Drowning is the second cause of unintentional injury-related death in children ages 1-4. Pediatric non-fatal drowning (PnFD) is prevalent; for every child dying by drowning, eight receive emergency care and survive. Despite the high prevalence of hypoxic-ischemic encephalopathy (HIE) in PnFD, data on clinical outcomes and outcome predictors are sparse. This study addressed this gap.

In prior work, we used quantitative MRI to delineate an HIE lesion topography consistent with selective deefferentation. A network-based behavioral scoring instrument (NBBS) was developed (5-level Likert-scale) and agreed with MRI predictions.

The NBBS supplemented with additional clinical and demographic items was administered as The Non-Fatal Drowning Survey. Surveys were distributed online using REDCap via social media support sites for parents of children with neurological injury from PnFD. Analysis was performed using Excel and RStudio.

161 responses met inclusion/exclusion criteria. Unsupervised clustering identified three groups: Group 1 (mild; n=37), Group 2 (moderate; n=75) and, Group 3 (severe; n=40). Severity of impairment ranged from near-normal to persistent vegetative state. Across the outcome spectrum (Groups 1-3), motor impairment predominated (p < 0.01). Locked-in syndrome was endorsed for 99 (61%) of survivors. The most reliable predictor of good outcome was alterness at discharge (Relative Risk = 0.11), irrespective of motor status. Admission status was not predictive. Pessimistic management recommendations – terminate care (acute) or institutionalize (chronic) – were common (n = 127) but were not predictive. Furthermore, less aggressive management was associated with poorer outcome.

The majority (112/161) of PnFD survivors were not severely impaired, contradicting current beliefs. Alertness on discharge was a reliable predictor of good outcome. Pessimistic prognoses and care recommendations, although commonly given, were not reliable and should be avoided. Pattern of injury – motor deficits predominating over perceptual and cognitive – replicated our prior work, consistent with the frequent endorsement of Locked-in Syndrome.