07. DROWNING RISK FACTORS AND EXPOSURE
Infants drown more often at or near home in bathtubs, toilets and water buckets where they are unable to extricate themselves due to their early development and lack of parental supervision. Byard, et al, (2004) also implicated bath seats in tubs, which gave parents a false sense of security to leave infants unattended with tragic results (26). A forensic evaluation of evidence from the drowning cases determined that the infants had easily slipped through the bath seats and turned over with their faces immersed in the tubs' water. In another study, Lee, et al, (2007) surveyed parental beliefs about bathing and water safety and found that 85% used baby bathtubs, 46% used bath seats in bathtubs, and, despite half of the respondents being instructed by their pediatricians about infant bathing safety, a number of them admitted to either leaving the infant alone or in the care of an older sibling (27).
Young children aged 1 to 4, being more mobile, curious but unable to swim, can quickly evade their parents' scrutiny and drown in indoor and outdoor pools because barriers, such as tall encircling fences and locking gates, are not present or maintained to prohibit their access. As children age and become more comfortable in the water with support from water wings and floating toys, they drown when separated from their buoyant support because they have not learned to swim (2, 15).
Brenner, et al, (2009) conducted a case-control study to determine if early childhood swimming lessons had any effect on reducing unintentional fatal drowning (28). Eighty-eight cases were identified after reviewing death certificates from six states and were matched with 213 controls. Interviews of families sought whether children aged 1 to 19 had had formal, informal or no swimming lessons. The authors concluded that among the 1- to 4-year old group there was an 88% reduction in drowning fatalities due to formal swimming lessons. Shields, et al, (2011) utilized the US Consumer Products Safety Commission (CPSC) database on portable above-ground pools and the occurrence of submersion incidents for children under the age of 12 years (29). They found that the risks of fatal and non-fatal drowning for children aged 1 to 4 were greater than drowning risks for in-ground pools and recommended that the above-ground pool industry provide multiple layers of protection, such as fencing, alarms and covers.
Globally, children from low and middle income countries fair worse with respect to drowning than their more advantaged, higher income counterparts, as they are less likely to learn to swim or survive immersion or submersion. Hyder, et al, (2008) found that remedying this problem must look at realistic strategies for intervening in deprived areas, including respect for cultural differences (30). Using Bangladesh as a case study for evaluating drowning prevention strategies, they focused on the cohort of children under 5 years of age where 20% of all deaths (all causes, both sexes) were due to drowning and compared it to the same cohort in the United States. In Bangladesh, children under 5 years of age often drown in or near their homes in drinking water buckets and natural waters (livestock ponds, ditches and rivers), whereas their counterparts in the United States are more likely to drown in bathtubs and recreational waters (wading ponds and swimming pools). Fencing off such natural waters in Bangladesh is impractical, but the authors recommended studying the effectiveness of parental water safety education and using household doors as barriers to the mobility of young children, which would prevent their access to the outdoor natural water hazards.
When they reach their teenage years, older children are more likely to become risk takers, often at the behest of their peers, and drown not because they cannot swim but because they exceed their ability, panic or are impaired by alcohol or drugs. Young adults aged 14 to 19 have the second highest rate of drowning fatalities, and males are nearly five times more likely to drown than females. As children age, their experiences with water shift from artificial pools to natural water environments where unfamiliar settings and conditions impose potential hazards, such as murky or cold water, weeds, abrupt changes in depth and currents. The absence of adult supervision, not wearing of personal floatation devices (PFDs), overconfidence about swimming abilities and a lack of water survival skills contributes to the drowning problem (2, 15).
Adults, who should know better and be role models for children with regard to risk taking behaviors (e.g., not wearing PFDs and becoming impaired by alcohol or drugs), drown also because unhealthy lifestyle choices and personal health issues become more problematic with increasing age. Water-related recreational pastimes play a significant part in the variety of fatal and non-fatal drowning injuries, with and without watercraft use (2, 15, 31).