Healthy Baby/Healthy Child
Dry Drowning: Myths and
Misconceptions
M. Denise Dowd, MD, MPH
ABSTRACT
Drowning is a leading cause of death in
children and is highly preventable. More
than 10 people die of drowning in the Unit-
ed States each day, most of them adults.
Rates of drowning are highest in children
given their developmental vulnerabilities.
Drowning incidents that result in cardio-
pulmonary arrest have a straightforward
emergency clinical response, but the man-
agement approaches to the more common
scenario of brief, nonfatal submersion is
less clear. Clinicians must make clinical-care
decisions based on evidence to provide
safe and effective care in a timely manner
and to help families avoid unnecessary anx-
iety. Such anxiety has been heightened by
reports of unanticipated “dry drowning” ap-
pearing in the media. This article discusses
this concept and provides guidance for cli-
nicians. [Pediatr Ann. 2017;46(10):e354-
e357.]
M. Denise Dowd, MD, MPH, is the Associate
Director, Office for Faculty Development, and
the Medical Director, Community Programs, De-
partment of Social Work, Children’s Mercy Hos-
pital; and a Professor of Pediatrics, University of
Missouri-Kansas City School of Medicine.
Address correspondence to M. Denise Dowd,
MD, MPH, via email: ddowd@cmh.edu.
Disclosure: The author has no relevant finan-
cial relationships to disclose.
doi:10.3928/19382359-20170925-01
e354
D
rowning represents an impor-
tant and highly preventable
cause of child death. Most pe-
diatricians give anticipatory guidance
during well-child visits on water and
pool safety as well as swim lessons.
However, parents may raise concerns
about drowning that can be challenging.
ILLUSTRATIVE CASE
An anxious mother presents with her
4-year-old son for an acute care visit. He
had been playing in the shallow end of
their neighborhood pool when she brief-
ly lost sight of him. After approximately
1 to 2 minutes, she spotted him emerging
from the water coughing and crying. Af-
ter an initial drying off and comforting
he appeared fine and eventually stopped
coughing and could eat lunch. After
they had left the pool later in the day,
she encountered a friend whom she told
what had happened earlier. Her friend
relayed a story she heard on television
about a child who “seemed fine” after
such an incident but died the next day
of something called “dry drowning.” Af-
ter hearing that information, the mother
proceeded directly to the doctor’s office.
WHAT IS DROWNING? WHAT IS
“DRY DROWNING”?
The story described above and other
reports1 are terrifying for any parent to
hear. The scenario of a child inhaling
water inadvertently and quick sponta-
neous recovery is quite common, but
should it lead to a real fear of unpredict-
able sudden death hours or days later?
The short answer is no. Children do not
choke on water, recover, seem fine for
several hours or days and, then suddenly
die. This is the description of something
that has been called “dry drowning,”
also known as secondary or delayed
drowning. The terms are not currently
recognized medical terms and are best
not used as they have led to avoidable
hysteria and parental fear around this
issue. The term originated from animal
studies in the 1930s and 1940s that con-
veyed the absence of significant water in
the lungs on postmortem examination.
This led to a theory that prolonged reflex
laryngospasm induced lethal hypoxia
through postobstructive pulmonary
edema.2 Those early studies have been
examined and have largely been dis-
missed on the basis that there is no firm
evidence that submersion events lead to
prolonged laryngospasm and then death.
