The Younger-Aged Diver

  • Lientra Q. Lu, BS, and Michael B. Strauss, MD
  • Volume 08 - Issue 1

 

Thriving in the aquatic environment

Diving in the younger age group is a gray area, especially with respect to scuba diving. Little data exist, and most information deals with divers in their teens. Diving activities can range from swimming/snorkeling on the surface, to breath-hold diving, to scuba diving. There are many anecdotal reports of divers who have not yet attained adulthood who scuba dive successfully. No studies exist on this subject, however, and all the recommendations seem to be opinions with little scientific basis.1-4

There are many challenges in diving — physical, physiological and psychological — that need to be considered when making decisions about diving in the younger age groups. Water skills are another essential criterion for safe and enjoyable diving, and, of course, these apply to adults as well as youthful divers. Age is also an important consideration. Diving activities that may be appropriate for the late teenager may be inappropriate for younger-aged divers. We will discuss these subjects and provide recommendations for “safe and sane” diving in the youthful population based on physical, physiological and psychological considerations.

Age Considerations

Age is a crucial variable for making appropriate recommendations for diving in the youthful population. The activity level applied to a teenager would likely be inappropriate for the child. For classification purposes, we divide the youthful diver into three age categories (Figure 1): childhood, ages 1-5; preteen, ages 6-12; and adolescence, ages 13-19. Remember age is relative and reflects a continuum of growth and maturation.

Age considerations in diving are arbitrary, albeit they were more conservative in the past. In 1999, with the intention of promoting diving as a sport to a larger audience, the World Recreational Scuba Training Council, whose main purpose was to create a standardized recreational diving guideline, removed its recommendation that one should be at least 15 years old before seeking junior-level certification.Without age-limit restrictions, several major training agencies began developing their own age-specific programs for children as young as 10 years old.

Age considerations are arbitrary. Chronological age must be paired with physiological age, which is the age physical and cognitive functions are equivalent to populations of different ages. At the transition points, the youth may be on either side of the specified ages we suggest. Many milestones exist for chronological ages, some absolute, others relative (Figure 2). For each age category, we offer specific recommendations for diving activities, as we will show later in this article.

FIGURE 1. The continuation of age considerations in youth

FIGURE-1

Legend: Chronological are groupings are used to categorize growing older in youth. The groupings are arbitrary, and at the transitions the physiological are — i.e., what activities a person of a corresponding age would be doing better — define the category. For diving, physiological age is a better criterion than chronological age for making decisions as to what type a young diver should do. Maturation and size are criteria that can help ascertain physiological age.

FIGURE 2. Chronological milestones

FIGURE-2

Water Skills

This term is laden with emotional connotations. One can imagine a parent boasting about their 1-year-old child being able to swim the width of a backyard pool. While a notable accomplishment, it does not equate to water safeness. Imagine what would happen if the child fell into the pool clothed; undoubtedly, he/she would require rescue. Likewise, for a grandparent bragging about their 10-year- old grandchild being able to swim a mile in a swimming pool. These conditions are far different from swimming in open water without walls for turns every 25 yards, currents and swells. Water safeness needs to be paired with age and situations (Table 1). For the child, we suggest that being able to swim easily 100 yards or more at a slow rate with swim gear or come to the surface and remain in place for five minutes if clothed is a reasonable measure of water safeness for this age, while for the preteen, swimming a quarter mile with swim gear and almost unlimited ability to stay on the surface if clothed. For the adolescent, and potential scuba diver, swimming ability sufficient to swim a quarter mile and/or be able to meet requirements for a Boy Scout Lifesaving merit badge or Red Cross Swimming Level 7 are reasonable criteria (Table 2).6 Consequently, water skills must be considered in light of not only swimming ability, but also the situation in which the young person is placed.

The American Red Cross has been active in water-safety training. Old designations such as Beginner, Intermediate, Swimmer, Junior Life Saver and Senior Life Saver designations have been replaced with Red Cross swim levels. For example, a Level 1 requirement is to establish comfort in the water and be able to swim 5 feet, whereas a Level 7 qualification requires swimming and skill proficiency, a quarter-mile swim, survival floating and the ability to retrieve an object from 7 feet of water.
The Red Cross Water Safety Instructor designation remains. Goals are to teach water safety and swimming skills. To qualify for this certification, the applicant must be at least 16 years old and have swimming skills equivalent to Red Cross Level 4 qualifications, which include being able to swim 25-yard segments with four different strokes (crawl, elementary backstroke, sidestroke and breaststroke) totaling 100 yards and 15 yards with the butterfly stroke, treading water on the surface for one minute and backfloat on the surface for one minute.

 

TABLE 1. Quantifying water skills in youngsters
Water Safe Skills

Age Groupings

Inadequate Minimal (optimal swim conditions*) Optimal

Comment

Inadequate water skills is a reason to defer diving and a reason for further training

Child

1---5 years

Nonswimmer Comfort in water; able to swim 25 yards and surface dive ** to 3 feet Able to swim almost unlimited distances Additional recommendation: ability to come to surface and remain there while fully clothed

Preteen

6---12 years

Marginal swimmer, tends to panic in the water Able to swim 100 yards and surface dive to 6 feet Equivalent to a Boy Scout Lifesaving Merit Badge, easily swim ¼ mile or more Enjoy water activities recreationally

Adolescent

13---19 years

Only minimal ability to swim with no form or finesse with swimming strokes Easily able to swim ¼ mile and surface dive to 10 feet, equivalent to Red Cross Swimming Level 7 Competitive swimmer, water polo player or synchronized swimmer By 16 to 17, much of growth has been achieved and fixing of diving equipment is easier

*Optimal swim conditions (calm, clear and warm open water without currents or waves; pool swimming)

