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Drowning 101: Understanding The Biology

Drowning is the third leading cause of unintentional injury-related death worldwide. In SA, the number of drownings has increased significantly over the years, with drowning mortality highest in children under 15 years of age. Shockingly, South Africa has been ranked among the top 10 in an analysis of 60 countries for child drowning mortality.

LET’S TALK DEFINITIONS

In 2005, the World Health Organisation simplified matters, so the terms near-drowning, wet, dry, active, passive, silent and secondary drowning are no longer medically recognised.

Drowning: the process of undergoing respiratory impairment as a result of submersion or immersion in liquid. The outcome can either be fatal or nonfatal.

Submersion: when the airway is BELOW the surface of the liquid.

Immersion: when the airway is ABOVE the surface of the liquid.

Aspirate: when you breathe something foreign into the lungs.

Hypoxia: when not enough oxygen reaches the tissues in the body.

THE BIOLOGY OF DROWNING

The water enters the mouth. Once the water travels down and touches the larynx it triggers a reflex, which causes a laryngospasm. This is when the larynx closes up tightly, therefore no water can enter the lungs.

Since the lungs are no longer getting air, the brain starts to lose oxygen which eventually causes this reflex to stop. The larynx then relaxes and water enters the lungs. If death occurred before water entered the lungs it was called dry drowning and when water entered it was wet drowning. Dry drownings are actually very rare.

Once water is in the lung the body absorbs it into the bloodstream. It is uncommon for the amount of water to exceed the rate of absorption because people who are conscious won’t actually breathe in that much water and when they become unconscious they are no longer actively breathing.

Surfactant

The lungs are made up of lots of little sacs called alveoli. These sacs are lined with a substance called surfactant. Surfactant keeps these sacs open so that air can enter them.

When water mixes with surfactant it no longer does its job and the alveoli collapse. With all these sacs collapsing the blood cells cannot absorb any oxygen. They then start to look elsewhere for oxygen and begin to flood areas of the lung where the alveoli are still open (this is known as shunting). Because of these high pressures, fluid starts to leak out of the blood and into the lungs. This then causes pulmonary oedema and is what used to be referred to as secondary drowning.

Eventually, because of the decreasing oxygen in the blood, you lose consciousness. Your brain will then continue to be without oxygen and the duration of this is the most important determinant of outcome.

DELAYED DROWNING

This is what many parents are afraid of will happen to their children. Delayed drowning happens when your child aspirates some water whilst swimming and develops symptoms much later after the incident. Usually you are not even aware of this and your child may not even tell you they had any problems in the water.

Physiologically speaking delayed drowning is the same as secondary drowning. The water that was breathed in causes enough alveoli to collapse to result in shunting and pulmonary oedema.

It’s important to know that there has never been a medically documented case where someone who had a drowning incident, experienced no symptoms at first but later deteriorated and died. Usually someone who has aspirated water will have some symptoms right after which will either get better or worse within a few hours. If your child has had any problems in the water you should watch them for the next 1-2 days. If any respiratory symptoms develop you should take them straight to the emergency room.

Signs and symptoms to watch out for:

  • Coughing
  • Shortness of breath
  • Difficulty breathing
  • Chest pain
  • Unusually tired
  • Pale skin
  • Vomiting

Remember… NEVER leave your children unsupervised around water. A child can drown in as little as 2.5 cm of water.

RESOURCES

van Beeck, E.F. et al. (2005) A new definition of drowning: towards documentation and prevention of a global public health problem. Bulletin of World Health Organization, [online]. Available from: https://www.scielosp.org/pdf/bwho/2005.v83n11/853-856/en [Accessed: 11 October 2018].

Hawkins, S.C., Sempsrott, J. & Schmidt, A. (2017) Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning. Emergency Medicine News [online]. Available from: https://journals.lww.com/em-news/blog/PhotographED/Pages/post.aspx?PostID=247 [Accessed: 11 October 2018].

High, P. (2016) Immersion submersion and drowning Available from: https://derangedphysiology.com/main/required-reading/trauma-burns-and-drowning/Chapter%204.0.7/immersion-submersion-and-drowning [Accessed: 11 October 2018].

Saunders, C.J., Sewduth, D. & Naidoo, N. (2018) Keeping our heads above water: A systematic review of fatal drowning in South Africa. SAMJ, [online] 108 (1), pp. 61-68. Available from: http://www.scielo.org.za/pdf/samj/v108n1/17.pdf [Accessed: 11 October 2018].

WHO (2018) Violence and Injury Prevention. [online]. Available from: http://www.who.int/violence_injury_prevention/other_injury/drowning/en/ [Accessed: 11 October 2018].

7 Tips To Keep Your Sleeping Baby Safe

I’m sure many of you have heard of SIDS, which is also known as cot death. SIDS is defined as the sudden unexpected death of an infant, which appears to happen during sleep, where the death can’t be explained even after an autopsy.

In the developed world, SIDS and suffocation are the most common cause of sudden unexpected infant deaths (an infant is a child under 1 year of age). Unfortunately, in South Africa, we don’t know the stats since most infants that die unexpectedly don’t undergo routine autopsies to identify cause of death.

