The burden of unintentional drowning: global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study

A reappraisal of childhood drowning in a pediatric emergency department

BACKGROUND

In the present study, we aimed to investigate the demographic and clinical features, laboratory and radiologic characteristics, management, and outcomes of pediatric drowning patients in order to identify predictors of hospital admission, and to evaluate the need for respiratory support, and prognosis.

METHODS

In this retrospective chart review, children aged 0 to 18 years who presented to the pediatric emergency department due to drowning between July 2009 and September 2019 were included. Demographics, initial vital signs, clinical findings, laboratory and radiologic results, and the need for respiratory support or cardiopulmonary resuscitation in the emergency department were recorded. Subjects were divided into 6 groups using the Szpilman classification system.

RESULTS

A total of 89 patients were enrolled. Among the children who were admitted to the hospital, initial Szpilman score, crepitations on lung auscultation, and pathologic chest X-ray (CXR) findings were higher and Glasgow Coma Score and oxygen saturation (SpO 2) levels were lower than those of children who were discharged from the emergency department. A Szpilman score of ≥4, a lactate level of >2 mmol/L, and pathologic CXR findings were identified as predictors of hospital admission. Of the 89 patients, 22 (24.7%) underwent non-invasive ventilation (NIV) treatment and were classified as grade 3 or 4 according to the Szpilman score. Length of stay in the pediatric intensive care unit (PICU) and in the hospital was lower in patients who underwent NIV. As the Szpilman score increased as of grade 3, a positive correlation was observed with lactate levels (p <0.001, r: 0.552) and the total length of stay in the hospital (p: 0.001, r : 0.491), both of which gradually increased.

CONCLUSION

The Szpilman score was associated with the duration of hospital stay and the degree of hypoxia, so it could help the physician make rapid decisions on ventilation strategy. Application of NIV in the emergency department shortened the length of stay in the PICU and in the hospital, suggesting that it can be used more often in pediatric emergency settings.

Exploring the Impact of Remoteness and Socio-Economic Status on Child and Adolescent Injury-Related Mortality in Australia

Injuries are a leading cause of harm for children. This study explores the impact of determinants of health on children (0-19 years) injury-related mortality (namely remoteness and socio-economic disadvantage, calculated using the index of relative socio-economic advantage and disadvantage (IRSAD)). Cause of death data from the Australian Bureau of Statistics were sourced for children in Australia between 1 July 2007 to 30 June 2017. Fifteen injury categories (ICD-10-AM external cause codes) were used. Burden and trends by injury mechanism were explored. A total of 5153 children died; with road traffic incidents (3.39 per 100,000 population), intentional self-harm (2.46) and drowning (0.72) being the leading mechanisms. Female fatality rates in very remote areas (8.73) were nine times higher than in major cities (Relative Risk [RR] = 8.73; 95% Confidence Interval [95% CI]: 4.23-18.00). Fatality rates increased with remoteness; very remote areas recording an injury-related fatality rated six times (RR = 5.84; 95% CI: 3.76-9.12) that of major city residents. Accidental poisoning and intentional self-harm fatalities were more likely in high IRSAD areas, while road traffic fatalities were more likely in low and mid socio-economic areas (X2 = 69.1; p < 0.001). People residing in regional and remote areas and from low socio-economic backgrounds already face significant health and lifestyle challenges associated with disadvantage. It is time to invest in injury prevention interventions for these populations, as well as upstream policy strategies to minimize any further preventable loss of life.

Impact of community-based first responder development for the management of drowning casualties in rural areas of Bangladesh

BACKGROUND

Drowning is the leading cause of childhood death in Bangladesh. In order to minimize the number of casualties Centre for Injury Prevention and Research, Bangladesh (CIPRB) incorporated a 'first responder' program which includes Cardio Pulmonary Resuscitation (CPR), in community based drowning prevention program, SwimSafe. Along with swimming lessons, swimming instructors provide first responder services in the community. The objective of this study was to describe the results of the volunteer based first responder services for the management of drowned casualties between 2012 and 2015 in the rural communities of Bangladesh.

METHODS

Adolescents and youths who volunteered as community swimming instructors were trained as first responders to provide first aid and resuscitation in the community. Trainers from the International Drowning Research Centre Bangladesh (IDRC-B) of CIPRB delivered the training. The first responders were also trained on the documentation of the first responder services they provided in the community. The documented records were collected from the volunteers on a regular basis; when drowning cases were reported CIPRB management followed up with an in depth data collection, using a structured form.

