Drowning Prevention: How the American Academy of Pediatrics is failing our children

Drowning prevention is about layers of protection, but there is one crucial layer of protection that the American Academy of Pediatrics does not want you to consider

In June 2021 I co-authored an article with drowning prevention parent advocate Nicole Hughes on the subject of water competency in 1-4 year old children and which national swim lesson program methodology aimed to teach this highest risk age group survival skills to best protect against an unplanned submersion.

The purpose of this article was to provide parents and primary care pediatricians with a direct comparison of popular formal swim lesson curriculums of the American Red Cross, YMCA, and Infant Swim Resource (ISR) to inform them on which program better aligns with the parent’s goals for water competency for their young child.

A secondary objective of this commentary was to highlight the methodology of survival swim as a type of formal swim program that in many ways appears superior for this high risk age group due to its ability to teach independent back floating and swim float swim without flotation devices. Despite being the only prominent formal swim lesson program that does this for the under 4 year olds, the AAP without any evidence has come out guns blazing against it.

This is evidenced by the recent parent article in JAMA Pediatrics which states: “Teaching children to swim is important, and the American Academy of Pediatrics has recommended swim lessons as early as age 1 year to provide another protection layer. However, infant swim classes such as Infant Swimming Resource have not been shown to lower the risk of drowning. As an alternative, families may seek out parent-child water play classes to gain familiarity and comfort with being around water together.”

Yet despite the lack of data on benefit vs. harm for each type of formal swim lessons, the AAP feels justified to advocate against ISR survival swim while advocating for Mommy and Me group swim lessons with the goal of comfort over survival.

One year after the publication of our article, the American Academy of Pediatrics authors of the 2019 Policy on Drowning Prevention submitted a Letter to the Editor to Contemporary Pediatrics criticizing our article to which we responded in an Author Response. For unexplained reasons neither letter was published by the journal of record.

Due to the importance of advancing this conversation to better understand the likely benefit and lack of harm of survival swim as a crucial layer of drowning prevention protection, I will publish both the AAP Letter to Editor and Author Response below. It is my hope that you read both. When reading, please do so within the context of an AAP that willingly advocates for non-pharmacological interventions (NPI) such mandatory masking of children for prevention of COVID-19 - stating that there is no evidence that it causes harm or developmental delays while willingly advocating against ISR survival swim - stating that it is harmful and lacks evidence of benefit without any such evidence to make either claim.

Letter to Editor

(Yusuf S, Denny SA, McCallin TE, Shenoi RP, Agran P,  Hoffman B, Quan L.)

We are responding to your article by Porter and Hughes, “How one child’s tragedy is making us reconsider our approach to drowning prevention.” [1]

As the co-authors of the American Academy of Pediatrics (AAP) publication “Prevention of Drowning” and “Technical Report on Drowning” (Pediatrics 2019 and 2021 respectively), we address multiple problems in Porter’s article to clarify the AAP’s policy. Our concerns are:

1. Misrepresentation of AAP Swim lesson policy. Authors Porter and Hughes state, “Currently, the American Academy of Pediatrics (AAP) advises families follow the advice of their child’s pediatrician to determine the appropriate age for formal lessons”. “However, experts only begin to agree that most children are ready for swim lessons by their fourth birthday, which is long after the highest risk age of drowning.”  The AAP’s most recent policy statement (2019) recommends swim lessons for children 1-4 years of age, if developmentally ready [2]. This revision was based on evidence of a protective effect of swim lessons in the 1-4-year-old age group, initially described by Brenner (2007) and then Yang (2009) [3,4].  Additional data continues to support swim lessons for this age group (5) However, no study has identified what aspect of swim lessons confers protection (5). Similarly Figure 1 misrepresents present AAP policy.

2. Misrepresentation of the AAP policy process:  Authors state, “The same water safety tips are casually tossed out each year: Watch your kids while swimming. Install a fence. Buy a life jacket. Wait until children are “ready” to start swim lessons.” These statements are based on evidence reviewed and outlined in the AAP Policy Statement and Technical Report [2,6], emphasizing the multiple layers of protection needed for drowning prevention which include supervision, life jacket use, recreating in a safe water setting with life guards, and rescue/response skills [7, 8]. These layers’ underscore Haddon’s approach to injury prevention that change the host (child) and his/her environment to decrease injury. [9] Reliance on a single skill or intervention as the panacea for drowning is dangerous. The revision process for the AAP policy statements (PS) and technical reports (TR) is thorough, evidenced based and undertaken with extreme thoughtfulness.  Authors do an in-depth assessment of peer-reviewed literature published since the publication of the previous recommendations and then update the recommendations to align with the latest evidence.  The completed PS and TR then undergoes a rigorous approval process that includes several AAP Sections and Councils, external review by key stakeholders, and then AAP Board of Directors gives the final approval.

3. Focus on achieving a single swim skill as drown-proofing. There are no data on the efficacy of teaching the single self-survival floatation skill to infants, how many infants master the skill, when they can achieve it, and most importantly, whether it decreases drowning risk [10]. Importantly, Asher (1995) showed that children between 24-42 months could learn and perform several swim survival skills but unreliably so in a simulated submersion [11]. Most importantly, even adults who are very good swimmers drown. While swimming ability may decrease drowning, it does not provide drown-proofing.” [12, 13]. Any level of swim ability should not lead to belief that a child can be drown-proofed.

4. Ignoring learning theory – The recent AAP swim Policy recommended swim lessons start at age one year based on Bruner’s (1966) learning theory [14]. Per this learning theory, learners need to be in a specific state of mind and motivated to learn (ready to learn (developmental readiness) as well comfortable tasks and situations (environment). Learning to swim requires “aquatic readiness” which is neuromuscular maturation with learned experiences (breath control, floating etc.). [15] Moreover, studies repeatedly show that learning is best achieved in a positive environment. [16]

5. Minimizing possible harm of their proposed intervention. The authors raise but do not address the possibility of harm in swim lessons that teach self-survival skills to infants by repeatedly having them submerge and struggle. Non nocere (Do No Harm) guides all medical recommendations. Injury prevention recommendations always have to consider the risk of unintended outcomes. Several studies have shown that parents of young children who have acquired some swimming competencies subsequently perceive those children as needing less supervision, thereby potentially increasing their risk. [12, 17]

   Specific to their proposed intervention, infant survival swim (ISR), the authors minimize

   the collateral harm of teaching process that involves repeatedly allowing the infant to

   submerge, without rescue and comforting, during each lesson for weeks. The concerns of

   a wide swath of parents, swim instructors and swim organizations, that these teaching methods are traumatic to infants and toddlers, cannot be dismissed.  Evidence supports

   reports that some children subsequently become averse to learning to swim and

   to participation in aquatic activities. In fact, when followed up, their acquisition of swim

   skills were impeded when compared to peers who did not have a negative aquatic    

   experience. [17]. In addition to potential effects on swim skill acquisition and attitudes,

   repeated negative experiences such as simulation of drowning and lack of appropriate

   caregiver rescue could potentially be a toxic stress that can affect child parent bonding

   with effects noted in later childhood. Increasing evidence shows that traumatic experiences among young children affect brain development leading to long-term behavior problems and social-emotion/cognitive deficits in adulthood [18, 19].   “The infant is exquisitely sensitive to environmental conditions. Early experiences during rapid brain growth laymfoundation for all social emotional, cognitive development and resilience” and has led to calls for pediatricians to advocate for “policies that hold the baby in mind” [20].

   The AAP Policy Report from its Committee on Psychosocial Aspects Of Child And Family Health, Section on Developmental And Behavioral Pediatrics, Council On Early

   Childhood Report on Preventing Childhood Toxic Stress, identifies the need for

   pediatricians to identify and prevent toxic stresses and adverse childhood experiences,

   noting that the “ecobiodevelopmental model” requires that the pediatrician actively

   promote positive relationships from infancy onwards. [21, 22]

6. Lack of data clarity

Age matters; the difference in motoric abilities and learning of infants versus those over 12 months are astronomic. Yet the authors do not clarify if their comparison involve similar age groups; In the Table, Column B involved infants 6-12 months, while in Columns A and C, age groups were unidentified. Elsewhere in the paper, the authors did not differentiate between less than 1 year and 1-4-year age group readiness for swimming and lumped infant and toddlers into the same group. What swim programs are represented in the Table’s columns and discussed at length are unclear.

Data sources for this table are not provided. Furthermore, authors use the terms swim programs interchangeably with curricula although a program can have multiple curricula and do not clarify to which curricula they refer. Authors use but do not define the term “parent-led lessons.” It suggests parents lead these swim lessons when in fact, all infant and child swim lessons are instructor-led, differing only in whether the parent participate or not.

Program B, for infants 6-12 months, appears to be “Infant swim rescue (ISR)” although not explicitly stated as such. It forms the basis of the authors’ thesis. The AAP does not support swimming lessons in children less than 1 year of age because infants are not developmentally ready to swim or to use skills for survival and can be stressed by repetitive proximation of drowning that the learning entails. Documented negative long-term outcomes in infants and young children who have been trained in ISR type program and the lack of evidence of a protective effect of these trainings provide the basis of the AAP’s recommendation to start swim lessons after infancy with existing best practices that promote a positive, safe aquatic experience for the child [23].

References:

1. Porter, T. R., & Hughes, N. (2021). How one child's tragedy is making us reconsider our approach to drowning prevention. Contemporary pediatrics, 38(6), 35-39.

2. Denny SA, Quan L, Gilchrist J, McCallin T, Shenoi R, Yusuf S, Hoffman B, Weiss J. Prevention of Drowning. Pediatrics. 2019 May; 143(5).

3. Brenner R, Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood: A Case-Control Study. Archives of Pediatrics & Adolescent Medicine, 163(3), 203–210. https://doi.org/10.1001/archpediatrics.2008.563.

4. Yang, Nong, Q.-Q., Li, C.-L., Feng, Q.-M., & Lo, S. K. (2007). Risk factors for childhood drowning in rural regions of a developing country: a case–control study. Injury Prevention, 13(3), 178–182. https://doi.org/10.1136/ip.2006.013409.

5.Taylor, Franklin, R. C., & Peden, A. E. (2020). Aquatic Competencies and Drowning Prevention in Children 2–4 Years: A Systematic Review. Safety, 6(2), 31–. https://doi.org/10.3390/safety602003.

6. Denny, Quan, L., Gilchrist, J., McCallin, T., Shenoi, R., Yusuf, S., Weiss, J., & Hoffman, B. (2021). Prevention of Drowning. Pediatrics (Evanston), 148(2), 1–. https://doi.org/10.1542/peds.2021-052227

7.Ramos, Beale, A., Chambers, P., Dalke, S., Fielding, R., Kublick, L., Langendorfer, S., Lees, T., Quan, L., & Wernicki, P. (2015). Primary and Secondary Drowning Interventions: The American Red Cross Circle of Drowning Prevention and Chain of Drowning Survival. International Journal of Aquatic Research and Education (Champaign, Ill.), 9(1), 89–101. https://doi.org/10.1123/ijare.2014-0045.

8.Bugeja, & Franklin, R. C. (2013). An analysis of stratagems to reduce drowning deaths of young children in private swimming pools and spas in Victoria, Australia. International Journal of Injury Control and Safety Promotion, 20(3), 282–294. https://doi.org/10.1080/17457300.2012.717086.

9.Runyan C. W. (2015). Using the Haddon matrix: introducing the third dimension. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 21(2), 126–130. https://doi.org/10.1136/ip.4.4.302rep

10. Langendorfer. (2015). Oh, Baby, Baby: Examining Claims for Water Safety and Drowning Prevention of Infants. International Journal of Aquatic Research and Education (Champaign, Ill.), 9(2), 114–115. https://doi.org/10.1123/ijare.2015-0026.

11.Asher, Rivara, F. P., Felix, D., Vance, L., & Dunne, R. (1995). Water safety training as a potential means of reducing risk of young children’s drowning. Injury Prevention, 1(4), 228–233. https://doi.org/10.1136/ip.1.4.228.

12. Morrongiello, Sandomierski, M., & Spence, J. R. (2014). Changes Over Swim Lessons in Parents’ Perceptions of Children’s Supervision Needs in Drowning Risk Situations: “His Swimming Has Improved So Now He Can Keep Himself Safe.” Health Psychology, 33(7), 608–615. https://doi.org/10.1037/a 0033881.

13.Stallman, Moran, K., Quan, L., & Langendorfer, S. (2017). From Swimming Skill to Water Competence: Towards a More Inclusive Drowning Prevention Future. International Journal of Aquatic Research and Education (Champaign, Ill.), 10(2). https://doi.org/10.25035/ijare.10.02.03.

14. Bruner, J. (1966). Toward a Theory of Instruction. Cambridge, MA: Harvard University Press.

15. Langendorfer. (2015). Changing Learn-to-Swim and Drowning Prevention Using Aquatic Readiness and Water Competence. International Journal of Aquatic Research and Education (Champaign, Ill.), 9(1), 4–11. https://doi.org/10.1123/ijare.2014-0082

16. Driscoll, Marcy P(2013). Psychology of Learning for Instruction. Harlow: Pearson Education UK.

17. Peden, & Franklin, R. C. (2020). Learning to Swim: An Exploration of Negative Prior Aquatic Experiences Among Children. International Journal of Environmental Research and Public Health, 17(10), 3557–. https://doi.org/10.3390/ijerph17103557

18. Nelson, & Gabard-Durnam, L. J. (2020). Early Adversity and Critical Periods: Neurodevelopmental Consequences of Violating the Expectable Environment. Trends in Neurosciences (Regular Ed.), 43(3), 133–143. https://doi.org/10.1016/j.tins.2020.01.002.

19. Graf, Schiestl, C., & Landolt, M. A. (2011). Posttraumatic Stress and Behavior Problems in Infants and Toddlers With Burns. Journal of Pediatric Psychology, 36(8), 923–931. https://doi.org/10.1093/jpepsy/jsr021.

20. https://www.aap.org/en/news-room/aap-voices/holding-the-baby-in-mind-in-times-of-war/.

21. Garner, & Yogman, M. (2021). Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health. Pediatrics (Evanston), 148(2), 1–. https://doi.org/10.1542/peds.2021-052582

22. Duffee, Szilagyi, M., Forkey, H., & Kelly, E. T. (2021). Trauma-Informed Care in Child Health Systems. Pediatrics (Evanston), 148(2), 1–. https://doi.org/10.1542/peds.2021-052579.

23. Goldberg, Lightner, E. S., Morgan, W., & Kemberling, S. (1982). Infantile water intoxication after a swimming lesson. Pediatrics (Evanston), 70(4), 599–600. https://doi.org/10.1542/peds.70.4.599

Author Response:

(Todd R Porter MD MSPH, Nicole Hughes)

We appreciate the interest in our commentary (1) on drowning prevention by the authors of the 2019 AAP policy statement on Drowning Prevention. Responding to your points #1 and #2, in review, the 2003 AAP policy on Prevention of drowning in infants, children, and adolescents (2) stated “there are no data to show that swimming lessons actually decrease the risk of drowning. Thus, swimming lessons are not recommended as a means of drowning prevention, and the American Academy of Pediatrics states that “children are not developmentally ready for formal swimming lessons until after their fourth birthday.” Even after the landmark 2009 Brenner study (3) that showed a protective effect of formal swimming lessons, the updated 2010 AAP Policy statement on Prevention of Drowning (4) states “The evidence no longer supports and advisory against early aquatic experience and swimming lessons for children of any specific age. However, current evidence is insufficient to support a recommendation that all 1-4 year old children receive swimming lessons”.  The 2019 updated AAP policy statement on Prevention of Drowning (5), heralded by parent advocate Nicole Hughes, does state: “Evidence suggests that many children older than 1 year will benefit from swim lessons” yet goes on to state “A parent or caregiver’s decision about when to initiate swim lessons must be individualized on the basis of a variety of factors including comfort being in water, health status, emotional maturity, and physical and cognitive limitations.”

In light of the above review of the 2019 policy on Drowning Prevention, it would be more fair to say that the policy statement suggests that swim lessons may be beneficial with the caveat that initiation of swim lessons is dependent on developmental factors of the child. This is far from a blanket ‘recommendation’ you state in your Letter to the Editor. 

As for the accusation that our Figure 1 misrepresents present AAP policy, each bullet point was taken verbatim from healthychildren.org  “Swim Lessons: When to Start & What Parents Should Know” (6) accessed at https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Swim-Lessons.aspx  

Responding to point #3, it is disingenuous to state that our article endorses the acquisition of a single skill (or layer of protection) as the panacea for drowning prevention. If one reads the article, we state that “It is well accepted that drowning prevention involves layers of protection and that enacting all layers achieves the best protection”. Yet we also highlight that “at least 1 layer of protection is breached in 9 out of 10 fatal pool drowning cases.” We feel that Dr. Jennifer Belzel Ward said it best in her response letter7 to the 2009 Brenner study: 

“As a pediatrician, I am frustrated that the AAP and researchers are not providing my colleagues and me with more tools to help parents differentiate various formal lessons from those specifically focused on helping their child survive an aquatic incident.” She goes on to say “it is only when we as pediatricians can help parents make specific, informed, and individualized decisions about the kind of lessons most appropriate to reduce drowning that any actual impact will be made.” In reply, Dr. Brenner writes: “Knowing what specific types of lessons are most beneficial for young children would be useful for parent and pediatricians. We agree that this type of information is extremely important.” (7)

Unfortunately, over a decade later there still remains a lack of data on effectiveness of various types of formal swim lessons on drowning prevention. We presume this to be due to preconceived knowledge, attitudes, and beliefs by the AAP and the water safety community that survival swim lessons are harmful and that parent-child classes are beneficial. This is evidenced by the recent parent article in JAMA Pediatrics which states: “However, infant swim classes such as Infant Swimming Resource have not been shown to lower the risk of drowning. As an alternative, families may seek out parent-child water play classes to gain familiarity and comfort with being around water together.” (8) 

We believe this is a bold statement considering the small sample size of the Brenner study which precluded it from being able to perform a subgroup analysis on which type of formal swimming lesson (survival swim vs. parent-child) was more effective. Yet despite the lack of data on benefit vs. harm for each type of formal swim lessons, the AAP feels justified to make such claims.

Yet to Dr. Belzel Ward’s point in her aforementioned letter, the primary goal or our commentary was to provide a side-by-side comparison of 3 mainstream national formal swim lesson program curricula (Infant Swim Resource, American Red Cross, YMCA). All three of these curricula were provided with consent of each program and the Table was constructed with direct responses from each national program director for each topic category. The intent of this comparison as stated in our commentary was to “compare these programs’ goals and methodologies for achieved water competency of children 6 months to 4 years” in order to “help caregivers and providers determine which program best meets their child’s water exposure needs.”

Responding to your point #4 about learning theory, it is presumptuous to state that infants less than 1 year of age lack the ability to acquire water competency skills based off of a 1966 theory. The ISR program has a database of hundreds of thousands of children who have participated in the program yet no research has been pursued to study the outcomes in infants < 1 year and to confirm or deny these statements.

Responding to your point #5: these claims presume an intimate knowledge of ISR swim lesson methodology that you do not provide evidence that you have. You claim that ISR repeatedly has the infant submerge and struggle. As stated in our commentary, ISR instructors are “trained in methodologies based in behavioral science, sensorimotor learning, schedules of reinforcement, and the building of behavioral chains with the goals of teaching infants and toddlers to learn skills to help them float and find air if met with an unplanned submersion.” What data do you have to refute this approach instead of basing your premise on the “concerns of parents, swim instructors, and swim organizations”. 

Another unsupported claim is the implication of a causal association between ISR and lack of future aquatic skills obtained due to negative prior aquatic experiences (NPAE). The article you cite to justify this claim consisted of a retrospective cross sectional review of parents in a small territory in Australia whose children attended a learn-to-swim program. As pointed out in the study limitations, the data represents self reports of parents about their child and is subject to recall bias. The study also lacks external validity given that the learn-to-swim program is not identified as the same ISR branded program provided here in the U.S. 

What is interesting about this cited study results is that several reported NPAE related to swim lessons consisted of feeling overwhelmed because the group was too large for the number of instructors. ISR has a 1:1 instructor/child ratio while the Red Cross and YMCA engage in group lessons (see the table in our commentary). Relating the teaching of ISR lessons to infants and young children (ISR ages are from 6 months to 5 years) equivalent to inflicting adverse child experiences is a non sequitur. Again, you present no data to support this claim. 

