Kimberly M. Thompson, ScD

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In This Article

Abstract and Introduction

Objective: The objective of this study was to quantify and characterize the role of bath seats in infant mortality from bathtub drowning.
Method: Risk analysis of bathtub drowning deaths for infants aged 6-10 months was performed using data available from the US Consumer Product Safety Commission (CPSC), birth and mortality data from the National Center for Health Statistics (NCHS) for US resident infants from 1990-1998, and bath seat ownership from the American Baby Group and industry sales data compiled by NPD to estimate bath seat use. The analysis computes the relative risks of infant drowning based on estimates of bath seat use with a cohort design and explores the potential confounding by a range of factors.
Results: In-depth analysis of the unintentional bathtub drowning deaths of American infants aged 6-10 months for the years 1994 through 1998 revealed 40 infant drowning deaths associated with bath seats and 78 deaths not associated with bath seats. Based on available data on sales and use that suggest approximately 45% of infants in this age group use bath seats, the existing data do not support a hypothesis that bath seats increase the risk of bathtub drowning for infants. Bath seats are not intended or marketed as safety devices, and analysis of the existing, albeit limited, data suggests that they either have no effect or they may provide some slight unexplained protection against unintentional bathtub drowning risks (with an odds ratio for the risk of drowning with a bath seat vs without a bath seat of approximately 0.6 [95% confidence interval (CI) 0.4-0.9]). Although all potential confounders cannot be fully explored due to incomplete data and large uncertainties remain, this analysis suggests that the US CPSC made the appropriate decision not to ban bath seats in response to petitions it received in 1994 and 2001.
Conclusions: Increasing market sales and surveys of reported bath seat use were associated with decreasing unintentional infant bathtub drowning risks. Rigorous risk analyses should be conducted when considering regulating products to ensure that regulation does not inadvertently increase injury risks. Analysis of the factors associated with these deaths suggests that additional efforts are needed to ensure that caregivers do not leave infants unattended in the bathtub and to collect data that will further improve our understanding and management of these risks.

Unintentional drowning remains one of the most significant and preventable causes of child mortality, and bathtubs present a significant hazard to infants and young children.[1,2,3,4,5,6,7,8,9,10,11,12] Currently, unintentional bathtub drowning accounts for approximately 1 of every 100 deaths of US resident infants aged 6-10 months, with a recent study showing that 55% of the children under the age of 1 year who died from drowning in 1995 drowned in bathtubs.[1] While current national goals emphasize the objective of reducing incidents of childhood drowning, none specifically focus on the prevention of infant bathtub drownings.[12]

The literature provides a number of insights about infant bathtub drowning-related mortality risks. Brenner and colleagues[2] found that the mortality rates of unintentional nonboat infant (children up to age 1 year) drowning increased from approximately 2 per 100,000 infants to 2.5 per 100,000 infants over the period of 1971 to 1988, and they reported that approximately 40% of infant drowning deaths occurred in bathtubs. Numerous studies identified the absence of a competent supervising adult as a key risk factor.[3,4,5,6,7,8] For example, for children under 5 years old, Budnick and Ross[3] reported that children under the age of 2 years old represented 30 of the 34 drowning victims reportedly left unattended in their study. Warneke and Cooper[4] reported that of the 25 cases of bathtub child drowning in their study of Harris County, Texas (1983-1990), 23 cases contained information on supervision and all 23 cases noted a lack of supervision. Pearn and colleagues[5] suggested and O'Carroll and colleagues[6] reiterated that children who can sit alone and pull themselves up represent a high-risk group for bathtub drowning because parents might be lulled into the false belief that the infant or toddler is strong enough to keep his head out of water. Several studies[5,7,8,13] also emphasized that the "dangerous practice"[5] of leaving infants in the bath in the custody of a sibling, often a sibling not much older than the infant, represents a significant risk factor, and Jensen and colleagues[7] suggested that this may be an indication that caregivers overestimate the sibling's ability to supervise the infant. Other significant risk factors identified for infant drowning include epilepsy (of the child or caregiver),[3,4,5,8] and child neglect or abuse[8,9,10] (which are not considered here since this analysis focuses on unintentional drowning).

Bath seats first entered the market as infant bathing aids in their current form in 1991, although bath rings that did not include a seat reportedly entered the US market in 1981.[14] The American Society for Testing and Materials published a Standard Consumer Safety Specification for Infant Bath Seats that provides standard definitions for bath seats.[15] In 1997, Rauchschwalbe and colleagues[14] reported a case series that indicated that the CPSC knew of 32 bathtub drowning deaths of children between 5 and 15 months old that occurred between 1983 and 1995 involving bath rings or bath seats. Based on their observed increase in these deaths reported over time and results from a small focus group of parents, they hypothesized that the use of bath seats might increase the risks of drowning among infants by increasing the likelihood that an infant would be left alone in the tub.

No comprehensive studies to date have explored this hypothesis by combining information about mortality and estimates of bath seat use. This analysis is the first to quantify the risks of unintentional infant drowning deaths in bathtubs with and without bath seats, focused on infants ages 6-10 months.

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