Bucket-Related Drownings in the United States, 1984 Through 1990

(1)

Bucket-Related

Drownings

in the

United

States,

1984

Through

1990

N.

Clay Mann, MS*; Susan C. Weller, PhD*; and

Renae Rauchschwalbe, MS

ABSTRACT. The purpose of the study is to document the incidence of bucket-related drowning in the United States and to identify factors associated with this type of submersion injury. Analysis of Consumer Product Safety Commission data revealed 160 bucket-related drownings for the years 1984 through 1989, representing a mortality rate of 0.367 per 100 000 persons (younger than 2 years old) per year in the United States. Eighty-eight percent of bucket drownings occurred in toddlers aged 7 to 15 months old. Black children were six times more likely to drown in a bucket than white children of similar age (P < .0001). Male toddlers were at significantly greater risk than females (P < .01). A seasonal trend present in the data indicated that infants are more likely to drown in warmer than in colder months (P < .01). States with the

highest rates of bucket drowning were Vermont (2.1/

100 000), Arizona (1.5/100 000), and Illinois (1.0/100 000). Through passive and active educational strategies, per-haps this fatal home injury can be prevented. Pediatrics

1992;89:1068-1071; home accidents, drowning, infant,

pre-school child, death certificates.

Traumatic injuries have become an important

de-terminant of childhood mortality, accounting for 46% of all deaths of children 1 to 4 years of age.’ Drowning is second only to motor vehicle injuries as the leading cause of death among children in this age group, with

almost 5 children per 100 000 drowning each year in

the United States.24 Public swimming pools and

fresh-water lakes or rivers are the major locations of “away-from-home” infant drowning while residential

swimming pools, bathtubs, canals, and ditches are

the most frequent sites of “in-or-around-home” infant drowning.59

Recently, Jumbelic and Chambliss’#{176} identified

5-gallon industrial buckets as an additional source of

accidental drowning for infants and toddlers in or

around the home. They indicated that 24% of all

toddler drownings in Cook County, IL, over a 4-year

period were due to toddlers falling into industrial buckets that were being used as mop buckets or diaper

pails. Two studies in Cape Town, South Africa, also

From the ‘Department of Preventive Medicine and Community Health, The

University of Texas Medical Branch, Galveston; and US Consumer Product

Safety Commission, Washington, DC.

Received for publication Sep 30, 1991; accepted Nov 26, 1991.

The contribution made to this article by Renae Rauchschwalbe, a Senior

Compliance Officer for the CPSC, was performed in her private capacity. It

is not intended nor should it be inferred that opinions expressed herein represent the official position of the Consumer Product Safety Commission.

Reprint requests to (N.C.M.) Dept of Preventive Medicine and Community

Health, 1.128 Ewing Hall, J-53, The University of Texas Medical Branch,

Galveston, TX 77550.

reported lare proportions of bucket-related toddler

drownings.’ 12 The sturdy construction and design of

5-gallon industrial buckets is thought to increase the

likelihood of serious sequelae following an

uninten-tional 3

Other studies of drowning performed in the United

States report that all types of pails and buckets,

including 5-gallon buckets, play an important but less significant role in childhood drowning than the

find-ings cited above.’4’6 Some studies do not identify

buckets as a contributing factor at all.’719

One reason for the conflicting results in previous research may be that the incidence of bucket

drown-ing varies by geographic region.20’2’ Knowing which

states or subpopulations are at increased risk would

allow interventions to be focused where the need is

the greatest. The purpose of this study is to document

the incidence of bucket-related drowning in the

United States and identify risk factors that may be

important in developing strategies for preventing this fatal home injury.

