Submersion Injury - Secondary Drowning

Parents can help save children’s lives by learning about water safety and drowning prevention and what measures to take so that children in their care will be safe while in or near water. An excellent resource is the video series entitled Swim, Play, Learn and Stay Healthy (S.P.L.A.S.H.) created by Craig Pymento, MD, Medical Director for Respiratory Care at Texas Children's Hospital The Woodlands and an authority on drowning and submersion injuries, along with the Respiratory Care team at The Woodlands.  

Swim, Play, Learn and Stay Healthy (S.P.L.A.S.H.) Swim Safety Series: 

Texas Children’s urges parents and guardians to learn and practice these precautions and safety measures so that children will be safe while in or near the water.

Submersion Injuries in Children

It’s a frightening scenario for any parent or guardian: a child’s head goes underwater in a swimming pool and stays there.

It’s a fortunate moment when the child comes up for air, coughs up any swallowed water and then seems fine.

But should a parent assume the child is going to be okay? 

Submersion injury is the medical term for complications that occur after a child inhales water into the lungs while submerged in water. Depending on the duration of the submersion, symptoms may occur immediately or be delayed. In general, the likelihood of severe complications rises the longer a child spends submerged underwater. 

When a child breathes in, aka aspirates, foreign substances, including fresh, salt and chlorinated water, it can cause progressive injury and inflammation within the lungs. This leads to fluid buildup known as pulmonary edema, which reduces the lungs' ability to oxygenate blood, potentially leading to breathing problems or even respiratory failure. 

Having trouble breathing is a medical emergency – parents should immediately call 911.

“Luckily, most healthy children who appear well after a submersion aspirate only small amounts of water, if any, and will recover spontaneously. However, continue to monitor your child closely for the next 24 hours after such an event occurs. Seek emergency medical treatment if symptoms occur," states Dr. Pymento, who is also an Attending Physician in Pediatric Critical Care at Baylor College of Medicine.

Symptoms

Symptoms of submersion injury can develop hours after the child has left the water, usually within 24 hours after the incident. Parents should become familiar with these common signs and symptoms of water in the lungs:

• Persistent and severe coughing
• Trouble breathing, such as rapid breaths, shallow breaths or visible chest retractions
• Fatigue
• Chest pain
• Vomiting  
• Behavioral changes such as confusion, irritability, or sudden changes in mood
• Pale or blue skin (cyanosis) 

Call 911 Instead of Going to Urgent Care

“We urge parents or guardians to immediately call 911 if the child has difficulty breathing in order to prevent severe complications​,” Dr. Pymento reiterates. 

What to expect in the emergency center? 

Depending on the submersion event and your child’s vital signs and examination, your physician will likely order a chest X-ray and possibly some blood tests. If the results are normal, the child may be observed in the emergency center until approximately 6 hours from the submersion. As long as your child continues to appear well while in the emergency center, he/she will likely be discharged home with detailed return precautions.  

However, if your child’s examination and/or workup are abnormal, he/she will be admitted for supportive care (e.g., oxygen, breathing treatments, intravenous fluids) to treat the symptoms and for observation. Children who are very sick with decreased or lack of responsiveness, severe breathing difficulties or very low oxygen levels are typically admitted to the pediatric intensive care unit (PICU) for increased respiratory support/treatment and close monitoring. 

Confusion over the Phrase “Secondary Drowning”

The term secondary drowning is a misnomer.

“While secondary drowning is a term popular in the media and with lay people, there is no medically accepted condition known as secondary drowning. Drowning is, by definition, fatal,” Dr. Pymento says.

“Similarly, there is no medical condition known as dry drowning or near drowning. We utilize the correct medical terminology of submersion injury for any sequelae, or after affect, of water injury that is nonfatal.”

Two popular media stories about secondary drowning symptoms helped raised parental and public awareness about the symptoms of aspiration of water due to being submerged in water, appropriately called submersion injury. 

• In a story posted by the Today show, a mother knew her 4-year-old daughter could be in danger after inhaling water in a swimming pool because she had read an article about another child’s tragic death due to aspirating water.
• Another mother shared her experience in her blog, Delighted Momma about her nearly 2-year-old son developing respiratory issues following submersion in a spa for fewer than 20 seconds. She took him to the closest pediatric hospital’s emergency center within an hour or so when her son seemed overly tired and began coughing. A chest X-ray showed that he had likely breathed in some of the water, which caused his lungs to not function normally. Fortunately, he was discharged after a 24-hour observation period. 

“We appreciate that parents and others have access to lifesaving information online. As always, ask your pediatrician if you have any questions or concerns. Call 911 if concerned about your child's breathing," Dr. Pymento says.

Preventing Submersion Injuries and Drowning

Drowning is the second-leading cause of unintentional injury-related death for children ages 1 to 14 years, with the highest rate of drowning in the 0- to 4-year-old age group.  

To prevent children from drowning or having submersion injury symptoms, take proactive measures to ensure the safety of your children around water. Some ways you can protect children are:

• Enclose and cover pools and hot tubs
• Childproof your home by closing bathroom doors, using safety locks on toilet seats, draining bathtubs, and emptying buckets and ice chests filled with water’
• Enroll your children in water safety and swim classes
• Continuously supervise or designate a responsible adult to watch over your children when swimming
• Learn first aid and CPR

What to Do if Your Child is Found Underwater

Drowning can happen in seconds, and knowing how to react immediately could save your child’s life. Whether your child is conscious or unconscious after being found underwater, it’s essential to take swift and appropriate action. 

If Your Child is Unconscious or Not Breathing 

1. Administer Rescue Breaths: Start by giving 5 rescue breaths if your child is not breathing.
2. Perform CPR: If there’s no pulse, begin CPR right away. Make sure a bystander calls 911 while you administer chest compressions and continue rescue breathing until help arrives.
3. Prevent Aspiration: If your child vomits, gently roll them onto their side to prevent choking or aspiration.
4. Neck and Head Support: If trauma is suspected (e.g., from diving into shallow water), keep your child's neck immobilized in a straight, midline position to avoid further injury. 

If Your Child is Awake and Alert

Keep your child warm and dry, and contact your pediatrician for further instructions. This is particularly important because the symptoms of submersion injuries can develop hours after the incident. Keep a close eye on your child and watch for breathing difficulties, skin color changes, persistent vomiting or abnormal behavior. If any of these symptoms occur, you should seek emergency medical care immediately.  

Additional Resources about Drowning Prevention  

Our Texas Children’s website has more useful information about drowning prevention, including these found in our Health Library:

• What Do You Know About Swimming Safety for Kids?
• Water Safety for Parents
• Water-Safety 101: Basic Guidelines