Drowning – Awareness and prevention

By Dr Martie Conradie, MBChB (UP), Diploma in Child Health (SA), Diploma in HIV Management (SA)

Playing in water is so much fun, especially for children, but it can be very dangerous when they are not carefully watched.

Drowning is a common and, in many cases, a preventable problem. Drowning is among the top five leading causes of accidental deaths in South Africa every year, with the highest rate among children of 0-4 years old. Another high-risk group is boys of the ages 15-19 years, where drowning is often linked to alcohol use.

It is really hard to write this article and to read about all the deaths related to drowning but creating awareness and educating people to know what to do in case of an emergency is a worthwhile cause. The more you read about this topic, the more likely it is that you will remember the important steps if you are ever faced with it.

Some global statistics about drowning:

• Ten people die every day due to accidental drowning
• Drowning is one of the leading causes of death in people with autism and children with autism spectrum disorder are about 160 times more likely than other children to experience drowning and near-drowning
• For every child dying because of drowning, five others had to receive emergency care for near-drowning or submersion injuries
• Nearly 70% of children under 5 years old who drowned were not expected to be in the water at the time

When drowning, there is a lack of oxygen delivery to the brain and it takes only a few minutes for severe damage to occur. Although drowning can be fatal, survival is possible if someone gets help immediately. Knowing how to administer CPR to someone who is drowning, could mean the difference between life and death. What you basically do during CPR is helping the person’s body to deliver the oxygen to the brain while that person is unable to. Unfortunately, if a heart has stopped for 8-10 minutes, the chance of survival is slim.

You might have heard about “dry” or “delayed” drowning. These occur very rarely, but it is important to be aware of these types of drowning. Dry drowning can happen when a child inhales water and it causes the vocal cords to go into spasm. The water does not reach the lungs, but if the vocal cords do not relax, the airways stay blocked and cause breathing difficulties. Delayed drowning happens when water enters the lungs and causes swelling of the small airways which then prevents oxygen from entering the blood. It can even occur days after the initial near-drowning incident.

Survival with permanent disability is unfortunately a possible outcome. The emphasis must therefore be on primary prevention, which mainly entails stopping the submersion from occurring. Currently pool fencing is an important strategy, and some countries are even considering making it mandatory. Additional important prevention strategies include training as many people as possible to know how to do CPR and to have alcohol abuse prevention programs for older children.

Where can drowning take place

Children under 5 years old are most likely to drown at home. Drowning at homes most often take place in pools owned by family or friends.

After pools, bathtubs are the second most common place where children drown, but buckets, wells, septic tanks, toilets and garden ponds are also potential sources for young kids. Up to 10% of bucket drownings can unfortunately be due to child abuse.

Children of 5-17 years old are more likely to drown in natural sources of water, such as lakes, rivers or the ocean.

Drowning can happen in 20 seconds and in less than 5 cm of water!

How to supervise children near water

Proper supervision is one of the most important ways to prevent drowning. It happens every day to children with loving, attentive caregivers and therefore it is important to be aware of a few tips when you are looking after children playing near water:

• Pay constant, close attention to where they are or what they are doing and do not get distracted by activities such as reading, using your cell phone or doing household tasks.
• Do not use alcohol or other drugs when you must watch children but also not when you are swimming.
• Keep younger children within an arm’s length to be able to reach them quickly.
• Let adults take turns being a “water watcher” during parties or other gatherings. Their job is then to constantly watch the children near the water.
• Do not let a child be responsible for other children.
• Let people who often supervise children, do a first aid course.

Swimming lessons

Too many children have limited or no swimming skills. It is especially common for children from low-income households to not be proficient swimmers and these children are at a higher risk of drowning.

Teaching kids to swim should be a priority for every family. The American Academy of Pediatrics have a few tips about swimming lessons:

• There is no exact age at which to start swimming lessons because of different rates of development, but it is recommended to start by 1 year old.
• Qualified trainers can teach very young children how to float, but currently there is no definite evidence that swimming programs for infants lowers their drowning risk. A parent-child water play class does help the infants get used to a pool and it is a fun activity.
• By the age of 4, most children are ready for swimming lessons and they can learn to at least tread water and get to safety.
• When choosing where your child is taught to swim, look for instructors who follow guidelines focussed on water survival competency skills and not only swim stroke techniques. The instructors should also evaluate the child’s progress and give feedback.
• Lessons should include safety habits near water and what to do when unexpectedly ending up in water.
• Lessons should be continued until basic water competency skills are mastered.

