Drowning and Submersion Injury

Children <1 Yr Old

Most (71%) drowning deaths in children younger than 1 yr occur in the bathtub , when an infant is left alone or with an older sibling. Infant tub seats or rings may exacerbate the risk by giving caregivers a false sense of security that the child is safe in the tub. The next major risk to children <1 yr is the large (5-gallon) household bucket, implicated in 16% of infant drowning deaths. These buckets are approximately 30 cm (1 ft) tall and designed not to tip over when half-full. The average 9 mo old child tends to be top-heavy and thus can easily fall headfirst into a half-full bucket, become stuck, and drown within minutes.

Children 1-4 Yr Old

Drowning rates are consistently highest in 1-4 yr old children, likely because of their curious but unaware nature, coupled with the rapid progression of their physical capabilities. From 1999 to 2015, U.S. rates are highest in the southern regions, in some areas as high as 3.8 per 100,000. A common factor in many of these deaths is a lapse in adult supervision, often reportedly <5 min. Most U.S. drownings occur in residential swimming pools . Usually, the child is in the child's own home, and the caregiver does not expect the child to be near the pool.

In rural areas, children 1-4 yr old often drown in irrigation ditches or nearby ponds and rivers. The circumstances are similar to those noted previously, in a body of water that is near the house. Drowning is one of the leading causes of farm injury–related deaths in children.

School-Age Children

School-age children are at increased risk of drowning in natural bodies of water such as lakes, ponds, rivers, and canals. Although swimming pools account for most nonfatal drownings across all ages, natural waterways account for a higher death rate in children 10-19 yr old. Unlike for preschool children, swimming or boating activities are important factors in drowning injuries in school-age children.

Adolescents

The 2nd major peak in drowning death rates occurs in older adolescents, age 15-19 yr. Almost 90% drown in open water. In this age-group particularly, striking disparities in drowning deaths exist in gender and race. From 1999 to 2015, adolescent males fatally drowned at a rate of 2.4/100,000 compared to 0.3/100,000 in adolescent females. The gender disparity may likely be related to males’ greater risk-taking behavior, greater alcohol use, less perception about risks associated with drowning, and greater confidence in their swimming ability than females.

Dangerous underwater breath-holding behaviors (DUBBs) are often performed by experienced healthy swimmers or fitness enthusiasts (hypoxic training) or when teenagers hold breath-holding contests during horseplay. DUBBs have been primarily reported in regulated swimming facilities. Behaviors include intentional hyperventilation before submersion, static apnea, and extended periods of underwater distance swimming or breathhold intervals. Swimmers are found motionless and submerged; resuscitation is often unsuccessful.

There is also significant racial disparity seen across drowning rates and causes. In 2015, as in previous years, drowning rates for black males age 15-19 yr were double those for white males of the same age. Non-Caucasian children are 4 times more likely to have a nonfatal drowning across all age-groups through 19 yr old. Black children are more likely to drown in unguarded public or apartment pools; white children are more likely to drown in private residential pools. Hispanic and foreign-born children have lower rates of drowning than their white counterparts. Those with private insurance have lower rates of nonfatal drowning. Other factors include differences in exposure to swimming lessons, cultural attitudes, and fears about swimming, as well as experience around water, all of which may contribute to overall drowning risk.

Underlying Conditions

Several underlying medical conditions are associated with drowning at all ages. A number of studies have found an increased risk, up to 19-fold, in individuals with epilepsy . Drowning risk for children with seizures is greatest in bathtubs and swimming pools. Cardiac etiologies, including arrhythmias, myocarditis, and prolonged QT syndromes, have been found in some children who die suddenly in the water, particularly in those with a family history of syncope, cardiac arrest, prior drowning, or QT prolongation. Some children with long QT syndrome are misdiagnosed as having seizures (see Chapter 462.5 ).

Drowning may also be an intentional injury . A history of the event that changes or is inconsistent with the child's developmental stage is the key to recognition of intentional drowning. Physical examination and other physical injuries rarely provide clues. Child abuse is more often recognized in bathtub-related drownings. Suicide usually occurs in lone swimmers in open water.