**Surface dive — i.e., pick up object off bottom

TABLE 2. Boy Scout Lifesaving Merit Badge requirements (highlights)
Requirement Comment
1. Continuous 400—yard swim in a "strong" manner using 4 stroke types (crawl, side, back and breast) Satisfactorily complete Second Class and First Class rank requirements that include shorter swim distances, turns in the water and elementary forms of lifesaving
2. Knowledge of Boy Scout "Safe Swim Defense" These include recognition of persons in the water who need assistance, options for rescue and situations where in — water rescue should not be done
3. Demonstration of elementary forms of lifesaving These include the mnemonic of TOW (i.e., reach with arm, towel, pole, paddle, etc), THROW (a lifebuoy), ROW and as a last resort GO and how to do these techniques
4. Awareness of "go" flotation devices Demonstrate how to use flotation devices for simulated rescues
5. Considerations for a swimming rescue Preparations for water entry (i.e., clothing/shoe removal), maintaining visual contact but avoiding physical contact with victim, calming the victim, towing victim using an aid
6. Perform lifesaving tows These include back underarm tow and cross chest tow
7. Demonstrate rescues for an unconscious victim With or without equipment aids; using front and rear approach
8. Demonstrate releases Include wrist hold, rear hold and front hold
9. Retrieve 10—pound objects in 10 feet of water Use feet—first and head—first surface dives
10. Demonstrate cardiopulmonary resuscitation skills  
11. Recognition and first—response management of spinal cord injury  
12. Recognition of other possible aquatic—related injuries These include hypothermia, sunburn, marine animal injuries, hyperventilation—panic and traumatic

Note: Bold font is knowledge and skills particularly apropos for teenage scuba divers

 

Fitness is another consideration in diving. It equates to the ability to meet exercise and activity challenges under ordinary conditions as well as to muster increased efforts to meet emergencies. While youngsters in land-based competitive sports may have superb fitness for their activities, this may not extend to water-related activities. Kenneth Cooper generated “The 12-Minute Swim Test for Assessing Cardiorespiratory Endurance.”7 The test consists of measuring the swimming distance covered in 12 minutes and rates it in five categories from very poor to excellent, in six age categories (from 12-19 up to 60 and over) and whether male or female.

The International Association of Dive Rescue Specialists (IARDS) watermanship test is another approach to measuring fitness in the aquatic environment.8,9  It consists of five exercises including timed-surface swim, snorkel swim with fins, treading water, rescue tow with fins, and object retrieval from 9 feet of water. The first four items are timed and graded from incomplete (equivalent to 0 points) to five points. A score of 12 points (of a maximum of 20 points) and object retrieval are required to meet IARDS standards. Whereas, a teenage competitive swimmer would be easily able to exceed this requirement, a fit basketball player without good water skills may fail.

What Does the Literature Show?

Our literature review located more than 20 articles pertaining to younger-aged divers and topics ranging from physical and cognitive challenges to preexisting conditions and common illnesses from diving. Most of the studies, however, were conducted in the 1980s and ’90s — more than 20 years ago. The information from previous reports describes potential problems the younger diver may encounter when diving.

  • Barotitis and barotraumas are caused by pressure changes during descent.10,11  Although the study was conducted for pressure changes in aviation, the pathophysiology is the same in flying and diving. The younger the child, the harder it is for him/her to successfully learn and complete a Valsalva maneuver to normalize middle-ear pressure.

  • Adolescents who enter puberty earlier than their peers are at risk for lower levels of cognitive complexity and propensity to engage in health risk behaviors.12 Some kids are still in the “concrete thinking” stage in which they can function well with specific instructions but are unable to solve unanticipated problems.
  • Reactive oxygen species, powerful mutagens that alter the body metabolism, generate more in oxygen-enriched diving tanks than in compressed-air tanks.13 Its effects on development are still unknown.
  • Patent foramen ovale (PFO), a small opening between the right and left atria of the heart, can remain open in some children until the age of 20. With diving and equalization techniques, people with open PFO can develop an embolism or decompression sickness.14,15
  • Bone growth retardation under hyperbaric pressure was raised as a possible concern but was not shown to occur in juvenile rats subject to decompressions stresses.16  This could be a concern in a growing child if nitrogen bubbles occur in the growth plates of long bones and hinder growth.

MEDICAL CONSIDERATIONS FOR YOUTHFUL DIVERS

Childhood Divers

Childhood divers include youth in the 1- to 5-year age group. Little consideration is given in the literature to this segment of the possible diver population.

Physical challenges: Six physical challenges can occur in the childhood diver. Size is a major physical challenge concern. Ramifications are small stature and lack of muscle strength and coordination. These could make water entry in the presence of waves or surges, steep beach inclines or rocky shorelines challenging encounters. A corollary to this is that a current, even if almost imperceptible, may be stronger than the child’s ability to swim against it. Second, the large surface-area-to-mass ratio of the child predisposes this age group to hypothermia when immersed in water below body temperature. With rapid growth of the child, it would be impractical to continually obtain new wetsuits to fit the child appropriately.

An article in Undercurrent magazine details cognitive challenges that a growing child might encounter while diving.17 Most escape a parent’s consideration.
On a cognitive level, Jean Piaget’s three developmental stages help set the boundaries for each age group: preoperational period from ages 2-7, concrete operational period from ages 7-11, and formal operational period from ages 11-15.18 A 10-year-old wanting to obtain a junior diving certification can appreciate objects present and logical sequences but still lack abstract thinking. This cognitive deficit will prevent the child from finding solutions to hypothetical situations as well as facing a real diving emergency.
The Child Development Institute, LLC, has issued information about scuba diving instruction for kids, most of which advise on the child’s personality, the instructor’s experience, and the teacher-to-student ratio for a class.19 Most of the concerns about diving for children are posted and addressed on the forum scubaboard.com.20 All the information provided in this text box, however, is more often than not personal experience and anecdotal.
The coauthor’s experiences treating children in the hyperbaric oxygen chamber indicate that as a group children clear their ears better than adults. Only in the rarest situations when pathology from tumor or infection is present adjacent to the Eustachian tube openings are ear tubes needed for ear clearing in this age group.
Comment: Middle-ear space pressure equilibration in the child diver is probably a “never” problem. If pain is experienced during descent after a surface dive, the child will probably stop the descent. It appears that with repetitive breath-hold dives over a few days, ear clearing becomes easier and easier and is a natural adaptive mechanism to this physical stress.

