Published online August 1, 2008
PEDIATRICS Vol. 122 No. 2 August 2008, pp. e388-e394 (doi:10.1542/peds.2008-0024)
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ARTICLE

Diving-Related Injuries in Children <20 Years Old Treated in Emergency Departments in the United States: 1990–2006

Coral Day, BSa, Uwe Stolz, PhD, MPHb, Tracy J. Mehan, MAb, Gary A. Smith, MD, DrPHb,c and Lara B. McKenzie, PhD, MAb,c

c Department of Pediatrics
a College of Medicine, Ohio State University, Columbus, Ohio
b Center for Injury Research and Policy, Research Institute, Nationwide Children's Hospital, Columbus, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The purpose of this work was to comprehensively examine diving-related injuries in the United States among children and adolescents <20 years of age.

METHODS. We conducted a retrospective analysis of diving-related injury data from the National Electronic Injury Surveillance System, including patients aged <20 years old who were seen in an emergency department for a diving-related injury from 1990 through 2006.

RESULTS. An estimated 111341 patients aged ≤19 years were treated in emergency departments for diving-related injuries over the 17-year period of the study. The average annual injury rate was 8.4 injuries per 100000 US residents <20 years old. Patients aged 10 to 14 years composed the largest group (36.3%) of injured divers. Injuries to the head and/or neck (38.2%) and face (21.7%) were the most common, with the most frequent diagnoses being lacerations (33.9%) and soft tissue injuries (24.3%). Collision with a diving board and/or platform was the leading cause of injuries (43.9%). Children <10 years old had increased odds of sustaining a laceration, children <5 years old had increased odds of injury to the face, and 10- to 19-year-olds had increased odds of sustaining a fracture or an injury to the extremities. The odds of injury caused by contact with the diving board dramatically increased if the child was performing a flip and/or handstand or a backward dive.

CONCLUSIONS. To our knowledge, this is the first study to examine recreational and competitive diving-related injuries among children and adolescents using a nationally representative sample. These results can help inform pediatricians, parents, coaches, and trainers regarding injuries seen during recreational and competitive diving and can help guide future prevention efforts.

Key Words: diving • diving-related • wounds and injuries • child • adolescent • emergency department • National Electronic Injury Surveillance System

Abbreviations: NEISS—National Electronic Injury Surveillance System • ED—emergency department • OR—odds ratio • CI—confidence interval

Recreational swimming and diving are the third most common physical activities in the country (after walking and camping), and the most common among children.1,2 Although the participation rate for recreational diving is not known, ~8.1-million swimming pools are available for private or public use throughout the United States.1 In addition, ~55-million citizens make an estimated 360-million visits annually to recreational water venues.1

The sports of swimming and diving are traditionally grouped together under the broad heading of "aquatic sports"; however, compared with the ancient practice of swimming, diving is relatively new. Diving was first established in the 17th century and was added to the repertoire of Olympic sports in 1920.3–6 The sport of diving, both recreational and competitive, continues to increase in popularity in the United States. There are >300 clubs and >20000 participants <18 years registered as members of the USA Diving National Sanctioning Committee, as well as countless others who dive as part of unregistered recreational programs, with or without instruction, across the United States.6

The recent growth of the sport of diving, coupled with the increasing complexity and difficulty of dives, has resulted in a greater potential for both competitive and recreational diving-related injuries.3,5 Compared with just 34 types of recognized dives in 1920, divers today can choose from any of the 227 competitive dives officially recognized by the International Olympic Committee for the 1- and 3-m springboard and platform events, with a higher point value awarded for more difficult dives.5,6

Diving-related injuries occur during both recreational and competitive activities; however, studies have focused on different types of injuries depending on the type of diving activity examined. Studies on recreational diving-related injuries have focused primarily on catastrophic spinal cord injuries. Because they are such devastating, costly injuries and occur among adolescent and young adult boys, most previous studies have focused on spinal cord lesions and largely discounted other types of injuries (and age groups) involved in recreational diving settings.7–23 In contrast, studies that have examined competitive diving have cited the predominance of joint injuries to the upper extremities that are commonly associated with both chronic stress and isolated injurious events, particularly on entry to the water.5,24–28 Injuries involving the head, neck, and back also occur during competitive diving and range from chronic lumbar pain to rare, but severe, spinal cord damage, paralysis, and death.3,5,24,29,30

To our knowledge, there are no published studies on national estimates of diving-related injuries in the United States, and whereas previous studies have reported diving injury trends, these have been restricted to case reports,3,25,26,31 single trauma center studies,8,22 or sports and recreation-related injuries.7,11,23,28,32 Our objective was to fill a significant epidemiologic gap in the literature by estimating rates of diving-related injuries for children using nationally representative data. This study examined the patterns of diving-related injuries related to various demographic, injury, and diving-specific characteristics.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Data Source
The National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission is a stratified probability sample of ~100 US hospital emergency departments (EDs), including 7 children's hospitals, representing 6100 hospitals with ≥6 beds and a 24-hour ED, and provides data on consumer product-related and sports activity-related injuries treated in the sampled EDs.33,34 Established in 1972, the NEISS has had sampling revisions in 1990 and 1997, which included the addition of a separate stratum for children's hospitals. The NEISS has successfully collected high-quality data on product-related injuries and risk factors and has been used to develop successful preventive interventions.33 NEISS data were adjusted by the Consumer Product Safety Commission to account for the sampling frame changes. NEISS data are recorded from a review of ED medical charts and include patients' age, gender, race, injury diagnosis, body part injured, product(s) involved, disposition of case, and a brief narrative describing the incident. NEISS case narratives contain information about the events surrounding the injury. The estimates were based on weighted data for 2927 patients treated for injuries related to the act of diving into a body of water.

Case-Selection Criteria
All of the diving-related injuries (identified by the NEISS consumer product code 127835 for "diving") among children aged ≤19 years for the 17-year period from 1990 to 2006 were identified from the NEISS database. Case inclusion and exclusion criteria and variable categories were developed after review of a subset of narratives. All of the case narratives were reviewed by the lead author. Ambiguous narratives and a subset of all of the cases were reviewed by ≥1 other author (Dr McKenzie and Ms Mehan), with disagreements resolved by consensus. Injuries resulting from scuba, skin, or sky diving were excluded, as were incidents involving diving accessories (ie, rings, sticks, and bricks); "running," "tripping," or "swimming" into a diving board; getting "hit" or "pushed" by another diver; getting out of a pool after diving; or falling from a pool ladder or "diving ladder." Cases that involved asthma, dehydration, or ear, nose, and throat infections were excluded. The single case fatality was excluded. Data were categorized into 4 age groups: <5 years, 5 to 9 years, 10 to 14 years, and 15 to 19 years to facilitate injury comparisons according to age and to calculate injury rates per year on the basis of 1990–2006 population estimates from the US Census Bureau.36,37

Variables
Body Region, Diagnosis, and Disposition
Injuries were categorized into the following body regions: lower extremities (upper leg, knee, lower leg, ankle, foot, and toe); upper extremities (upper arm, elbow, lower arm, wrist, hand, and finger); head and neck (includes ears); face (nose, mouth, eyes, and area surrounding the eyes); trunk (upper and lower trunk and pubic region); and other (occurring on 25%–50% of the body or all of the body). The diagnoses were categorized as follows: laceration (lacerations, punctures, amputations, and nonbone avulsions); soft tissue injury (contusions and/or abrasions and hematomas); fracture (fractures, dislocations, and bone avulsions); strain or sprain; and other (dental injury, foreign body, nerve damage, submersion, concussion, hemorrhage, internal organ injury, tympanic membrane rupture, and other). Disposition from the ED was categorized as released (patients who were treated and released or left the ED without treatment) or hospitalized (patients who were admitted, transferred to another hospital, or held for observation).

