Abstract
Objective. To assess pediatricians' knowledge about the epidemiology of childhood drowning, their opinions and current practices regarding its prevention, and their interest in taking on more responsibility for its prevention.
Design. A self-administered questionnaire was mailed to 800 pediatricians in the United States, randomly selected from the American Academy of Pediatrics' approximately 18 000 full fellows.
Results. A total of 560 completed surveys were returned, a response rate of 70.1%. Although 85% of respondents believe it is the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning, only 4.1% were involved in such efforts. Only a minority of respondents provided written materials and anticipatory guidance on drowning prevention to their patients. Women were more likely than men to discuss drowning prevention with their patients. Younger physicians were more likely than older physicians to discuss drowning prevention with their patients. Physicians who received formal education on drowning prevention during their pediatric residency training were more likely to provide written materials and anticipatory guidance on drowning prevention to their patients. However, only 17.9% of respondents received formal education on drowning prevention during their pediatric residency training. Seventy-four percent of all respondents felt that further education on the prevention of childhood drowning and near-drowning would be useful to them.
Conclusion. Although drowning is the second leading cause of death by unintentional injury in the pediatric population (aged 0 to 19 years), most pediatricians do not routinely provide information to their patients, or to their patients' parents, on drowning prevention.
Implication. Pediatricians have been effective child advocates in many areas of injury prevention. If the prevention of drowning is made a priority in pediatric practice, many more children's lives will be saved.
- US =
- United States •
- AAP =
- American Academy of Pediatrics
Drowning and near-drowning (we define a “drowning” as an immersion incident that leads to death within 24 hours of the incident, and a “near-drowning” as an immersion incident in which there is survival for at least 24 hours after the incident) are a significant cause of morbidity and mortality in the United States (US). More than 2000 children die each year by drowning, which places drowning as the second leading cause of death by unintentional injury in the pediatric population (aged 0 to 19 years).1,2 Toddlers and teenagers account for an inordinate number of these drowning and near-drowning events. In at least three states (Arizona, California, and Florida), drowning is the leading cause of death by injury in children less than 5 years old.3-5 In the US, the death rate from drowning in the pediatric age group is 3–5/100 000 children (aged 0 to 19) per year.3,6-8 Although childhood drowning morbidity data is collected much less rigorously than mortality data, it is estimated that the near-drowning rate is 10–14/100 000 per year.5,7,9 Up to 20% of near-drowning survivors experience permanent neurologic sequelae.3,10-12 Several investigators have shown that there are approximately four hospitalizations for every drowning death, and approximately four visits to the emergency department for every hospitalization.4,5,10
Boys are 2 to 10 times more likely to drown than are girls.6,8-10,13,14 The drowning rate in boys peaks at age 2, and again at age 16 to 18.6,8,9 The second peak in boys is primarily attributed to the three “Ds”—drinking, drugs, and dares. Alcohol and/or illicit drug use are a contributing factor in 40% to 50% of adolescent drownings.1,4 The drowning rate in girls peaks around age 1, and does not peak again during the adolescent years.6 As adolescents, girls are less likely than boys to be influenced by drinking, drugs, and dares.
In the toddler age group, boys are more likely to drown, less likely to survive a near-drowning, and more likely to be found in full arrest than are girls.12 Although difficult to evaluate, this probably relates to longer immersion times in boys. For sociocultural reasons, boy toddlers may be allowed more freedom of exploration than are girls. Consistent with higher drowning rates in boys is the fact that boys account for the majority of all injuries in the toddler age group.2,6
Drowning rates are highest in the southern and western states and in Alaska.6,15 Drowning rates are higher in rural areas than in urban or suburban areas, attributable in part to decreased access to emergency medical care in rural areas.6 The overall pediatric drowning rate has been declining since the 1960s, but the rate of swimming pool drownings has steadily increased, reflecting increased access to swimming pools.5,6 The number of residential swimming pools has increased from 10 000 in 1950 to 3.4 million in-ground pools and 3.2 million above-ground pools today.16
Sixty to ninety percent of drownings in children less than 5 years old occur in residential swimming pools.3,4,7,17,18 Nearly two thirds of these drownings occur in the child's home pool. An additional third occur in relatives' or neighbors' pools. In most cases, the child has been unsupervised for less than 5 minutes.18,19 Bathtubs are the second most common site of drowning in young children.6,13,14,20 Bathtubs are a particular threat to children 6 months to 1 year old, who can sit but may not be able to right themselves if submerged. Five-gallon cleaning buckets have also led to a number of drowning deaths in children under the age of 1 year.4,21 Hot tubs pose a growing threat to young children as more and more people have them installed in their homes.18
Sixty to eighty percent of pediatric drownings occur in the summer months—from May to August.6,9,17,22 This is true even in areas with year-round warm climates such as southern California and southern Florida. Although the consistency of the pattern across climates has not been fully explained, it may in part be related to the school year. Overall, drowning rates are highest on Friday through Sunday, presumably secondary to a concentration of drinking and/or boating on those days.6,17,22 In toddlers, drowning rates are highest at noon and 6 pm, when their care takers are likely to become preoccupied with other concerns.