A 2004 retrospective review of drown-
ing cases found that the finding of no
penetration of liquid in the lungs in the
context of drowning is very rare.2
The World Congress on Drowning
adopted a standard definition of drown-
ing in 2002 as “a process resulting in
primary respiratory impairment from
submersion/immersion in a liquid me-
dium.”3 The outcome can be death, last-
ing impairment (morbidity), or complete
recovery but all are considered drown-
ing incidents and should be assessed as
Copyright © SLACK Incorporated

such. The terms near drowning or near-
fatal drowning have also fallen out of
favor because they are inaccurate and
their use has led to confusion. Standard
classification of drowning incident out-
comes is now simply two categories:
fatal or nonfatal drowning. Drowning
begins when a person’s airway goes be-
low the surface of the water (submer-
sion) or significant water is splashed on
the face and water enters the orophar-
ynx (immersion). When water enters
the oropharynx, the person is triggered
to spit it out or swallow it. If the water
exposure continues, breath holding is
the next continuum, which lasts for no
longer than approximately 1 minute.4
The natural inspiratory drive prevails
and the individual will inhale, aspirat-
ing water into the airway leading to
coughing and possible laryngospasm,
which quickly ceases with the onset
of brain hypoxia. As hypoxia worsens,
loss of consciousness occurs followed
by apnea. The entire process from sub-
mersion to cardiac arrest occurs in sev-
eral seconds to a few minutes. Rarely,
in situations of hypothermia, the pro-
cess can last for 1 hour.5
Unfortunately, terms like “dry
drowning” have been used in several
frightening stories in mainstream and
social media.6 Parents reading these re-
ports are led to believe that there are
no warning signs and that critical dis-
tress or death comes “out of nowhere.”
Fortunately, children who have trouble
hours after submersion event have
warning signs that can be detected by
an experienced provider. Having a firm
knowledge of how drowning occurs is
essential in clinical care of patients as
well as in discussion with parents.
THE EPIDEMIOLOGY OF
DROWNING
More than 10 people die in the
United States from drowning each
PEDIATRIC ANNALS • Vol. 46, No. 10, 2017
Healthy Baby/Healthy Child
day.7 One in five are children and
teenagers younger than age 15 years,
for a total of 681 in 2015.7 For every
child who dies another five receive
emergency medical care for a nonfatal
submersion injury.7 About one-half of
those are admitted to the hospital for
further care. Most recover completely,
but some will have severe long-term
neurologic deficits, usually associ-
ated with submersion times of more
than 5 minutes, cardiopulmonary re-
suscitation delayed for greater than
10 minutes, and coma on emergency
department presentation.8 Over the
past 3 decades, fortunately, drowning
has significantly decreased. Drowning
deaths in 19-year-olds decreased from
1,886 in 1985 to 892 in 2014, repre-
senting almost a 60% reduction in the
rate of fatal drowning over the 30-year
period (from 2.7/100,000 in 1985 to
1.1/100,000 in 2014).9
Age is a significant risk factor for
drowning, with children age 1 to 4
years at the highest risk, followed by
adolescents. Circumstances also differ
by age group with younger children
more often drowning in swimming
pools and teens in lakes or rivers.9 Rates
of drowning also vary by gender, race,
and household income. Boys are more
likely to drown than girls; account-
ing for nearly three-fourths of all fatal
drownings. Black and Indian/Alaskan
Native children have higher rates than
other groups.7 More than two-thirds of
all fatal drownings in children occur
during the warmer weather months, re-
flecting recreational exposure.
Drownings can occur more rarely
in the home environment, with risks
greatest for infants and toddlers. Buck-
ets, wells, ponds, bathtubs, and toilets
provide a potential drowning source
for this age group. These incidents re-
flect the fact that young children have
a much higher center of gravity than
teenagers and older children, making
them susceptible to tipping head first
into a body of water. Lack of adult
supervision is a well-recognized risk
factor for child drownings.10 However,
one study11 found that parents were
present in 62% of drowning deaths. In
many cases, supervision was compro-
mised by drugs, alcohol, sleepiness, or
distraction.11
Epilepsy is a well-studied risk factor
for drowning. It is estimated that risk
of drowning is 4 times that of children
without epilepsy.12 Interestingly, when
supervision is implemented, children
with seizure disorders have no greater
risk than children without seizures.13
Other risk factors, pertinent to teenag-
ers, include alcohol and illicit drug use.
It is estimated that risk of fatal drown-
ing for a person with a blood alcohol
level of 0.10 g/100 mL is 10 times that
of a sober person.14
CLINICAL CARE
Less than 6% of people rescued by
lifeguards require emergency depart-
ment care and most spontaneously
recover onsite without intervention.15
Symptoms of drowning most common-
ly appear immediately, but infrequent-
ly can develop subtly between 4 and
6 hours after the incident. Symptoms
can range from persistent to worsening
cough, tachypnea, vomiting, and men-
tal status changes. If, after a brief im-
mersion event, children are persistently
symptomatic or if the parent is wor-
ried, they should be taken to the nearest
emergency department for assessment.
They should receive a complete exami-
nation and have their oxygen saturation
checked. If symptoms resolve, oxygen-
ation is normal, and the child is doing
well 6 to 8 hours after the incident they
can be safely discharged home with ad-
equate follow-up care. As children will
often present immediately after an event,
e355
 Healthy Baby/Healthy Child
this will require a short period of obser-
vation in the emergency department.
Nonresolution of symptoms or hypoxia
(oximetry less than 96% on room air)
warrants further observation in an in-
patient setting. Checking electrolytes or
complete blood count is unnecessary as
are prophylactic antibiotics. Obtaining
a chest radiograph should be based on
symptoms and examination findings.
PREVENTION
The American Academy of Pediatrics
(AAP) recommends a multipronged ap-
proach to child drowning, referred to as
use of “Layers of Protection.”16 This ap-
proach recognizes that effective preven-
tion requires not only adequate supervi-
sion but physical barriers to the danger
(eg, pool fencing), proper training of
the child, and readiness to respond to an
emergency (Table 1).
OTHER MYTHS
“My child knows how to swim, so
is unlikely to drown” is a statement
that probably assures many parents as
to the safety of their children around a
body of water. However, knowing how
to swim does not “drown proof” any-
one, especially children. For several
years, the AAP16 advised against swim-
ming lessons for children prior to age 4
years. This was, in large part, based on
lack of data examining whether lessons
increased or decreased risk of drown-
ing.16 The most current policy state-
ment has relaxed this stance based on
current evidence that swimming lessons
do not increase the risk of drowning
for young children and in fact may be
protective.17,18
“I will be able to see my child strug-
gle and flail about if he gets into trouble
in the water” is another misconception
about water safety and children. Drown-
ing most often happens in children si-
lently and quickly. It can happen in
e356
TABLE 1.
Drowning Prevention:
Layers of Protection
• All pools should have four-sided, isolation
fencing with a self-closing/latching gate
• All children should wear a United States
Coast Guard-approved personal flotation
device in and around natural bodies of
water
• Touch supervision for all infants, toddlers,
and weak swimmers (child is within an
arm’s reach with constant visual contact)
• Constant focus supervision for all older
children (nondistracted, close, and
constant)
• No alcohol, drug, or excessive cell phone
use for those who are supervising chil-
dren near water
• Swimming lessons and water safety
education for children and adults
• Teach children to not swim alone
• Learn cardiopulmonary resuscitation and
have a phone ready to call emergency
medical services
Adapted from the American Academy of Pediatrics, Com-
mittee on Injury, Violence, and Poison Prevention Policy
Statement on Prevention of Drowning.17
seconds and in most fatal scenarios the
child has been out of sight for less than
5 minutes.9
CONCLUSION
A clinician who is knowledgeable
about drowning and the myths around
the notion of “dry drowning” would con-
fidently help the mother of the 4-year-
old child described earlier in the article.
You would gather further history and
find that 8 hours have transpired since
the incident and that the child has no
current symptoms. The initial coughing
resolved in the first 20 minutes. He ap-
pears well, with normal lung examina-
tion, respiratory rate, and oxygen satura-
tion. He has had something to eat and
drink since the incident with no vomit-
ing. You reassure the mother that her son
is fine, out of danger and all right to go
home without further intervention. You
talk over things to watch for if this hap-
pens again (ie, persistent and worsening
cough, not acting right, color change)
and the need to go to the emergency
department if this happens. Most impor-
tantly, you emphasize the importance of
touch supervision at this age.
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