Injury Location and Diving-Related Variables
The location of injury was dichotomized into either pool (private or public pools) or nonpool (natural bodies of water, such as lakes, rivers, and oceans). Case narratives were used to generate new variables: dive height (most swimming pools have a 1-m springboard, and, to distinguish between dives near the surface of the water and those significantly higher, these were dichotomized into ≤1 m and >1 m), dive direction (forward or backward, depending on the orientation of the diver when initiating the dive), and dive skill (jump and/or cannonball, head-first dive, or flip and/or handstand). "Dive sequence" describes the stage of the dive sequence during which an injury took place on the board or platform, in flight, during water entry, and underwater. "Dive interference" represented the proximate cause of the injury to the diver and, when available, allowed for a distinction to be made between injuries resulting solely from diving into the water and injuries resulting from contacting a structure or an object. "Diving interference" was categorized as water only, diving board and/or platform, side of pool, bottom of pool, or other object.

Statistical Analysis
Data were analyzed by using SPSS 14.0 (SPSS Inc, Chicago IL) and Stata SE 10.0 (Stata Corp, College Station, TX). The sample weight assigned to each case was based on the inverse probability of selection. Statistical analyses consisted of univariate logistic regression to produce odds ratios (ORs) along with associated 95% confidence intervals (CIs) accounting for the complex survey sample design of NEISS. Means are reported with associated 95% CIs. All of the data reported in this article are national estimates unless otherwise specified as actual unweighted cases. The institutional review board of the Research Institute at Nationwide Children's Hospital approved this study.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Demographics and Overall Injury Trends
From 1990 through 2006, an estimated 111341 patients (95% CI: 93660–129023 patients) aged ≤19 years were treated in EDs for diving-related injuries. This yielded an average of 6549 injuries per year and an average yearly rate of 8.4 injuries per 100000 US residents <20 years old. Annual injury rates by gender and age are shown in Fig 1. The estimated national mean age of patients was 12.2 years (95% CI: 11.9–12.5 years). Table 1 contains the actual unweighted counts, as well as national estimates and frequencies of diving-related injuries, for the variables used in this study. Patients aged 10 to 14 years composed the largest group (36.3%) of injured divers. Seasonal variation of diving-related injuries is shown in Fig 2, with a peaking during the warm, summer months of June, July, and August (77.8% of all of the cases).


Figure 1
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  		FIGURE 1 Diving-related injury rates for children treated in US EDs. A, Injury rates for boys versus girls. B, Injury rates according to age group.

 

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  		TABLE 1 Characteristics of Diving-Related Injuries Received in US EDs: 1990–2006

 

Figure 2
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  		FIGURE 2 Number of estimated diving-related injury cases received in US EDs according to month of the year: 1990–2006.

 
Lacerations and soft tissue injuries were the most common diagnoses, representing 33.9% and 24.3% of all injuries, respectively. The head/neck was the most common body area injured (38.2% of all injuries) and, along with injuries to the face area, accounted for 59.9% of all of the diving-related injuries. A total of 4.7% of case injuries were serious enough to warrant hospitalization. When the proximate cause of injury was available, interference with a diving board or platform was leading cause (43.9%). Similarly, when information was available regarding the stage of the dive sequence during which patients were injured, on the board or platform was the most common (32.3%), followed by in-flight (29.8%).

Diving-Related Injuries and Associated Risk Factors
Table 2 shows the bivariate relationships (ORs and 95% CIs) between selected diving-related variables and risk factors. Children <5 years old had 4.7 times the odds of an injury to the face (versus all other body regions) compared with those ≥5 years old. In addition, the odds of an injury to the extremities (versus all other body regions) were 3.6 times higher for patients 10 to 19 years old (compared with those <10 years). Children <10 years (versus those ≥10 years) had 3.2 times the odds of a laceration, whereas those ≥10 years (compared with those <10 years) had >4.1 times the odds of a strain or sprain compared with all of the other diagnoses.


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  		TABLE 2 Selected Characteristics and Risk Factors for Children With Diving-Related Injuries Treated in US EDs: 1990–2006

 
Boys (compared with girls) had almost double the odds of a head and/or neck injury (compared with all of the other body regions, OR: 1.9) or a fracture (compared with all of the other diagnoses, OR: 1.7). Boys had double the odds of being injured during the underwater dive sequence (versus all of the other stages of the dive, OR: 2.0) and nearly twice the odds of injury because of contact with the bottom of a pool (versus all of the other sources of interference, OR: 1.9).

Compared with other body regions, the odds of a laceration (versus another diagnosis) were >5 times greater when the injury occurred to the face (OR: 5.1), whereas the odds of a fracture (versus another diagnosis) were 7.6 times higher for injuries to the upper extremities. The odds of a laceration (versus another diagnosis) were 3.1 times higher if the dive direction was backward (compared with forward) and 2.1 times higher if there was contact with the diving board and/or platform (compared with other types of interference).

The odds of injury to the lower extremities (compared with other body regions) were elevated when the dive skill was a jump or cannonball dive (versus other dive skills, OR: 4.7), when it occurred during the on-board or platform stage of the dive sequence (versus any other stage, OR: 4.7), or when there was contact with the diving board or platform (compared with any other type of interference, OR: 5.9). The odds of injury to the head and/or neck (versus any other body region) were significantly increased when the dive skill was a flip or handstand (compared with any other dive skill, OR: 2.4), when there was contact with the bottom of the pool (compared with any other type of interference, OR: 2.5), or when the injury occurred during the underwater stage of the dive sequence (compared with any other stage, OR: 2.9).

The odds of hospitalization were 6.0 times higher when the injury diagnosis was a fracture compared with all of the other diagnoses. A dive height >1 m (versus ≤1 m) increased the odds of hospitalization by ~5 times (OR: 4.9). Diving into a nonpool body of water increased the odds of hospitalization by 3.5.

The odds of an injury from contact with the diving board (versus any other type of interference) were 25.3 times higher if the direction of the dive was backward and 9.2 times higher if the dive skill performed was a handstand or flip (compared with any other dive skill). The odds of injury from contact with the water alone (compared with any other type of interference) were >16.4 times greater when the dive height was >1 m and 10.1 times higher when the body of water was not a pool. A dive height of >1 m also increased the odds of injury during the water entry stage of the dive sequence (versus any other stage, OR: 9.5) and when the dive occurred in a nonpool body of (OR: 8.1).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Many sources cite diving as a high-risk athletic activity9,11,18,23,32 but largely neglect to discuss injuries other than catastrophic spinal cord injuries or injuries among younger participants, particularly when focusing on recreational diving injuries.7,14,18 An expected seasonal variation in diving-related injury was found, with the vast majority of injuries occurring during the summer months, which correspond with summer vacation and a well-recognized peak in recreational aquatic sports participation.8,9,14,20,22,38 The nearly two thirds of diving-related injuries occurred among children <15 years of age. This contrasts with most previous published literature asserting that diving injuries occur predominately among older teenagers and young adults who suffer either an acute injury from a recreational dive into water of an unknown depth3,8,11–14,17,18,22 or a chronic injury from the repetitive forces experienced by a competitive diver during the many hours spent training.5,7,25,26,28 A total of 90% of diving-related injuries over the 17-year study period occurred in swimming pools.