DESIGN AND METHODS
A questionnaire was developed to assess pediatricians' knowledge about the epidemiology of childhood drowning, their opinions and current practices regarding its prevention, and their interest in taking on more responsibility for its prevention. To determine what factors might influence a pediatrician's concern for this topic, information was collected on demographic variables, residency training, and current practice type. The survey was pretested on 24 pediatricians known to one of the authors.
A random sample of 800 US pediatricians was selected from the membership list of the American Academy of Pediatrics (AAP). One selected pediatrician was immediately disqualified for having participated in the pretest. The approximately 18 000 full fellows of the AAP were eligible for random selection. Resident fellows, postresidency training fellows, candidate fellows, emeritus fellows, and honorary fellows were excluded from eligibility because they were less likely to have an established clinical practice. Because the consequences of pediatric drowning can affect all pediatricians, primary care and subspecialty pediatricians were included in the sample.
The survey was administered to all 799 pediatricians according to a protocol modified from the Total Design Method developed by Dillman.23,24 An initial packet, consisting of a cover letter, questionnaire, and postage-paid return envelope, was sent to the 799 pediatricians. One week after the initial mailout, a reminder postcard was sent. Three weeks after the initial mailout, a second packet, consisting of a cover letter, a questionnaire, and a postage-paid return envelope, was sent to all nonrespondents. Finally, 7 weeks after the initial mailout, a third packet, consisting of a handwritten note, a questionnaire, and a postage-paid return envelope, was sent to those who still had not responded. The survey was conducted in March, April, and May of 1993. The study was approved by the Institutional Review Board of the University of Minnesota. All survey responses were handled confidentially. Data analysis was performed using the Statistical Analysis System, Version 6.08 (SAS Institute Inc, Cary, NC). Ninety-five percent confidence intervals and χ2 tests of significance were performed where indicated. An α level of 0.05 was considered significant.
RESULTS
A total of 560 completed surveys were returned for a response rate of 70.1%, with 70.2% of respondents male, 28.8% female, and 1% not answering this question. Thirty-seven respondents (6.6%) were 25 to 34 years old, 259 (46.3%) were 35 to 44 years old, 164 (29.3%) were 45 to 54 years old, 72 (12.9%) were 55 to 64 years old, and 22 (3.9%) were over 65 years old. Responses were received from 46 states and the District of Columbia. At least one response was received from graduates of 149 of the 214 US residency training programs. In addition, responses were received from graduates of 8 foreign programs. Over 91% of respondents were practicing pediatricians, 3.8% were in administration, and 4.1% were in specialties that overlap with pediatrics. Seventy-one percent of the practicing pediatricians were generalists, and 28% were subspecialists. Sixty-six percent of those who responded said that they were primarily community-based, and 31% responded that they were primarily hospital-based. Twenty-two percent of the respondents were primarily in academic medicine.
Three hundred ninety-three respondents said they provided primary care to children (aged 0 to 19 years). Their current practices of providing written materials concerning accident prevention are summarized in Fig1. Three hundred eighty-nine respondents routinely provided verbal anticipatory guidance to parents of younger children (less than or equal to 12 years), and 382 respondents routinely provided anticipatory guidance to adolescent patients (greater than 12 years). Their current routines for discussing different types of accident prevention are also summarized in Fig 1.
Accident prevention practices among primary care providers. Error bars represent 95% confidence intervals. Significance tests using paired data were performed for each prevention measure versus drowning prevention. Primary care providers more commonly advised their patients on these other accident prevention measures than on drowning prevention (P < .001).
Only 17.9% of respondents remembered receiving formal education on drowning prevention during their pediatric residency training. Twenty-three people (4.1% of respondents) were personally involved in community education or legislative efforts to prevent childhood drowning. An additional 18.6% of respondents were aware of educational or legislative efforts to prevent childhood drowning in their communities.
