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• Response to Seizures, safety and submersion: sense and sensibility
  Richard Appleton
  Published on: 27 December 2017
• Response to Seizures, safety and submersion: sense and sensibility
  Richard C Franklin, John H Pearn and Amy E Peden
  Published on: 28 September 2017

• Published on: 27 December 2017

  Response to Seizures, safety and submersion: sense and sensibility

  • Richard Appleton, Consultant and Honorary Professor in Paediatric Neurology Alder Hey Children's NHS Foundation Trust

  I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...

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  I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders that affect adults and children, the latter with a markedly heterogeneous range of seizure types, syndromes, causes, treatments and outcomes, all of which can be used to provide an individualised care plan. Failure to do so in certain situations might constitute discrimination against children with an epilepsy.

  Richard E Appleton

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  Conflict of Interest:
  None declared.

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• Published on: 28 September 2017

  Response to Seizures, safety and submersion: sense and sensibility

  • Richard C Franklin, Associate Professor Royal Life Saving Society – Australia and James Cook University
  • Other Contributors:
    • John H Pearn, Professor Paediatrics and Child Health
    • Amy E Peden, National Manager - Research and Policy

  The Editorial by Professor Richard Appleton, ‘Seizures, safety and submersion: sense and sensibility’ addresses crucial points relating to children with epilepsy and their optimal, but safe, participation in aquatic activities 1. All agree that the goal is to ensure that children from all backgrounds and with pre-existent medical conditions grow up to have a ‘normal and unrestricted life’ 1. Aquatics are an important activity for all children in both developed and developing nations 2. Our study was undertaken specifically to determine the relative risk of different medical conditions 3. Like the other studies quoted by Professor Appleton, pre-existent epilepsy has been found to pose an increased risk of drowning by a factor of between 2 and 10. The absence of other pre-morbid diagnoses may either reflect a selection bias in that parents are not allowing those children to participate in aquatics or that parents recognise the hazards and put in place appropriate safety strategies. Differential aquatic exposure rates, specific for different pre-existent medical conditions, are unknown; and therefore denominators which define specific risks remain unknown. In our paper we recommend that ‘Children with epilepsy may swim with safety if drug levels are in the therapeutic range, the child has been seizure-free for 6-12 months and compensatory extra supervision is in place’ (3). These reflect the opinions of the authors, but are generally cognat...

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  The Editorial by Professor Richard Appleton, ‘Seizures, safety and submersion: sense and sensibility’ addresses crucial points relating to children with epilepsy and their optimal, but safe, participation in aquatic activities 1. All agree that the goal is to ensure that children from all backgrounds and with pre-existent medical conditions grow up to have a ‘normal and unrestricted life’ 1. Aquatics are an important activity for all children in both developed and developing nations 2. Our study was undertaken specifically to determine the relative risk of different medical conditions 3. Like the other studies quoted by Professor Appleton, pre-existent epilepsy has been found to pose an increased risk of drowning by a factor of between 2 and 10. The absence of other pre-morbid diagnoses may either reflect a selection bias in that parents are not allowing those children to participate in aquatics or that parents recognise the hazards and put in place appropriate safety strategies. Differential aquatic exposure rates, specific for different pre-existent medical conditions, are unknown; and therefore denominators which define specific risks remain unknown. In our paper we recommend that ‘Children with epilepsy may swim with safety if drug levels are in the therapeutic range, the child has been seizure-free for 6-12 months and compensatory extra supervision is in place’ (3). These reflect the opinions of the authors, but are generally cognate (albeit more conservative with respect to children) with the recommendations of Royal Life Saving Society – Australia and other Australian water safety organisations (Table 1). We acknowledge that our advice, concerning therapeutic levels of medication and the duration of seizure-free periods, is arbitrary. It reflects our collective experience of seven decades of drowning research, extensive aquatic involvement and participation in national and international formulation of safety doctrines. We also acknowledge that children with persistent febrile convulsions may have lower risks when taken for recreational swimming; but at this stage of knowledge we opine that heightened surveillance is nevertheless required. We agree that there are differential risks associated with different epileptic conditions and pre-existent syndromes. Judgement concerning such risks must reside with a child’s treating physician, as every child is different.

