Drowning is the second most prevalent cause of unintentional injury-related death in children ages 1-4. Pediatric nonfatal drowning (PnFD) is still more common, as 2 of 3 drowned children are resuscitated. Anoxic brain injury (ABI) is a common sequela of PnFD, with long-term outcomes ranging from full recovery to minimally conscious or persistent vegetative states. However, PnFD pathology and outcomes have received scant attention in the medical literature.

Our laboratory was the first to report locked-in syndrome (LIS) in PnFD, consistently observing motor deficits more severe than perceptual, cognitive, and emotive impairments. Structural lesions were consistent with selective deefferentation, with basal ganglia atrophy and corticospinal tract (CST) disruption. CST lesion severity predicted motor impairment. Further, integrity of canonical networks as assessed by fMRI, correlated with network-based behavioral scores. Sample size in the pilot cohort (n=11) was uninformative regarding prevalence. To expand the sample, a PnFD Family Caregiver Survey was performed.

Surveys were distributed using REDCap via social media support sites for parents of children with ABI from PnFD. Survey neurobehavioral assessment items were designed to correspond to canonical brain functional networks. Analysis was performed using RStudio.

170 surveys were completed. Strong spearman correlations were shown between motor domains (gross and fine motor function, eating/drinking ability, and expressive language) with ρ>0.69 and sensory/cognitive domains (auditory and visual function, tactile perception, and receptive language) with ρ>0.62. Frequency plots of average behavior scores revealed 70% of motor scores to be ≤2 while 71.3% of sensory/cognitive scores were ≥4. These findings corroborated the motor and cognitive dissociation shown in previous behavioral and imaging studies.

This study provides the first caregiver-reported evidence of locked-in-syndrome as a long-term outcome of pediatric nonfatal drowning. The presence of this previously unreported but devastating condition argues that standard of care for PnFD needs immediate attention by the medical community.