Eighty-five percent of respondents answered that they believe it to be the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning. Overall, respondents felt that pediatricians could be most effective in the prevention of childhood drowning by providing drowning prevention information at routine well-child checks. Strategies considered less effective, but still potentially effective, included working with local community organizations, working through the AAP's Committee on Injury and Poison Prevention, and lobbying for legislation that would help protect children and adolescents from drowning.
When asked what sources of information on pediatric drowning prevention had been useful to them, more than one third responded that continuing education, medical journals, and AAP brochures had been helpful or very helpful sources of information. Less helpful sources included medical meetings, the lay press, and discussions with colleagues. Seventy-four percent of all respondents felt that further education on the prevention of childhood drowning and near-drowning would be useful to them.
Women were more likely than men to discuss drowning prevention both with parents of patients less than or equal to 12 years old and with their adolescent patients (Fig 2). This difference was seen in each age category of practitioner except in the youngest category (age 25 to 34 years, N = 37), where practices between men and women are similar. Twenty men (5.1% of the male respondents) and 3 women (1.9% of the female respondents) reported being personally involved in community education or legislative efforts to prevent childhood drowning. A slightly larger percentage of women than men (90.5% of women vs 87.1% of men) believe it is the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning, although this difference was not statistically significant at P < .05. Women were more likely than men to express an interest in further education on the prevention of childhood drowning and near-drowning (86.5% of women vs 73.1% of men, χ2 = 10.99, P < .01).
Drowning prevention practice differences between male and female providers.
The data were analyzed separately according to five age categories: 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, and greater than 65 years. The youngest age group of physicians was the most likely to discuss drowning prevention as a part of anticipatory guidance. This is not surprising, because younger physicians were more likely to have received formal education on drowning prevention during their pediatric residency training (Fig 3). Physicians who received formal education on drowning prevention during their pediatric residency training were significantly more likely to provide written materials and anticipatory guidance on drowning prevention to their patients (Fig 4). Across the five age categories, younger physicians were progressively more likely to express an interest in further education on the prevention of childhood drowning and near-drowning.
Percent of respondents who received formal education on drowning prevention during their pediatric residency training, by age group. A significance test for trend across the five age groups was performed, χ2 = 33.9, P < .001.
Relationship between formal education on drowning prevention during pediatric residency training and current drowning prevention practices.
Ten generalists (2.8% of the generalists) and 11 subspecialists (7.8% of the subspecialists) were personally involved in community education or legislative efforts to prevent childhood drowning. Ninety-three percent of subspecialists and 85% of generalists believe it is the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning (χ2 = 5.33, P < .05). Eighty-five percent of generalists versus 63% of subspecialists expressed an interest in further education on the prevention of childhood drowning and near-drowning (χ2 = 30.50, P < .01).
Hospital-based physicians were more likely than community-based physicians to include drowning prevention in their anticipatory guidance to parents of children less than or equal to 12 years (58.8% vs 50.1%) and to adolescent patients (42.6% vs 32.1%), although these differences were not statistically significant atP < .05. Eleven hospital-based physicians (6.9% of the hospital-based physicians) and 10 community-based physicians (3.0% of the community-based physicians) were actively involved in community education or legislative efforts to prevent childhood drowning. Ninety-three percent of hospital-based physicians and 85% of community-based physicians believe it is the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning (χ2 = 6.60, P = .01). Community-based physicians were more likely to express an interest in continuing education on the prevention of childhood drowning and near-drowning—84.0% versus 69.5% (χ2 = 13.44, P < .01).
DISCUSSION
Although pediatricians are conscientious about providing written materials and anticipatory guidance to their patients on a variety of other injury-related topics (general accident prevention, car seat and safety belt use, driving safety, bicycle safety, poison prevention, and alcohol and drug use), most do not routinely provide information to their patients on drowning prevention (Fig 1). Those who received formal education on drowning prevention during their pediatric residency training were more likely to discuss drowning prevention with their patients. Unfortunately, over 80% of the respondents did not receive any such information during their residency training. Not surprisingly, 74% of all respondents felt that further education on the prevention of childhood drowning and near-drowning would be useful to them.
