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Your child is in the pool, she swallows a bit of water and goes on playing—but a few hours later, she’s in the hospital on life support.

It sounds a bit extreme, doesn’t it? Yet this is a genuine concern that has bubbled through the parenting community in the past several years. Viral social media posts are spread at the start of each summer, warning of the dangers of “dry drowning.” And as a result, pediatricians get dozens of phone calls, emails, and Facebook messages from friends and patients’ parents worried about their kids in the pool or even the bathtub.

But what is “dry drowning”—and, more importantly, how much do you have to worry about it?

This article is going to give you everything you need to know about “dry drowning” and “secondary drowning,” including what they are, what symptoms to watch for, and how worried you should be. We’ll also cover what to do if you think your child might be experiencing secondary drowning, plus the best ways to prevent it and keep your children safe.

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Why is Dry Drowning in the News?

The phenomenon of “dry drowning” first gained national attention in 2008 through the tragic story of John Jackson, who was a 10-year-old boy with autism and ADHD. John accidentally inhaled some water while swimming in a pool. At the time, he coughed for a bit, but then calmed down. As the day went on, however, he started to seem a bit off—he had two poop accidents in his pants and he was overly tired, eventually putting himself to sleep earlier than usual. When his mom checked on him later, he was unresponsive and, ultimately, died.

John’s story is a terrible one that, obviously, no parent would ever want to experience. And so his story and those of others have inspired warnings about what has been framed as “dry drowning,” with these cautionary tales getting passed around online and on morning news programs every summer.

Now, technically, John Jackson didn’t actually experience dry drowning—he suffered from what’s called “secondary drowning.” So let’s talk about each of these and what the difference between them is.

“Dry Drowning” vs. “Secondary Drowning”

 What is “dry drowning?”

True dry drowning usually occurs when water is quite cold and suddenly enters the airway very quickly. This might happen if you jump face-first into water with your mouth open—water rushes in so quickly that instead of going toward your stomach, it passes down toward your vocal cords.

This sudden rush of cold water causes the vocal cords to spasm, meaning that they tightly squeeze shut. They do this to protect your lungs—to make sure nothing gets inside—but they end up essentially closing off the airway. With the vocal cords clamped down and the airway closed, the affected person can’t breathe. So in the case of dry drowning, water never actually reaches the lungs at all—hence, “dry” drowning.

Unfortunately, the symptoms of dry drowning are often fairly nonexistent—the effects are so fast that most people who experience it never come up from the water.

Luckily, true dry drowning is exceedingly rare, which we’ll get to in a moment.

What is “secondary drowning?”

Now what the children in the stories we hear about usually suffer from is not technically “dry drowning,” but instead is a process called “secondary drowning” or “delayed drowning.”

In secondary drowning, the child accidentally inhales an amount of water down into the lungs while playing or swimming in water. This is more similar to true drowning than to dry drowning, as water is actually making it into the lungs.

This inhalation of water, also called aspiration, might be demonstrated in the moment it happens by just a small bout of coughing or gasping. That first coughing fit may end after a few moments. However, over the next several hours, the small amount of water that got into the lungs begins to wreak havoc. After all, we’re not meant to have pool, lake, or ocean water in our lungs, so over time it begins to cause swelling and inflammation.

That inflammation, in turn, causes some of the body’s own fluids to start building up inside the lungs—which makes it hard for the lungs to do their job and bring oxygen into the blood. Air is coming into the lungs with each breath, but the tissue can’t pull the oxygen out because the fluid is in the way.

The effect is that over time, the affected person isn’t getting enough oxygen and effectively suffocates even though they’re breathing. This can happen many hours later, in some reports even as far out as 3 days after the initial aspiration, though that’s really quite rare. So this is why in many of these stories that we hear, the child passes away while napping or after they go down for bed at night—hours after the event in the pool.

It really is every parent’s worst nightmare. And the way that the stories are often told, it seems even worse—because the articles will often imply that the child was perfectly fine before they passed.

But the truth is, there ARE signs that you can watch for that can let you know that something is wrong. You just have to know what you should look for.

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What to Watch For

So let’s talk about the symptoms of secondary drowning so you know what to watch for, should your child have an event in a pool that has you concerned:

• Coughing – This is the first and most common symptom. In fact, you are highly unlikely to see secondary drowning arise without a big coughing event in the water.

But kids swallow water and cough in the pool all the time, right?

What we’re really talking about here is coughing after the event in the water. For example, if your child sputtered and coughed while swimming, but then an hour or two hours later starts having progressively worse bouts of coughing seemingly out of nowhere, then that’s a concern.

• Chest pain – Any significant chest pain after a pool-related coughing event should be a worry, as it might indicate difficulty breathing or a feeling of fullness in the lungs. So might impressive belly pain, because kids will often complain that their tummy hurts when the real issue might actually be in the chest.

• Shortness of breath – This might seem obvious to some, but another sign of worry would be shortness of breath. If your child is breathing faster than normal—and not just for a few seconds, but sustained over several minutes—then this may be cause for concern.

• Behavior change – Here, your child might be confused, might speak more slowly than normal, or might do things that don’t quite fit with her usual behavior. In the example of John Jackson, he had two poop accidents after his bout of coughing in the pool—something that wasn’t normal for him.

• More tired than usual – Perhaps the most notable symptom is that your child is more tired than usual.

