Anoxic cerebral damage is the limiting factor in recovery from near-drowning accidents. This study reports factors associated with poor outcome in 100 near-drowned patients admitted to the Red Cross War Memorial Children's Hospital from 1976 to 1987. The study was designed as a retrospective folder search. Children with fixed dilated pupils, flaccidity, decerebrate or decorticate posturing, or clinical signs of cerebral oedema are more likely to have a poor outcome. Patients with metabolic acidaemia and those requiring cardiopulmonary resuscitation in the emergency room or subsequent mechanical ventilation also do poorly. Those requiring more aggressive management can be identified and a more accurate working prognosis may be possible in the hours after the accident.