Many aspects of drowning prevention can be effectively addressed through anticipatory guidance. The 1987 US Consumer Product Safety Commission report on childhood drowning estimated that at the time of drowning 69% of young children were being supervised by one or both parents, and that a lapse of supervision occurred for only a few minutes.19 Pediatricians are in an ideal position to make this fact known to parents. It should be emphasized to parents that young children should never be left unattended near a pool or in a bathtub. Pediatricians should make an effort to identify pool owners, and then direct specific anticipatory guidance toward them. Pool owners should be reminded to keep toys away from and out of pools, as these can attract children to the pool's edge. Pool owners should be strongly encouraged to fence their pools in such a manner as to completely isolate the pool from the house, so that there is no access to the pool from the house.5,18,25-27 The pool fence should be nonclimbable, at least five feet in height, and have a self-closing and self-latching gate.5 Pool owners should also be encouraged to have a phone installed poolside, both for emergency use and to eliminate the need to leave the pool area to answer the phone. Finally, pool owners should be advised that currently available pool covers and pool alarm systems cannot be depended on to prevent childhood drownings.5,28
Parents can be encouraged to teach their children over 3 years old to swim, but should be cautioned that even children who know how to swim are not “drown-proof.” Cardiopulmonary resuscitation training should be advocated, particularly among pool owners, because immediate resuscitation at the scene by someone trained in cardiopulmonary resuscitation has been shown to improve a victim's chance of survival without disability.11,12,29,30 Bathtub safety should be reviewed at both the 6- and 9-month visits, and parents of toddlers should be reminded not to leave out any buckets partially filled with water. A review of boating safety should include the use of personal flotation devices. Finally, adolescent patients should be warned of the dangers of mixing alcohol and water-related activities. Efforts to reduce alcohol and drug use in adolescents should continue.5,28
Although 85% of respondents believe it is the responsibility of pediatricians to become involved in community and/or legislative efforts to prevent childhood drowning, only 4.1% are currently involved in such efforts. Many pediatric drownings and near-drownings are amenable to primary prevention through legislative or community efforts. Pool fencing, which has been studied extensively in Australia and New Zealand, has been shown to significantly decrease the risk of swimming pool drownings.25-27,31 The widespread use of pool fencing could prevent an estimated 60% to 90% of pediatric swimming pool drownings.19,31 It has been shown that swimming pool owners are unlikely to voluntarily fence their pools.32 Currently, only 15% of in-ground pools in the US are adequately fenced.19 Pediatricians are in a powerful position to influence the legislation of appropriate pool fencing. In addition, stricter regulation of alcohol consumption at water recreation areas by communities could prevent a number of adolescent drownings.5 Finally, pediatricians should support research in the epidemiology, prevention, and treatment of childhood drowning, and encourage the pool and spa industries to continue to develop effective drowning prevention technologies.
Pediatricians have a strong history of child advocacy. As the primary threat to child health has evolved from infectious disease to injury, pediatricians have taken on an increasingly active role in injury prevention. In 1952, the AAP's newly established Accident Prevention Committee first surveyed the Academy membership (then about 3000) regarding common childhood injuries in the home and found that 50% of the reported injuries involved some type of poisoning. As a result of the Committee's survey, the first poison control center was established in Chicago in 1953. The movement spread quickly, and soon there were more than 200 poison control centers, almost all of which were managed by pediatricians. In 1958 the American Association of Poison Control Centers was established. Seventy-five percent of its members were pediatricians. A decade later, pediatricians in cooperation with the pharmaceutical companies were instrumental in promoting the Poison Prevention Packaging Act, which became law in 1970. Overall, poisoning deaths in children have been reduced more than fourfold since the 1960s (up to 40-fold in the case of aspirin).6,33
Today, the number of young children who drown in residential swimming pools annually is approximately the same as the number of young children who died by poisoning in the year before the enactment of the Poison Prevention Packaging Act.19 As with poisoning, many interventional strategies, both educational and legislative, are available to pediatricians to combat childhood drowning. If the prevention of childhood drowning is made a priority in pediatric practice, many more children's lives will be saved.
ACKNOWLEDGMENTS
This research was supported by a grant from the Division of Epidemiology at the University of Minnesota's School of Public Health.
The authors wish to thank Karen Virnig for technical assistance and Pat Brothen for data entry.
Footnotes
- Received August 8, 1995.
- Accepted March 14, 1996.
Reprint requests to (J.E.O.) University of Virginia, Box 238, Health Sciences Center, Charlottesville, VA 22908.
REFERENCES
Summary of Knowledge Questions Included in Survey
- Copyright © 1997 American Academy of Pediatrics
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