A third physical challenge not to be discounted is sunburn. It is expected the diving activities in this age group would primarily be surface swimming with a mask to visualize the wonders of the underwater environment. A few minutes of surface swimming in a sunny environment could lead to sunburn to the back and backs of the neck and thighs. A fourth physical stress is middle-ear barotrauma with surface dives to inspect the bottom. Although this diver age group would not be expected to make surface dives to more than 5- to 6-foot depths, the pressure differentials are still sufficient to generate ear squeezes. The smaller-sized Eustachian tubes and/or hypertrophic tonsils could interfere with middle-ear space pressure equilibration.

A fifth stress is infection of the external auditory canal, commonly referred to as swimmer’s ear. Water retention in the external auditory canal coupled with a warm environment and commensal bacteria in the canal is the precursor for infection.21  It is likely that the childhood diver will be engaging in “diving” activities only in warm, clear water, so the warmth plus water retention precursors can alter the ear canal environment enough that infection is able to develop in the canal.

The sixth and final physical challenge is injuries from marine animals. This is probably the greatest of the physical risks because penetrating injuries from sea urchin spines and stingrays are possible when entering water from the beach. The other marine animal injury risk is from jellyfish stingers. Bite injuries from sharks are possible but, compared to the likelihood of spine and jellyfish injuries, much less likely.

Physiological challenges: These are probably the least of the challenges in this age group because it is unlikely that the childhood diver would be using scuba gear and experiencing the physiological stresses (e.g., ongassing and offgassing) that it imposes. Near-drowning and drowning, however, are important considerations in this age group. Because of their young age, children may not have learned to generate anxieties/fears about water. The younger the child, the less likely he or she will have an aversion to aspirating water. Struggling may not be apparent.

Even though children are purported to be water safe, there are 3,000 drownings each year in the USA in youth from birth to 19 and probably 1,000 or more times that of near- drownings.22 This makes near-drownings the leading cause of accidental deaths in the USA, even higher than automobile accidents.23 Since drownings without anoxic encephalopathy range from a momentary submersion to brief anoxia periods that do not require cardiopulmonary resuscitation, there is no requirement to report such. Consequently, the incidence of near-drownings with sequelae is probably 1000-fold more than for drowning deaths. Most drownings and near- drownings occur in backyard swimming pools when the child enters the water unsupervised. While this information seems remote to diving, it emphasizes the importance of adult supervision for “divers” in this age group.

Psychological challenges: In contrast to the older age groups of youthful divers, anxieties about the aquatic environment are likely not to be present in the childhood diver. Consequently, the lack of psychological responses to stresses of the aquatic environment may place the child in jeopardy. It is unlikely that the child will have full or even any appreciation for the six physical stresses described previously. Conversely, an unpleasant water-related event such as aspiration, hypothermia, a jellyfish sting, etc., especially as the child approaches the preteen years, may cause such profound anxieties that the child remains fearful of the water.

Clinical Scenario: A 4-year-old child jumps off a diving board into a 10-foot-deep diving pool. Somewhat mysteriously, he slowly makes what appear to be purposeful swimming movements below the surface of the water with no attempt to come to the surface, and there’s no evidence of any struggling or desire to breathe. After what seemed an eternity to the lifeguard, but probably less than 30 seconds, the lifeguard brought the child to the surface and then onto the pool deck. After a couple of burps the child said he was OK, did not show any signs of anxiety or distress and was able to stand and walk normally. He was instructed to continue his water activities in the shallow end of the pool.
Comment: The child, not knowing otherwise, did not show panic or anxiety symptoms in the ideal environment of a warm swimming pool. Obviously, the above scenario demonstrates that comfort in the water does not equate to water safeness. Had the lifeguard not appreciated that something was wrong with the child appearing to swim underwater as a bird flies through the air, a near- drowning or drowning could have resulted. Probably some breathing efforts were done while the child was submerged because of the initial burps. Again, the child showed no signs of panic.

Preteen Divers

The years between ages 6 and 12 are ones in which phenomenal growth and physiological (metabolical, endocrinological/hormonal, neurological/brain-related and musculoskeletal) changes take place. Strength, coordination and endurance increase sufficiently that this age group can become actively engaged in aquatic activities.

FIGURE 3. Scuba in a childhood diver
FIGURE-3
Legend: Breathing with a regulator is no more difficult than using an inhaler. More skill and equipment challenges are required for buoyancy control (e.g., proper fit of a buoyancy compensator). Finally, judgement will be fully dependent on adult supervision.

 

Physical challenges: The physical challenges described for childhood are even more applicable to preteen divers because they are gaining the size and strength to spend longer times at the aquatic activity and may have so much confidence that they can do so without adult supervision. While fitting of diving equipment may not be optimal for the preteen, options are increasingly available and easily located on the Internet.24 The major equipment challenge in this age category is proper fitting of a buoyancy compensator. Smaller-capacity scuba tanks and smaller-sized second-stage scuba regulators mitigate these equipment considerations. Swimming fins and appropriately sized dive masks for youngsters are available. Exposure suits can be custom made but can be expensive. A better choice for this age group and size of diver is to dive in warm, tropical waters where only minimal protective clothing — for example, surfing trunks and long-sleeved T-shirts — is used.

