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AAP Issues Guidelines on Limiting Sun Exposure in Children – Feb 2011

Laurie Barclay, MD February 28, 2011 — The American Academy of Pediatrics (AAP) has issued guidelines on limiting sun exposure in children and supporting legislation to prohibit salon tanning by minors, according to a policy statement entitled "Ultraviolet Radiation: A Hazard to Children and Adolescents."

The new recommendations and an accompanying technical document are reported online February 28 and published in the March issue of Pediatrics.

"Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma," write Sophie J. Balk, MD, former chairperson, AAP Committee on Environmental Health, and colleagues.

"Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR."

Despite these risks, sunburn continues to be prevalent, and teenagers as well as adults continue to make frequent visits to tanning parlors. Therefore, the policy statement suggests that pediatricians offer advice about UVR exposure during health supervision visits and at other appropriate times.

Specific recommendations for pediatricians include the following:

  • Health-supervision practices should include advice about UVR exposure, such as avoiding sunburn and suntan, wearing clothing and hats with brims, using sunglasses, and applying sunscreen. If possible, outdoor activities should be scheduled to limit exposure to peak-intensity midday sun (10 AM to 4 PM).
  • When a child or adolescent might sunburn, he or she should use sunscreen to reduce the known risks for sun exposure and sunburn, including the increased risk for skin cancer. Sunscreen with a sun-protection factor (SPF) of at least 15 should be applied every 2 hours and after swimming, sweating, or drying off with a towel. People may prefer avoiding sunscreens containing oxybenzone, as these may have weak estrogenic effects when absorbed through the skin.
  • Although all children need counseling about UVR exposure, this is particularly true for children at high risk for the development of skin cancer, including those with light skin, nevi, and/or freckling; and/or a family history of melanoma.
  • Skin cancer prevention is a lifelong effort, and beginning in infancy, at least 1 health maintenance visit per year should include advice about UVR exposure. All children are at risk for adverse effects of UVR exposure on the eyes and immune system, although not all children sunburn. Especially appropriate times for counseling about UVR exposure include during the spring and summer in northern states, before anticipated sunny vacations, and during visits for sunburns.
  • Because outdoor physical activity should be strongly encouraged, this should be promoted in a sun-safe manner.
  • Sun-protection practices tend to wane in early childhood. Beginning at age 9 or 10 years, it may be helpful for pediatricians to discuss sun protection with children, together with parents, to encourage joint responsibility for the child's sun protection.
  • Infants younger than 6 months should be kept out of direct sunlight and covered with protective clothing and hats. When sun avoidance is impossible, parents may apply sunscreen only on exposed areas. Absorption of sunscreen ingredients may be higher in preterm infants.
  • Pediatricians should become familiar with chemical photosensitizing agents. People using these oral or topical agents should limit sun exposure and avoid all UVA from artificial sources. When sun exposure is inevitable, they should wear fully protective clothing and high SPF sunscreen that also blocks UVA wavelengths.
  • Breast-fed and formula-fed infants and other children should receive vitamin D supplementation in accordance with guidelines, for a total intake of at least 400 IU of vitamin D daily. Children at risk for hypovitaminosis D may need laboratory testing of 25-hydroxyvitamin D concentration.
  • Deliberate UVR exposure to artificial sources and overexposure to sun with the goal of increasing vitamin D concentrations or for other reasons should be avoided.
  • Pediatricians should advocate for adoption of sun-protective policies (eg, shaded playgrounds, outdoor time before 10 AM, and allowing hats at schools and child care facilities).
  • Pediatricians should support and advocate for legislation banning use of tanning parlors by children younger than 18 years.

Benefits of Limiting Exposure to UVR

The AAP, the World Health Organization, the American Medical Association, and the American Academy of Dermatology all support legislation prohibiting access to tanning salons or use of artificial tanning devices by children younger than 18 years.

"Skin cancer is a major public health problem; more than 2 million new cases are diagnosed in the United States each year," write Dr. Balk and coauthors of the accompanying technical report. "Approximately 25% of sun exposure occurs before 18 years of age. The risk of skin cancer is increased when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR."

In addition to describing new evidence on the association of exposure to sun and artificial sources of UVR with skin cancer and other health risks, the report also highlights sun-protection methods, vitamin D, community skin cancer–prevention efforts, and the pediatrician's role in preventing skin cancer.

This report describes the interrelationship between sun exposure and vitamin D status, and the requirement of adequate vitamin D for bone health and for various other health conditions. Sunlight exposure is needed for cutaneous vitamin D production, but the efficiency of this production is complicated by many factors.

"Ensuring vitamin D adequacy while promoting sun-protection strategies, therefore, requires renewed attention to evaluating the adequacy of dietary and supplemental vitamin D," the report authors write. "Daily intake of 400 IU of vitamin D will prevent vitamin D deficiency rickets in infants. The vitamin D supplementation amounts necessary to support optimal health in older children and adolescents are less clear."

CLICK HERE for full policy statement