There has been a considerable amount of discussion on the internet recently, concerning what has been termed ‘secondary drowning’. This has come about following the case reported by the mother of a child called Ronin Kajawa.
There has been much confusion about the case, resulting in misinformation being circulated. Understandably, these mixed messages and the condition which has been called ‘secondary drowning’, is causing anxiety amongst parents. So it would seem an appropriate time to review what is actually known about drowning and its consequences; and in particular how it relates to this case and the subsequent discussions.
It is always difficult to comment on cases when you are not directly involved. In this case the child seems to have had a near drowning episode – being immersed for about 30 seconds before being rescued by her mother, then subsequently developing breathing difficulties.
It is this later development of symptoms which is causing most concern. Some websites have even stated that following any immersion, secondary drowning may occur up to 7 days later.
In this case, the mother did say that the child was bobbing up and down struggling to breath and coughing up water by the time she got to him. He seemed lethargic immediately after the incident and deteriorated over a couple of hours. She took him to hospital and it seems that a chest X-ray revealed the child had aspirated water into the lungs and was now getting symptoms from this. This would imply an episode of near drowning, as opposed to a period of simple immersion.
Fortunately, with appropriate treatment the child survived without any long term problems.
Definition of Drowning
Defining the term drowning is more difficult than it may seem.
Before 2002 there were many definitions with regards to the various aspects of drowning; indeed there were over 20 different terms associated with different aspects of the drowning process.
A World Congress on Drowning was held in Amsterdam in 2002 with the aim of trying to accurately define the process. It was decided that the majority of the old terms, including ‘secondary drowning’ should be disregarded. Other terms disregarded included wet drowning, dry drowning, active/passive drowning, near-drowning and silent drowning.
The Congress defined drowning as follows:
Drowning is a process resulting in primary respiratory impairment from submersion in a liquid medium. Implicit in this definition is that a liquid-air interface is present at the entrance to the victim’s airway, which prevents the individual from breathing oxygen.
This may result in rapid death, delayed death, or rapid or delayed morbidity.
So, let’s examine what happens when an individual is immersed fully in water covering their airway.
There is a natural reflex designed to protect our airways; firstly, we hold our breath, however if water enters the airway and reaches the larynx, there is an intense reflex spasm of the larynx which effectively closes the entrance to the lungs.
With the passage of time, the levels of oxygen in the body decrease. Eventually the laryngeal spasms subside and the airway is then open for water to be breathed in. If this happens it results in water entering the lungs and causing what was known as wet drowning. In between 10%-20% of cases, the laryngospasm either doesn’t subside or the individual doesn’t make breathing efforts; water then doesn’t enter the lungs, this was known as dry drowning.
Drowning is a complex subject and it is impossible to fully discuss its mechanisms of causing either death or morbidity in a short article such as this. So let us concentrate on what was known as ‘secondary drowning’, as this is the issue being raised. As we are now aware it is recommended not to use this term but to think in terms of delayed morbidity from near drowning.
Secondary drowning was thought to be when an individual had undergone a period of immersion and survived, followed by the development of symptoms at a later time. It was thought to occur when the lungs became inflamed; resulting in water entering the lungs and causing physical damage to the linings of the lungs. Many things ranging from chemicals or infectious agents in the water, or even foreign bodies such as mud and sand have been aspirated into the lungs causing delayed damage.
In the case of Ronin Kajawa there is clear evidence that the child was immersed and required rescue. The child is also described as coughing significant amounts of water and not being himself immediately following the incident before experiencing deterioration. Clearly there were symptoms immediately after the incident. For a case such as this where the child experiences symptoms following the near drowning, I would recommend a period of observation in a medical facility where the full extent of the problem can be assessed.
There is evidence to suggest that if no significant symptoms are present after 6 hours following the near drowning, then the patient can be discharged safely.
The diagnosis of near drowning is difficult to make. What, for instance, is the difference between an individual who can hold breath for a few minutes, and a child who becomes immersed and struggles with their face under the water? I would suggest the difference is a pragmatic one; in adults and older children they should be able to communicate their difficulties. With a smaller child I would suggest that this would involve a period of difficulty in the water with obvious symptoms of respiratory distress. It is more difficult to determine in infants who are not able to communicate so well, so infants should be under supervision at all times in the water.
In summary, drowning and near-drowning is a complex condition. Near-drowning however, should be suspected in all small children who undergo a period of unsupervised immersion, particularly if they experience any breathing difficulties in the period following the immersion. Symptoms may take up to six hours to develop, but are more commonly immediate.
Swimming remains a safe activity; when the usual safety considerations are followed, particularly with regards to supervision of small children.