of water safety education for the parents. Maybe they just result in improved caregiver supervision.
The American Red Cross Advisory Council put out a policy statement in 2009, which has not been updated since, stating that swimming instruction in younger children hadn’t been shown to increase the risk of drowning but didn’t decrease it either. They didn’t proscribe introduction to water/water safety classes for any age, but felt that there was no proven drowning risk reduction benefit linked directly to skills taught to children less than essentially 2 years of age. Their take home point was that any classes for younger kids should focus on teaching a comprehensive approach to water safety that involves caregivers and their behaviors as well as means of preventing unsupervised access to water.
In their 2010 statement, the AAP did not yield when it came to pushback against claims of drowning safety benefits when it came to infants. The Red Cross Advisory Council agreed. They both specifically went after the common tactic of teaching back floating to infants who are first forced under the water, pointing out the absence of evidence in support of it as a specific risk reduction strategy. In my 2013 post, I discuss how the videos demonstrating babies doing this are unrealistic marketing videos and how this technique is unreliable and potentially dangerous.
The AAP updates its policy on drowning prevention
In 2019, the AAP released an updated policy statement on the prevention of drowning. Although I’m focusing on infant swimming lessons in this post, there are some important issues discussed in the new update. One aspect of drowning that was fleshed out a bit more was the role of certain underlying medical conditions, such as epilepsy, autism, and cardiac arrhythmias, all of which increase the risk of drowning. The AAP also went into more detail regarding the potential impact of some culture and traditions, as well as a lack of resources ($$$) on the ability for a child to learn how to swim, and they offer some potential ways to work around them.
The statement places importance on children developing water competency as well as swimming skills, but they appropriately place these in the context of layers of general drowning prevention strategies that are equally important. They discuss a matrix for preventing drowning that involves personal, physical environment, and social environment factors as well as equipment. For example, this could include caregiver supervision, swimming where lifeguards are present, laws to increase access to affordable swim lessons that are culturally competent, and 4-sided fencing respectively.
When it comes to infant swimming lessons being promoted as a means of reducing the risk of drowning, the AAP hasn’t budged:
In contrast, infants younger than 1 year are developmentally unable to learn the complex movements, such as breathing, necessary to swim. They may manifest reflexive swimming movement under the water but cannot effectively raise their heads to breathe. There is no evidence to suggest that infant swimming programs for those younger than 1 year are beneficial.
So yes, this is dangerous nonsense.
Here is an example of how to do it right.
And here is a nice summary of the AAP policy statement.
Don’t be fooled by infant swim lesson marketing hype
You can find many videos online showing older infants being pushed underwater who then float to the surface and turn on their backs for a few moments before being picked up by a caregiver or instructor. I’m not saying that infants can’t sometimes or even often do these behaviors in a controlled environment. But these are cherry picked videos. You won’t see marketing videos of infants sputtering with water in their mouths or noses, or being quickly grabbed when the instructor sees that they aren’t going to get their faces clear of the water in order to breathe. You also won’t see videos of babies with hypothermia or electrolyte aberrations caused by swallowing large amounts of pool water during these lessons, although admittedly this is a rare occurrence.
More importantly, these lessons do not translate to the events that lead up to drownings. It is dangerous to believe that any toddler, and certainly any mobile infant, will reliably perform these skills when falling into a pool and not immediately lifted up by a caregiver or lifeguard. And what if the water is cold? What if they aspirate when their face hits the water as they fall into it? What if they hit their head on the side of the pool? What if it’s a toilet or bucket of water and they can’t push themselves up and out of it? What if it’s a pond and they become stuck in mud or tangled in water plants? What if a child’s caregivers develop a false sense of security and relax their supervision, even for a few minutes?
That’s all it takes. Minutes. Maybe less.
Classes where infants and a caregiver spend time in the water are fine. They should include general water safety education. They should promote constant supervision and encourage water competence and safety skills appropriate to your child’s developmental stage. They should not claim or even imply that they somehow teach your child to save themselves from drowning.