Physiological challenges: Although scuba diving is generally not an activity promoted for this age group, parents often boast of their youngsters’ ability to breathe with a scuba regulator and participate in diving activities (Figure 3).25 In actuality, it is probably no more difficult to breath with a scuba regulator than using an inhaler for managing asthma. Since depths of dives are so closely controlled by parents or dive guides, decompression sickness is an unlikely occurrence. In fact, the authors are not aware of any reports of decompression sickness occurring in a preteen. A more serious concern is that a panic-provoking situation will cause the preteen to dart to the surface while breath-holding and cause an arterial gas embolism. Air embolism has been described in this age group.26 Air embolism can occur with breath-holding of compressed air from depths as shallow as 7 feet (2 meters).

A more serious physiological concern in the preteen diver is blackout. Through networking, young breath-hold divers may learn that they can extend their breath-hold times by hyperventilation, which effectively removes carbon dioxide from body tissues and delays accumulation of this waste product, which normally causes almost irrepressible desires to breathe.27 Since oxygen stores are not increased with hyperventilation, the breath-hold diver may blackout from hypoxemia before he or she develops a desire to breathe from carbon dioxide reaching the breath-hold breakpoint. For “macho” reasons of wanting to set new depth or underwater swim distance records for themselves, the uninformed diver (or swimmer) may hyperventilate enough to delay the desire to breathe and blackout without a desire to breathe while underwater. Since snorkeling and breath-hold dives from the surface to explore the bottom are likely to be the main diving activities of the preteen, it behooves anyone responsible for the diving and swimming activities in this age group (e.g., parents, lifeguards, coaches, trainers, dive supervisors, boat operators, etc.) to not permit hyperventilation before engaging in underwater activities.

The authors are aware of a surface-supplied hookah-like rig that has been mentioned for compressed-air diving in older children (Figure 4). A small air compressor sitting in an innertube-like floatation device has hoses attached to it. The divers breathe through a second-stage scuba regulator. By limiting the length of the hose, the childhood diver can go no deeper than the hose length, which may be 20 feet or so. While decompression sickness is unlikely at such shallow depths, air embolism is a possibility if something goes wrong and the diver holds his or her breath while making an emergency ascent.
Clinical scenario: Several youngsters were playing in a backyard swimming pool. They decided to tie weights to a bucket handle and let the bucket filled with air sink to the bottom. After almost exhausting the air from the bucket, one of the kids swam to the surface holding his breath. Upon surfacing, the kid sighed and immediately lost consciousness. Resuscitation efforts by paramedics were futile.
Comment: The diagnosis was arterial gas embolism. Calculations from diving physics show that an ascent from as little as a 3-foot (about 1 meter) depth after a full inhalation of air into the lungs will theoretically result in a 10 percent overexpansion of the lungs upon reaching the surface. This differential pressure may be sufficient to rupture alveoli and cause an arterial gas embolism.
Dictum: Breath-holding while ascending after breathing compressed gas must be avoided. In the above scenario, it is unlikely the kids were aware that it was dangerous to ascend while breath-holding after taking a deep breath from air in the submerged bucket.
 

 

A remote, theoretical concern for diving in this age group is bubble formation with ascent in areas of slow blood flow, such as sinusoids, bone marrow, venous plexuses (Babson) in the spinal canal, and growth plates. Whereas, bubble formation in sinusoids and bone marrow may remain silent, it could have ramifications if it occurred around the spinal cord or in the growth plates of the rapidly elongating preteens’ long bones. Generation of angular deformities if the bubbles occluded circulation on the medial or lateral edges of the growth plate or total arrest of growth if the entire growth plate was involved. These problems remain theoretical possibilities, and again we are unaware of any reported cases of them occurring. Peter Walker’s study of growth plates in rats after decompression stresses showed no abnormalities.16

FIGURE 4. Surface-supplied gas-supply diving

FIGURE-4

Legend: Surface—supplied air system (e.g., Brownie's Third Lung Hookah) is an alternative to scuba (self-contained underwater breathing apparatus diving). The hose length prevents enough ongassing to cause decompression sickness after surfacing. If the diver panics, however, and has an uncontrolled ascent to the surface, arterial gas embolism can occur.

 

Psychological challenges: For the preteen diver, this is probably the biggest concern of the three categories of challenges. The physical challenges, which predominate activities for the childhood diver, are gradually being mitigated by growth. Participation in competitive sports activities, which is often started in the preteens, rapidly builds strength, stamina, coordination and confidence in this age category. What is lacking are judgment and experience. Consequently, while the physical challenges as described for the childhood diver still exist, they are no longer such an impediment to aquatic activities in the preteen. Whereas, the childhood diver may not engage in water activities without one-to-one adult supervision, the preteen diver may do such with his or her buddies. Dares and goading can likely exceed judgment, leading to unsafe aquatic-related activities — in particular, as mentioned above, is using the hyperventilation technique to increase underwater swimming distance, breath-hold dive durations or depth excursions.

Scuba diving in this age group raises the same judgment and experience concerns as described in the childhood diver. The newfound ability to “breathe” underwater may give the preteen diver confidence that there are no limits as to what he or she can do underwater. This age group may not yet have the capacity to fully appreciate the challenges of diving and the medical problems that can arise from them.

MEDICAL CONSIDERATIONS FOR THE TEENAGE DIVER

Physical challenges: Teenage divers exhibit extremes in their ability to dive. In terms of physical challenges, they are probably as fit and strong as any times in their lives. This is understandable because of the high probability of participation in competitive sports, dancing, martial arts or other physical fitness activities. Conversely, in terms of judgment and daredevil activities, this age category exceeds that of the preteen diver. With growth, increased size and strength, and an attitude, there is no obstacle too great to surmount. The likelihood of risk-taking behavior increases proportionately and may be exacerbated by the use of alcohol and street drugs. Most of the physical challenges of diving as summarized in the childhood section are easily overcome because of maturation of their musculoskeletal system. At this point in development, fitting of diving equipment is not a problem except for the extremes of size.