Older children had increased odds of suffering injuries during the underwater dive stage and from contact with the bottom of pools compared with younger children. Injuries occurring during the underwater dive sequence or because of contact with the bottom of a pool increased the odds of a head and/or neck injury. Thus, older, male divers may be at higher risk for traumatic head and/or neck injuries, a finding consistent with previous studies.7–23

Children ≤4 years of age had higher odds of injury to the face, whereas those aged 10 to 19 had higher odds of an injury to the extremities. Children <10 years old had higher odds of a laceration, whereas those 10 to 19 years old had increased odds of fractures. Possible explanations for these findings are that younger children have a high center of gravity and tend to fall headfirst,39 and/or the higher prevalence of extremity injuries among older children may represent the increased participation in year-round competitive diving with a higher prevalence of stress fractures and other types of acute injuries that have been documented with increasing years of training, competition, and more difficult diving skills being attempted.5,7,24

Collision with the diving board was the most frequent proximate cause of injury for all of the children (44%). Even 15- to 19-year-olds, who had higher odds of sustaining an underwater injury from contact with the bottom of the pool, had a greater overall number of injuries resulting from contact with the diving board. The odds of colliding with a diving board or platform were dramatically increased if the diver was attempting a flipping or handstand maneuver or backward dive. Successful execution of higher complexity diving maneuvers requires greater strength, flexibility, and spatial orientation than completion of less intricate maneuvers.24,40

Injuries during the water entry dive stage were associated significantly with the upper extremities and trunk, as well with a diagnosis of sprain or strain. Diving from a height at >1 m dramatically increased the odds of injury because of contact with the water only. The majority of competitive diving injuries have been documented as occurring during the water entry stage of the dive as a result of the force that the diver's body sustains on impact with the water.3,5,24 Most studies document water entry injuries as occurring to the upper extremities and lumbar spine, with diagnoses of strains, sprains, and fractures.3,5,24

Prevention strategies have been proposed to reduce diving-related injuries, these include: stretching and strengthening to prevent shoulder injuries for competitive divers,41 education to prevent young children from jumping into shallow or turbid water from the pool edge,42 supervision or presence of a lifeguard,13 visible depth indicators around the pool,13 teaching proper diving technique when attempting new and unusual dives,13 and soft pool bottoms and removal of obstacles from lakes, rivers, and oceans.15 A combination of these recommendations and strategies warrants consideration given our study findings. In addition, given the high percentage of cases because of diving-board interference, educational efforts aimed at improving diving-board safety may be useful.

This study has several limitations. The total number of diving-related injuries was most likely underestimated, because the NEISS sampling frame only captures injuries treated in EDs. Accordingly, the estimates of this study may not be representative of diving-related injuries treated by urgent care centers, family physicians, physical therapists, trainers, or any other source of medical care. We were unable to distinguish between competitive and recreational dives because of the lack of detail in case narratives. Our study does not address diving fatalities, because the NEISS is generally not regarded as useful for identifying fatal injuries. We do not have diving exposure data for children <20 years old; therefore, we could not calculate risks. ORs were used to determine the degree of association between variables and to approximate risk. Despite these limitations, the strengths of this study are its large, nationally representative sample and its 17-year study period.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The findings of this study can help inform pediatricians, parents, coaches, and trainers regarding the types of injuries seen during recreational and competitive diving, as well as associated risk factors. This information can guide future prevention efforts.


   ACKNOWLEDGMENTS
 
We thank Brenda Shields, MS (Center for Injury Research and Policy, Columbus, OH) for helpful comments and suggestions concerning this article.


   FOOTNOTES
 
Accepted Mar 4, 2008.

Address correspondence to Lara B. McKenzie, PhD, MA, Center for Injury Research and Policy, Research Institute, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: lara.mckenzie{at}nationwidechildrens.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Recreational swimming and diving are the third most common physical activities in the country (after walking and camping) and the most common among children.

 

What This Study Adds

This is the first study to examine national rates of diving-related injuries for both recreational and competitive diving. Diving-related injuries among pediatric patients can be severe (eg, fractures and head and/or neck trauma) and require hospital admission.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




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