RESULTS

2,305 community volunteers were trained between 2012 and 2015. Of them 1,461 reported providing first responder services among 6,773 casualties, including 184 drowning casualties. Of the drowning casualties, volunteers treated 31 casualties with Cardiopulmonary Resuscitation (CPR), 51 casualties by putting into the recovery position and 102 casualties were treated for the shock on site. Of those given CPR, 22 (71%) survived and 9 (29%) died. After receiving treatment from the first responder 104 (56.5%) of the drowning casualties were referred to health facilities for further treatment.

CONCLUSIONS

The training of community first responders seems to be an effective way of managing and reducing drowning causalities in countries like Bangladesh, where drowning is a significant public health hazard.

Next steps for drowning prevention in rural and remote Australia: A systematic review of the literature

OBJECTIVE

To examine unintentional drowning by remoteness in Australia.

DESIGN

A systematic review of both peer-reviewed and grey literature published between January 1990 and December 2019 (inclusive).

METHOD

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest), SPORTDiscus and Google Scholar were searched for studies exploring fatal and non-fatal unintentional drowning by remoteness. Epidemiological data, common factors and prevention strategies were extracted and mapped to Australian standard geographical classifications (major cities, inner regional, outer regional, remote and very remote). Level of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation and prevention strategies aligned to the hierarchy of control.

RESULT

Thirty-two studies satisfied inclusion criteria (66% reporting epidemiology; 59% risk factors; and 44% prevention strategies). All (100%) included studies were assessed very low against Grading of Recommendations Assessment, Development and Evaluation. Findings indicate rural populations (ie, excluding major cities) have higher rates of drowning positively correlated with increasing remoteness. Common factors included age (child), natural water bodies, undertaking boating and watercraft activities and alcohol consumption. While a range of prevention strategies has been proposed, only one study outlined a rural drowning prevention strategy which had been implemented and evaluated. Strategies were generally low on the hierarchy of control.

CONCLUSION

Rural populations are proportionately overrepresented in drowning statistics. Proposed prevention strategies have unknown efficacy. Greater research into rural drowning of Australians is needed especially exploring behavioural motivations, program delivery, cost-effectiveness and evaluation. Development and use of a standard definition for remoteness are recommended. Rural populations use water extensively; therefore, there is an urgent need to keep them safe.

Medical care-seeking behaviours among drowning casualties: Results from a national survey conducted in Bangladesh

Objective

Despite the high magnitude of drowning, medical care-seeking behaviours among drowning casualties remain unexplored in Bangladesh. This study aimed to explore this behaviour among drowning casualties in Bangladesh.

Methods

A population-based cross-sectional study was conducted using a multi-stage cluster sampling method. Data were collected using a structured questionnaire from 299,216 rural and urban residents.

Results

From the survey, we found 191 drowning cases: 40.84% (n = 78) were fatal and 59.16% (n = 113) were non-fatal. Among the drowning cases, 71.2% (n = 136) were referred to healthcare providers, while 62.8% (n = 120) received medical care from different health service providers. Further analysis showed that 66.6% (n = 116) of children and 26.6% (n = 4) of adults sought healthcare. As many as 78.9% (n = 120/152) of rural residents sought healthcare, as compared to 61.5% (n = 24/39) of urban residents. Among all drowning casualties, 31.7% (n = 38) received healthcare from a qualified healthcare provider, whereas 68.3% (n = 82) received it from non-qual]ified healthcare providers. About 59 (49%) casualties received care from a pharmacy and 34 (28%) from a recognised hospital. The hospital admission rate for drowning was 11.7%. About 14 (11.7%) drowning casualties were brought to hospitals in motorised or non-motorised vehicles. As many as 97 (80.8%) patients sought healthcare attention and managed to survive.

Conclusion

A significant number of drowning casualties sought medical care from qualified and non-qualified healthcare providers. In Bangladesh, it is necessary to develop guidelines for providing medical care for drowning casualties.

