Position statement - Sun protection and infants (0-12 months)

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Position statement - Sun protection and infants (0-12 months)


This position statement is endorsed by the Australasian College of Dermatologists

Summary statement

It’s important to have a healthy balance of ultraviolet radiation (UV) exposure. Too much UV can cause sunburn, skin and eye damage, and skin cancer. Overexposure to UV during childhood and adolescence is a major factor in determining future skin cancer risk[1][2][3][4]. Too little UV can lead to low vitamin D levels. Vitamin D forms in the skin when exposed to UV from sunlight, and is necessary for the development and maintenance of healthy bones and muscles, and for general health.

A baby’s skin is sensitive and can burn easily[5]. The mechanisms are unclear, but it may be that the skin is particularly susceptible to the harmful effects of solar UV during childhood. The possibility that sun exposure during childhood stimulates the initial mutational step in the development of melanoma is supported by epidemiological research[6]. The cumulative nature of sun damage indicates that infants should be protected from exposure to UV from the day they are born[7]. It is recommended that infants under 12 months are not purposely exposed to direct sun when UV levels reach three and above.

When UV levels are low, sun protection is generally not required and a small amount of direct UV exposure is considered safe and healthy for infants. However, if spending longer periods of time outdoors during low UV periods, it is recommended that your baby’s skin be protected from UV exposure by wearing sensible clothing and seeking shade when available.

Parents and care providers are encouraged to access the daily SunSmart UV Alert which indicates local sun protection times. It is available in the weather section of the newspaper, as an iPhone or Android app, and at the Bureau of Meteorology website.

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Recommendations

To keep infants well protected from solar UV, Cancer Council Australia recommends using a combination of sun protection measures whenever UV Index levels reach three and above.

Plan daily activities to ensure the infant is well protected from the sun. Aim to minimise time (or take particular care) outside during the middle hours of the day during the summer period when UV levels are at their strongest.

  • Use a combination of sun protection measures:
    • Slip on clothing that covers as much of the infant’s skin as possible. Choose cool, loose fitting clothes and wraps made from densely woven fabrics. Some fabrics have an ultraviolet protection factor (UPF) rating. The higher the UPF, the greater the protection provided by the fabric. If possible, choose fabrics that are at least UPF15 (good protection), but preferably UPF50 (excellent protection).
    • Slop on broad spectrum water resistant sunscreen with a sun protection factor (SPF) of 30 or above. When direct sun exposure is unavoidable, broad spectrum water resistant sunscreen (SPF30 or higher) may be applied to any small areas of skin that cannot be protected by clothing (such as the face, ears and backs of hands). Sunscreen should be applied 15–20 minutes before going outside and reapplied every two hours or more often if it has been wiped or washed off. It is best to test the sunscreen on a small patch of skin to ensure there are no reactions. (Please see further information below.) Sunscreen is your last line of protection.
    • Slap on a broad-brimmed, bucket or legionnaire style hat so the infant’s face, neck and ears are protected. For young babies, choose a fabric that will crumple easily when they put their head down. Consider the hat’s size and comfort, the amount of shade it provides to the face, if it will obstruct vision, hearing or safety. Hats that can be adjusted at the crown are best. If the hat is secured with a long strap and toggle, ensure it has a safety snap, place the strap at the back of the head or trim the length so it doesn’t become a choking hazard.
    • Seek shade. Make use of any available full shade and provide shade for the infant’s pram, stroller or play area. The material used should cast a dark shadow. Babies still need to be protected from scattered and reflected UV radiation. Consider using a cover for the car windows. Clear auto glass (side windows) blocks almost all UVB radiation, but only 21% of UVA radiation[8].
    • Slide on some sunglasses, if practical, to protect the eyes. Look for sunglasses that are labelled AS/NZS 1067:2003 and are a close fitting, wrap-around style that covers as much of the eye area as possible. Some infant sunglasses have soft elastic to keep them in place. Toy or fashion-labelled sunglasses do not meet the requirements for sunglasses under the Australian Standard and should not be used for sun protection.
  • Check the infant’s clothing, hat and shade positioning regularly to ensure he/she continues to be well protected from UV.

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Sunscreen use and infants

Physical protection such as shade, clothing and broad brimmed hats are the best sun protection measures for all children. If infants are kept out of the sun or well protected from UV radiation by clothing, hats and shade, then sunscreen need only be used occasionally on very small areas of an infant’s skin.

