The American Heart Association (AHA) and American Academy of Pediatrics (AAP) released their first-ever joint focused update on pediatric drowning resuscitation, emphasizing the critical importance of rescue breathing and addressing the unique challenges of resuscitating children who have drowned. The guidelines, published in Pediatrics, provided evidence-based recommendations for both healthcare professionals and trained rescuers.
The update marked a significant shift in resuscitation protocols, prioritizing immediate cardiopulmonary resuscitation (CPR) with rescue breaths over automated external defibrillator (AED) application in drowning cases. This recommendation stemmed from data showing that shockable rhythms constituted only 2% to 12% of cardiac arrests following drowning.
The guidelines incorporated systematic reviews from 2021-2023 performed by the International Liaison Committee on Resuscitation related to drowning resuscitation. The writing group analyzed 26 observational studies and one randomized controlled trial for public-access defibrillation programs in adult out-of-hospital cardiac arrest, along with two observational studies evaluating these programs in pediatric cases.
Key statistics underscored the scope of the problem: drowning accounted for 7% of all injury-related deaths worldwide. In children specifically, Brazilian lifeguard data showed that only 0.7% of drowning rescues required respiratory resuscitation or CPR, with the incidence of resuscitation approximately 1 in 112,000 lifeguard actions.
Clinical outcome data revealed that when respiratory arrest was corrected by rescue breathing that interrupted the drowning process, the death rate was 44% compared to 93% when full CPR including chest compressions was needed. Even with effective CPR, cardiac output, cerebral oxygenation, and blood flow ranged from only 12% to 42% of pre-arrest values.
The guidelines outlined specific protocols for healthcare professionals, allowing them to check for a pulse for up to 10 seconds before initiating CPR. For ventilation techniques, trained rescuers were advised to provide rescue breaths using mouth-to-mouth, pocket mask, or bag-mask ventilation based on their training level and available equipment. Manikin studies demonstrated that mouth-to-mouth ventilation resulted in fewer chest compression interruptions and more effective ventilation compared to pocket masks or bag-mask ventilation.
The update addressed public access defibrillation (PAD) programs, recommending their implementation in aquatic environments with high cardiac arrest risk. While AED use showed benefit in some studies, the guidelines emphasized that AED application should not delay the initiation of CPR with rescue breathing.
The recommendations superseded the last full set of AHA recommendations for drowning made in 2020. The writing group noted that more than 90% of all drownings were considered preventable, with up to 90% of childhood drownings occurring in low- and middle-income countries.
The guidelines included specific knowledge gaps requiring future research, particularly in areas of rescue breathing competency, optimal resuscitation sequences, and outcomes in different settings. The authors called for more rigorous, prospective studies using standardized drowning event reporting and outcomes.
These guidelines represented the first time drowning resuscitation guidelines for children were published independently of adult guidelines with dual endorsement from both the AAP and AHA. The update aimed to provide comprehensive guidance for healthcare professionals, trained rescuers, and untrained lay rescuers involved in pediatric drowning resuscitation.
Conflict of interest disclosures were not made available at time of publishing.
