The issue of pool safety often pits builders and dealers against legislators and public watchdog agencies. Pool professionals feel they know pools better than anyone — and of course they do — and they often feel like others are trying to force unnecessary changes upon their work in the form of building codes, mandatory fencing, dual drains, etc. Some legislators, for their part, feel the industry is dragging its feet and standing in the way of progress. The truth is everyone wants pools to be safe, but there's disagreement on how to go about it.
One thing all sides agree on, though, is that safety is the most important issue facing the industry. Ensuring public safety, especially that of children too young to understand the danger inherent in water, whether that's a pool, a natural body of water or a bathtub, is everyone's business.
The first step in reducing the risks associated with drowning among children is getting a grasp on how many children drown, and why. Only then can proper steps be taken to reduce such incidents. That's where researchers like Dr. Ruth Brenner come in. Dr. Brenner is a researcher at the National Institute of Child Health and Human Development, the biomedical research arm of the U.S. Department of Health and Human Services. In past research she gathered data on trends in the number of child drownings and the location in which they occur, and now she's focusing her attention on trends in the causes and circumstances of drownings in a study titled "Environmental and Behavioral Risk Factors for Childhood Drowning." Then, she says, we'll have a better understanding of how to prevent them.
AQUA spoke with Dr. Brenner about her past work in the field, the scope of her current research project and what she hopes it will accomplish.
AQUA: Tell us about your work.
Dr. Ruth Brenner: My training is in pediatrics and epidemiology. Much of my recent career has focused on the prevention of childhood injuries and specifically on the epidemiology and prevention of drowning.
Epidemiology is the study of the distribution and determinants of disease and health outcomes.
AQUA: What got you interested in that field?
Brenner: Injuries are the leading cause of death in children. While most injuries are preventable, information is needed about the circumstances leading to the injury to guide development of appropriate intervention strategies.
Drowning is the second-leading cause of death due to unintentional injury (after motor vehicle crashes) in children between the ages of 1 and 14 years. Because these are largely preventable occurrences, and there is still much that is not known about the circumstances surrounding these events, I chose to focus my attention to this area.
AQUA: Tell us about your study.
Brenner: We have a current study in the field that's gathering detailed information about the circumstances surrounding the drowning events, as well as information about the characteristics of the environment. For example, information is gathered about the presence of a fence surrounding the body of water, whether there was a gate, and whether the gate was self-closing and self-latching. We also obtain information about behavioral characteristics of the child, like whether or not they were afraid of the water or felt comfortable in it and how well they could swim. Finally, we're also obtaining information from a comparison population of children who live in the same area, so they have roughly the same exposure, but didn't experience the outcome. By comparing these two groups we are hoping to identify factors that put some children at risk. Again, identification of these factors will help us better target our prevention strategies.
To get the data, we're working with medical examiners and coroners in a number of states, including jurisdictions in Florida, California, Texas, New York and Maryland. We're also just beginning to work with the state of North Carolina.
AQUA: What are your findings so far?
Brenner: Data collection is not yet complete and it is too soon to draw conclusions. However, there are previous studies that have informed the development of a number of prevention strategies. For example, the need for adequate pool fencing is certainly one of the key prevention messages. Pools need to be surrounded by a fence and that fence has to include a gate that is self-closing and self-latching. There are very good studies that show that four-sided fencing, that is a fence that completely surrounds the pool — also called isolation fencing — is a very effective way to decrease drowning rates.
Supervision is also a key prevention message. For example, for bathtub drownings, supervision is the main prevention message: never leave the child unattended, even for a second. Of course this goes for other bodies of water as well. There are many cases where young children are known to be in the pool area, but there is a brief lapse in adult attention, with a tragic outcome.
AQUA: How many children drown each year, and how does that number compare to the leading cause of death?
Brenner: Among children under the age of 20 years, there were 1,237 unintentional drowning deaths in 2001, the most recent year for which data are available.
Children between the ages of 1 and 4 years are at particularly high risk for drowning. In fact, in this age group the number of drowning deaths is only slightly lower than the number of deaths from motor vehicle crashes. Among older children, the number of deaths due to drowning declines while the number of deaths due to motor vehicle crashes increases, so the gap grows.
AQUA: Do you break those numbers down by natural bodies of water and pools?
Brenner: Yes. Infants are most likely to drown in bodies of water located in and around the home, such as bathtubs and buckets. Toddlers are most likely to drown in swimming pools and older children are most likely to drown in natural bodies of fresh water, such as rivers, lakes and ponds.
Certainly exposure to the body of water is one of the factors that increases a toddler's risk of drowning in a residential pool. We know that the usual scenario involves a toddler who enters a pool area and then falls into the pool. Generally, nobody witnesses either the entry to the pool area nor the fall into the pool. Once in the water, the young child is unable to get out of the water and subsequently drowns. As kids get older the usual scenario changes. Drowning among older kids usually occurs in natural bodies of water that are unguarded and without adult supervision. The sites are likely to be more remote and water conditions, such as the presence of currents, may also be a factor.
AQUA: Is there information on the types of pools children drown in?
