Discussion

Numerous studies have highlighted the efficacy of preventive strategies such as pool fencing, lifeguard presence, and swimming skill acquisition in reducing drowning incidence. ^{Reference Denny, Quan and Gilchrist9} However, assessing the tangible impact of these interventions on drowning-related morbidity and mortality remains challenging. ^{Reference Peden and McGee2,Reference Peden and Işın10} This study aimed to discern patterns within the escalating phenomenon of pediatric drowning, revealing younger male children from minority groups to be notably vulnerable.

From the years 2004-2023, 129 drowning cases presented to the PED of Hadassah hospitals in Jerusalem. The age and gender distribution within this cohort aligned with globally reported drowning risk factors, emphasizing the heightened susceptibility of toddlers and males. ^{1,Reference Peden and McGee2} Notably, a consistent increase in pediatric drowning events was observed over the study period, correlating with population growth (Figure 1).

Figure 1.

Number of Pediatric Drowning Cases in Jerusalem per Year.

Five of 123 cases had reported or suspected epilepsy (3.9%). This percentage is higher than their reported incidence in Israel, which is estimated to be 0.6% of all children under 18 years of age. ¹¹ Previous studies showed an increased risk of submersion and drowning among children with epilepsy. ^{Reference Denny, Quan and Gilchrist9,Reference Diekema, Quan and Holt12} This underscores the importance of tailored preventive measures for vulnerable populations with underlying medical conditions.

Arab individuals who drowned in this study were notably younger (Table 3; P = .04), had longer ICU lengths of stay (Table 3; P = .02), and exhibited a higher likelihood of subsequent transfer to a rehabilitation center (Table 3; P = .03). No other significant differences were observed between demographic groups. As of the end of 2022, Israel had a population of 9.56 million, with 73.6% being Jewish and 21.1% Arab. ¹³ In Jerusalem, the largest city, the population in 2023 was 984,000, comprising 60.8% Jewish and 39.2% Arab residents. ¹⁴ A retrospective analysis of drowning rates among Israeli children and adolescents aged 7-17 from 2008 through 2018 found no significant differences in drowning outcomes between Jewish and Arab populations. Ethnic minorities, including Arab populations, have been identified as more susceptible to drowning-related injuries and fatalities. ^{Reference Abihasira, Moran, Orr and Eliyahu15} Minorities have been found to be more susceptible to injury and death by drowning. An Australian review identified high-risk populations to be ethnic minorities, First Nations/Aboriginal people, migrants, and rural residents. ^{Reference Willcox-Pidgeon, Franklin, Leggat and Devine4} The American Academy of Pediatrics (Itasca, Illinois USA) policy statement on prevention of drowning reports African American children to have the highest drowning fatality rates, followed by American Indian/Alaska Native (AI/AN) children. ^{Reference Denny, Quan and Gilchrist9} Consequently, there is a rationale for tailored and attentive drowning prevention programs for children from minority groups.

Table 3 outlines the cohort of drowning victims from Jericho. The temporary closure of public pools during the COVID-19 pandemic led to a surge in the use of private pools lacking adequate supervision. From 2021 through 2023, 11 out of 22 drowning victims at the Mt. Scopus PED originated from private pools in Jericho, three of whom died. In contrast, in 2022, there were 101 reported accidental deaths of children and adolescents under 17 in all of Israel, with drowning accounting for 16% of these fatalities. Arab children and adolescents represented 47% of these deaths, despite comprising only 24% of the youth population in Israel. ³ However, this study found that the proportion of Arab drowning victims was comparable to their percentage in the population, at 38% and 39%, respectively.

The current analysis of minority populations, particularly Arab drowning victims and drowning cases originating from Jericho, revealed significant associations with younger age and a higher likelihood of requiring rehabilitation. Despite the absence of other significant differences between groups, these findings highlight the need for targeted interventions addressing cultural and socioeconomic disparities in drowning risk.

A total of 66.7% of this cohort had initial prehospital resuscitation by parent, bystander, or skilled rescuer (Table 2). Previous studies proved immediate intervention by a parent or bystander to be associated with lower odds of severe outcome. ^{Reference Loux, Mansuri and Brooks16}

Forty-eight percent of children required ICU admission (Table 2). Eight children (6.2%) were transferred to a rehabilitation facility after their admission. These findings align with previous studies and demonstrate the heavy burden of drowning. ^{Reference Raess, Darms and Meyer-Heim17}

There were 14 deaths from drowning in this cohort (10.9%). During a similar period (2008-2020), there were 222 drowning fatalities under the age of 17 years in all of Israel. ³ A systematic literature review of drowning in the Eastern Mediterranean region from 2022¹⁰ showed that all-age fatal drowning rates varied from a low of 0.48 per 100,000 (United Arab Emirates; 2002) to a high of 18.5 per 100,000 (Egypt; 2014). Variation in rates may result from demographic and geographic differences between countries in this area.

The current study also identified weekends as a high-risk period for drowning incidents, potentially attributed to reduced supervision and staffing levels in pediatric emergency settings during these times. Children who drowned during weekends were significantly younger (Table 4; P = .04), had longer hospitalization length (P = .01), and had higher risk for need of further rehabilitation (P = .04). Crowded pools that may lead to longer immersion time till rescue may also contribute to severity of outcomes during weekends. However, further studies are needed to investigate this assumption.

Additionally, children from larger families were found to be relatively older at the time of drowning (Table 5; P = .01). It may suggest complex supervision dynamics within these households, as described in other studies. ^{Reference Anderson, Ramos and Schuman18,Reference Chang and Ozanne-Smith19}