Physiological challenges: With approaching adulthood, the physiological challenges for the teenager are probably little different than that for adults. Because of longer and deeper scuba dives, decompression sickness and nitrogen narcosis become a possibility but are probably no more likely than in the adult diver. In addition, motivation, spearfishing and possibly competition place the breath-hold diver at risks for hypoxic blackouts. Breath-holding hypoxic blackouts are not only associated with hyperventilation (i.e., breath-holding after hyperventilation)27 but also distractional (i.e., subjugating the breath-hold breakpoint due to fixation on an underwater goal) and diffusional causes associated with deep breath-hold dives in which the diver remains on the bottom until his or her blood oxygen content approaches the point of losing consciousness. During ascent with decreases in ambient pressure, blood oxygen contents decline as quantified by Dalton’s law and can reach levels at which consciousness is lost. Blackouts may also arise from arrhythmias, which may be precipitated by cold-water immersion coupled with breath- holding, both components of the diving reflex.

Pathophysiology associated with chronic medical conditions becomes a consideration in the adolescent scuba diver. Diabetes, asthma and seizure disorders are the three most commonly encountered problems. Typical diabetics in the adolescent age range are of the type-1 variety in which the pancreas has lost the ability to produce insulin. Without insulin to act as an enzyme to carry blood glucose across the cell membrane and then be used as the substrate (fuel) for metabolism, cell function ceases. If blood sugars are too low, consciousness can be lost; if profound enough, death of brain cells occur; if too high, metabolic derangements termed ketoacidosis can be life-threatening. Consequently, decisions regarding scuba diving require careful medical consideration. If blood sugars are stable, and the adolescent patient is compliant with insulin use and monitoring, diving under controlled circumstances is a reasonable decision. Controlled conditions include diving to minimize stresses such as in warm, clear water, minimizing swimming required by diving off of boats with descending lines, utilizing finger-stick tests of blood glucose before entering the water and after surfacing, diving with a buddy aware of the adolescent’s diabetes condition, and carrying an emergency sugar source to take if symptoms of hypoglycemia are noted.

Recommendations for diving in adolescent asthmatics require similar decision-making and diligence. If wheezing requires use of inhalers more frequently than several times a year, scuba diving is not recommended. The breathing of dry, dehumidified air in the scuba tank cooled to the ambient water temperature may precipitate an asthma attack. With bronchospasm, air may be retained in the alveoli during ascent and lead to extra-alveolar air problems such as arterial gas embolism, pneumothorax and/or mediastinal emphysema. Conversely, if the patient with an asthmatic history is generally asymptomatic and is asymptomatic at the time of the dive, diving under the controlled conditions described above for the diabetic is a reasonable decision.

A history of seizures is an absolute contraindication for the adolescent scuba diver. Adult scuba divers with a seizure history might dive, but this is generally done against medical advice. The adolescent scuba diver does not have as much independence as the adult in obtaining equipment, selecting diving sites and diving without supervision. Seizures are an absolute contraindication in scuba diving for several reasons. First, increased partial pressures of oxygen are known to cause seizures. Scuba diving increases oxygen partial pressures, as explained by Dalton’s law. For example, at a 33-foot (10-meter) depth, which is equivalent to 2 atmospheres absolute, the oxygen partial pressure doubles. Second, a seizure while underwater with associated loss of consciousness is tantamount to a near-drowning/drowning incident. If the dive buddy is skilled enough to bring the submerged, unconscious victim to the surface, retention of air in the lungs and expansion with ascent may lead to an arterial gas embolism. Third, if the diver with a seizure disorder requires recompression in a hyperbaric chamber because of decompression sickness, the breathing of pure oxygen under hyperbaric conditions may precipitate a seizure. Fortunately, this latter risk can be substantially reduced by giving anticonvulsant medications intravenously to the victim before and during the treatment.

A patent foramen ovale (PFO) is another physiological problem that occurs in divers, and since the condition is present from birth, it can occur in teenage divers as well. The foramen ovale is an opening in the septum of the ventricles that allows blood in the fetus to bypass the lungs. At birth, it typically closes with the first breath of air taken by the newborn baby. If it remains open or partially open, which occurs in about 25 percent of humans, silent bubbles (which almost always occur with ascent from a scuba dive and are usually harmlessly filtered out through the lungs) moves from the right ventricle to the left ventricle. This allows bubbles to enter the arterial bloodstream and cause stroke-like symptoms if they lodge in the brain.

Clinical scenario: A newly certified 19-year-old male has begun scuba diving as an outlet for a behavior disorder. After an unremarkable dive to 50 feet (15 meters) for less than hour, his fifth open-water scuba dive, he was asymptomatic on the surface. While talking with other divers, one of them tells a joke. The diver in question begins laughing hysterically (possibly a side effect of his behavior problem) and immediately collapses unconscious and unresponsive.
Fortunately, a recompression chamber was nearby, and after hyperbaric oxygen recompression, the patient recovered without any residual problems. Before being allowed to resume diving, he required a medical clearance. A heart bubble study demonstrated a patent foramen ovale (PFO). The patient was intent on resuming scuba diving but was advised to not do such until the problem was repaired.
Comment: Although the diver had a few previous uneventful scuba dives, the hysterical laughter and consequential increased intrathoracic pressure apparently forced silent bubbles in the venous circulation to pass from the right ventricle through the PFO to the left ventricle and into the arterial circulation. The collapse symptoms resulted from bubbles blocking the brain circulation.
With current technology, invasive cardiologists are able to close the PFO using percutaneous techniques, thereby minimizing the morbidity associated with open-heart surgery. Once the PFO is closed, divers are cleared to resume scuba diving.

 

 

Psychological challenges: Judgment has to be paired with experience for the teenage diver (Figure 5). Also, water skills must be considered. If the teen is not comfortable in the water, scuba diving training should not be encouraged. Loss of control accompanied by panic is a leading cause of death in scuba divers and most frequently occurs in the inexperienced divers.28 The same attitudes and feelings of immortality that had their origins in the preteen years is likely to be carried over and even magnified in the adolescent diver. In diving, there can be no substitute for judgment, and judgment comes with experience and maturity. Society has set some norms for judgment, which is reflected in setting the voting age at 18 and the obtaining of driver’s licenses after age 16 (Figure 2). These requisites are reasonable criteria for scuba diving as well.

FIGURE 5. Growth vs. maturity in preteens and adolescents

FIGURE-5Legend: Judgement and experience lag behind growth and development. This has important ramifications for making decisions when to begin scuba diving.

 

Behavior problems and scuba diving is a subject that deserves further research (see previous clinical scenario). With the risk of reckless behaviors and inability to follow directions, adolescents with attention deficit hyperactivity disorder (ADHD) need to be carefully scrutinized before allowing snorkel and scuba diving. One criterion is if they can obtain a driver’s license, they can follow directions well enough to scuba dive. Patients with more serious problems such as Asperger’s syndrome, neuroses, dyslexia or cognitive function impairment may find scuba diving and being able to visualize the aquatic environment so fulfilling that it mitigates their neurological problems. Diving with these conditions requires one-to-one competent adult supervision and diving with optimal conditions (described in the childhood diver section). Similar benefits of scuba diving and requirements to do such apply to patients with paralyzed extremities, cerebral palsy and single-limb amputations.

What diving activities should be encouraged in the teenage diver? The coauthor’s sons did not obtain their scuba diving certifications until after they obtained their driver’s licenses. Both were competent swimmers, being on swimming and water polo teams since their early teens and having their Boy Scout Lifesaving merit badges.
During family outings at diving programs, they would snorkel dive. Both enjoyed the freedom of this activity and easily could breath-hold more than a minute and submerge to greater than 30-foot (10-meter) depths. Even today on scuba diving trips they spend their time between scuba dives with snorkeling or in lieu of doing repetitive scuba dives.

Certifications for the Younger-Aged Diver

In their goals to expand and promote scuba diving, diving certification organizations have designed programs for younger-aged divers. Most provide certifications and have catchy names. For teenagers, it is advisable that scuba classes be limited to students their own ages. Consider the following:

The National Association of Underwater Instructors (NAUI) features the Skin Diver program for kids 8 years old and older for snorkeling and breath-hold surface diving to a 5-foot depth.29 Next, at age 10 and above, they can take beginner scuba diving courses and earn their Junior Scuba Diver certificate. At 15 years of age and with 25 scuba dives, they can earn the Experienced Scuba Diver certificate.

The Professional Association of Diving Instructors (PADI) provides the Supplied Air Snorkeling for Youth (SASY) for children ages 5 to 7.30 It also has the Bubblemaker Diving Program, in which kids as young as 8 years old can blow bubbles underwater by scuba diving in a pool or shallow water. The PADI Seal Team offers formal lessons for kids from 8 years old and up to complete AquaMissions toward earning a certificate. From 10 years old and above, kids can get schooled and certified in the official PADI Open-Water Diver Course for scuba diving.

Scuba Educators International (SEI) took over the Y-SCUBA programs from the Young Men’s Christian Association (YMCA) in 2008.31 SEI now offers the Open-Water Diver Course for both adults and children 12 years and older.32 Upon completing the course, however, children ages 12-15 years are awarded the Junior Open-Water Diver certification.

Scuba Schools Internationals (SSI), which merged with the National Association of Scuba Diving Schools (NASDS) in 1999, designs the Scuba Rangers program for children ages 7-12 and the Junior Scuba Program for adolescents ages 10-14 with a variety of special names, including Junior Scuba Diver, Junior Open-Water Diver, Junior Advanced Adventurer, Junior Rescue Diver, etc.33,34

Our Recommendations

With the above information, logical recommendations can be made for younger-aged divers (Table 3, Figure 6). A few maxims need to be mentioned, however, in conjunction with making decisions who, when, where and with what equipment a youngster should dive. They include the following:

  1. Water skills are both a function of swimming skills and the environment in which the young swimmer/diver is placed.

  2. Three age categories — childhood, preteens and adolescents — are useful for making recommendations about diving activities in youth.

  3. Physical challenges of the aquatic environment by and large pertain to how the external environment influences the diver.

  4. Physiological challenges are those that reflect how the diver's body responds to these challenges.

  5. Psychological challenges are how the human mind responds to the combination of the physical and physiological challenges.

  6. Younger-aged individuals should not be forced into water-related activities they do not enjoy; obviously not every young person wants to become a diver.

  7. Diving certification agencies have developed programs for younger-aged divers with specifications for equipment used and depths of diving.

  8. Scuba diving training is best deferred until judgment becomes equivalent to that required to obtain a diver's license and swimming skills are equivalent to those required for a Boy Scouts Lifesaving merit badge (Table 2) or being able to pass the IARDS watermanship test.

  9. While decompression sickness is not likely to occur shallow depths (e.g., using a hookah rig), air embolismis possible, especially if the diver panics and breath-holds while making an uncontrolled ascent.

  10. While breathing compressed gas through a regulator is almost as easy as breathing itself, before doing such the younger-aged diver must be aware of the limitations and hazards when using this equipment for diving.

