Pediatric Nonfatal Drowning

Drowning is a leading cause of unintentional injury death globally and the single most frequent cause in children less than four years of age, with more than 3,500 cases annually in the United States. Drowning followed by successful cardiopulmonary resuscitation (nonfatal drowning) is most prevalent in children, with an estimated 2/3 surviving. Behaviorally, post-drowning children have severe motor impairments, which effectively prevents adequate clinical assessment of cognitive and emotional status. The condition has been widely presumed to entail diffuse neuronal loss (chiefly in grey matter), most severe in the basal ganglia, resulting in a minimally conscious state coupled with quadriplegia. However, conventional imaging studies are minimally informative and often normal.

To better establish the neuropathology and the cognitive/emotional status, we applied a multi-modal protocol of advanced neuroimaging techniques not previously used in this disorder to 11 post-drowning children and 11 healthy control children. These data clearly demonstrate that the lesion is focal, not diffuse, and almost entirely limited to the motor system. Brain systems supporting perception (vision, hearing, and touch), interoception (hunger, thirst), social awareness, language and emotion are largely intact. Collectively, these studies indicate that these children suffer from Locked-in Syndrome in which they are aware of their environment but cannot communicate. The imaging protocol we have developed is suitable for clinical use and should be widely adopted. The focal nature of the lesion raises numerous acute treatment options which need further research.