   

  Organisation and Title	Policy reference to epilepsy
  Royal Life Saving Society - Australia Epilepsy Medical Policy (2014)	The general rule is that persons suffering from epilepsy are medically eligible for all society awards, patrol duties and aquatic competition provided they have been free of seizures for two years. This is irrespective of whether medications are being taken or not. Where the seizure is the result of any of the following, a further six months must elapse without seizure before water activities can be resumed: a) medication omitted; (b) inadequate sleep; or (c) physical exhaustion. Where a seizure has occurred following withdrawal of medication on medical advice a minimum period of one month must elapse before water activities can be resumed. Where a seizure is the result of; alcohol abuse, head injury or brain surgery water activity may not be resumed for a further two years.
  Guidelines (SU6) for Safe Pool Operation, RLSSA (2013)	Qualified lifeguards with a diagnosis of epilepsy are eligible to participate in lifeguard activity provided they have the approval of their medical attendant who is fully aware of the nature and duties of pool lifeguarding. The responsibility for a lifeguard’s management of their epilepsy at all times rests with them and their medical attendant.
  Australasian Council for the Teaching of Swimming and Water Safety (AUSTSWIM) Teachers of Aquatics - Access and Inclusion Manual (2013)	A person with epilepsy should be under the care of a doctor and have their condition managed with medication. If this is the case, there is no reason why they should not participate in aquatic activity. Cold water conditions and high-intensity activities should be avoided. Long periods of immersion should also be limited. It is recommended an ‘observer’ be present to watch for signs of a pending episode and assist in the event of an epileptic fit.
  Surf Life Saving Australia Seizures and Epilepsy Policy (2012)	Individuals diagnosed with a seizure disorder, child or adult, should not swim, surf, or paddle on craft at a beach; unless they have been free of seizures for at least one year. They should not swim, surf or paddle on craft for at least three months after cessation of medications. Where the seizure is the result of a clear precipitating cause that can be remediated, a further six months must elapse without seizure before swimming, surfing, craft paddling is resumed. Individuals with a seizure disorder should not swim, surf or paddle alone. Companions should be aware of the potential for seizures and the possible need for rescue. They should never hyperventilate for any reason and this is especially important prior to swimming and diving.
  International Life Saving Federation MPS 17 – Seizures and Epilepsy Risks for Bathing, Swimming, Lifesaving and Lifeguarding (2016) 4	Bathtub use for children with epilepsy should have direct, close (in the room), and continuous supervision. Older children and adolescents with epilepsy should not bathe or shower with the bathroom door locked.   Epilepsy carries increased relative risk of submersion and drowning. Children and adults should be advised of this increased relative risk. Individuals with unstable, or potentially unstable epilepsy should avoid water activity until stability is re-established.   Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures; - those with unpredictable convulsive seizures; and/or those who have other disabilities. Extra precautions and attention are warranted. This patient group should avoid water activities, or should participate in clear, shallow, still water, with a (securely fastened) personal flotation device that will support an unconscious person, and they should be within arm’s length of a capable support person.   Individuals with stable, controlled epilepsy and no other risk factors, who participate in recreational, instructional, and competitive water activities, should do so in supervised areas and with another capable person. Individuals with chronic disabilities who are intellectually and neurologically able, and medically stable should be encouraged to undertake swimming and lifesaving training.

   

  References

  1. Appleton RE. Seizures, safety and submersion: sense and sensibility. Archives of Disease in Childhood 2017;102:883-884.

  2. Pearn, J. H., & Franklin, R. C. (2013). Disability and Drowning: Personal Experiences, Research, and Practicalities of Adapted Aquatics. International Journal of Aquatic Research & Education, 7(2). 157-162

  3. Franklin RC, Pearn JH, Peden AE. Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017;102:888-893.

  4. International Life Saving Federation (2016) Medical Position Statement – MPS 17: Seizures and Epilepsy Risks for Bathing, Swimming, Lifesaving and Lifeguarding. Accessed via: http://www.ilsf.org/about/position-statements

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  Conflict of Interest:
  None declared.

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