Introduction

Drowning is a significant cause of disability and death. Given the shortcomings of previous definitions ,drowning was redefined as a process resulting in primary respiratory impairment from submersion in a liquid . Outcomes were classified as life without morbidity, delayed morbidity or death. Globally, drowning causes half million deaths annually, 60% of these are children .Rates for near drownings are undetermined due to inadequate reporting. The epidemiology of near drowning in childhood was reviewed elsewhere(₁,₂,₃,₄,₅,₆,₇,₈) In developed settings , robust epidemiologic studies directed research , provided guides to policy makers and espoused sustainable preventive measures. [₉,₁₀,₁₁,₁₂]. This is lacking in developing countries .Descriptive epidemiology intimates that the incidence of common childhood illnesses in this setting are decreasing, but that of near drowning is undetermined. This study aimed to review the features ,outcome of near drowning cases seen at the Paediatric ED in a developing country's setting, and proffer sustainable preventive measures.

Methods

The data from the inpatient case records were retrospectively
reviewed from september1999 to September 2008 for descriptors, premorbid coincidental
self regulating defects, seizure disorders, the circumstances of near drowning and the
immersion time. Also information on site and pre-drowning activities, the time of the
year and contributing factors such as adverse pre-existing medical conditions, trauma,
medications, cardiopulmonary disease, head trauma, hypothermia, fractures, aspiration
syndromes, the complications, sequalae, the management strategies applied and outcomes
were also determined.

Results

A total of seven cases of drowning and near drowning were admitted to the
Paediatric emergency department during this period.5(71.43%) males and 2(28.57%)
females.2(28.57%) were aged from 6 months to 1 year,3(42.86%) were aged above 1
year to 6 years,2(28.57%) were aged more than 6 years to 12 years.

Figure 1

Table 1: Type of water where accident happened

Figure 2

Table 2: Linked circumstances to event.

The approximate submersion times were more than 10 minutes 2(28.58%) of cases,10 to
20 minutes 2(28.58%) of cases, more than 20 minutes to 30 minutes 1(14.29%),more
than 30 minutes 2(28.58%)

The times that elapsed from the event to presentation to The Emergency Department
were undetermined in the 2(28.58%) cases these were the two cases who were brought in
already dead. All the 5 (71.43%)cases brought in alive presented less than 6 hours after
the incident. They were brought directly from the scene of the event to the Paediatric
emergency department.

Figure 3

Table 3: Clinical features on presentation to the Paediatric Emergency Department.

2(28.57%) of the cases were hospitalized for at least 24 hours, 1(14.29%) case for at least
48 hours,another1(14.29%)case for at least 48 hours,14.29%,2(28.29%) of the cases for
at least one week,another1(14.29%) of the cases for more than one week. This case had
the longest inpatient stay of nine days and developed organic cerebral dysfunction
syndrome.

The outcomes of the cases were a spectra ranging from alive and well. 4(57.12%) cases
,cerebral dysfunction syndrome 1(14.29%) to brought in already dead. 2(28.57%)

Figure 4

Table 4:Radiologic Features of cases.

All the cases brought to the Paediatric Emergency Department alive 5(100%) had normal
haematological indexes.1(14.29%) of the cases had a hypochloraemic metabolic acidosis.

Figure 5

Table 5:Management Strategies applied to cases.

Discussion

Drowning is an event of much historical interest .It was employed as a means
of execution until the 17th century and the 18th centuries. It was used more often than
hanging as a means of capital punishment.

It was thought to be a more humane form of execution, and was used mainly for the
execution of women, although some privileged men were executed in this way as well.
In this study an attempt was made to explore the incidence and some potential risk factors
of near drowning and drowning-associated deaths in this setting within this period. A
detailed history was undertaken and obtained in all cases. It was indistinct in 28.57% of
cases. (Tables 1-5)

The derived figures showed that drowning associated deaths were significantly higher among children aged 1-4 years compared to other age groups which compares with other series where the peak incidence is usually in the first decade. Male children were more likely to drown or to be nearly drowned. These findings are very close to observations in other settings. [_{13141516171819202122}] Where as the few studies in developing countries showed that many cases of drowning took place in domestic settings such as wells, septic tanks, ditches and receptacles, in the developed countries most cases of near drowning or drowning were related to swimming in a domestic swimming pool. River water was the most common place of these events in this series .Although most deaths occurred in the river, children have drowned in baths, buckets and toilets. These findings are consistent with observations elsewhere [_23242526].In this setting, wells, septic tanks and sometimes the rivers and seas are located very close to individual households. Given the proximity of these bodies of water to the household, children can easily roam around them. Whenever they are unsupervised, accidents including near drowning, and drowning occur more Commonly in this age group because they are more curious, can move around independently and usually they have a natural affinity for water. On the average children who survive near drowning generally do well clinically. They were pre-morbidly more intelligent and explorative as a group. All the cases were pre-morbidly physically and neuropsychologically normal children with no epilepsy, psychopathology, or defects of self regulation. In this series, the manner of near drowning was accidental in 71.43%, and was undetermined in 28.57% who were met already dead. None of the cases showed any sign of physical trauma. All cases brought in alive were seen in severe respiratory distress. The consciousness levels were impaired in 57.14%.In none of the cases did family members have any retrieval or cardiopulmonary resuscitation knowledge or training.28.57% of the cases were brought in already dead.