You all probably know that back sleeping is the safest for your baby, but there are other additional ways you can reduce the risk of SIDS and other sleep-related causes of death. I have put together some tips in which to create a safe sleep environment for your baby from birth up until 1 year of age.

1. POSITION

Always place your baby to sleep on his or her back, for night sleeps AND naps. There is no evidence to prove that your baby is more like to choke if he or she vomits or regurgitates in this position, compared to a baby that sleeps in any other position. Placing your baby to sleep on their side is also not recommended, unless indicated for medical reasons by your practitioner.

Once your baby starts to roll, continue to place them to sleep on their backs but do not drive yourself mad by constantly repositioning them if they do roll over in their sleep. Once babies have mastered the art of rolling they can roll themselves right out of trouble if their breathing becomes difficult.

It’s important to also talk a little bit about flat head syndrome (plagiocephaly). Back sleeping is associated with this condition. Babies’ skulls are soft and constant pressure on the same spot can cause the head to change shape. You can avoid this deformity by repositioning your baby’s head to face opposite sides with each sleep.

2. SURFACE

Your baby should sleep on a firm flat surface. Not a soft surface like a couch, pillow or blanket. Babies should not sleep in car seats, baby swings and carriers either (this is not back sleeping). If your baby does fall asleep in one of these, it’s better to place them flat in their cot or bassinet as soon as possible. I spoke about recline angle and heads blocking airways in my post about car seat safety.

In addition to floppy heads its important to realise that a baby’s head is very large compared to their body. So if you elevate the head too much the airway can also become obstructed.

 

What happens to the airway when the head is elevated

 

3. BEDDING

It’s hard to avoid decorating your little one’s room when there are so many gorgeous accessories available. Just remember to remove all loose items from their beds before naps and bedtime. Such items are a potential entrapment, strangulation and suffocation hazard. Pillows, blankets, stuffed animals and even cot bumpers should not be in your baby’s bed whilst they sleep. There is no evidence to even prove that cot bumpers actually do prevent injury and infants don’t need pillows.

Please also be aware of mobiles. Depending on how high your mobile is your little one may be able to reach for it, as he or she gets older. Then the strings and other components could become a choking and/or strangulation risk.

4. LOCATION

This tip is debatable since there is mixed evidence in the literature. The American Academy of Pediatrics (AAP) recommends that your baby share your room but not your bed. This recommendation was introduced after many infants who co-shared died by either becoming trapped in the bedding or smothered by a parent.

Interestingly in African and Asian countries, this has not been seen. These countries, where co-sharing is the norm, actually have lower rates of sleep-related infant deaths than Western countries. Researchers suggest that co-sharing is actually protective because infants who sleep next to their parents are constantly stimulated. This stimulation keeps them in a more aroused state so they spend less time in deep sleep and are therefore at a lower risk of stopping breathing.

5. TEMPERATURE 

Your baby should not get too hot in their sleep. Dress your baby in only ONE extra layer than you would comfortably wear. A sleep sack is a safe option. No blankets please!

The room temperature should also be kept comfortable. Most baby monitors have a built in temperature function but if yours doesn’t, keep an indoor thermometer in the room and don’t let the temperature go higher than 22o Celsius.

6. PACIFIER

It has been shown that a pacifier reduces the risk of SIDS. You can try giving your baby a pacifier but only once breastfeeding has been well established (if you choose to breastfeed). The nipple can confuse your baby if given too early and you may then have problems with latching.

Remove dummy chains or strings before giving your baby a pacifier to sleep. Also, don’t stress if the dummy falls out during sleep (it most probably will), you don’t need to replace it.

Don’t force a dummy. It’s ok if your baby doesn’t like it, not all babies do.

7. FURNITURE

Now take a step back and look around your baby’s room. Make sure all electrical cables, window blind cords and any other potentially hazardous items within arms reach from the cot are removed.

Looking after our babies is a lot of work and we always need to be on call and think 2 steps ahead. But now that your little one is sleeping SAFELY, go and put your feet up and have a cup of coffee… or maybe go take a nap yourself!

RESOURCES

Cadematori, M.E., Piranian, M.A., Skrzypek, P.A. & Pron, A.M. (2016) Caregiver Compliance With Safe Sleep Guidelines. Newborn & Infant Nursing Reviews, [online] 16, pp. 122–125. Available from: https://www.sciencedirect.com/science/article/pii/S152733691630054X [Accessed: 26 September 2018].

Kibel, M.A., Molteno, C.D. & De Decker, R. (2005) Cot death controversies. Cot death. SAMJ, [online] 95 (11). Available from: http://www.samj.org.za/index.php/samj/article/viewFile/1881/1202 [Accessed: 26 September 2018].

Koren, A., Reece, S.M., Kahn-D’angelo, L. & Medeiros, D. (2009) Parental Information and Behaviors and Provider Practices Related to Tummy Time and Back to Sleep. Journal of Pediatric Health Care, [online] 24 (4), pp. 222-230. DOI: 10.1016/j.pedhc.2009.05.002 [Accessed 26 September 2018].

Miller, L.C., Johnson, A., Duggan, L. & Behm, M. (2011) Consequences of the “Back to Sleep” Program in Infants. Journal of Pediatric Nursing, [online] 26, pp. 364-368. Available from: https://0-ac-els–cdn-com.innopac.wits.ac.za/S0882596309002930/1-s2.0-S0882596309002930-main.pdf?_tid=dccfa213-e0d1-4850-beeb-18fd49b69dd5&acdnat=1537520788_cb816c0abb2f56d365e5a1b195a3ca24 [Accessed 26 September 2018].

10 Essential Tips To Prevent Poisoning In Your Home

I was recently prescribed some analgesics for a small day procedure. That afternoon, when I got home, I placed the packet of meds on my dresser and later found my daughter sitting on the floor inspecting the packet. My heart stopped! This careless mistake could have had devastating consequences.

Unfortunately poisoning data in South Africa is lacking. One study dating back to 2012 found that the most common cause of accidental poisoning in SA children is pesticides. However, the list of potential poisons throughout our homes is extensive; here are just a few more obvious ones:

  • Medications
  • Household cleaners and disinfectants
  • Cosmetics and toiletries
  • Insect and rodent repellants
  • Weed killers and other outdoor chemicals
  • Swimming pool chemicals
  • Flea and tick shampoos and other products for pets

I have put together a list of some useful tips to prevent accidental poisoning at home. Some of them may seem fairly obvious but as I have recently experienced it is easy to forget.

  1. Keep all potential household and other hazards in their original containers. DO NOT transfer into coke bottles or Tupperware’s.
  2. Make sure seals of potential hazards are tight and secure before locking away. Please note that child resistant packaging of medications is NOT childproof.
  3. Keep potential hazards locked away in the highest cupboard with a childproof lock. The cupboard should even be high for you, as little minds can get quite creative with boxes and stools and climb up onto countertops.
  4. Keep potential hazards out of reach of children when in use and never leave bottles or buckets unattended.
  5. Never call medicine sweets/candy. This is a common mistake parents make in order to get their kids to take medicine when sick. This could lead to a child one day consuming an entire bottle of ‘sweets’.
  6. Never leave your handbag lying around and be extra cautious when you have visitors over as many people keep painkillers in their bags.
  7. Alcohol is often overlooked and is very dangerous to your little ones if consumed in excess. Keep alcohol out of reach of children especially when hosting parties.
  8. Any kind of battery can be dangerous if leaking or ingested. Keep remote controls and other battery containing devices away from children.
  9. If you are unsure about whether or not a household item is hazardous, assume it is and keep it locked away. Things that seem harmless are most often extremely dangerous.
  10. Most importantly TEACH your children about the dangers!

It may be a good idea to identify what potential hazards you have in your home. Do a check of every room in the house including your garage and make sure your home is safe.

RESOURCES

Balme, K., Roberts, J.C., Glasstone, M., Curling, L. & Mann, M.D. (2012) The changing trends of childhood poisoning at a tertiarychildren’s hospital in South Africa. South African Medical Journal. [Online] 102 (3), pp. 142-146. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000300023&lng=en&tlng=en [Accessed 8 August 2018].

Veale, D.J.H., Wium, C.A. & Müller, G.J. (2012) Toxicovigilance I: A survey of acute poisoning in South Africa based on Tygerberg Poison Information Centre data. South African Medical Journal. [Online] 103 (5), pp. 293-297. Available from: http://www.samj.org.za/index.php/samj/article/view/6647/5054 [Accessed 8 August 2018].

Emergency Numbers Every Parent Should Know

It occurred to me the day I went back to work after my maternity leave that I didn’t know any other emergency number besides 10111. Thankfully I have never had to use this but I couldn’t risk leaving my daughter at home with her caregiver without leaving a more comprehensive list of important numbers by the phone.

The last thing you want to do in an emergency is dial the wrong number. In the US, the UK and Europe there is only one toll-free number to call from any landline or mobile phone. In South Africa, things are not as simple. Unfortunately there isn’t one single number for an emergency.

I spent a really long time searching the web and making a couple of phone calls but I finally managed to put together this simple list. It is vital that you as parents and/or caregivers know what number to dial when and it is perhaps even more important that your little ones know this too.

USING YOUR CELL PHONE:

Any emergency nationwide – 112 (this number will still work even if you have no airtime)

USING YOUR LANDLINE OR CELL PHONE:

Police/Fire – 10111

Nationwide ambulance (public EMS) – 10177

Netcare 911 (private EMS) – 082 911

ER 24 (private EMS) – 084 124

Poison Information Centre – 0861 555 777

Remember, before making that emergency call, try to stay calm. You also need to have important information ready such as, the type of emergency, details of any injuries and the exact location of the emergency needing attention.

You can download a list of important emergency numbers here. It may be a good idea to stick this on your fridge or somewhere nearby the phone.

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