Objectives

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Objectives

• 1. To recognize that drowning and near drowning
  
• represent very significant tragedies in
  the United States.
• 2. To gain a behavioral perspective as to why
  the past and
• current strategies have not been effective.
• 3. To learn the components of a behavioral
  approach for a
• more effective drowning prevention
  strategy.
• 4. To recognize the pediatricians role in
  drowning
• prevention.

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A Behavioral Approach to Pediatric Drowning
Prevention
All Childrens Hospital St. Petersburg, Florida
April 3, 2009 Harvey Barnett, Ph.D. St.
Petersburg, Florida
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• Safety is not about accident prevention
• It is about admitted points of failure and
  redundancy via engineering and education.

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not one more child drowns
not one more child drowns

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What is it and how does it happen ?

• The traditional description of drowning has
  been that the victims experience a sense of panic
  and then initiate an exhausting struggle to keep
  their head above the water to reach safety
  breath holding begins with submersion. After a
  variable period, the victim swallows water,
  vomits, and coughs violently. Finally
  involuntary gasping causes the air passages and
  lungs to become flooded. The subsequent
  unconsciousness and convulsive movements are
  followed by death.
• 
  Andrew Neuman, M.D.
• 
  Scientific American
  Medicine.
• 
  August, 1994

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the predicted scenarios, the real example and
solutions

• 1. aquatic exposures were or are ongoing
• We had all been in and out of the
  pool for hours. I left for just a second to help
• my youngest into the house when I
  came back my oldest was floating lifeless face
  down .
• 
  
  (mother of
  3)
• segmented supervision by a
  trained expert
• 2. aquatic exposures were not expected
• I put my 18 month old down for his
  nap and went out to talk to the pool
• repair man. He had to use our home
  phone to call about a part for our filter.
• I went back out to close the gate
  only to find my son on the bottom of the pool.
  (mother of 1)
• redundant alarms on all
  intelligence fences, gates doors
• 3. water was a background for social activities
• There were 26 of us at the office
  cookout, we were all watching the
• children playing. One was missing, we
  found him at the bottom
• of the hot tub.
  
  (a pediatrician)

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Behavior modification is not possible

• WHAT can be engineered ?
• WHO can be educated ?

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WHAT can be engineered ?

• Fences and GATES
• Pool areas
• POOLS
• Bathtubs
• Toys
• Toilets
• 5 gallon buckets

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WHAT can be engineered GATES and fences

LEFT RIGHT CALL 911 CALL NEIGHBORS
over-rides current work on any computer calls
cell phones and land lines video streams to any
compatible device
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from the remote pool camera at 315 Davis Court
4/3/09
124632 PM
LEFT RIGHT
CALL 911 CALL NEIGHBORS
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WHAT can be engineered home pools
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WHAT can be engineered 5 gallon buckets
http//www.cpsc.gov/cpscpub/pubs/cpsr_nws24.pdf

• 1996 1999
• 58 deaths
• All were 18-months-old or younger when the
  incident occurred.

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WHO can be educated ?

• Professionals
• Public
• Parent
• Caregivers
• Baby

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Prominence of Drowning 0 to 59 months of age by
State 2005 CDC ICD-10 W
65-74 16
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Prominence of Drowning 0 to 59 months of age by
State 2005 CDC ICD-10 W
65-74 16 / 19 (35)

• 2001 568
• 2002 542
• 2003 555
• 2004 526
• 2005 587

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Prominence of Drowning 0 to 59 months of age by
State 2004 18 / 16

• PEDIATRICS Vol. 92 No. 2 August 1993, pp.
  292-294
• Drowning in Infants, Children, and
  Adolescents
• Committee on Injury and Poison
  Prevention
• Drowning and near-drowning are major
  causes of childhood mortality and morbidity from
  injury. From 1980 to 1985, drowning was the
  second leading cause of injury death of infants
  and children younger than 15 years of age in the
  United States. In 18 of the 50 states, drowning
  was the number one cause of unintentional injury
  death of children 1 to 4 years of age.
  Drowning, by definition, is fatal near-drowning
  is sometimes fatal. Drowning has been defined as
  a death resulting from suffocation within 24
  hours of submersion in water victims of
  near-drowning survive for at least 24 hours. For
  every child who drowns, four children are
  hospitalized for near-drowning. One third of
  those who are comatose on admission but survive
  suffer significant neurologic impairment. pg
  292

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Drowning 1 5 year olds 2004 United States
Florida

• In Florida, for children under age 5, the
  rate of drowning is increasing each year. From
  2004 to 2005, there was a 17 increase in
  children ages 1 to 4 who drowned. The majority of
  these children, over 60, drowned in a swimming
  pool. Pool submersions involving children happen
  quickly and silently, with most child drowning
  victims missing from sight for less than 5
  minutes.
• BROWARD COUNTY and MIAMI-DADE
• COUNTY, FLORIDA
• DROWNING PREVENTION PRACTICES
• PILOT STUDY
• JUNE 2007 pg 5