Reducing inequities among adult female migrants at higher risk for drowning in Australia: The value of swimming and water safety programs

ISSUE ADDRESSED

Drowning is a global public health challenge with a need to ensure equity to drowning prevention information and interventions. In Australia, people born overseas are identified as being at greater risk of drowning. This paper presents findings from a community-based qualitative evaluation of swimming and water safety (SWS) programs delivered to adults from migrant backgrounds in Sydney, Australia.

METHODS

A qualitative study was conducted in November-December 2019 among 35 female participants of SWS programs targeted to adult migrants. While offered to all SWS program participants, no males took part in the study. Focus groups and interviews were recorded, transcribed and thematically analysed using a deductive approach. The domains of enquiry were guided by the health belief model and the theory of planned behaviour.

RESULTS

Study participants were ≥25 years, first generation and most had lived in Australia for ≥10 years. Most were nonswimmers and were fearful of water prior to the program. Key themes were: direct SWS program outcomes, health and well-being; enablers and barriers to participation including: motivation, a program coordinator, fear and settlement priorities.

CONCLUSION

Findings suggest that in order to increase SWS participation among migrant communities, the broader determinants of health need to be considered. Culturally appropriate strategies are required to enable both men and women equal opportunities to access SWS programs.

SO WHAT

SWS programs provide multiple benefits for adult migrants; however, the impact on reducing inequities is limited, with broader multi-strategic health promotion approaches and policies required for inclusion and sustainability.

The epidemiology of fatal drowning in children: a 13-year retrospective study in Turkey

This retrospective study aimed to investigate the prevalence of unintentional fatal drowning in children aged 0-17 years in Turkey between 2005 and 2017 and to determine the risk factors in drowning. This study is based on media reports, and all data were obtained from the media. All data were presented in frequency and percentage. Relative risk and 95% confidence intervals were calculated using the relevant population data. A total of 3,419 children died by drowning in these 13 years. The unintentional fatal child drowning rates in Turkey were 1.16; 1.80 for males and 0.48 for females per 100,000 children, which means males drowned nearly four times more than females. In terms of season, the highest rate of unintentional fatal drowning was in summer (0.69 per 100,000 children), and the lowest rate in winter (0.05 per 100,000 children). The unintentional fatal drowning rate decreased after reaching a peak in 2010 (1.52 per 100,000 children). As of 2015, the rate of unintentional fatal drowning decreased every year and reached a minimum in 2017 (0.66 per 100,000 children). Even if the mortality rate in children has decreased in recent years, more measures are still needed to prevent drowning in children.

Is Low-Frequency Electrical Stimulation a Tool for Recovery after a Water Rescue? A Cross-Over Study with Lifeguards

This study aimed to evaluate the degree to which transcutaneous electrical stimulation (ES) enhanced recovery following a simulated water rescue. Twenty-six lifeguards participated in this study. The rescue consisted of swimming 100 m with fins and rescue-tube: 50 m swim approach and 50 m tow-in a simulated victim. Blood lactate clearance, rated perceived effort (RPE), and muscle contractile properties were evaluated at baseline, after the water rescue, and after ES or passive-recovery control condition (PR) protocol. Tensiomiography, RPE, and blood lactate basal levels indicated equivalence between both groups. There was no change in tensiomiography from pre to post-recovery and no difference between recovery protocols. Overall-RPE, legs-RPE and arms-RPE after ES (mean ± SD; 2.7 ± 1.53, 2.65 ± 1.66, and 2.30 ± 1.84, respectively) were moderately lower than after PR (3.57 ± 2.4, 3.71 ± 2.43, and 3.29 ± 1.79, respectively) (p = 0.016, p = 0.010, p = 0.028, respectively). There was a significantly lower blood lactate level after recovery in ES than in PR (mean ± SD; 4.77 ± 1.86 mmol·L^-1 vs. 6.27 ± 3.69 mmol·L^-1; p = 0.045). Low-frequency ES immediately after a water rescue is an effective recovery strategy to clear out blood lactate concentration.