METHODS

Mortality data for unintentional bucket-related drownings in the

United States from January 1984 through December 1990 were obtained from the National Injury Information Clearinghouse at the US Consumer Product Safety Commission (CPSC). Bucket-related drownings were collected from three different data banks

maintained by the CPSC: (1) CPSC Death Certificate File; (2) CPSC

Reported Incidence File; and (3) CPSC Accident Investigation File. The CPSC Death Certificate File includes death certificates in which

consumer products are likely to be involved. (The death certificates

are sent to the CPSC by the departments of health in all 50 states and two municipal health jurisdictions [the District of Columbia and New York City].) The CPSC Reported Incidence File is a

computerized data bank with product-related consumer

com-plaints, newspaper accounts of product-related incidents, and re-ports of product-related deaths from participants in the CPSC’s Medical Examiners and Coroners Alert Program. The CPSC Acci-dent Investigation File includes investigational abstracts of product-related injury and mortality inquiries conducted or sponsored by

the CPSC. To obtain the total number of bucket-related drownings in the United States by state, deaths identified in the CPSC death certificate file as drownings (rubric E910.9-8, E984.0)22 were

cross-referenced with CPSC incidence and investigation file data for

relevant product codes (CPSC codes: 0459, manual cleaning equip-ment; 1528, diaper pails; 0954, general purpose household cleaners;

and 0694, beds, not specified).

Risk factors were recorded from CPSC abstracts contained in the accident investigation file and the reported incidence file. The following environmental risk factors were coded: (1) type and size of the bucket; (2) location of the bucket at the time of the injury; (3) use and contents of the bucket; and (4) the caretaker of the toddler at the time of injury. Month of death, gender, age, and

ethnicity of cases (coded as black, white, and Hispanic) were

assigned by the CPSC on the basis of information contained on individual death certificates and/or investigational abstracts.

(2)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1920 21 22 23 24

Age in months

.--. White Females -e#{149}-White Males -- Black Females Black Males

ARTICLES 1069

and state populations, compiled by the Bureau of the Census.2324 Estimates were based on the years 1984 through 1989 or 1984 through 1990 depending on the completeness of CPSC data. The total number of children 2 years of age or younger was estimated using two fifths (40%) of the total number of children reported by the Bureau of the Census to be younger than the age of 5, nationally and by state. Population sizes were estimated for boys, girls, blacks, whites, and Hispanics.

To assess the reliability of the CPSC data, the total number of bucket-related drownings included in the three CPSC data files was compared with the number reported in other independent

sources matched by state, county, and time period. A X2 test was

used to test for differences in the number of drownings by season, gender, ethnicity, and age.

RESULTS

The 1984 through 1989 CPSC data contain

com-plete reporting for all states and health jurisdictions

except for Maryland, which did not report data for

1989. The three CPSC files contained 188 deaths for

the period 1984 through 1990. The death certificate file included 147 reported deaths related to buckets.

Forty-one additional deaths were abstracted from the

CPSC Accident Investigation File (n = 25) and the

CPSC Reported Incidence File (n = 16).

According to the CPSC, 23 toddlers drowned in

buckets or pails in 1984, 24 in 1985, 26 in 1986, 29

in 1987, 27 in 1988, and 31 in 1989. The 1990 data

contain complete data for only 23 states. (AL, AR,

AZ, CA, DE, FL, IA, KY, MO, MS. NC, ND, NH, NJ,

OH, OK, OR, SC, SD, TN, UT, VA, WV, and the

District of Columbia had reported for 1990 at the

time data were collected. Other states had partially or

not reported at all.) To date (November 1991), 28

deaths have been reported in 1990. Because the 1990

data are incomplete, the analyses of season, age,

gender, and ethnic differences are based on CPSC

data from January 1984 through December 1989 (160

deaths). National and state drowning rates are based on the total number of years each state reported.

The reliability of the CPSC files was estimated by

comparing the total number of bucket drownings

reported from available sources, Florida25 (n 2) and

Illinois’0 (n =

12),

to matched cases contained in the

combined CPSC files (n = 2 and n = 9, respectively).

In addition, all accidental drowning deaths that

oc-curred among children in Harris County, TX, from

March 1984 through March 1990 were abstracted

from Harris County death certificates (n 2) and

compared to CPSC files (n = 1). The results of this

analysis (12 deaths reported in CPSC data sources

and 1 6 documented deaths) showed that the CPSC

files underestimated these deaths by 25%.

The total number of bucket drownings from 1984

through 1989 represent a mortality rate of 0.367 per

100 000 persons (younger than 2 years old) per year

in the United States (95% confidence interval = 0.3 10,

0.424). Two states had rates higher than Illinois (1.0/

100 000): Vermont (2.1/100 000) and Arizona (1.5/

100 000). Washington, DC (0.85) and 13 additional

states had rates higher than the national average:

Colorado (0.79), Florida (0.77), Kentucky (0.67), New

Mexico (0.61), Alabama (0.60), Oregon (0.55),

Mary-land (0.54), Louisiana (0.53), Georgia (0.44), Texas

(0.43), Virginia (0.43), South Carolina (0.42), and

Ohio (0.41).

Girls accounted for 37% of the deaths for 1984

through 1989. Assuming equal numbers of male and

female toddlers, there was a significant difference

between genders in the number of cases

(x2

[1] =

10.57, P < .01; n 159). The mortality rate for boys was 1 .69 times higher than that for girls.

Of cases reporting the ethnicity of the child, whites

accounted for 43%, blacks for 46%, and Hispanics for

8% of the total number of deaths. The distribution of

ethnicity is significantly different

(x2

[2] = 140.21, P

< .0001; n = 140) from that in the United States (ie,

81% white, 14% black, and 5% Hispanic).24

Further-more, black toddlers are at greater risk of drowning than white toddlers

(x2

[1] = 141.12, P < .0001; n =

129). The mortality rate for blacks was 6.21 times

higher than the rate for white children of similar age.

This difference remains significant even when all

missing cases (n = 15) are assigned as “white” (P <

.0001). Because of the small number of Hispanic

cases, no comparisons were made.

Gender, ethnicity, and age-specific mortality rates

for 1984 through 1989 are presented in the Figure.

Children between the ages of 7 months and 15

months accounted for 1 13 (88%) of the deaths, with

very few toddlers younger than 7 months (6%) or

older than 15 months (6%) drowning in buckets or

pails.

The greatest percentage of drownings occurred in

October (15.6%), and February had the smallest

per-centage of deaths (3. 1%). Assuming a homogeneous

distribution of bucket-related deaths through the

months, a seasonal trend was present in the data

(x2

[11] = 30.12, P < .01; n 160).

The CPSC data files contained investigatory

ab-stracts or injury-related information on 178 deaths.

Of cases reporting the size of the bucket (n = 99),

88% reportedly took place in 5-gallon, industrial

(straight-sided) buckets, 9% in 1- to 3-gallon buckets or pails, and 3% in a 6- to 10-gallon bucket.

Abstracts containing descriptions of the location of

the bucket (n = 83) indicated that drowning took

place inside the home (92%), in the yard (7%), or

while fishing (1%). Most of the drownings occurred

in the kitchen (24%), bathroom (17%), bedroom

(1 7%), or on the porch (1 3%). In 1 0 cases, drowning

occurred because a sleeping infant rolled off an adult bed, couch, or out of a crib into a liquid-filled bucket.

Figure. Age-specific drowning rate by ethnicity and gender. Rates are based on drownings reported for 1984 through 1989.

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(3)

The buckets were used for mopping (47%), for general cleaning (19%), as a diaper pail (10%), to soak soiled clothes or to bathe a toddler (7%), to flush a broken toilet (7%), for watering animals (4%), to catch drip-ping water (2%), or as a chamber pot (1 %) at the time of drowning.

Most of the buckets (88%) contained fresh water or

water and some type of household cleaner, including detergent (12%), pine cleaner or disinfectant (10%),

bleach (7%), wallpaper stripper (1%), or some

com-bination of these substances (10%). One of the

buck-ets contained urine. The content of 21 buckets was

not indicated.

