Drowning is the leading cause of death in children ages 1 to 4 years and a common cause of death in toddlers and adolescents. New data released in May 2024 points to an urgent need for greater prevention: Among 1- to 4-year-olds, drowning deaths have increased 28% over the past 4 years.

Common Pediatric Drowning Risks and Scenarios

“In children under the age of 1, the overwhelming majority of drowning events happen in the home, most of them in bathtubs,” said Benjamin Hoffman, MD, FAAP, president of the  American Academy of Pediatrics (AAP). “Often this is due to momentary lapses in supervision. The parent leaves the room for 20 or 30 seconds to answer the door or to grab their phone. And tragically, children can drown in that short a period of time.”

When children become toddlers, their curiosity and newfound mobility draw them toward water, said Hoffman, who practices general pediatrics at Oregon Health and Science University Doernbecher Children’s Hospital in Portland. “This makes swimming pools and natural bodies of water significant hazards.”

In adolescence, poor decision making may collide with a lack of water competence and lead to drowning. “Teens don't always make the best decisions, and they tend to take risks,” Hoffman said. “Having access to open water, especially water that produces currents — whether it's large lakes or rivers or a nearby creek — can be especially risky.” 

Layers of Protection From Drowning

AAP has developed national and community initiatives for drowning prevention that focus on establishing layers of protection. In addition, AAP created an education program, Pediatric Education for Prehospital Professionals (PEPP) that equips emergency responders to respond skillfully and confidently to pediatric emergencies including drowning.  

In an interview with Public Safety Group, publisher of AAP’s manual for the PEPP program (Pediatric Education for Prehospital Professionals, 4^th edition), Hoffman outlined four layers of drowning prevention:

• Layer 1: Supervision and the development of water competency
• Layer 2: Establishing barriers to water access
• Layer 3: Consistent use of flotation devices
• Layer 4: CPR training

Supervision and water competency. Direct supervision of children while they are near or in water is essential to prevent drowning, Hoffman said. Hand in glove with supervision is teaching water competency to young children: the ability to float, move safely in water, and to get out of water. These skills are taught in standard swim lessons.

Barriers to water access. “If kids can’t get to water, they can’t drown,” Hoffman said. Placing four-sided fencing and a locked gate around a swimming pool can reduce drowning risk by 50%, he said. Adults should also block access to other water sources around the home. Empty spas and inflatable pools after use, install fencing around ponds, etc.

Flotation devices. “Wearing a life jacket absolutely saves lives,” Hoffman said. “Most states require life jacket use until age 13, but use tends to drop off after that. This increases risk and leads to tragedy.”  

CPR training. “In the event of a drowning, access to competent CPR can be lifesaving. It’s a crucial layer of protection,” Hoffman said. AAP recommends that parents and other adults who spend time around children receive CPR training in order to respond effectively in an emergency that has cardiopulmonary impact.

Challenges in the Prevention of Drowning

Despite layers of protection and best efforts by parents and surrounding adults, nearly 1,000 children die from drowning each year. Two reasons are steeped in circumstances that are difficult to change: human behavior and cultural or socioeconomic environments.

“Although supervision is absolutely essential and can be lifesaving, it can never be perfect,” Hoffman said. “Even the most attentive parent may still lose a child to drowning.”

A strategy to prevent this is appointing a dedicated “water watcher,” even when lifeguards are present. “The watcher has no phone, no book, no beverage — their job is to ensure eyes on the child in the water at all times,” Hoffman said.

Environments are another contributor to gaps in prevention. In some cultural and economic circumstances, access to swimming lessons and flotation devices is scarce, resulting in stark disparities in drowning rates.

"American Indian and Alaska Native children have the highest rates of drowning, often due to traditional practices like fishing, and limited access to water competency training," Hoffman said. "And as children get older, we see the impact on minoritized and marginalized communities. These disparities require a community commitment to address as many of the layers of protection as we possibly can."

Challenges particularly exist in economically disadvantaged communities. “In the same way that there are food deserts and issues around food security and housing security, access to swimming lessons or water competence is not necessarily a priority if you're worried about surviving day to day,” Hoffman said.

“Until we are willing to make the commitment and identify water competence as an essential life skill, in the same way we think about driver education and competence behind the wheel of a vehicle, I don't think we're going to be able to address this disparity in the way that we really need to,” he said.

AAP recognizes the many challenges in drowning prevention and has developed resources to help healthcare providers and other child advocates better equip their communities. The academy also has taken action on legislative fronts. Efforts by AAP include:

• Publication of a policy statement on the prevention of drowning 

• Issuance of a technical report on drowning prevention

• Development of a drowning prevention campaign toolkit for use in healthcare settings and community outreach 

• Federal and state advocacy for laws including reauthorization of the Virginia Graeme Baker Pool and Spa Act

How Emergency Responders can Prepare for Pediatric Emergencies

For emergency responders, being called to the scene of a pediatric drowning can be especially challenging. Read the recollections of one paramedic here.

‘When a prehospital provider responds to a drowning call, the number one need is ensuring that everyone will be safe,” Hoffman said. “We see tragic circumstances in which a child or adolescent has submerged, and somebody goes to get them and ends up drowning as well. Making sure that the rescue is as safe as possible, by being as prepared as possible, will reduce the likelihood of  putting other people at risk.”

To equip prehospital providers to manage pediatric emergencies including drowning, AAP developed the PEPP course. Hoffman credits it with building knowledge as well as confidence.

“Pediatric emergencies and drownings are incredibly tragic, and I think one way to ensure that healthcare providers are as ready and prepared as possible is to have the knowledge, skills and attitude to be able to address these emergencies when they occur,” he said. “I think that's a place where something like PEPP can be really helpful, because it can help build your build your confidence as a first responder.”

PEPP training is distinct from a pediatric advanced live support (PALS) course in its focus and application, Hoffman said.

"PEPP covers all of the information that's contained in PALS, but it's specific to prehospital providers," Hoffman said. "It's a richer, more targeted education that’s specifically for prehospital providers, covering a comprehensive range of emergencies and situations that impact them."

To learn more about the PEPP course developed by AAP, visit the Pediatric Education for Prehospital Professionals homepage. Find information on the course textbook here.