Swimming is part of summer fun, especially for my son, Aidan, who has Down syndrome. It provides opportunities for him to exercise while being with family and friends. He’s been a member of our local swim team for the past 10 years and was a varsity swimmer on the Haverford High School swim team for the past four years.

Babies and children with Down syndrome can benefit from being in the pool and learning early swim skills. When introducing the pool to your child it’s important to provide lots of opportunities for repetition of each new aquatic motor skill such as: blowing bubbles, floating, kicking and reaching in the pool. Learning these skills is the result of repeating the skill many times. Once your child masters each individual skill, encourage them to try two skills at the same time such as kicking and blowing bubbles, or kicking and reaching in preparation for swimming.

When to start water training

Babies with Down syndrome are at an increased risk for aspiration (stopping breathing). This should be assessed and considered before bringing your baby into a pool. A recent study found that 89.8% of babies with Down syndrome studied demonstrated disorder during the oral stage of development (typically from birth to year; and 72.4% had disorders in the involuntary pharyngeal phase of swallowing.5)

Aquatic therapy can be dangerous for babies with Down syndrome if they do not protect their airway. Babies may swallow water or have challenges blowing out and blowing bubbles while in the pool. Parents should be aware of this increased risk and assess their ability to protect the child’s airway with lip closure and blowing toys or bubbles.

Skills practice

The aquatic environment is a place where respiratory and oral motor skills can be practiced and improved. Casey and Emes³ studied the effects of swim training on respiratory aspects of speech in adolescents with Down syndrome and found a significant increase in the mean phonation duration (MPD) in participants with Down syndrome. This highlights possible respiratory and speech benefits swimming may provide in the DS population.

Children with Down syndrome tend to have sensory processing considerations such as:

• sensitivity to noise or certain sounds,
• sensitivity to water,
• hypersensitivity to tactile stimulation on their face,
• resistance to handling, or
• resistance to deep pressure input on their hands or feet.

Will et al. studied sensory processing disorders in children with Down syndrome and reported that the under-responsiveness found in many children with the disorder is linked to maladaptive behaviors.⁶ These considerations and impairments may make it challenging for families to participate in a community swim program as a first pool experience.

Most community swim programs use demonstration and verbal directions and move at a fast pace. There are many sensory stimuli which need to be processed while in a pool including temperature, pressure, the tactile feeling of the water, sound, vestibular and visual stimulation as well as the auditory changes in sound quality often found in a pool environment. Your child with Down syndrome may have challenges processing all these new stimuli.

Often, children with Down syndrome require more time to process information and more repetitions to practice new skills than their peers without the disorder. They benefit from repeating skills such as closing their mouth, holding their breath, and exhaling before being submerged in water – when they are at increased risk for aspiration. This additional sensory input in the pool may improve a child’s responsiveness and lead to less maladaptive behaviors. Therapists should be aware of how stimulating the aquatic environment can be and provide strategies to help the child mentally adjust and become more comfortable in the pool.

Pool safety

Pool safety is emphasized during pool groups held at Children’s Hospital of Philadelphia (CHOP). One way to start introducing your young child to pool safety is by implementing a consistent and safe entry and exit from the pool.

During our aquatic groups at CHOP, we have each child sit at the edge of the pool on a towel and wait for their parent or caregiver to enter the pool. The parent then makes eye contact with the child and counts to 3, the child is then encouraged to reach toward the parent to enter the pool. This method encourages the child to wait, make eye contact and reinforces safe pool entry practices.

Children tend to be excited about getting into the water and are often impulsive or they may have attention challenges. This consistent entry routine ensures the child is safe waiting and only enters when a caregiver is available to assist them into the pool.

After mastery of the forward entry, the child can advance to a posterior entry by having the child transitions sit on the edge of the pool, roll to their belly, and then push off into the pool.

Most children, including those with Down syndrome, love to swim but we must consider how they learn best and set them up for success. Consider working with a therapist privately or starting with one-on-one lessons as a first exposure to swimming. Individual lessons can ensure your child is provided the right amount of instruction and feedback needed to be successful.

Providing a fun, safe and successful experience will help your child achieve the skill of swimming and make it an activity they can participate in their entire life.

Tips when starting in the pool

Entering/exiting

• Provide a consistent routine to enter and exit.
• Encourage eye contact and gesturing.

Blowing bubbles

• Practice blowing pinwheels or blowing ping pong balls in and out of the pool.
• Work on blowing bubbles in a cup with a straw.
• Practice blowing bubbles in the pool.

Floating

• Practice floating by supporting your child around their body and have them rest their head on your shoulder.
• Slowly bring your shoulder lower and lower into the water to try to submerge your child’s ears into the water.
• When comfortable having their ears submerged, try to practice without your shoulder for support.

Reaching

• Throw a toy in the water and practice floating on the tummy and reaching with each arm for the toy.

Kicking

• Support the child around their body and move through the water and encourage them to kick.
• Practice kicking with a kickboard.

Side-to-side support

• Support the child around their body and move the child side to side in the water. This is a nice warm up activity and a good core strengthening exercise.

Resources

• Water Safety by CHOP’s Injury Prevention Program, includes tips to prevent drowning, swimming pool safety, and water safety tips by age group
• Water Safety for Your Special Needs Child
• Preventing Drowning Accidents: How to Keep Your Child Safe

References

1. Mai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010-2014. Birth Defects Res. 2019;111(18):1420-1435.
2. Bull MJ, Committee on G. Health supervision for children with Down syndrome. Pediatrics. 2011;128(2):393-406.
3. Casey AF, Emes C. The effects of swim training on respiratory aspects of speech production in adolescents with down syndrome. Adapt Phys Activ Q. 2011;28(4):326-341.
4. Foti F, Menghini D, Alfieri P, et al. Learning by observation and learning by doing in Down and Williams syndromes. Dev Sci. 2018;21(5):e12642.
5. Narawane A, Eng J, Rappazzo C, et al. Airway protection & patterns of dysphagia in infants with down syndrome: Videofluoroscopic swallow study findings & correlations. Int J Pediatr Otorhinolaryngol. 2020;132:109908.
6. Will EA, Daunhauer LA, Fidler DJ, Raitano Lee N, Rosenberg CR, Hepburn SL. Sensory Processing and Maladaptive Behavior: Profiles Within the Down Syndrome Phenotype. Phys Occup Ther Pediatr. 2019;39(5):461-476.
7. Russell D, Palisano R, Walter S, et al. Evaluating motor function in children with Down syndrome: validity of the GMFM. Dev Med Child Neurol. 1998;40(10):693-701.
8. Tirosh R, Getz M. Halliwick-Based Aquatic Assessments : Reliability and Validity. International Journal of Aquatic Research and Education. 2008;2:2244-2236.
9. A. Social Learning Theory. New York: General Learning Press; 1977.
10. Buckley S, Bird G. Cognitive development and: Perspectives on Down syndrome from a twenty-year research program. London: Whurr; 2002.

Helen Milligan, DPT, PT, is a physical therapist in the Trisomy 21 Program at Children's Hospital of Philadelphia.