FIGURE 6. Diving type recommendations vs. age

FIGURE-6Legend: Each age category deserves special recommendations. For the childhood diver, it should be surface swimming with one—to—one adult supervision. For the preteen, snorkel diving with shallow breath-hold dives with buddies is OK. Scuba diving becomes appropriate for the mid—and late—adolescent.

Conclusions

The pleasure and educational value of diving for younger age groups must be weighed against the risks involved. By categorizing younger-aged divers as childhood, preteen and adolescent, the first step in making appropriate decisions about their diving activities is made. The second step is to consider the physical, physiological and psychological challenges that each age category imposes. Although many articles have been written about diving in children and young adults, almost all are opinions and observations. Scuba diving certification agencies have generated programs for young divers. Before considering any diving activities, adequate water skills are essential. These must be coupled with comfort in the water.

Our approach provides thoughtful guidelines for each age category of diving. The guidelines provide information on 1) appropriate dive equipment, 2) environmental considerations, 3) level of supervision required, 4) depth recommendations, 5) fitness recommendations and 6) special concerns such as medical problems of diving and diving with concurrent illnesses for each age category. While growth and maturation exhibit a continuum of changes, the guidelines offer flexibility in application as the diver transitions from one age category to the next. Probably the biggest question to answer is when to begin scuba diving. Breathing with a regulator is probably the easiest challenge. The greatest challenge is deciding whether or not the adolescent diver has sufficient judgment to dive safely. Excellent preteen snorkel divers easily transition into competent scuba divers. This chapter shows how the younger-aged diver can dive safely, smartly and securely.

TABLE 3. Diving type recommendations vs. age
Age Groups Equipment Environment Supervision Depth Recommendations Special Considerations

Child

1---5 years

Swim mask and fins Optimal conditions with warm water, good visibility, shallow depths and no currents or waves; a swimming pool is ideal place to begin this diving activity One---on---one supervision by an adult diver Learning to pick up an object on the bottom at a 3 foot (1 meter) depth Make exposures short, avoid sunburn by wearing protective coverings, encourage breath control and mobility

Preteen

6---12 years

Swim mask, snorkel and fins Good conditions with diving off the beach ora boat in warm water, good visibility and minimal current, swells or waves One---on---one adult or a responsible late teen snorkel diving "partner" Surface dive to explore the bottom at 6 foot (3 meter) depth Learn how to use a snorkel, avoid hyperventalation before surface dives, become comfortable with middle---ear pressure equilibration with descents, be aware of the marine environment and how marine animals can inflict injuries, teach respect for the underwater environment by seeing rather than touching

Adolescent

13---19 years

Training and supervision with scuba gear Safe diving conditions with use of appropriate thermal protection suits Preferably a buddy with equal or greater diving experience Sixty feet initially or as additional certifications dicate; use no decompression dive profiles with use of dive computer or tables Always plan the dive, preferably with a dive briefing, including reviewing hand signals before entering the water, following other appropriate recommendations such as ear---clearing techniques and protecting and respecting the environment as mentioned in the other age categories