Eighteen of the abstracts reported objects in the

water that may have attracted the attention or

height-ened the curiosity of the unsuspecting toddler,

in-cluding toys (22%), clothing (16%), a dog leash (11%), fish (1 1

%),

diapers (1 1

%),

a mop (5%), a baby bottle (5%), bread (5%), orange peels (5%), and toilet paper

(5%). Buckets used for household cleaning also may

have contained bubbles. Of the abstracts identifying the care giver at the time of the drowning (n = 77), a

third (38%) of infants were in the care of a

baby-sitter.

DISCUSSION

The average number of young children who

drowned in bucket-related injuries, 27 per year, is

considerably less than the number of drownings

attributed to bathtubs for this age group.’#{176}’26”

Nevertheless, it is higher than estimates of drowning

due to other in-home water sources (eg, toilets or

basins).’0’28 On average, one child drowned in a

bucket-related incident every 1 3 days. It is important

to point out that these findings represent minimal

estimates of the number of bucket drownings that

occur, thus, the “true” number may be higher.

Mortality rates for states indicate that the risk of

bucket drowning in Vermont and Arizona may be

greater than that reported by Jumbelic and

Chambliss’#{176} for Illinois. Note, however, that estimates of risk for individual states lack precision because of

the small numbers of reported drownings. In

partic-ular, the mortality rates for Vermont and Washington,

DC, are notably unstable because of the small

popu-lation of toddlers (VT, 16 000; DC, 18 400) and the

small number of bucket drownings reported in these

areas (VT, 2; DC, 1). Nevertheless, it does appear that many of the states that are at high risk for other forms of fatal injuries4’20’21’29 also report high rates of bucket-related drowning.

The risk factors associated with bucket drowning are similar to those reported for other submersion injuries. The difference in the rates of bucket-related

drownings between boys and girls is similar to that

reported for other sources of childhood drowning,

which indicate that boys are generally at higher

risk.’4”8’28’30 In this study, black toddlers were found to be at greater risk than white toddlers of similar

age. An increased risk of drowning among black

toddlers has not been described in studies that report rates that combine all sources of drowning.3’7”2’31’32 Bucket-related drownings are similar to other sources of drowning in that most deaths occur during warmer

months,7’26 although bucket drownings peak in

Oc-tober. The greatest risk occurs in the age range at

which youngsters can stand momentarily, walk

hold-ing onto furniture, stand alone, and walk well.33 There are several limitations in the data, the most serious of which is the likelihood of underreporting

bucket-related drownings. Our estimate (based on

mortality rates for two states and one county)

mdi-cates that CPSC data underestimated bucket-related

mortality by 25%. Based on a multiple recapture

model, the CPSC indicates that the number of deaths

(from 1985 through 1989) may be underestimated by

as much as 52%. These estimates emphasize that

the results of this study should be viewed as minimal

estimates of risk that may be biased. Errors due to

misclassification of cause of death as drowning on

death certificates are also possible, but unlikely in

that most of the victims underwent either postmortem examination and/or a state or federal accident inves-tigation. Far more likely is the possibility that a toddler

drowning was not identified as a bucket-related

drowning.

An additional source of error may be coding bias.

Certain ethnic groups (eg, blacks) may be more likely to be recorded on death certificates.35 In this study,

however, the ethnicity analyses remained

signifi-cant with all missing cases coded as “white.”

In-tentional bucket drownings may also bias these

results, although the direction of the bias is

Un-clear. Studies indicate that potential abuse may

cause underrecording36 or overrecording37 of deaths

as homicides.

Lastly, the process used to calculate age

distribu-lions is based on the assumption of equal numbers of

children in each age stratum. This assumption could

cause the rates for the youngest group (0 through 6

months) to be overestimated and the rates for the

oldest group (16 through 24 months) to be

underes-timated. However, the general pattern presented in

the Figure for toddlers aged 7 to 1 5 months would

probably remain the same.

Infants appear to be at particular risk of drowning

in 5-gallon industrial buckets because of the large

capacity and stability of this type of bucket.38 These

containers are about 14 inches high, about half the

height of the typical ‘top-heavy” toddler, with the

rim just below the child’s upright center of gravity.