The Australasian College of Dermatologists recommends the use of a sunscreen at any age when there is exposure to the sun. Sunscreens should be applied to areas of the skin not protected by clothing[9]. The American Academy of Pediatrics (AAP) has stated that sunscreens may be used on infants younger than six months on small areas of skin if adequate clothing and shade are not available[10].

Some infants may develop minor skin irritation in response to sunscreen use. True allergic contact dermatitis to the active chemicals in sunscreen is very rare, but may result from reactions to preservatives or perfumes in the product.

Sunscreen milks or creams formulated for sensitive skin usually contain titanium dioxide or zinc oxide and are less likely to contain alcohol or fragrances that might irritate the skin. It is recommended to first test the sunscreen on a small area of the baby or toddler’s skin to check for any skin reactions. As with all products, use of any sunscreen should cease immediately if any unusual reaction is observed.

Babies with dark skin need sun exposure for longer periods and to more of their body to get adequate vitamin D. Whilst skin cancer, including melanoma, can occur in dark skin populations, the risk is low. This is due largely to the higher concentrations of melanin naturally formed in this skin type which acts as a natural protection against UV radiation. There is currently no evidence that suggest sunscreen use on babies or children with naturally very dark skin (i.e. Type V and VI) further reduces their long term risk of developing skin cancer.

Infants and children with naturally very dark skin should still protect their face and eyes from over exposure to UV exposure by wearing a brimmed hat, close fitting wrap-around sun glasses and using shade when it is available when UV levels are three and above.

Children often copy those around them and learn by imitation. Research shows that if adults adopt sun protection behaviours, the children in their care are more likely to do the same[11].

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Vitamin D

Vitamin D is a hormone that controls calcium levels in the blood. It is needed for the development and maintenance of healthy bones, muscles and teeth and it is also important for general health[12][13]. There are very small amounts of vitamin D that occur naturally in fish and eggs, while margarine and some types of milk have added vitamin D. However, it is not possible to get sufficient vitamin D through a normal diet. Most vitamin D is made in the skin from exposure to the sun’s UV radiation.

Babies get their initial store of vitamin D from their mothers, so they are at risk of low vitamin D if their mother has low levels[14]. Premature infants have low vitamin D stores[15]. Breast milk is considered the best type of feed for babies, but it does not contain much vitamin D.

It is recommended that breast fed babies with risk factors for low vitamin D, including premature dark-skinned babies, be supplemented with daily vitamin D (e.g. in infant multivitamin drops) from birth until 12 months[16].

Infant formula in Australia is fortified with vitamin D and babies that are fed formula should receive adequate vitamin D from this source.

If concerned about a baby’s vitamin D levels, it is best to speak with a doctor.

The balance between sun protection and vitamin D

When it comes to the amount of unprotected (or incidental) sun exposure that is considered appropriate and safe for infants, we do not currently have specific recommendations. However, during summer in southern parts of Australia (Sydney, Canberra, Melbourne, Adelaide, Hobart and Perth)and all year round in the north (Brisbane, Darwin) most people need just a few minutes of sun exposure each day to the face, arms, hands (or equivalent area), to help maintain adequate vitamin D levels. But be cautious in the middle of the day when UV levels are at their most intense, aim for mid-morning and/or mid-afternoon.

In winter in the southern parts of Australia, where UV levels are below three all day, most people need about two to three hours of sun exposure, spread over each week, to the face, arms, hands or equivalent area (so about 30 minutes a day during the middle part of the day, this is the best time to access winter UVB from the sun).

Therefore, small amounts of direct UV exposure on unprotected skin is considered healthy for infants when UV levels are low (under three). However if spending time outdoors with your baby during this ‘low’ UV period then sensible sun protection is still advisable such as covering baby’s skin with clothing and/or seeking shade where available. Always adopt a combination of sun protection measures when spending time outdoors with your baby when UV levels are three and above.

Children with darker skin have natural sun protection from their pigment, therefore their risk of developing skin cancer later in life is much reduced. Their risk for vitamin D insufficiency, however, is likely to be higher and they therefore need more sun exposure. Infants’ faces and eyes should still be protected with a sensible hat and sunglasses.

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Nappy rash

Nappy rash includes a number of inflammatory skin conditions of the groin and buttock area that are direct or indirect result of wearing nappies. Nappy rash is extremely common and generally results from a combination of factors that begin with prolonged exposure to moisture from urine and faeces. Appropriate recommendations include frequent nappy changing, applying barrier creams to the affected areas and exposing the inflamed area to the open air as much as possible[17]. The practice of exposing a naked infant to direct or indirect sun puts them at high risk of sunburn and skin damage and therefore is not recommended.

