Water skills training (formal swimming lessons) to reduce the risk and/or occurrence of drowning

Conclusion: Indications for effectiveness

The review of Brenner et al. (2003) contains several correlational studies on swimming ability and drowning in children. They found several correlational studies suggesting that many drowning victims are able to swim. This shows swimming ability does not result in 'drown-proofing'. Some correlational studies also suggest that swimming ability could potentially increase exposure to water and risky situations. One correlational study (Ozanne-Smith et al, 2002) shows that previously higher drowning rates for the Australian state of Victoria fell significantly compared with the rest of Australia from the moment school-based swimming instructions were introduced. Due to the study-design, a causal relation could not be demonstrated. Brenner et al. (2003) also found one case-control study (Rogers, 1989) suggesting that swimming ability decreased the risk of drowning. A randomized trial (Rivara et al, 1995) was found showing water safety instructions for preschool children significantly improved swimming ability, ability to stand up in the shallow end when dropped from two feet above the water, and ability to jump from the edge of a pool into the pool and swim back to the side. The latter two skills were seen as a measure of in-water safety skills that might simulate drowning risk, but correlation to survive in the water was unproven.

The Technical Report of Weiss et al. (2010) found two recent case control studies that revealed swimming lessons may reduce drowning risk in small children. One study from rural China (Yang et al, 2007) examined drowning deaths in children 1 to 4 years of age and revealed drowning 'case' children were less likely to have had swimming lessons than were controls (6.8% vs 12%,respectively). One study from the USA (Brenner et al, 2009) on 61 drowning deaths in children 1 to 4 years revealed that the drowning victims were reportedly less likely (3% vs 26%) to have participated in formal swimming lessons (OR 0.05; CI=0.01-0.34, P=.002), although the estimates were imprecise and 95% CIs included risk reductions ranging from 3% to 99%. In a cross-sectional survey Ma et al. (2010) found that one of the significant risk factors for non-fatal drowning in rural China was poor swimming skills (OR = 2.74, 95% CI: 1.14-6.62).

The AAP (2010) reports that in recent years, water-survival skills programs designed for infants younger that 12 months have become popular both in the United States and internationally. However no scientific study has clearly demonstrated the safety and efficacy of training programs for such young infants.

Recommendations (for research & practice)

Practice and policy
Although some evidence is available about the effectiveness of swimming lessons in reducing the risk of drowning, it is highly recommended that parents be strongly encouraged to continue close supervision of their children around water. The child's ability to swim do not replace the need for close supervision.

AAP (2010) advices regarding swimming skills are:

Knowing how to swim well in a swimming pool does not always make a child safe in natural water environments. Children need to be taught never to swim alone and not to swim without adult supervision.
Because children develop at different rates, not all children will be ready to learn to swim at exactly the same age. For example, children with motor or cognitive disabilities may not be ready for swimming lessons until a later age.
Swimming skills are just one potential prevention strategy that must be considered in the context of a multifaceted approach that includes effective barriers, appropriate adult supervision and training in CPR.

Further research
It is very hard to show the protective effect of swimming ability. If only because of ethical reasons it is not possible to set up a RCT study. A case-control study is the optimal analytic study design to evaluate the relationship between swimming ability and the risk of drowning. Therefore it will be necessary to routinely collect data of swimming ability among a high proportion of drowning victims and simultaneously from the general population or a suitably selected control population (Brenner et al., 2003). To facilitate this kind of research, Weiss et al. (2010) refer to the recommended guidelines for uniform reporting of data from drowning of the American Heart Association (Idris et al., 2003), a consensus of a group of international investigators, which is available online through http://circ.ahajournals.org/cgi/content/short/108/20/2565

Weiss et al. (2010) and the AAP (2010) suggest that more research is needed to determine which types of swim instructions and water-survival skills training are most effective in preventing drowning in children.

Review Date: 18/04/2011
Version: 2.0
Status: Publish

Procedure
Articles (reviews) and reports were included that were published between 1985 and 2010, in English and Dutch. The outcomes of the study were reviewed by the Dutch Consumer Safety Institute.

Strategy: An online literature search was performed by a researcher of the Consumer Safety Institute. First the titles and then abstracts were scanned in order to include relevant studies. In the case of insufficient information obtained from abstracts the full text articles were obtained. Irrelevant studies were excluded, i.e. the article does not comprise [1] the evaluation or effectiveness, [2] the prevention of child injuries, [3] the specific preventive measure studied. Relevant articles were scrutinized and background documents were created. In addition, relevant references of included articles were checked on new and relevant articles (i.e., snowball search).

The outcomes of the study were reviewed by an expert in the field of child safety in the spring of 2011.

Background documents

Technical report : prevention of drowning (version 1.0)
Jeffrey Weiss (2010)

Swimming lessons, swimming ability, and the risk of drowning (version 1.1)
Ruth A. Brenner, Gitanjali Saluja, Gordon S. Smith (2003)

Association between swimming lessons and drowning in childhood : a case-control study (version 1.0)
Ruth A. Brenner, Gitanjali Saluja Taneja, Denise L. Haynie ...[et al.] (2009)

Policy statement - prevention of drowning (version 1.1)
Committee on injury, violence, and poison prevention (2010)

An analysis of risk factors of non-fatal drowning among children in rural areas of Guangdong Province, China : a case-control study (version 1.0)
Wen Jun Ma, Shao Ping Nie, Hao Feng Xu ...[et al.] (2010)