June 5, 2008

Secondary drowning: Did you know you could drown after you get out of the water?

A little boy drowned during his nap after he got out of the pool and walked to bed:
Johnny would have only had to inhale four ounces of water -- about six teaspoons -- to drown, and even less to injure his lung enough to become a victim of secondary drowning...

"If your child comes out of the pool and seems sleepy or lethargic, watch them very, very closely... Rush them to the hospital or call 9-1-1 immediately."

ADDED: There are actually 24 teaspoons in 4 fluid ounces.

IN THE COMMENTS: Read what Pogo says. He's a doctor.


George said...

There's an article in the June Harper's--In Pursuit of the Drowned--that touches on on this. Apparently, the throat muscles seize up, constrict, and that's it. Happens quickly.

The story is about a couple who make their living searching for drowning victims, typically in rivers and deep lakes, using special photographic equipment. They often find people clutching the item they jumped in the water to retrieve--a ball cap, that sort of thing.

These are the folks who found that couple who disappeared in the northwest back in the 1930s or 1940s, kids were raised as orphans, had tragic lives, always thinking their parents ran off. Turned out the parents' car flew off the road at night, missing a turn, landed in a lake, and sunk in several hundred feet of water. Incredible detective work.

Ann Althouse said...

George, that sounds like primary drowning. The distinctive thing in this case is that it took a long time. He got out of the water and walked to bed, then died taking a nap.

George said...

Yes, indeed.

After I wrote the above, it dawned on me that I did not want to consider the possibility that the death was due to foul play.

But, being conditioned to believe that everything, including breathing is dangerous, my mind immediately accepted the implausible notion that he had drowned. The article also suggests that chlorine killed him.

Just yesterday the wife and I were at our daughter's elementary school. There we saw a five-page list of play rules on a bulletin board.

One was—do not let children slide down a slide on a hot day, because they might get burned.

Another, under a section titled "Exercising Children," said that as the weather warms up, one must not allow children to play vigorously right away, as they need 10-15 days of conditioning to get used to warm weather.

rhhardin said...

It also fits the modern news genre, namely scaring women, ie. don't tune away.

Discussed by John and Ken with a caller June 18, 2000.

Abducted little white girls was having a good news year then.

Pogo said...

This story doesn't sound quite right.

A 10 year old who defecated twice in his pants? That is an indication that something is seriously wrong. Some major parts of the story are missing. Asthma? Head injury? Something else is untold.

Regardless, the message should be: teach your kids how to swim. A 10 year old shouldn't have to use swim rings on his arms. Being unable to swim is a health hazard.

Pogo said...

And I doubt pulmonary edema from the mere inhalation of pool water is correct, because if that were so, scores of infants and toddlers would be dying annually from the same thing.

knoxwhirled said...

Regardless, the message should be: teach your kids how to swim. A 10 year old shouldn't have to use swim rings on his arms. Being unable to swim is a health hazard.

Pogo, I agree, but the article does mention further down that the child was autistic. This might have made it difficult to teach him? I really don't know enough to say, just a thought...

Jennifer said...

The defecating in his pants and his mom saying nothing out of the ordinary happened gave me pause, too. But, like knoxwhirled, I thought perhaps the autism explained that.

Pogo said...

If this 'secondary drowning' were so obvious a cause, as the MD quote suggests, where are all the secondary drowning cases of infants and toddlers, who seem to quaff, inhale, cough up, drink, breathe, snort, and sometimes swim in chlorinated pool water by the score?

Acute pulmonary edema is unusal in akid. Inhaling chloruine gas would cause it, but not the monor amount in pool water. Unless there was background lung disease like asthma.

I have taken care of autistic kids before, as well as many retarded ones (sorry, I forget this week's correct PC term), and fecal incontinence is quite infrequent in all but the most severely affected, and those kids you wouldn't put in a pool alone, you'd be holding them like an infant. If incontinence was no big change, I doubt mom would have mentioned it in the story. Seems like a detail that didn't fit the "nothing happened" narrative.

Vewy scwewy, this tale.
Sorry, but I am very very skeptical of medical news of the Secret Things That Can Kill You variety. More often urban legend or misdiagnosis.

Because it calls into question this crappy advice:
If your child comes out of the pool and seems sleepy or lethargic, watch them very, very closely... Rush them to the hospital or call 9-1-1 immediately."
They can't be serious.