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Prevention Strategies PAST PRESENT
Florida 2002-2004

• Ranking by Florida County
• 2002 - 2004,
• Drowning, 0-4 years of age
• 1. Broward
• 2. Dade
• 3. Hillsborough
• 4. Orange
• 5. Palm Beach
• 6. Duval
• 6. Lee
• 8. Marion
• 9. Brevard
• 9. Polk
• 9. Seminole
• 9. Volusia
• 13. Manatee
• 14. Collier

• These 15 Counties contributed 75 of the
  drownings in the State over the three year period
  of the study. n229
• With these Counties identified, the State
  through CMS and other agencies utilized some
  initiatives and strategies suggested by the Safe
  Kids Coalition under their Keep an eye on your
  kid program for a designated supervisor.
• Joseph Chiaro, M.D.
• Deputy Secretary, Department of Health
• Childrens Medical Services
• personal communication July, 2006.
  
• In 2006, the Florida Department of Health funded
  a study

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DROWNING PREVENTION PRACTICES PILOT STUDY
BROWARD COUNTY and MIAMI-DADE COUNTY, FLORIDA
2002-2004

• The community was aware of the severity of the
  drowning problem for children under 5 years of
  age in Florida.
• (94) agreed that at least being poolside was
  a sufficient supervision environment
• (64) have fencing that surrounds the pool on
  all sides
• (20) have fencing that surrounds the pool on
  all sides
• with a self-closing, self-latching
  gate.
• ( 70 ) of families with a pool and a child
  under 4 have CPR training.
• (83) of survey participants believe children
  should start learning water safety skills at some
  point younger than age of three. More than half
  of the survey participants reported that the age
  range of 1-2 years old is the most appropriate
  age for a child to learn water safety skills like
  being able to get to the side of the pool or
  floating on his/her back. pg 22

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the scenario, the drowning, the near-drowning
survivor, the problem solver

• Video of a simulated drowning
• Video of the foreclosed home/pool
• Video of a near-drowning survivor
• Video of educated and practiced problem solvers

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• SUPERVISION
• FENCING
• CPR

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• SUPERVISION
• Eighty-eight percent of children were under some
  form of supervision when they drowned. Forty-six
  percent of drowning victims in the reviewed
  deaths were in the care of a parent at the time
  of the incident. Twenty-six percent were in the
  care of a relative other than a parent, including
  5 percent in the care of a sibling younger than
  18 years of age and 6 percent in the care of a
  grandparent. Ten percent of the drowning victims
  were completely unsupervised at the time of the
  drowning and determined by reviewers to have
  required supervision.
• Clear Danger. A National Study of Childhood
  Drowning and Related Attitudes and Behaviors,
  2004 http//www.usa.safekids.org/NSKW.cfm
  

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• FENCING
• Our research suggests that even if all of the
  residential pools in the United States were
  properly fenced most drownings among children lt5
  years of age would not be prevented. Thus,
  additional strategies to prevent drownings will
  be needed.
• Pediatrics 101 (6) E3, 1998 Jun
• Childhood drownings and fencing of outdoor pools
  in the United States 1994

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• FENCING
• The Pool and Spa Safety Act of 2007 (H.R. 1721)
  provides federal incentive grants to states that
  adopt laws requiring the use of pool and spa
  safety devices recommended by the U.S. Consumer
  Product Safety Commission. Such devices include
  four-sided isolation fences, anti-entrapment
  drain covers, safety vacuum release systems and
  multiple drains.
• Passed the House of Representatives October 9,
  2007 (S. 1771)

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• CPR
• US News and World Report, October 19, 1993. The
  Art of Staying Alive
• Few are aware of CPRs unimpressive track record,
  both inside and outside the hospital. However
  heroic the technique may appear, it forces only a
  small amount of blood into the brain. (CPR 15
  survival rate, out of hospital CPR 2-5 p.70)
• If supervision does not work, if fences cannot
  stop a young child from getting to the water and
  if current CPR is an after-the-fact-emergency
  management with an uncertain outcome

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• Drowning prevention has nothing to do with
  aquatics
• Aquatics has nothing to do with drowning
  prevention

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the near drownings numbers

• It is estimated that delayed deaths from
  near drowning almost equal in number the deaths
  from drowning and that for each drowning death,
  there are 4 or more non-fatal submersions that
  will require hospitalization. pg 668
• Wintemute, GJ. Childhood drowning and near
  drowning in the United States. Am J
• Dis Child. 1990 144 663-669.
• Fifty percent of those victims will suffer
  severe and permanent disability. pg 137
• Kyriacou, DN, et. al. Effects of immediate
  resuscitation on children with
• submersion injury. Pediatrics. 1994 94
  137-142.