In addition, containers weigh more than most 8- to

12-month-old infants when filled with just a few

gallons of liquid.’3 Although this research provides no data dealing with survival after near-drowning episodes, bucket-related injuries may be particularly dangerous because of the toxic material that is often in the buckets at the time of injury.

Measures can be taken to lessen mortality due to

drownings in buckets or pails. An information and

education campaign initiated by the CPSC and the

Coalition for Container Safety provides brochures, posters, and self-adhesive labels that can be placed on buckets by manufacturers, fillers, or consumers. (The Coalition for Container Safety may be contacted

by dialing 1-800-BUCKET-5.) The Gypsum Industry

and Proctor and Gamble, which respectively fill about

(4)

manu-ARTICLES 1071 factured, are the only industries presently printing

permanent warning labels on new buckets before they

are shipped for commercial use. To our knowledge,

none of the 5-gallon industrial buckets available in

retail stores include either self-adhesive or permanent

warning labels. Perhaps the offer of a refund for

recycling buckets would reduce their home use.

Anticipatory guidance to parents may also reduce

the incidence of bucket-related drowning. During a

6-month well-baby checkup, pediatricians could

in-struct parents to never leave the toddler alone with

any large container of liquid, empty the container

immediately after use, and store the container out of

the toddler’s reach until the toddler is 20 months old. In conclusion, large-capacity buckets are potentially dangerous to young children. Because bucket-related

drownings occur suddenly, in a presumably safe

en-vironment, the psychological effect of an injury may

be more traumatic than deaths from some other

causes.39’4#{176} By focusing on specific etiologic and epi-demiologic patterns associated with bucket-related drownings, interventional efforts can be concentrated

in states and among ethnic groups where the

mci-dence of this type of drowning is the greatest.

ACKNOWLEDGMENTS

We are indebted to the National Injury Information Clearing-house and the Directorate for Epidemiology of the US Consumer Product Safety Commission for providing the data for this article.

In addition, we thank Drs G. Wilkinson, T. Miller, D. Jenkins, and

D. McCormick for comments on an earlier draft.

REFERENCES

I. Committee on Trauma Research, Commission on Life Science. Injury in

America. Washington, DC: National Academy Press; 1985:18-19 2. Rivara F. Traumatic deaths of children in the United States: currently

available prevention strategies. Pediatrics. 1985;75:456-462

3, Gulaid J, Sattin R. Drownings in the United States, 1978-1984. MMWR.

1988;37:27-33

4. Baker SP, Wailer AE. Childhood Injury: State-by-State Mortality Facts.

Baltimore, MD: The Johns Hopkins Injury Prevention Center; 1989

5. Rowe MI, Arango A, Allington G. Profile of pediatric drowning victims

in a water-oriented society. ITrauma. 1979;17:587-591

6. Pearn JH, Wong RYK, Brown J, et al. Drowning and near-drowning involving children: a five-year total population study from the city and county of Honolulu. Am I Public Health. 1979;69:450-454

7. Dietz PE, Baker SP. Drowning: epidemiology and prevention. Am I

Public Health. 1974;64:303-312

8. Press E, Walker J, Crawford A. An interstate drowning study. Am I Public Health. 1969;58:2275-2289

9. Accidental drownings by cause and site. Stat Bull Metrop Insur Co. 1977;

58:9-11

10. Jumbelic M, Chambliss M. Accidental toddler drowning in 5-gallon buckets. JAMA. 1990;263:1952-1953

11. Kibel SM, Nagel FO, Myers J, et al. Childhood near-drowning: a

12-year retrospective review. S Afr Med I.1990;78:418-421

12. Davis S. Smith LS. The epidemiology of drowning in Cape

Town-1980-1983. S Afr Med J.1985;68:739-742

13. Large buckets are drowning hazards for young children. Med Examiners

Coroners Alert Project News. 1989;14:1-2

14. Griest KJ, Zumwalt RE. Child abuse by drowning. Pediatrics. 1989;83: 41-46

15. Flood TJ, Aickin M, Tucker D. Childhood drownings and near drownings

associated with swimming pools-Maricopa County, Arizona, 1988 and 1989. MMWR. 1990;39:441-442