Pogo said...

(911:) Emergency. Police? Fire? Ambulance?

Me, distraught: Yes, I need an ambulance right away. My 7 year old child went swimming for 4 hours and then took a nap.

(911:) And...?

Me, distraught: Well, the newspaper said to call because this was an emergency.

(911:) Uhhhh ....oooookay. So your son is taking a nap. Is that right?

Me, distraught: Yes! Please hurry.

(911:) We'll send someone right out.

Jennifer said...

I, for one, can't count the number of times I've swallowed/inhaled/ingested what seemed like massive amounts of chlorinated pool water as a kid without any apparent harm. I've asked around and no one I know has ever even heard of this.

I'm inclined to agree with Pogo here, but it still freaks me out a bit.

Revenant said...

The story sounds fishy to me, too. But even if it is entirely on the up-and-up, trying to scare parents into panicking when their kids come out of the pool tired is pretty contemptible. "Secondary drowning" is not a serious risk to children or anyone else.

Ann Althouse said...

The idea of a child going to bed and dying is so alarming to parents. It may be rare, but it's not that rare, and you don't want to be the one who let your child die.

OldGrouchy said...

The loss of a child should never be trivialized and this article seems to do just that. Pogo's comments seems most apt yet what was the motive of the reporter?

Yes, this 10-year old boy should still be living but what was the real reason for his demise? The reporter points to nothing that would answer that question, which should have been the point of the article.

It doesn't matter what the age of a child is when he, or she, is lost, the pain is beyond describing and if this article helps the parents of that poor young 10-year old, so be it! Yet, my comments about the article trivializing this death remain.

Henry said...

The idea of a child going to bed and dying is so alarming to parents. It may be rare, but it's not that rare, and you don't want to be the one who let your child die.

My mother-in-law collects stories like this. At a certain point the number of terribly unpredictable ways that a child can be killed approaches the infinite.

Meanwhile, we put our kids in the car every day and drive them around the death course.

Pogo said...

you don't want to be the one who let your child die.
Exactly, hence my disappointment with this kind of article.

It offers nothing at all for a parent to do or watch out for that would help.
Mom, I'm tired.
Well, honey, you were at the pool all day ... ohmygooodddd.
I mean seriously, what's a mom or dad supposed to be alert for? Sleepiness after physical exertion? Taking a nap?
It's fear-mongering.

From the British Medical Journal. 1980 October 25; 281(6248): 1103–1105.
(empahsis mine))
"Secondary drowning (and near-drowning) is one of the post-immersion respiratory syndromes. It is defined as deterioration of pulmonary function that follows deficient gas exchange due to loss or inactivation of surfactant. A review of 94 consecutive cases of near-drowning in childhood showed that this syndrome occurred in five (5%) cases. Its onset was usually rapid and characterised by a latent period of one to 48 hours of relative respiratory well-being. It occurred more rapidly after immersion in fresh water. [included but not limited to chlorinated pools ~Pogo] The two children immersed in salt water died of secondary drowning, while the three immersed in fresh water recovered completely. If it is anticipated, recognised, and treated vigorously, prognosis of secondary drowning is good in fresh water cases but bad after salt water immersion."

That is, these were all clear-cut, not easily missed cases of near-drowning. All five cases of secondary drowning happened when the children "were unconscious and apnoeic when pulled from the water", i.e. they "almost drowned", according to the paper. These are the kids "found at the bottom of the pool, not the ones merely coughing or spitting after inhaling water in a pool.

The authors concluded "Although it is not always done, all near-drowned victims must be admitted to hospital for observation, irrespective of their apparent relative wellbeing within several hours after rescue. Respiratory deterioration after apparent post-rescue well-being can occur rapidly."

This is beacuse "Fluid aspiration results in varying degrees of hypoxemia. Both salt water and fresh water wash out surfactant, often producing noncardiogenic pulmonary edema and the acute respiratory distress syndrome (ARDS)." (UpToDate)

As a result, ambulance and EMS responders the world over are routinely advised to take all near-drowning victims to the hospital for admission and observation, even if the kid seems "fine".

This story was a disservice, but likely out of ignorance of the whole story.

Pogo said...