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Jaundice

Neonatal jaundice generally only causes concerns in about 10% of infants[7]. Treatment for jaundice should be under medical supervision in a controlled environment. Exposing infants to direct sun is inappropriate to treat neonatal jaundice.

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Position statement details

This position statement was developed by Cancer Council Australia's National Skin Cancer Committee. The position statement was externally reviewed by Dr Catherine Drummond, Dermatologist; and Dr Rod Phillips, Paediatric dermatologist, Royal Children's Hospital Melbourne. It was endorsed by Cancer Council Australia's principal Public Health Committee and published in June 2013.

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References

  1. Armstrong B. How sun exposure causes skin cancer: An epidemiological perspective. In: Hill D, Elwood JM, English DR. Prevention of Skin Cancer. Dordrecht, Netherlands: Kluwer Academic Publishers; 2004. p. 89-116.
  2. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control 2001 Jan;12(1):69-82 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11227927].
  3. Khlat M, Vail A, Parkin M, Green A. Mortality from melanoma in migrants to Australia: variation by age at arrival and duration of stay. Am J Epidemiol 1992 May 15;135(10):1103-13 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1632422].
  4. Autier P, Boyle P. Artificial ultraviolet sources and skin cancers: rationale for restricting access to sunbed use before 18 years of age. Nat Clin Pract Oncol 2008 Apr;5(4):178-9 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18268545].
  5. Seidenari S, Giusti G, Bertoni L, Magnoni C, Pellacani G. Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound. Dermatology 2000;201(3):218-22 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11096192].
  6. Armstrong BK. Epidemiology, causes and prevention of skin diseases. In: Grob JJ, Stern RS, MacKie RM, Weinstock WA. Melanoma: childhood or lifelong sun exposure. Carlton: Blackwell Science; 1997 Available from: http://ebookscentral.com/book/67645/epidemiology-causes-prevention-skin-diseases#.
  7. 7.0 7.1 Hurwitz S. The sun and sunscreen protection: recommendations for children. J Dermatol Surg Oncol 1988 Jun;14(6):657-60 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3372848].
  8. Bernstein EF, Schwartz M, Viehmeyer R, Arocena MS, Sambuco CP, Ksenzenko SM. Measurement of protection afforded by ultraviolet-absorbing window film using an in vitro model of photodamage. Lasers Surg Med 2006 Apr;38(4):337-42 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16596658].
  9. Australasian College of Dermatologists. A-Z of skin: baby & toddler protection. [homepage on the internet] ACD; 2016 Jun 25 [cited 2011 Dec 8; updated 2001 Mar 3]. Available from: http://www.dermcoll.asn.au/public/a-z_of_skin-baby_toddler_protection.asp.
  10. American Academy of Pediatrics. Policy statement: ultraviolet radiation: a hazard to children and adolescents. AAP 2011 Mar 3;127(3):588-97 [Abstract available at http://pediatrics.aappublications.org/content/127/3/588.full.pdf+html].
  11. Dobbinson S, Fairthorne A, Bowles K-A, Sambell N, Spittal M, Wakefield M. Sun protection and sunburn incidence of Australian children: summer 2003–04. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria; 2005 Jul.
  12. Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group, Papadimitropoulos E, Wells G, Shea B, Gillespie W, Weaver B, et al. Meta-analyses of therapies for postmenopausal osteoporosis. VIII: meta-analysis of the efficacy of vitamin D treatment in preventing osteoporosis in postmenopausal women. Endocr Rev 2002 Aug;23(4):560-9 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12202471].
  13. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ 2003 Mar 1;326(7387):469 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12609940].
  14. Nozza JM, Rodda CP. Vitamin D deficiency in mothers of infants with rickets. Med J Aust 2001 Sep 3;175(5):253-5 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11587256].
  15. Hollis BW. Vitamin D requirement during pregnancy and lactation. J Bone Miner Res 2007 Dec;22 Suppl 2:V39-44 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18290720].
  16. Victorian Government Department of Health. Low vitamin D in Victoria. Key health messages for doctors, nurses and allied health. Melbourne: Victorian Government; 2012 Aug Available from: http://docs.health.vic.gov.au/docs/doc/6BEEB5338D770451CA257A530000930B/$FILE/low_vitamin_d_info_jul12_WEB-v02.pdf.
  17. Harrison SL, Buettner PG, MacLennan R. Why do mothers still sun their infants? J Paediatr Child Health 1999 Jun;35(3):296-9 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10404454].

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