Aquatic Competencies and Drowning Prevention in Children 2–4 Years: A Systematic Review

Aquatic competencies have been proposed as a prevention strategy for children aged 2–4 years who are over-represented in drowning statistics. For this recommendation to be made, exploration of the connection between aquatic competencies and drowning is required. This review critically analyzed studies exploring aquatic competencies and their effect on drowning and/or injury severity in children 2–4 years. English language peer-reviewed literature up to 31 July 2019 was searched and the PRISMA process utilized. Data were extracted from twelve studies that fulfilled the inclusion criteria. Findings from this study included that aquatic competencies were not found to increase risk of drowning and demonstrated children aged 2–4 years are capable of developing age-appropriate aquatic competencies. Age-appropriate aquatic competencies extracted were propulsion/locomotion, flotation/buoyancy, water familiarization, submersion and water exits. The acquisition of these competencies holds benefit for the prevention of drowning. No evidence was found relating to injury severity. There was limited exploration of the relationship between aquatic competencies attainment and age-related developmental readiness. The review highlights the need for consistent measures of exposure, clarity around skills acquisition, better age-specific data (2 years vs. 3 years vs. 4 years), studies with larger sample sizes, further exploration of the dose–response relationship and consistent skill level testing across age groups. Further investigation is required to establish the efficacy of aquatic competencies as a drowning prevention intervention, as well as exploring the relationship between aquatic competencies and age-related developmental readiness. In conclusion, early evidence suggests aquatic competencies can help to reduce drowning.

Fatal intentional drowning in Australia: A systematic literature review of rates and risk factors

INTRODUCTION

Unintentional drowning deaths are only part of the drowning profile, with little attention being paid to intentional drowning in Australia. Strategies for the prevention of intentional drowning deaths are likely to be different from unintentional. Quality documentation, analysis and dissemination of intentional deaths data is crucial for developing appropriate strategies for prevention.

OBJECTIVE

To conduct a systematic literature review to investigate the mortality rates and risk factors of intentional drowning deaths in Australia.

METHODS

A systematic search guided by PRISMA was performed using Ovid MEDLINE, CINAHL, PsycINFO (ProQuest), Scopus, Google Scholar, and BioMed Central databases to locate relevant original research articles published between 2007 and 2018.

RESULTS

Ten papers reporting the mortality rates and risk factors of intentional drowning deaths in Australia published between 2007 and 2018, with study periods of the included articles spanning from 1907 to 2012, were reviewed. Most studies investigated suicidal drowning deaths in Australia, none reported homicidal drowning deaths. The downward trend of fatal suicide drowning was identified in Australia. The annual rate of intentional drowning between 1994 and 2012 can be inferred from eight studies, ranging from 0.06 to 0.21 for nation-wide mortality rates. The highest annual state-wide mortality rate was identified in the state of Queensland, ranging from 0.02 to 0.11 per 100,000 individuals. Of four studies examining the risk factors of fatal intentional drowning in Australia, being of older age groups, being female, and the presence of substance use were identified as important factors for suicidal drowning deaths. The national-scale proportion of suicide drowning in Australia, ranging from 2% to 3% of all intentional self-harm deaths, was also identified.

CONCLUSION

Limited publications reporting the mortality rates and risk factors of intentional drowning deaths in Australia were identified. Being of older age groups and being female were recognised as factors for suicide drowning deaths, and psychoactive substances were widely identified amongst cases. Future research on improving death reporting systems and the legal framework for medico-legal death investigation, along with the investigation of the risk factors of intentional drowning, are required to inform the planning, implementation, and evaluation of prevention interventions for intentional drowning deaths in Australia.

Learning to Swim: An Exploration of Negative Prior Aquatic Experiences among Children

Learning to swim via a structured program is an important skill to develop aquatic competencies and prevent drowning. Fear of water can produce phobic behaviors counterproductive to the learning process. No research examines the influence of negative aquatic experiences on learning to swim. This study explored the influence of children’s negative prior aquatic experiences (NPAE) on learn-to-swim achievement via swim school data. Children’s enrolment records (5–12 years) in the Australian Capital Territory were analyzed via demographics, level achieved and NPAE. NPAE was recorded as yes/no, with free text thematically coded to 16 categories. Of 14,012 records analyzed (51% female; 64% aged 6–8 years), 535 (4%) reported a NPAE at enrolment. Males, children with a medical condition and attending public schools were significantly more likely (p = 0.001) to report a NPAE. Children reporting a NPAE achieved a lower average skill level at each year of age. The largest proportion (19%) of NPAE reported related to swimming lessons. NPAE have a detrimental influence on aquatic skill achievement. We recommend increased adult supervision to reduce likelihood of an NPAE occurring, while also encouraging swim instructors to consider NPAE when teaching swimming and develop procedures to ensure a NPAE does not occur during instruction.