BTW, when the linked news story mentioned "...noticed what appeared to be cotton balls stuffed in his nose," Jackson said of what turned out to be the foam from his nose and mouth" ,
that is the external sign of noncardiogenic pulmonary edema and the acute respiratory distress syndrome (ARDS).

Jennifer said...

Thanks, Pogo. That puts my mind at ease and I've fired it off in response to the two emails I've already received from friends worrying about this secondary drowning thing now.

I'm not sure I would have taken either of my kids in to the hospital if they happened to nearly drown - unless of course they were unconscious. So, I've learned that now.

I have to say that I'm a little disturbed that I was a certified lifeguard in high school and my husband has his combat lifesaver (lifeguard) qualification and neither of us have ever heard of this secondary drowning thing. OR the fact that someone who nearly drowns should be kept under medical observation.

SWBarns said...

Thanks Pogo.

Im a firefighter/EMT and CPR instructor and would like to add two points:

1) If someone isn't breathing or is unconcious dial 911. Do it right away.

2) Never "rush [your child] to the hospital" If junior needs CPR on the way to the hopital are you going to stop or just drive like a madman the rest of the way. You are much beter off to dial 911 and have the medics come to you.

Pogo said...

"neither of us have ever heard of this secondary drowning thing"
That's because this is really, really rare. Near-drownings are infrequent, and death after near-drowning a smaller percentage of those. It is simply impossible to find any literature on what can only be called "small volume aspiration related ARDS that was fatal and completely asymptomatic until the child was discovered dead.

I suspect the incidence is close to zero, existing at best at the level of case reports in the medical literature. I would be interested to discover a case.

Prevalence of traumatic injuries in drowning and near drowning in children and adolescents
E. C. Quintana MD, MPH
Annals of Emergency Medicine
Volume 43, Issue 4, April 2004, Page 540
"In the United States each year, about 4,000 children aged 0 to 19 years die, 8,000 are hospitalized, and 31,000 make emergency department (ED) visits because of drowning or near drowning.

For perespective, in 2004 when the article was written, there were over 73 million children under the age of 18 in the United States, 25% of the total population.

4,000 ÷ 73,000,000 (x 100)= 0.0054%,
or 5.47 deaths per 100,000 children. So drowning and near-drowning are infrequent in the USA.
But in my view, near-drowning is not an easily missed problem.

The article continues: "Thirty percent of the children had preexisting conditions, including congenital heart disease, seizure disorder, cerebral palsy/mental retardation, and developmental delay. Only 7 patients (4.9% of the sample) had traumatic injuries, and all were boys. These injuries occurred in a swimming pool and involved the cervical spine; diving was the cause of the injury in all but 1 patient. None of the injured children died. Patients who suffered injury were more likely to be older (mean age 13.5 years vs 5.1 years for uninjured children) and to have a history of diving (85.7% vs 2.2% for uninjured children). The initial evaluation for 95 of the 143 children was conducted at outside hospitals. One hundred thirty-three children were admitted to the hospital; of these, 99 were discharged home, 11 were sent to a rehabilitation facility, and 23 died of anoxic brain injury caused by submersion in water."

The story as printed was incomplete, and intended to frighten, in my view, because there was seemingly nothing you could to to even recognize something was wrong until it was too late. I really reaqlly hate this kind of medical reporting.

The moral for me remains:
teach the little ones how to swim!

Drowning is the leading cause of death in some parts of the world and the second leading cause of accidental death worldwide, but it can prevented through a variety of known strategies.
...In some developing nations, drowning is the leading cause of death for children, outstripping even disease. Over 47,000 children drowned in Vietnam alone in 2006. Although developed nations generally appear to be safer from accidental injury than developing nations, the proportion of child drowning remains very high in each.

Pogo said...

(apologies for the verbosity ...these kind of stories irritate me greatly, as should be obvious)

Jennifer said...

I'm glad it irritated you and you cleared it all up.

I'm a little frightened to be agreeing with rhhardin, but I am thoroughly disgusted with the "BEWARE MOMMY!" stories that pass for reporting these days.

Angeleyes1382 said...

I just went swimming and am sleepy... Being out in the sun and in the water will make anyone a little tired and want to take a nap.

Pogo said...


I know this is several days later, but I just called an ambulance for you.

alexis said...

He had autism

alexis said...


alexis said...