All people who are pulled from the water after drowning should receive CPR with rescue breaths and chest compressions, according to updated guidance from the American Heart Association and the American Academy of Pediatrics.

The guidelines were published in the journals Circulation and Pediatrics. The article in Pediatrics focuses on literature supporting changes to resuscitation guidelines for children, while the Circulation article includes literature backing updates on how to resuscitate both children and adults following drowning.

The guidelines also include a section on the "drowning chain of survival," which includes prevention, recognition of a person in distress, the use of flotation devices to prevent a person from going under, how to safely remove a person from the water and how to provide lifesaving care.

"The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned, offering practical guidance for health care professionals, trained rescuers, caregivers and families," writing group co-chair Dr. Tracy E. McCallin said in a news release. McCallin is an associate professor of pediatrics in the division of pediatric emergency medicine at Rainbow Babies and Children's Hospital in Cleveland.

Drowning is the third-leading cause of death from unintentional injury worldwide, accounting for an estimated 236,000 deaths each year, according to the World Health Organization. It is the leading cause of death for 1- to 4-year-olds in the U.S., according to the Centers for Disease Control and Prevention.

Drownings are highly preventable. Most infants drown in bathtubs, while most school-aged children drown in swimming pools. Drowning rates in the U.S., where there are disparities in access to swim lessons and other preventive strategies, are highest among Black, American Indian and Alaska Native people under 18. The AHA and AAP recommend being water aware and practicing water safety.

The guidelines include topics not previously addressed by the AHA, such as giving someone rescue breaths while they are still in the water, oxygen administration after drowning, use of an automated external defibrillator (AED) in cardiac arrest after drowning and public access defibrillation programs.

According to the updated guidelines, anyone removed from the water with no signs of normal breathing or consciousness should be assumed to be in cardiac arrest, when the heart stops beating. Rescuers should immediately begin CPR. Trained rescuers should initiate CPR by giving two rescue breaths followed by 30 chest compressions. If the rescuer is unwilling, untrained or unable to provide rescue breaths, it is reasonable to provide chest compressions only until help arrives.

Research shows people who have cardiac arrests from non-heart-related causes such as drowning are more likely to survive when CPR includes rescue breaths, compared to when they receive compressions only.

In-water rescue breathing should only be given by people trained to provide it and only if it does not compromise their own safety, according to the guidelines. Trained rescuers should also provide supplemental oxygen when available.

Drowning can progress quickly from initial respiratory arrest, when a person stops breathing, to cardiac arrest, when the heart stops circulating blood throughout the body, starving it of oxygen.

"CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation," writing group co-chair Dr. Cameron Dezfulian said in the news release. He is a senior faculty member in pediatrics and critical care at Baylor College of Medicine in Houston.

"Cardiac arrest following drowning is most often due to severe hypoxia, or low blood oxygen levels," he said. "This differs from sudden cardiac arrest from a cardiac cause where the individual generally collapses with fully oxygenated blood."

The guidelines also say an AED can be used, if one is available, after the person has been removed from the water. But CPR should be started before using an AED.

"Drowning can be fatal," Dezfulian said. "Our recommendations maximize balancing the need for rapid rescue and resuscitation while prioritizing rescuer safety."

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American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved.