Day: October 3, 2011

When Can a Child Go Into A Pool?

Patient Presentation
A pediatrician was at an outdoor community swimming pool and noted 2 very young infants being played with in the pool. Both were being submerged up to their trunks and had sun hats on. Knowing that the pool contained various chemicals and that there was the possibility of water-borne infectious disease, he wondered at what age a child could go into a pool. He later looked up several references from medical professional societies and national non-profit agencies. He did not find a specific answer, but did learn more information to better advise parents.

Discussion
Water safety is clearly important for all ages. Drowning was the second leading cause of unintentional injury death in US children from 1-19 years between 2000-2006. Non-fatal drowning victims usually do well, but 5-10% have severe neurological damage. The highest rate of drowning is in 0-4 year olds, with half of the drowning occurring in swimming pools. Infants < 1 year have a high rate of drowning in bathtubs and large buckets of water. To prevent drowning, experts generally recommend "layers of protection" including:

  • Adult supervision – a designated adult supervisor who is not distracted by other activities such as sun bathing, reading, or talking with other adults
  • Pool fencing – separate 4-sided fencing isolating the pool from other structures including a house
  • Pool covers – always totally removed during use and replaced after use
  • Pool alarms
  • Lifeguards
  • CPR training
  • Swimming instruction and water-survival skills
  • Personal flotation devices – see “What Type of Life Jacket Should He Wear”

The American Academy of Pediatrics recommends that “[a]ll children should eventually learn to swim.”
The AAP supports swimming lessons for most children > 4 years of age. Some children may not be ready for various reasons until later than this age.
For children < 1 year the AAP recommends these experiences be individualized. They state "…the current evidence is insufficient to support a recommendation that all 1- to 4-year-old children receive swimming lessons."

Learning Point
Potential concerns for infants and young children regarding pools and other recreational water include:

  • Neonatal immunity
  • Infectious water-borne agents especially gastrointestinal tract infections – see the CDC’s Alphabetical Index of Water-related Health Data
  • Skin problems including dermatitis and sunburn
  • Acute respiratory illnesses including potential increased risk of asthma and bronchitis secondary to chlorination byproduct exposure
  • Hypothermia – secondary to cool/cold water and air exposure
  • Hyperthermia – secondary to high water temperature exposure in spas and hot tubs
  • Hyponatremia – secondary to water ingestion

Questions for Further Discussion
1. What are the concerns about pool drain entrapment?
2. What are the differences in potential problems for fresh water versus salt water drowning?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Water Safety (Recreational) and Drowning.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Bernard A, Carbonnelle S, Dumont X, Nickmilder M. Infant swimming practice, pulmonary epithelium integrity, and the risk of allergic and respiratory diseases later in childhood. Pediatrics. 2007 Jun;119(6):1095-103.

Committee on Injury, Violence, and Poison Prevention. Prevention of Drowning Policy Statement. Pediatrics 2010 126: 178-185.

Weiss J. and the Committee on Injury, Violence, and Poison Prevention. Prevention of Drowning Technical Report. Pediatrics 2010 126: e253-e262.

ACGME Competencies Highlighted by Case

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital