According to the Thai healthcare delivery system data from 2015 to 2019, the mortality rate due to drowning was similar to that reported in Australia [7]. This comparison underscores the severity of drowning incidents in both countries and underscores the need for effective drowning prevention strategies, despite differences in geographic location, healthcare systems, and population demographics. The age group with the highest mortality rate was children under six, which aligns with prior studies [8, 9]. Younger children, often unsupervised, are more likely to drown during bathing or in pools, typically having minimal swimming skills and frequently unwitnessed events, leading to worse outcomes [10, 11]. This contrasts with adolescent drowning incidents which are commonly observed and occur primarily in natural water bodies [12, 13].

Most drowning events involved males, consistent with findings from other studies [7, 14]. This suggests that greater participation of boys in outdoor activities could be a contributing factor [9]. Drowning incidents peaked annually in April, during the summer season in Thailand, similar to the results of other study [15] Reasons for higher drowning rates in summer include hot weather attracting children to water bodies and increased alcohol consumption among adolescents, a risk factor for drowning. Geographically, most drownings occurred in the northeast region, which had the lowest average monthly income per household [16]. Furthermore, higher mortality rates were noted in this region and the central region when compared to the south region and Bangkok.

The trends in our research have remained consistent from 2001 to 2009 to 2015–2019, with the highest mortality rates consistently observed among children under six and males in low socioeconomic regions [8, 9]. This supports earlier findings of higher drowning incidence and mortality in rural areas with a lower socioeconomic status and educational levels [17,18,19]. Despites various policies in drowning prevention, these may not have been fully effective due to persistent socioeconomic and educational disparities in rural areas, limiting access to swimming lessons and water safety education [20]. Additionally, rural communities often face challenges like limited access to emergency medical services and lower overall awareness of drowning risks [21]. Therefore, focusing drowning prevention strategies on these persistent high-risk groups could significantly reduce the mortality rate.

Drowning can lead to serious complications such as pulmonary edema, aspiration pneumonia, and ARDS, causing acute respiratory failure and occasionally cardiac arrest. These complications are primary triggers for endotracheal intubation requirement and multiorgan failure [22]. According to our study, a significant portion of drowning patients required intubation, paralleling findings from previous studies [23]. Children aged between 6 and 18 years were more likely to require intubation, possibly due to witnessed accidents in pools or natural waters, resulting in a higher level of intervention compared to the younger age group [11,12,13].

Our study revealed that patients suffering from cardiac arrest and other drowning-related complications, particularly renal failure, had a high mortality rate. Consistent with previous research, children requiring advanced CPR were more likely to have had unwitnessed or prolonged submersion injury, consequently increasing the risk of fatal outcomes [13]. Patients with hemodynamic instability, renal failure, ARDS, hyperglycemia and metabolic acidosis were significantly higher risk of multiorgan dysfunction and cardiac arrest, leading to death or extended hospital stays in non-fatal cases [10, 22, 24, 25]. Early detection, immediate CPR, and bystander intervention could significantly reduce severe outcomes, including a decrease in the rate of intubation, and shorten hospital stays [26].

Pneumonitis was found to be a protective factor in our study. This contrasts with the more severe complication of ARDS, which often leads to poorer outcomes. This may be explained by the fact that the pulmonary lesion caused by pneumonitis is often temporary and localized. Consequently, these patients tend to recover much faster than patients with ARDS, and late pulmonary sequelae are uncommon [27]. Hypokalemia also emerged as a protective factor. The previous research found that nearly half of the patients who survive after drowning had hypokalemia, in contrast to hyperkalemia, which is commonly found in non-survivor patients. Hypokalemia might indicate a milder metabolic response. In contrast, hyperkalemia, often resulting from significant red cell lysis and cellular breakdown, is associated with severe injury and poor outcomes [28, 29]. Therefore, early detection and management of drowning complications before the progression of organ failure are crucial for improving survival outcomes.

Our study highlighted the need for targeted drowning prevention efforts. Based on our findings, targeted drowning prevention strategies are crucial. Since males and younger children in low socioeconomic areas were found to be at higher risk, specific measures should be implemented, especially during the summer months. These measures include providing adequate parental supervision and water hazard awareness education. Early detection and effective management of complications from drowning, such as pulmonary edema, aspiration pneumonia, and ARDS, are crucial. Prompt referrals to tertiary care facilities with intensive care specialists for close monitoring could enhance recovery outcomes and reduce mortality rates.

This study uses extensive national data from Thailand’s healthcare system over five years, providing a detailed analysis of pediatric drowning incidents. The use of reliable national data is a significant strength, as it allows for comprehensive insights into the trends and risk factors associated with intubation and mortality due to drowning.

However, the study has certain limitations. Its retrospective design makes it susceptible to potential coding errors, while the absence of a control group limits comparative insights. There may be underreporting of non-hospitalized drowning cases, and reliance on hospital data could distort the actual incidence rates. Additionally, the study does not differentiate between drowning types in various water bodies and lacks data on clinical drowning severity, transportation modes, and witness status, potentially affecting the applicability of specific preventive measures. The exclusive use of ICD-10 coding could result in missed cases due to miscoding. Consequently, the database contains minimal amounts of missing data. However, the classification of certain items using ICD-10 may be inaccurate. Nevertheless, our research is limited to life-threatening conditions with straightforward diagnoses, which typically have fewer miscoding in the database. Therefore, we declare this to be our limitation. Furthermore, the absence of long-term outcome measures beyond intubation and mortality limits a comprehensive understanding of the incident’s impact. These factors highlight the need for future studies to address these gaps and improve the generalizability and applicability of findings across various regions and settings.