Speaking on a personal level, Dr. Porter’s 3 children started ISR at the respective ages of 3 years, 18 months, and 10 months. All 3 children graduated out of their ISR lessons at 5 years of age and went on to join the swim team. They love swimming and going to the pool to play and show no NPAE. Nicole Hughes did not do ISR with her first 3 children (Levi was her third). She and her anesthesiologist husband chose to enroll their 4th (9 months) and 5th (6 months) children in ISR. Her daughter is 3 now, and she can swim across the pool, loves swimming, and her water experience has been enhanced as a direct result of ISR. Her son is 19 months, can float independently, and enjoys being in the water with his parents holding him, which is exactly what ISR encourages at this age. 

Responding to your point #6: the table clearly shows a side by side comparison of each program for each specific topic going down the left column. We did not highlight in the commentary which swim program was which so as to not attempt to endorse or disparage any one specific program. The programs represented are American Red Cross, ISR, and YMCA. As stated earlier, the responses listed under each program are taken from direct responses from each program’s national representative to our inquiry and we feel therefore is an accurate reflection of the goals and methodology of the program. 

As the title of the table states, the characteristics of swim program A, B, and C encompass the age range of 6 months to 4 years. There is no difference in ages represented in each program. It appears that you are misinterpreting the question: “age when program endorses child is developmentally ready to float independently on back” The answers listed under each program A,B, and C again were derived from the National Program Director and reflect the age in years or months that each program believes the child is capable of learning that skill.

The last paragraph in your Letter to the Editor is dangerously misleading and unsubstantiated and represents the research void that continues to exist in our understanding of what ages children can developmentally achieve, with independent success, water competency skills as well as what water competency skills are more protective. We are both disappointed and confused as to why both the AAP and water safety community continue to claim documented long term negative outcomes in infants and children who have trained in ISR programs without offering any evidence to support this claim. The AAP and water safety community also seem to lack curiosity in advocating for research to prove that infants are not developmentally ready to swim nor able to use skills for survival. It would seem that all they would have to do is advocate for prospective studies on the outcomes of infants engaged in ISR or other survival swim lessons.

In summary, the double standard at work here is dangerous and threatens to ruin the scientific credibility of the representatives of the AAP.

You state: “Documented negative long-term outcomes in infants and young children who have been trained in ISR type programs and the lack of evidence of a protective effect of these trainings provide the basis of the AAP’s recommendation.”

We would argue for positive long-term outcomes in infants and young children who have been trained in ISR type programs and the lack of any evidence proving ISR to be traumatic provide the basis for our confusion as to why the AAP can recommend against ISR or survival swim in general.

Additionally, you state: “The concerns of a wide swath of parents, swim instructors and swim organizations, that these teaching methods are traumatic to infants and toddlers, cannot be dismissed.  Evidence supports reports that some children subsequently become averse to learning to swim and to participation in aquatic activities.”

We would argue that one cannot dismiss the experience of a wide swath of parents, swim instructors and swim organizations that view these teaching methods as empowering and effective for infants and toddlers. 

Respectfully,

Todd R Porter MD MSPH

Nicole Hughes

References:

1. Porter, T. R., & Hughes, N. (2021). How one child's tragedy is making us reconsider our approach to drowning prevention. Contemporary pediatrics, 38(6), 35-39.

2. Brenner RA. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(2):440-445. doi:10.1542/peds.112.2.440

3. Brenner R, Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood: A Case-Control Study. Archives of Pediatrics & Adolescent Medicine, 163(3), 203–210. https://doi.org/10.1001/archpediatrics.2008.563.

4. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning. Pediatrics. 2010;126(1):178-185. doi:10.1542/peds.2010-1264

5. Denny SA, Quan L, Gilchrist J, McCallin T, Shenoi R, Yusuf S, Hoffman B, Weiss J. Prevention of Drowning. Pediatrics. 2019 May; 143(5)

6. Swim lessons: when to start & what parents should know. healthychildren.org. Updated March 15, 2019. Accessed August 15,2022. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Swim-Lessons.aspx

7. Carr WD. Formal swimming lessons must be defined. Arch Pediatr Adolesc Med. 2009;163(10):961-962; author reply 962. doi:10.1001/archpediatrics.2009.184

8. Stern AM, Thompson LA. What Parents Should Know About Drowning and Dry Drowning. JAMA Pediatr. 2022;176(8):830. doi:10.1001/jamapediatrics.2022.1434