Research In Action

Moderator's note: This post is part of our ongoing series highlighting articles from the "Preventing Unintentional Injuries Among Children and Youth" issue of Pediatric Clinics of North America. Today’s entry, written by Drs. Caitlin Farrell and Rohit Shenoi, features the article “Pediatric Considerations for Water Safety”. Dr. Caitlin Farrell is a pediatric emergency medicine physician at Boston Children's Hospital and Associate Professor of Pediatrics and Emergency Medicine at Harvard Medical School. Dr. Rohit Shenoi is pediatric emergency medicine physician at Texas Children's Hospital and Professor of Pediatrics - Emergency Medicine at Baylor College of Medicine. 

Drowning is a leading cause of unintentional injury death in US children. While overall drowning rates once declined, deaths are rising again. Widening racial and ethnic disparities in death rates persist. Our recent review in Pediatric Clinics of North America underscores the urgent need for an equitable and comprehensive public health approach to water safety.

Persistent Disparities

Drowning disproportionately affects young children and is the leading cause of death in US children 1 to 4 years old. Adolescents, especially males, are another risk group. The burden of drowning is not shared equally, however. Black and Native Hawaiian/Pacific Islander children experience substantially higher fatal drowning rates compared to white children. These disparities are not explained by biologic differences, but rather by social determinants of health, including historic segregation, structural racism, limited availability of safe aquatic environments, and unequal access and economic barriers to swimming lessons.

High Risk Conditions

Children with autism, epilepsy, and certain cardiac conditions are also at higher risk for drowning. Autistic children are vulnerable because of wandering behaviors and increased attraction to water. Adapted aquatics programs may help improve their safety while also supporting developmental and psychosocial benefits.

Layers of Prevention

No single intervention can prevent all drownings. Effective prevention requires multiple overlapping “layers of protection”. Core evidence-based strategies include close and competent supervision, hazard recognition, four-sided isolation pool fencing, swimming lessons and water competency, proper life jacket use, and rapid rescue and resuscitation.

Young children can drown quickly and silently, often during brief lapses in supervision Designating a distraction-free “water watcher” who maintains touch supervision for inexperienced swimmers is an important recommendation for caregivers. Four-sided isolation pool fencing is an effective drowning countermeasure. Pools with four-sided fencing that completely separates the pool from the home carry significantly lower drowning risk than pools with three-sided fencing with direct home access. Swim lessons are another protective factor. The American Academy of Pediatrics recommends beginning swim lessons after age 1, with an emphasis not only on swimming skills but also on water competency such as hazard recognition and survival skills. Other drowning countermeasures include hazard recognition and CPR training.

Clinicians play a critical role in providing age- and context-specific water safety anticipatory guidance to families. Systems-level interventions that include legislation, coalition building, organizational change, and community education are also recommended. Preventing drowning is a team effort involving clinicians, parents, and community stakeholders who work together to advocate for equitable access to water safety resources and evidence-based drowning prevention policies.