As summer approaches, we look forward to sunshine, flip-flops and endless days splashing in the pool. As a pediatrician, I highly encourage my patients to switch off their electronics and get outside and into the water as often as possible. As a mom, I am wary of the risks of infections caused by swimming in public pools. This article is not meant to send you off the deep end, but rather to help guide best practices for keeping our little ones healthy and safe. Here is what you need to know about recreational water illnesses (RWI).

Contaminated water and diarrhea

Gastrointestinal illnesses are the most common RWI. These are caught by swallowing small amounts of contaminated water, and are caused by parasites, bacteria and viruses. These can be present on anyone, especially those having diarrhea symptoms or young children in diapers or with poor hygiene. Just a few drops of contaminated water can make someone feel ill. Microorganisms that can cause diarrhea include the parasite giardia, bacteria including shigella and e. coli and norovirus. The leading culprit is actually a parasite known as cryptosporidium. Cryptosporidium is somewhat resistant against chlorine, so it can stay alive even in properly treated pools for up to 10 days.

For most gastrointestinal illnesses, we do not tend to diagnose or treat the particular causative organism, as most illnesses go away with time and supportive care alone. If your child is ill, please encourage good hand hygiene and keep him or her hydrated. Seek medical advice if your child's diarrhea lasts longer than five days or is associated with severe pain, or if you are concerned that your child is getting dehydrated. Monitoring your child's urine output is a good way to ensure good hydration.

Water illness prevention

How can you prevent catching or spreading these germs? Diarrheal illnesses are highly contagious and we ask patients not to swim for at least two weeks after diarrhea symptoms are resolved. Even the small amount of fecal matter normally present on most healthy bottoms can contaminate a pool. So it is important to wash yourself and your child with hot water before and after you swim, and to take small children out of the water for frequent bathroom breaks. While pool diapers are more protective than regular diapers, they do not prevent the spread of germs. Make sure you change diapers often and always do so away from the pool areas, in the assigned changing areas. Also ensure you and your child wash your hands after using the bathroom. Finally, keep working with your children on not swallowing any water while in the pool.

Swimmer's ear

There is some truth to the age-old wisdom: "Do not get water in your ear or you will get an ear infection." If you have recently been in the pool and have ear discomfort that is worse when you move your ear lobe or push the front of your ear, you may have otitis externa, better known as swimmer's ear. Rarely, you may also see slight redness inside the ear or some drainage of clear fluid or notice an abnormal odor.

Unlike the common childhood middle ear infection, this is an infection of the outer ear that is caused by water sitting in the ear canal. Fortunately, swimmer's ear is easily treated with antibiotic ear drops and usually clears up within a week. Occasionally, we may have to clean out any excess debris so the drops can get to the infection. Some people, especially avid swimmers, are prone to recurrent infections. If your child falls in this category, please discuss it with your physician.

You can prevent swimmer's ear by equipping your kids with ear plugs, a swim cap or custom-fitted molds. You should also ensure that, after swimming, children dry their ears with a soft towel and drain water by tilting their heads and pulling the lobes. You might even use a hairdryer on the low setting (a few inches away from the ears) to more thoroughly dry the ear canal.

Bumps and rashes, oh my!

Skin problems that children are most likely to pick up at the pool include warts, athlete's foot and hot tub rash. Most are not serious, but can be bothersome and spread easily.

Warts are caused by direct transmission of the human papilloma virus, which enters through breaks in the skin - so be sure to keep any cuts covered. The warm and wet poolside is the perfect spot for the virus to thrive, so wear sandals when walking near the pool or in the shower area. Warts are benign and generally go away with time; however, your doctor can tell you about various treatment options if they become bothersome.

Athlete's foot, or tinea pedis, is caused by a fungus and also spreads by direct contact. It is generally red and itchy and can be treated with a topical antifungal medication.

We usually also warn our teenage patients of "hot tub rash," which is caused by bacteria called pseudomonas. This itchy red rash that generally appears after a session in a hot tub may require antibiotics.

You should seek care if any rash is warm and/or painful to the touch or does not resolve in one to two weeks.

Can you trust your pool?

The best way to protect your kids from recreational water illnesses is to patronize a well-managed pool. Ask for the latest inspection results and find out how often the pool management checks the water's pH and free chlorine levels. You can even buy inexpensive water testing kits in hardware stores or online to check the levels yourself.

If a pool doesn't seem well-maintained or is overly crowded, it is probably best to trust your instincts and avoid it. Also, it is not a good sign if a pool smells strongly of chlorine, because you are probably actually smelling chloramines, a compound created when chlorine combines with urine, feces, sweat, dirt, skin cells and skin or hair care products. Chloramines are highly irritating to skin, eyes and lungs, and can cause flare-ups of asthma and allergies.

Swimming is a great way to spend time as a family and be active in the summer. A little due diligence - about both the condition of your pool and your family's hygiene practices - can keep your family afloat while making a splash this summer!

To learn more about RWIs, visit the website of the Centers for Disease Control and Prevention:


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Anita Mantha, MD, is a board-certified pediatrician with the Mid-Atlantic Permanente Group. She cares for patients in Kaiser Permanente's Fair Oaks office in Fairfax, Virginia.