IN TOO DEEP: Diving into Pediatric Drowning

by Alli Georgadarellis, MD (’21)
Teaching Resident Capstone Project
reviewed by Meghan Beucher, MD (Pediatric Emergency Medicine)

While summertime usually brings decreased patient volume in our hospital, it is often accompanied by increased traumas and injuries. Fatal and nonfatal drownings are unfortunate but common causes of pediatric injury and death. In fact, unintentional drowning is the leading cause of death in the 1-4 year old age group in the United States. Drowning doesn’t just affect younger children. We see a second peak among males in the 15-25 year old age group. For every child that dies from drowning, at least five more children are seen in the ED for treatment of non-fatal submersion injuries. Given how prevalent pediatric drowning is, it is important to not only understand the mechanism of injury and know the management on presentation, but as pediatricians it is also important to empower our patients and their families with education on prevention. 

Drowning affects multiple organ systems due to hypoxemia, which ultimately leads to tissue hypoxia. Most intuitively, drowning affects the lungs. Aspiration of fluid leads to surfactant wash out, which can result in noncardiogenic pulmonary edema and acute respiratory distress syndrome. Neurologic damage can result in increased intracranial pressure and cerebral edema. Patients may suffer arrhythmias (such as sinus tachycardia or sinus bradycardia) secondary to hypothermia as a result of submersion.

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It is important to immediately initiate resuscitation, with emphasis on ventilation. In contrast to typical cases of cardiac arrest, rescue breathing should begin as soon as safely possible. Two rescue breaths that make the chest rise should be delivered, and high-quality chest compressions should immediately begin if the patient does not respond. 

Despite prompt recognition and correction of any signs of resulting tissue hypoxia, there are certain poor prognostic factors at time of patient presentation. 

– Submersion >5 minutes 
– Time to effective BLS >10 minutes 
– Resuscitation >25 minutes
– Age >14 years 
– GCS <5 
– Arterial blood pH <7.1 
– Persistent apnea and need for CPR in the ED

It is recommended that patients who are asymptomatic after a non-fatal drowning be observed for approximately eight hours, as most patients will develop symptoms within seven hours of immersion. For stable children who are expected to have a short hospital inpatient stay, Hasbro Children’s Hospital has the ability to monitor these patients in our Pediatric Clinical Decision Unit. If patients who are initially asymptomatic show signs of deterioration, they should be admitted for continued management. 

Luckily, there are steps we can all take to prevent fatal and non-fatal drownings. It is important to educate families about water safety at routine well child visits, as drowning does not just occur during the summer season and children are at risk of drowning even in shallow bodies of water such as the bath tub. Research has shown that formal swimming lessons can reduce the risk of drowning among 1-4 year olds. We also know that learning CPR can save lives and improve outcomes. Simple tips such as assigning a responsible adult to supervise swim time and installing four-sided fencing around pools can help children stay safe. At Hasbro Children’s Hospital, we are lucky to have so many pediatricians equipped to take care of these patients, from our phenomenal PEM trained physicians in the ED to our outstanding intensivists in the pediatric ICU- we want you to be too!


The Lifespan Community Training Center offers a variety of classes such as: 

  • Hands Only CPR (CPR without certification); free 
  • Heartsaver AED (CPR with certification) 
  • Safe Sitter (teaches children ages 11-14 CPR, choking rescue, first aid, etc.) 

All classes require pre-registration (401-444-8009).


  • Brenner R.A., Taneja G.S., Haynie D.L., Trumble A.C., Qian C., Klinger R.M., & Klevanoff M.A. (2009). Association between swimming lessons and drowning in childhood: A case-control study. Archives of Pediatrics & Adolescent Medicine,163(3), 203-10. 
  • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. 
  • Kyriacou D.N., Arcinue E.L., Peek C., & Kraus J.F. (1994). Effect of Immediate Resuscitation on Children with Submersion Injury. Pediatrics, 94(2), 137-142. 
  • Olshaker J.S. (1992). Near drowning. Emerg Med Clin North Am, 10(2), 339. 
  • Orlowski J.P. (1979). Prognostic factors in pediatric cases of drowning and near-drowning. JACEP, 8(5), 176.