Brenner: When you look at the types of pools in which children drown, among toddlers, most occur in residential pools, ones that are readily accessible. As kids get older, an increasing number of the swimming pool drownings occur in pools that are more accessible to the public, such as hotel or motel pools, community pools, or pools located in apartment complexes.
In summary, as the epidemiology changes, it's important to target prevention strategies toward the risks for that child, for that age range.
AQUA: Suction entrapment is a hot-button issue for our industry. Is there data on deaths due to entrapment?
Brenner: The current study includes all unintentional drownings among children between the ages of 1 and 19 years that occur in relatively large bodies of water. In answer to your question, if a drowning that was caused by entrapment occurred during the study period and within a jurisdiction that is participating in the study, we would obtain information about that event.
AQUA: Will you work on prevention strategies?
Brenner: Our efforts focus on research to help understand circumstances surrounding drownings and factors that place children at risk. The results of this study can then be used to develop intervention strategies that can be broadly applied.
AQUA: Is there a clearinghouse to help dealers sort out the studies, such as the ones you mentioned on fencing?
Brenner: For pediatric drownings, I think a good starting place is the technical report and policy statements published by the American Academy of Pediatrics. These papers reference many of the studies that would be relevant. The Consumer Product Safety Commission has information related to pool drowning and other drownings that are directly related to consumer products. (See related sidebars on pages 88 and 90.) AQUA: How long will your current study take.
Brenner: It's a little difficult to say, but I would estimate that results should be available within the next couple of years. Again, there are a number of preventive efforts that could be implemented now, based on previous research.
AQUA: Have you had any interaction with the pool industry?
Brenner: No. We haven't had any interaction with the pool industry. We have worked with the Consumer Product Safety Commission on a number of projects examining the various aspects of the epidemiology of childhood drowning.
AQUA: What can dealers and builders do to help their customers prevent children from drowning?
Brenner: There are a number of recommendations about the prevention of drowning, such as the need for isolation fencing, and the recommendation that pool owners learn CPR. I think it would be great to discuss these issues with pool owners when they are getting their pools serviced or installed. Prevention of drowning requires multiple layers of protection and the more times that we can get these prevention messages out there, the better.
Doctors' Orders
AAP issues safety guidelines.
Last August, the American Academy of Pediatrics issued a policy statement aimed at helping to reduce the number of childhood drownings. They recommend multiple layers of protection, since no preventative measure is able to prevent all deaths and injuries. The Academy's recommendations are based on the cumulative body of research done by many investigators.
Here are the AAP's recommendations:
Four-sided fencing
According to the AAP, installation of four-sided fencing has been shown to reduce the number of pool immersion injuries among young children by more than 50 percent. The fences should be at least 4 feet high, and no opening under the fence or between uprights should be more than 4 inches.
Gates should be self-latching and self-closing and should open away from the pool.
Alarms and covers
The AAP suggests pool alarms and "rigid pool covers" be used in addition to four-sided fencing because, the Academy says, "they are not likely to be used appropriately and consistently" and because "some types of covers present an additional hazard for young children." The message: multiple layers of protection are needed.
Swimming instruction
While the Academy admits there are no studies that show swimming lessons for children decrease the risk of drowning, a number of studies have shown they improve swimming ability. Still, "swimming lessons are not recommended as a means of drowning prevention" by the Academy because it feels children are not ready for them until after they're 4.
Supervision/lifeguards
According to the AAP, close supervision is an essential prevention strategy, "but inevitable lapses make supervision alone insufficient."
Resuscitation
"Immediate resuscitation at the site of a submersion incident, before the arrival of paramedic personnel, is an important means of secondary prevention and is associated with a significantly better neurological outcome in children with submersion injury," according to the AAP's policy statement. Recommended methods include rescue breathing (mouth-to-mouth) and chest compressions when the patient shows no signs of circulation.
The Heimlich maneuver has been recommended by some, but the AAP says most experts agree it "should not be used as a first-line therapy . . . because it delays the onset of CPR and may induce vomiting and the aspiration of gastric contents."
Personal flotation devices
While it stands to reason that personal flotation devices are likely to reduce drowning risk, the Academy's recommendations cite this as helpful mostly for children who are boating or playing beside natural bodies of water.
— B.K.
CPSC To Hold Public Hearing On Childhood Drowning
In May the Consumer Product Safety Commission launched a campaign to reduce the number of children who drown in swimming pools. According to the agency, about 250 children under the age of 5 drown in swimming pools each year, while hundreds more are treated in hospitals for submersion injuries.
"That so many children drown each year is devastating," says Hal Stratton, chairman of the CPSC. "Each of these deaths is not only the pointless end of a promising life, but an overwhelming grief for the family that goes on for years and years."
In addition to promoting pool safety through a nationwide video news release and participating in local safety efforts, the CPSC is holding two public hearings to explore strategies for preventing drowning deaths. The first took place in Tampa, Fla., in June, and the second is scheduled for July 27 in Phoenix.
"We believe that using multiple layers of protection can prevent many of these deaths, but still too many children are dying," Stratton says. "We are conducting these public meetings to find out what has worked around the nation."
— B.K.