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with children ages 4 and under
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with children ages 4 and under accounting for
____ _illion annually.
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for selected StatesThe near-drowning direct
medical costs per year lt1 to 59 months of age
(2005 State/US X total costs ND)

• Alabama 46,300,000
• Arizona 135,000,000
• California 425,000,000
• Florida 425,000,000
• Indiana 70,000,000
• Kentucky 68,000,000
• Maryland 23,100,000
• Michigan 104,000,000
• Minnesota 46,300,000

• Missouri 40,500,000
• New York 86,800,000
• Ohio 144,800,000
• Oklahoma 75,300,000
• Pennsylvania 81,000,000
• Tennessee 102,000,000
• Texas 329,000,000
• Virginia 78,200,000
• Washington 57,900,000

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• The total cost of a single near-drowning
  that results in severe brain injury can be more
  than 4.5 millionwith children ages 4 and under
  accounting for 3.4 billion annually.
• www.safekids.org/NSWK.cfm

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little lives lost a great many ruined
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What can we do ?
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Pediatric Drowning Preventionin the United
States 1966 to 2009

• SUPERVISION
• FENCING
• CPR

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Pediatric Drowning Preventionin the United
States 1966 to 2009

• Segmented SUPERVISION
• Permanent pool FENCING with intelligent
• alarms for the gate
• the possible inclusion of aquatic self rescue
• lessons for the infant and the resulting parent
  education
• CREATED BY THAT OPPORTUNITY

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consider a behavioral strategy that utilizes
these features

• SEGMENTED supervision
• PERMANENT pool fence with intelligent gates
  alarms
• at many levels /
  locations
• Make the distinction between swimming skills and
  self rescue skills from a drowning prevention
  strategy.
• Realize that when infants and young children are
  being taught to survive in the water, their
  parents see the NEED for drowning prevention
  education first for their family and then to
  become community resources for the greater
  propagation of the strategy.

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how to advise ?

• Generally children are not developmentally
  ready for swimming lessons until after their 4th
  birthday. Aquatic programs for infants and
  toddlers have not been shown to decrease the risk
  of drowning and parents should not feel secure
  that their child is safe in water or safe from
  drowning after participating in such programs.
• AAP Policy
  Statement SWIMMING, 2000
• Ultimately, the decision of when to start a
  child in swimming lessons must be individualized.
  Parents should be reminded that swimming lessons
  will not provide "drown proofing" for children of
  any age.
• AAP Policy
  Statement DROWNING PREVENTION, 2003
• Participation in formal swimming lessons
  was associated with an 88 reduction in the risk
  of drowning in the 1 to 4 year old children
• The American Academy of Pediatrics
  encourages parents to teach their children to
  swim by 5 years of age to reduce these risks.
• http//archpedi.ama-assn.org/cgi/content/full/1
  63/3/288
• ARCHIVES
  of PEDIATRIC and ADOLESCENT MEDICINE, MARCH 2009

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protect each baby through sensorimotor skills
and thereby gain the opportunity to educate the
parents to protect many more throughcommunity
education... Parent to Parent

• Video of return to entry point
• 22 month old boy
• Video of swim-float-swim sequence
• and important person in pediatric drowning
  prevention

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6 Months later free pool fences lessons
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Drowning within 24 hours of submersion
incident, unintentional, all races, both sexes,
0-5 years, United States (last year of reported
data by CDC)

• CDC All Races, Both Sexes,
• Ages 0 to 5 years United States ICD-9 Codes
  E830, E832, E910
• ICD-10 Codes W 65 - 74
• 1990 716
• 1991 789
• 1992 697
• 1993 714
• 1994 626
• 1995 677
• 1996 639
• 1997 616
• 1998 650
• 1999 632
• 2000 625
• 2001 568
• 2002 542
• 2003 555
• 2004 526
• 2005 587

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life or death
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life or death face down
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life or death face down or
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life or death face down or face up ?
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life or death only the educated survive
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Education and Engineering

• Supervision
• And
• Fenced
• Environments
• Survival
• Taught
• And
• Responsibility (true meaning)
• Taken

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repeat Repeat REPEATREPEATsupport and utilize
what works

• SEGMENTED supervision
• PERMANENT pool fence with intelligent gates
  alarms
• at many levels /
  locations
• Make the distinction between swimming skills and
  self rescue skills from a drowning prevention
  strategy.
• Realize that when infants and young children are
  being taught to survive in the water, their
  parents see the NEED for drowning prevention
  education first for their family and then to
  become community resources for the greater
  propagation of the strategy.

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Questions

• www.harveybarnett.com