References

  1. Dembert, M, Keith, J. Evaluating the Pediatric Scuba Diver, AJDC, 140, Nov. 1986; p. 1135-1141.
  2. Bernd WE, Claus-Martin M, Tetzlaff K. Should children dive with self-contained underwater breathing apparatus (SCUBA)? Acta Paediatrica. 2012; 101(5):472-478.
  3. Taylor, L. Why I do NOT train kids? http://www-personal. umich.edu/~lpt/kids.htm
  4. Campbell ES. Scubadoc’s Diving Medicine. http://scuba-doc.com
  5. World Recreational Scuba Training Council. Minimum Course Content for Open Water Diver Certification. Effective 01October 2014. http://wrstc.com/downloads/03%20-%20Open%20Water%20Diver.pdf
  6. American Red Cross Swimming Levels. https://spu.edu/ depts/casey/recreation/documents/Red-Cross-Swim-Level- Information.pdf
  7. Cooper KH. The Aerobics Program for Total Well-Being. New York: Bantam Books. 1982.
  8. IADRS. Annual Watermanship Test. http://www.iadrs.org/ media/IADRS_Watermanship_Test.pdf
  9. Strauss MB, Busch JA, Miller SS. SCUBA in Older Aged Divers. Wound Care and Hyperb Med. 2013; 4(3):27-38.
  10. Stangerup S. Tjernstrom, O. Klokker, M. Harcourt, J. & Stokholm, J. Point Prevalence of Barotitis in Children and Adults After Flight and Effect of Autoinflation, Aviation, Space and Envirn. Med. 69(1),1998, 45-49.
  11. Purcell G. & Becker, G. Conservative Management Of Inner Ear Barotrauma Resulting From Scuba Diving, Otolaryngol Head Neck Surg. 93(3), June, 1985, 393-397.
  12. Orr D. & Ingersoll, G. The Contribution of Level of Cognitive Complexity and Pubertal Timing to Behavioral Risk in Young Adolescents, Pediatrics, 95(4), April 1995, 528-533.
  13. Fantel A. Reactive Oxygen Species In Developmental Toxicity: Review and Hypothesis, Tetrology, 53(1996), 196-217.
  14. Langton P. Patent Foramen Ovale In Underwater Medicine, SPUMS, 26(3), Sept. 996, 186-191.
  15. Mitcheli L. Glassman, R. & Klein, M. The Prevention of Sports Injuries In Children, Clinics In Sports Medicine, 19(4), October, 2000, 821-832.
  16. Walker P. et. al. Effects Of Hyperbaric Pressure On The Growth Plates Of Rats, SPUMS, 27(3), Sept. 1997, p. 125-130.
  17. Doc Vikingo. The Minds and Bodies of Children. Undercurrent. 2001; 16(9). http://www.undercurrent.org/ UCnow/dive_magazine/2001/TheMinds200109.html
  18. Piaget, J. (1983). Piaget’s theory. In P. Mussen (ed). Handbook of Child Psychology. 4th edition. Vol. 1. New York: Wiley.
  19. Myers P. Scuba Diving for Kids – What You Should Know about It. 2012. https://childdevelopmentinfo.com/fitness-for- kids-teens/scuba-diving-for-kids-what-you-should-know- about-it/#.WIOiILYrJE5
  20. Diving Community Forum. https://www.scubaboard.com/ community/threads/physiological-risk-factors-for-pre-teen- divers.9152/
  21. Strauss MB, Dierker RL. Otitis Externa Associated with Aquatic Activities (Swimmer’s Ear). Clinics in Dermatology 5:103-111, Jul/Sep 1987.
  22. Brenner R A, Trumble A C, Smith G S. et al. Where children drown, United States, 1995. Pediatrics 200110885–89.89.
  23. Stanford Children’s Health. Water Safety - Injury Statistics and Incidence Rates. http://www.stanfordchildrens.org/en/topic/ default?id=water-safety--injury-statistics-and-incidence-rates- 90-P03004
  24. Amazon. Children’s Aquatic Gear. https://www.amazon.com/ Aquatic-Exercise-Equipment/b?ie=UTF8&node=13279551
  25. Pouliquen H. L’Enfant et la plongee. South Pacific Underwater Med Soc J. October-December 1982, p 3.
  26. Tsung JW, Chou KJ, Martinez C, et al. An adolescent scuba diver with 2 episodes of diving-related injuries requiring hyperbaric oxygen recompression therapy: a case report with medical considerations for child and adolescent scuba divers. Pediatr Emerg Care. 2005 Oct;21(10):681-6.
  27. Strauss MB, Le PJ, Miller SS. Stresses in SCUBA and Breath- Hold Diving. Part IV: The No Panic Syndromes. Wound Care & Hyperb Med. 2014; 5(4):10-27.
  28. Denoble PJ, Marroni A, Vann RD. Annual Fatality Rates and Associated Risk Factors for Recreational Scuba Diving. Recreational Diving Fatalities Workshop Proceedings, p 73-85.
  29. National Association of Underwater Instructors. NAUI children programs. https://www.naui.org/
  30. Professional Association of Diving Instructors. Open Water Diver. https://www.padi.com/padi-courses/open-water-diver
  31. Scuba Educators International. Open Water Diver course. http://www.seidiving.org/become-a-diver/open-water-diver/
  32. http://www.seidiving.org/news/2014/08/28/main/sei-collaborates-with-ymca-of-the-usa-to-service-divers-certified- under-former-yscuba-training-program-for-verification-and- replacement-card-needs/
  33. Scuba Schools International. Kids & Scuba Rangers. https:// www.divessi.com/children
  34. SSI merged with NASDS. Scubaboard.com https://www. scubaboard.com/community/threads/does-nasds-still- exist.249010/

About the Authors

MSTRAUSS

MICHAEL B. STRAUSS, M.D., has had a long-time relationship with water activities. He took his first Red Cross (RC) swim class as a 6-year-old under the direction of his father, a frustrated furniture merchant whose teaching and coaching of water-oriented activities was a predominant feature of his life. As a youngster, he rapidly advanced through Junior and Senior Lifesaving and the Boy Scout Lifesaving merit badge as well as the Scout Lifeguard Award. He started swimming competitively when he was 9 years old and continued with this while adding water polo during college. In the summers, he lifeguarded, coached swimming and taught RC swimming lessons. While enrolled in a college RC Water Safety Instructor’s course, he so impressed the instructor that he ended up teaching the course while the instructor watched from the sidelines. Immediately before starting medical school, Dr. Strauss played for the U.S. Maccabiah Water Polo Team in Israel. While in medical school in Portland, Oregon, he introduced the sport of water polo to the state.

After entering the US Navy, he was heavily oriented to water-related activities, including submarine school, diving school, a nuclear submarine patrol, diving medical officer for salvage divers in the Philippines and Vietnam, and then with the West Coast UDT and SEAL Teams. While with the UDT and SEAL Teams, he coached the local high school water polo team, played club water polo and was the advisor for an Explorer Scout scuba diving post. After joining the Long Beach Memorial Hyperbaric Medicine Program in Long Beach, California, he organized diving, diving medical programs to more than 20 countries, played for the U.S. Water Polo Team for the World Masters’ Games in Australia and remained attached to the Navy Reserve West Coast SEAL Teams for 24 years. In addition, he has almost 50 publications on diving medicine, some of which have appeared in this magazine. He is currently working on the second edition of his Diving Science text. Like his father, of blessed memory, his fondness for water-related doings remains unabated.

 

 


LU

LIENTRA LU was born and raised in a seaside city in Vietnam. She has been accustomed to the water since childhood. After learning to swim at 7 years old, she enjoyed frequent snorkeling trips with her family every summer in the islands surrounding Nhatrang, Vietnam. Since working with Dr. Strauss, Miss Lu has learned an amazing amount of information about the medical aspects of scuba diving. She is pleased to have collaborated with Dr. Strauss on four dive medicine articles to date and is thrilled with the opportunity help co-edit the upcoming and totally revised 2nd edition of Drs. Strauss and Aksenov’s Diving Science text. Her next diving goal is to become a certified scuba diver and help others enjoy this sport in a safe and sensible fashion.

 

Contact Us

Best Publishing Company
631 US Highway 1, Suite 307
North Palm Beach, FL 33408

Email:
This email address is being protected from spambots. You need JavaScript enabled to view it.

Phone:
561.776.6066

Fax:
561.776.7476


Copyright © 2018 Best Publishing Company, a company of WCHMedia Group, Inc | All rights reserved
Find more information at www.WCHMediaGroup.com