A 4 month-old female came to clinic for her health maintenance examination.
The pertinent physical exam revealed a healthy child with normal growth parameters.
The diagnosis of a healthy 4 month old was made and
as part of the parent education, the physician recommended that her parents keep her covered with clothing, a hat and sunglasses and out of direct sun as much as possible.
Her parents asked about using sunscreen, and were told that there was controversy over using sunscreen in children under 6 months of age but that it was probably okay to use it on limited places such as the face and back of the hands.
The physician discussed other anticipatory guidance issues such as appropriate use of a child safety seat, childproofing the home, not putting the baby to bed with a bottle and the importance of talking, singing and playing with the baby and instituting a healthy bedtime routine.
Ultraviolet radiation is light with a wavelength that is <400 nanometers. It is further divided into UV-A (320-400 nanometers) and UV-B (290-320 nanometers). UV-B is only <0.5% of the sunlight that reaches the earth but is responsible for most of the damage to skin.
UV-B increases in intensity close to the equator or at high altitudes, and also in the summer and in the midday sun. Common objects also reflect UV-B thereby increasing its intensity such as water, snow, sand or concrete.
Tanning is a protective response that begins during sun exposure. It is maximized at the end of exposure for acute tanning and at 7-10 days for delayed tanning. Acute tanning does not make new melanin in the skin but delayed tanning does.
Sun exposure causes vasodilatation and increase in blood volume in the dermis with resultant erythema. A person’s skin reacts to this exposure differently depending on his/her type. The following types are based upon 45-60 minutes of sun exposure after the winter time or with no previous sun exposure.
- Type I – Always burns easily, never tans
- Type II – Always burns easily, tans minimally
- Type III – Burns moderately, tans gradually and uniformly (light brown)
- Type IV – Burns minimally, always tans well (moderate brown)
- Type V – Rarely burns, tans profusely (dark brown)
- Type VI – Never burns, deeply pigmented (black)
Sun exposure over a long time is important in the development of nonmelanoma skin cancer (e.g. squamous and basal cell carcinoma) which is the most common malignant tumor in the adult population in the United States. It is rare in children and is generally non-fatal.
Malignant melanoma is related to exposure of large amounts of sunlight that is episodic. Unfortunately the rates of malignant melanoma are increasing. Survival is increased if caught before metastasis has occurred.
Chemical phototoxicity occurs when a chemical is taken systemically or applied topically and then sun exposure occurs and the person has an adverse cutaneous reaction. This is solely a chemical reaction and not due to the patient’s immune response.
Photoallergy is an acquired adverse cutaneous reaction that is similar to phototoxicity but occurs because of an antigen-antibody or cell-mediated hypersensitivity. Common agents include sulfonamides, tetracycline, thiazides, and tretinoin.
Sun exposure chronically without sunscreens results in excessive wrinkles and skin thicknesses changes and weakens the skin’s elasticity.
Ultraviolet radiation is also absorbed by the eye and children < 10 years old are at an increased risk because of increased transmissibility during these ages. It can contribute to cataracts, pterygium and photodermatitis.
The immune system is also affected by ultraviolet radiation in laboratory animals.
Prevention is important for sun-related problems.
Avoiding exposure is the best prevention for infants and children. Activity should be done during non-peak times (<10 AM and after 4 PM). Clouds only reduce the ultraviolet radiation by 20-40%. Parents should also be more careful when the child is around snow, sand, concrete or water.
Clothing is often the simplest and practical means of sun protection. Lightweight, tightly-woven, long-sleeved shirts and pants work well. Hats also are effective. Wet clothing decreases sun protection.
A hat decreases the UV-B exposure to the eyes by 50%. Sunglasses are recommended if the child will be in the sun long enough to tan or burn. Glasses labeled to block 99-100% of the UV-B spectrum should be chosen.
Some professional organizations question the use of sunscreens as protective agents, but many other organizations continue to promote sunscreens including the American Academy of Dermatology and American Cancer Society. A SPF (sun protection factor) of 15 or more is recommended including lip protection. SPF-15 filters >92% of the ultraviolet radiation.
Sunscreens should be used when the child might tan or burn. The sunscreens should be applied BEFORE exposure, i.e. before going outside. Parents need to be reminded to apply the sunscreen as they get ready for their outdoor activity, and not to do it later (e.g. applying sunscreen after they are at the beach.)
There is no data showing sunscreens prevent melanoma, and tanning prevention may also prevent or delay skin aging and nonmelanoma skin cancer.
Infants <6 months should be kept out of direct sunlight as they cannot move themselves, have less melanin for protection and are at risk for heat problems and dehydration.
It is controversial whether or not infants <6 months old should use sunscreen because of their possible risk of different absorption, metabolism and excretion of drugs. The American Academy of Pediatrics states that in addition to avoiding exposure "in situations where the infant's skin is not protected adequately by clothing, it may be reasonable to apply sunscreen to small areas, such as the face and the back of the hands."
Questions for Further Discussion
1. Should adolescents and children use tanning beds?
2. How is SPF (sun protection factor) measured?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MEDLINEplus for this topic: Sun Exposure
and at Pediatric Common Questions, Quick Answers for this topic: Sun Protection.
To view current news articles on this topic check Google News.
American Academy of Pediatrics Committee on Environmental Health. Ultraviolet Light: A Hazard to Children. Pediatrics. 1999:104-328-333.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Mary 8, 2006