16. Saunders LD, Green M, Doebbert G, et al. Mortality from unintentional injuries in California, 1985. West J Med. 1989;150:478-483

17. Pearn J, Nixon J, Wiley I. Freshwater drowning and near-drowning

accidents involving children: a five-year total population study. Med I

Aust. 1976;2:942-946

18. Quan L, Gore EJ, Wentz K, et al. Ten-year study of pediatric drownings and near-drownings in King County, Washington: lessons in injury prevention. Pediatrics.1989;83:1035-1040

19. Nichter MA, Perry BE. Profile of drowning victims in a coastal

commu-nity. J Fla Med Assoc. 1989;76:243-256

20. Baker SP, Whitfield MA, O’Neill B. County mapping of injury mortality.

I Trauma. 1988;28:741-745

21. Waller AE, Baker SP, Szocka A. Childhood injury deaths: national analysis and geographic variations. Am I Public Health. 1989;79: 310-315

22. World Health Organization. Manual on International Statistical Classifi-cation of Diseases, Injuries, and Causes of Death. Geneva, Switzerland: World Health Organization; 1975. Based on the 1975 recommendations of the Ninth Revision Conference

23. US Bureau of the Census. County and City Data Book, 1988. Washington, DC: U.S. Government Printing Office; 1988

24. US Bureau of the Census. Statistical Abstract of the United States: 1989.

109th ed. Washington, DC: US Government Printing Office; 1989

25. Hyma BA. Accidental drowning of toddlers in buckets. JAMA. 1990;

264:1407

26. Budnick LD, Ross DA. Bathtub-related drowning in the United States,

1979-81. Am IPublic Health. 1985;75:630-633

27. O’Carroll PW, Alkon E, Weiss B. Drowning mortality in Los Angeles County. 1976 to 1984. JAMA. 1988;260:380-383

28. Davis S, Ledman J, Kilgore J. Drownings of children and youth in a desert state. West JMed. 1985;143:196-201

29. Wintemute GJ. Childhood drowning and near-drowning in the United

States. AJDC. 1990;144:663-669

30. Wintemute GJ, Kraus JF, Teret SP, et al. Drowning in childhood and adolescence: a population-based study. Am I Public Health 1987;77: 830-832

31. Calder RA. Clay CY. Drownings in Florida: 1977-1986. 1Fla Med Assoc.

1990;77:679-682

32. Smith JD, Marcus RA, Sikes RK. Drownings-Georgia, 1981-1983.

MMWR. 1985;34:281-283

33. Frankenburg WK, Dodds JB. The Denver Developmental Screening Test.

JPediatr.1967;71:181-191

34. Nicholls C. EPHA Report on Bucket Related Drownings. Washington. DC:

US Consumer Product Safety Commission/EPHA; April 1991

35. Suthutvoravut 5, Hogue CJ, Guyer B, et al. Are preterm black infants larger than preterm white infants, or are they more misclassified?J Biosoc

Sci.1989;21:443-451

36. Jason J, Carpenter MM. Tyler CW. Underrecording of infant homicide

in the United States. Am J Public Health. 1983;73:195-197

37. Lapidus GD, Gregorio DI, Hansen H. Missclassification of childhood homicide on death certificates. Am I Public Health. 1990;80:213-214

38. Van Houten T. EPHF Report on Bucket Drownings. Washington. DC: US

Consumer Product Safety Commission/EPHF; August 1989

39. Haddon W. Advances in the epidemiology of injuries as a basis for

public policy. Public Health Rep. 1980;95:41 1-421

40. Nixon J, Pearn J. Emotional sequelae of parents and sibs following the drowning or near-drowning of a child. Aust NZ I Pediatr. 1977;11:265

(5)

1992;89;1068

Pediatrics

N. Clay Mann, Susan C. Weller and Renae Rauchschwalbe