Bathtub Drowning: Unintentional, Neglect, or Abuse

Medicine and Health Rhode Island, Dec 2003 by Alpert, Brad

Lavelle et al in 1995(13) reported 21 bathtub near-drownings. This represented 24% of the 88 near-drownings admitted over a 10 year period; 75% were younger than 24 months old. The patients were divided into four categories: abuse, defined as evidence of physical abuse or admitted intent; severe neglect, defined by the presence of one or more of the following-physical signs of previous intentional injury, history incompatible with diagnosed injuries, multiple versions of the drowning event, previous abuse reports, a delay in seeking care, or history of psychiatric illness in the caretaker; simple neglect, defined as inadequate supervision or poor parenting skill with absence of the above risk factors; and none of the above risk factors. Twenty of the 21 were maltreated. Six were abused, 8 were severely neglected, and 6 were neglected. Only a 6-year-old boy who had a seizure was considered unintentional.

Gillenwater, et al10 reviewed 205 submersions of children younger than 19 years old. They determined that 16 (8%) were inflicted, nine (56%) of those occurred in bathtubs, and the remainder in rivers, lakes, pools, or other bodies of water. Of the 34 bathtub submersions, 9 were considered inflicted. Physical findings consistent with abuse were the most frequent criteria (69%) used to judge that submersions were inflicted. This probably underestimated the cases of abuse. For example, in Shaken Baby Syndrome, physical injuries are frequently isolated to the head. The presence of other findings, such as fractures or bruises, is not required to make the diagnosis. In addition, this study did not consider the duration of submersion as a diagnostic criterion. Maltreatment was also underdiagnosed, since acts of omission, ie. caretaker neglect, were classified as unintentional submersions. It is likely that many infant victims of bathtub submersions are willfully neglected and passively drown.

DISCUSSION

Bathtub submersion injuries in young children should be considered highly suspicious for abuse or neglect. However, children who have a seizure disorder are predisposed to this type of injury, and should never bathe unsupervised. A review of the literature indicates that many cases of abuse or neglect have probably gone unrecognized. In fact, Reece and Grodin17 called for all cases of infant drowning to be dealt with as nonaccidental. Children can suffer submersion injuries as a result of maltreatment by disregarding the danger though lack of supervision, willfully leaving a child to passively drown, or forced submersion.

The medical literature does not support the notion that young children can drown as a result of a brief submersion. On the contrary, over 90% of children after submersions of less than 5 minutes have a complete recovery or minimal brain injury.

In most bathtub drownings, the child was left alone or in the care of another young child. In most publications this has been accepted as a reasonable explanation, and these cases were determined to be accidents. However, it is very uncommon for even high risk parents to leave a child under 3 years of age unsupervised in the bathtub, much less an infant. These scenarios should be regarded as highly suspicious for abuse or neglect. In addition, most infants who are not developmentally able to sit well are not bathed in bathtubs because of the difficulties involved. This should also raise concerns in infants under six months who suffer submersion injuries in bathtubs.