Remember, swimming lessons do not make children “drown proof”.

What to do in an emergency

A lack of oxygen must be prevented and therefore it is important to follow the usual C-A-B (circulation-airway-breathing) resuscitation procedure if it has been confirmed that the person is not breathing. The below description is meant as a guideline in the case of a child drowning and there are minor changes to what is done for adults, but this does not replace the need for caretakers to learn how to do CPR correctly by attending a first aid course.

The steps:

1. Remove the child from the water.

You should only enter the water if you have the swimming skills to do so.

2. Ask someone to call for help if you are not alone, but do not delay the start of CPR.

Give about 2 minutes of care before calling emergency services if you are alone.

3. Check for breathing and responsiveness – place your ear next to the child’s mouth and feel if air moves over your cheek and check if the chest is moving.
4. If the child is not breathing, start rescue breathing:

• Place the child on a firm surface on his or her back. If a head or neck injury is suspected, move the head, neck, spine and hips together and keep them aligned when movement or rolling the child over is necessary.
• Tilt the child’s head back and lift the chin but be careful not to tilt the head too much for a baby. Only open the jaw if a neck injury is suspected and do not tilt the head.
• Form a tight seal with your mouth over the child’s mouth and pinch the nose closed. For an infant, your mouth will be placed over the mouth and nose.
• Blow a one-second breath into the child’s mouth and look to see that the chest is rising when you do this.
• Repeat this for a second time.

5. If the child is not breathing, check the pulse:

• Check by putting two fingers on the child’s neck just to the side of the Adam’s apple. For infants, the pulse can be felt between the elbow and shoulder on the inside of the arm. Feel for about 5 seconds.
• If there is a pulse, one breath can be given every three seconds and the pulse checked every minute until the child is breathing without help.

6. If there is no pulse, start chest compressions:

For a baby:

• Put 2 fingers on the breastbone and press down about 4 cm then release the pressure and let the chest rise completely.
• Do 30 compressions in about 15 seconds (which means nearly two compressions per second, which is quite fast) and count out loud with every compression.
• Check to see if the baby has started breathing.

For a child:

• Put the heel of a hand on the centre of the chest at the nipple-line and put your other hand on top of that hand.
• Press the chest down about 5cm and then release the pressure, letting the chest rise completely.
• Do 30 compressions in about 15 seconds (which means nearly two compressions per second) and count out loud with every compression.
• Check to see if the child has started breathing.

7. Repeat the steps

• 2 breaths then 30 chest compressions.
• Continue until the child starts breathing or emergency personnel arrive.

Remember, resuscitation may still be possible even if a person has been underwater for some time. Never assume it is too late to save a child’s life.

If your child is awake, sputtering and coughing when you take him or her out of the water, it is a good sign. Everything will likely be okay. These children can be calmed down and observed for the next few days and taken to a doctor if you are worried. Signs you can look out for over the following days can include persistent coughing, trouble breathing, tiredness or anything abnormal.

Prevention

The American Academy of Pediatrics mention the “layers of protection” approach to prevent drowning. These layers should include:

• Teach all children and adults to swim.
• Properly supervise children near water.
• Empty all buckets, bathtubs or other containers of water immediately after use and keep bathroom doors closed if you have young children. You can also make use of toilet safety locks.
• Enclose pools with a fence, a self-closing and self-latching gate and additional barriers such as pool covers or alarms.
• Older children and adults should learn CPR.
• When you partake in water sport, wear a life jacket.
• Be aware of the increase risk of drowning associated with alcohol and drug use near water.

 

I hope none of us ever have to experience any of our children drowning. We should do what we can to prevent it and create awareness wherever we go. And remember, if a child is missing, check the water first.

The following websites have useful tips:

https://pediatrics.aappublications.org/content/143/5/e20190850#sec-13

https://www.westerncape.gov.za/general-publication/tips-prevent-child-drownings