Editorials

Childhood drowning is a global concern

Prevention needs a multifaceted approach

Papers p 1070

Drowning is a significant cause of childhood death in many parts of the world. It is estimated that in 1998 almost half a million deaths worldwide were caused by drowning, 57% of which were among children aged up to 14 years.¹ A recent Unicef report found that, in 26 of the world's richest nations, injuries were the leading cause of death among children. Drowning was the second leading cause of injury related death, exceeded only by deaths due to road traffic crashes.² Drowning is also unique in that case fatality rates are as high as 50% and medical care makes little difference in outcomes for victims brought to the emergency department without spontaneous respiration.

The study by Sibert et al in this week's journal (p 1070) identified a significant decline in the incidence of childhood drowning in the United Kingdom between 1988-89 and 1998-99.³ A strength of the study was the use of multiple data sources to identify circumstances surrounding deaths due to drowning. Although data are not presented on the site of drowning by age, previous studies in the United Kingdom and other industrialised countries provide a consistent picture. Infants are most likely to drown in the home (usually in a bathtub); toddlers in bodies of water close to the home such as swimming pools or ponds; and older children in natural bodies of water such as lakes and rivers, generally located away from the home.^4-6 Although data from developing countries are sparse, developmental capabilities of children are likely to lead to comparable patterns. For example, in Guadalajara, Mexico, 60% of drowning incidents among children aged 1-4 years were in underground cisternsa structure located close to the home.⁷

Sibert et al found a significant increase in drowning incidents in garden ponds and large declines in drowning incidents that occurred in natural freshwater sites, for example lakes, rivers, and canals. These trends are comparable with those in the United States, where the largest declines in drowning rates were seen among older children.⁸ Interestingly, a systematic review of primary preventive strategies found pool fencing, a strategy which specifically targets toddlers and young children, to be the only intervention which was effective.⁹ Yet, in many countries toddlers continue to have the highest drowning rates, pointing to the challenges in implementing this strategy. In contrast, deaths due to drowning in older children have declined despite the lack of effective interventions. This decrease might be explained by decreased exposure as older children adopt more sedentary lifestyles and families move from rural to urban areas. However, studies examining this hypothesis are lacking and other explanations such as decreased risk taking or improvements in swimming ability should also be considered.¹⁰

A number of important preventive messages have been emphasised including: constant supervision of infants by adults in the bathtub and around other bodies of water; pool fencing, particularly with isolation fencing that completely surrounds the pool, separating it from the home; and not swimming alone or in remote, unguarded sites.¹¹ Furthermore, parents, adolescents, and homeowners with pools on their property are advised to obtain training in basic life support techniques as studies have shown that if initiated promptly, resuscitation by a bystander, before the arrival of emergency personnel, results in significantly better neurological outcomes. ^{11 12}

(Credit: POOL SAFETY BARRIERS OF LA)

Some studies recommend that after the age of 5 years all children should be taught to swim, but, although it seems obvious that better swimmers would be less likely to drown, the relation between swimming lessons, swimming ability, and the risk of drowning is unknown.¹¹ It could be argued that better swimmers might take greater risks, like swimming in rougher or unguarded waters. Additionally, the provision of swimming lessons to all children might result in increased exposure to water and subsequent increases in drowning rates. Clearly there is a need for scientifically rigorous studies to determine which interventions work.

In 1997 Pless referred to drowning prevention as the "final frontier of injury prevention."¹³ It is time for renewed efforts on several fronts. Adequate fencing of pools will be achieved only if fencing is both required by law and regulations are enforced. Furthermore, research findings about pool fencing must be translated to other comparable sites, be it ornamental ponds in the United Kingdom or cisterns in Mexico.¹³ Finally, we must evaluate recommended prevention strategies and begin to think creatively about potential new strategies. Comparisons of practices in regions with varied drowning rates might lead to new insights for prevention. For example, are there familial bathing practices that protect infants from drowning? Complete and consistent documentation of the circumstances surrounding drowning deaths would greatly facilitate these efforts.

Ruth A Brenner, investigator, epidemiology branch. 

Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, Bethesda, MD 20892, USA(BrennerR{at}NIH.GOV)

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2.	Unicef. A league table of child deaths by injury in rich nations. Florence: Unicef Innocenti Research Centre, 2001.
3.	Sibert JR, Lyons RA, Smith BA, Cornall P, Summer V, Craven MA, et al. Preventing deaths by drowning in children in the United Kingdom: have we made progress in 10 years? Population based study. BMJ 2002; 324: 1070-1071[Free Full Text].
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