This can sometimes be hard to tell because you might think that your child is simply tired after a long day at the pool or the beach. But if your child seems like he’s excessively tired, more than you might think would make sense, more than you think is reasonable for the activity he’s done—and especially if it’s occurring after your child had a notable coughing spell while in the water—then it may be worth to talk to your pediatrician.

Knowing these symptoms is key, because as scary as it is to hear stories of kids who go to sleep after swimming and never wake up from their nap, etc., the vast majority of these and other children who experience secondary drowning are going to show at least some of these symptoms.

If we think back to the story of John Jackson, he coughed significantly in the pool, then showed signs of behavior change by soiling himself twice, and later was excessively tired and put himself to bed earlier than expected.

Of course, hindsight is 20/20. But now that you know the symptoms of secondary drowning, you’ll be able to see the red flags as they occur.

What Should You Do?

If you see any of these symptoms after your child has been swimming—and especially if you know that your child had a coughing spell in the water—then call your pediatrician urgently. If your pediatrician is taking longer than 30 minutes to return your call and your child is still experiencing these symptoms, then seek medical attention right away.

Notice, however, that secondary drowning becomes a consideration if you see these symptoms, not if the only thing that has happened is a coughing spell in the water. Tons and tons and tons of kids—and adults, too—cough in the water every single day. But dry drowning and secondary drowning are, in reality, exceedingly rare.

So How Worried Should You Be?

While some of the articles that get passed around online every summer state that dry drowning and secondary drowning comprise 10% of drowning deaths in the United States, I have seen articles from medical professionals that state that the number is actually much lower—closer to only 1 or 2%.

In the United States, a little less than 4,000 people drown each year. So 1-2% of that would mean about 40-80 people a year die from dry and secondary drowning.

Now, I don’t mean to trivialize that in any way. Each of those 40-80 people is somebody’s child or loved one. On top of that, drowning in general is the second most common cause of death for kids aged 1-4, so it’s not to be taken lightly.

But to put it in perspective, take a trip to your community pool and you will likely hear 10 kids coughing at some point within just an hour or two of being there. Or, perhaps a better perspective: roughly the same number of people as those who die from secondary drowning are killed by lightning strikes in the United States—an average of 30-50 people a year. And yet the vast majority of us don’t worry about getting struck by lightning every time we go outside.

And so in the same way, fears of secondary drowning shouldn’t keep you from enjoying the water with your family or cause you to worry every time your child has a small cough in the pool or bathtub.

How to Prevent All Types of Drowning

Instead, take precautions and be prepared. When it comes to lightning strikes, we all know that the safest thing to do when you see lightning is to head indoors. And definitely no kites with keys attached.

When it comes to secondary drowning, these are the most important precautions you can take:

The first is to teach your children how to swim. While not bulletproof, this is the number one way to reduce the odds of any type of drowning.

The second is to stay close to your children, especially if they are under 4 years old. I’m a big fan of letting kids go off and do their own thing. I believe in giving kids plenty of unstructured, fairly unsupervised time so that they can explore, be creative, and become self-reliant. But kids 4 and under really should be within arms’ reach of an adult whenever they’re in the pool, no matter how good a swimmer you think they are.

And finally, arm yourself with the information we covered in this article. Know the symptoms of secondary drowning—because there are symptoms. Kids swallow water and cough now and then when they swim. Heck, adults do, too. But if we all panicked every time someone sputtered and coughed around water, pools would be empty and ERs would be full.

So instead, know what to watch for—not so that you have to be anxiously vigilant, but so that when the symptoms do arise, they stand out and you know what to do.

In the meantime, enjoy that time in the water with your loved ones!

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[Update: There has been a shift among fellow medical professionals to move away from using the terms “dry” and “secondary” drowning, and to instead call all types of death in the water simply “drowning.” After conversations with several other physicians in the field, I believe it is still important to make distinctions between what is typically associated with “drowning”—that is, inhaling water and dying in the water—and these very rare occurrences of inhaling water and dying many hours later. Here’s why: The choice to call all of these mechanisms of water death by the one simple term of “drowning” is thought to be a preventative safety measure—the idea being that we continue to say that drowning is a leading cause of death in children, so you should be careful and closely monitor your child at all times when in the water. This is certainly a noble endeavor—after all, who would argue against encouraging parents to be safe? However, our role as pediatricians is not just to keep kids safe, but also to properly and astutely let parents know when they do and do not have to worry when something does happen. My fear is that by no longer distinguishing between “typical” drowning and “secondary” drowning—and by saying simply that drowning is a leading cause of death and can occur many hours later—we will fail in our task of appropriately managing parents’ anxieties. When we stop distinguishing between the different mechanisms of drowning, that means we also no longer inform parents that inhaling water and dying several hours later (“secondary” drowning) is extremely rare—the result being that we don’t just make parents more vigilant when their children sputter in the water, we also dramatically ramp up the amount of fear and anxiety that many parents will face every time their child does something as common as cough in the pool. Every pediatrician who answers phone calls in the summertime knows that there is already far greater worry about secondary drowning than there are actual occurrences of it. There must be some way to strike a reasonable balance between vigilance and anxiety—and there is: education. With all of my articles and podcasts with The Child Repair Guide, I aim not to dumb things down, but instead to clearly explain. Calling everything “drowning” is the former; this article seeks to do the latter. I hope you agree and have found this work informative.