None of the patients admitted to the intensive care unit through the paediatric emergency
department died. All the cases were admitted for at least 24 hours in the intensive care
unit. Hypochloraemic metabolic acidosis could have contributed to the post
encephalopathic organic brain dysfunction syndrome in the case of the child having this
as an associated complication to the near drowning, this case had the longest hospital
inpatient stay of nine days.

Consent for a limited Computer assisted tomographic virtual or conventional extended
autopsies were declined by the relatives of the drowned cases.

Children who survive near drowning accidents are at risk of encountering the event in the future; therefore they will need an enhanced supervision. Overall the difference between salt and fresh water drowning has little clinical relevance, except that hypovolumiae is more common in the former and atelectasis more common in the latter. Administration of dextrose infusions were avoided as much as possible in these cases because if applied they could get converted to adenosine which causes vasodilatation and worsens the hypotension. All the cases revealed radiological features consistent with aspiration pnuemonitis and interstitial pulmonary oedema, no sand or air bronchograms were seen. There were febrile responses in two cases which could have been attributed to an acute phase inflammatory response secondary to aspiration , hypostatic pneumonitis or severe bacterial infections. These two cases received antipyretics. All the cases in this series received broad spectrum antibiotics and crystalloids. Intravenous aminophylline and frusemide were administered to 42.86% and 57.14% of these cases respectively. Living in close proximity to a body water may be considered a risk factor of drowning. In developed countries, children aged between 1 to 4 years age are most likely to drown in swimming pools, particularly those located in private residential area. (₂₇,₂₈,₂₉,₃₀). The case in this series that drowned in a hotels swimming pool was aged nine, and was found lying face down in the pool during a visit to a mother who just returned from overseas. Various studies in the developed countries proposed several preventive measures such as pool fencing, installation of pool-alarms ,telephones and drowning awareness education and cardiopulmonary resuscitations training programs. In this setting, proper fencing of swimming pools,wells,septic tanks, the fencing of ponds or other open body of water, temporary door fencing to confine children indoors, enhanced age appropriate supervisions, formal training in swimming lessons, use of floatation devices, ,arranging for parents and guardians to undertake formal cardiopulmonary and retrieval trainings, introduction of formal swimming training lessons in the physical educational sessions of the school pupils , increasing the awareness on the possibility of the occurrence of these events, parental and child's educational campaigns, are cost effective, feasible and sustainable preventive options. [₃₁,₃₂,₃₃,₃₄,₃₅,₃₆,₃₇,₃₈] Results of most studies in developed countries showed that drowning-associated deaths among children aged 1-4 years occurred in swimming pools [₃₉,₄₀,₄₁,₄₂], which is not comparable to the situation in this setting where the event is related to activities in other bodies of water such as a river, the sea, a septic tank, the well and a domestic water receptacle. The wet season is the most common time for near drowning events because most artificial and natural bodies of water increase in depth and overflows.Indeeed, occasionally pools of water after a rain is enough to cause near drowning or drowning in young children.

Lack of maternal formal education and overcrowded living conditions could influence unintentional drowning associated deaths among these high-risk age groups. In this setting female literacy was estimated at 24.9%.In developed countries, different preventive strategies were proposed to policy makers and health authorities, and then implemented thereafter based on results of different investigations appeared to be effective in decreasing the mortality related to this event [₄₃,₄₄,₄₅,₄₆,[[[47)]]]] However the situation appears to be different for developing countries where the policy makers and health care professionals may lack adequate figures to direct their decisions on this public health problem. The figures derived from this review highlight the spectra of the features associated with drowning and near drowning, its management implications and outcome in this setting. This reiterates the relevance of undertaking observational epidemiological studies on the societal knowledge, attitude and practice of issues related to near drowning and drowning in this setting. The figures derived from this could assist the generation of hypothesis for future research direction and implementation of appropriate interventions in this setting. Even small sample sized studies could be useful initially in achieving these goals.