prevention of skin cancer for children in the 1-4 year age group. During summer ... The ages of infants and toddlers ranged from 5-11 months and. 28-45 months ...
Sun exposure and primary prevention of skin cancer for infants and young children during autumn/winter
Abstract
Warren R. Stanton, Bijaya Chakma
Objective and method: Excessive sun exposure in childhood has been associated with the development of skin cancer, and appropriate levels of sun protection during the early years of a
Centre for Health Promotion and Cancer Prevention Research, University of Queensland Medical School
David L. O’Riordan, Margo Eyeson-Annan Southern Public Health Unit Network, Queensland
child’s life can significantly reduce the risks. A survey of 133 mothers was undertaken in south-east Queensland to examine the levels of sun exposure and skin protection of infants and young children.
Results: Among this sample of 133 mothers, use of appropriate skin protection was relatively high for themselves and their children. However, even by six months of age, a third had been sunburnt and 15% had experienced painful sunburn. By three years of age, 82% had been sunburnt and one-third had experienced painful sunburn, though mothers’ knowledge levels of sun safety issues were very high. The predictors associated with primary prevention varied across the type of prevention behaviour, but indicated that interventions should focus on susceptibility to sunburn and history of sunburn. Similar programs could be applicable across a broad range of sociodemographic groups, but require attention to mother’s country of birth as a factor that significantly influences their use of protection for their young children.
Conclusions: Ongoing public education that targets specific groups and settings may contribute to adoption of appropriate sun protective behaviours for young children.
Implications: Results of the study provide some of the needed baseline data to assist future skin cancer prevention campaigns for young children and infants. A similar study of levels of sun exposure and skin protection for children during summer is under way.
T
here is strong evidence of an association between sun exposure and the development of skin cancer.1 Previous data suggest that cumulative sunlight exposure over a prolonged period is important in the development of nonmelanoma skin cancer. On the other hand, episodic, relatively infrequent exposure to a large amount of sunlight sufficient to cause sunburn is important in the pathogenesis of melanoma.2,3 It is likely that for young children, reduction in both episodic exposure and cumulative exposure are important, particularly if the exposure is sufficient to cause sunburn.4,5 Reduction of sunburn among young children is amenable to prevention by four simple sun protection strategies: • cessation of deliberate tanning; • use of a sunscreen with a sun protection factor (SPF) of 15 or greater; • use of a protective clothing such as a wide-brimmed hat and/or long sleeved shirt; and • limitation of outdoor activities either by ceasing them entirely or by avoiding sun exposure during the hours between 10 am and 2 pm.6 Studies have indicated that excessive sun exposure during the first 10 to 20 years of life greatly increases the risk of developing skin cancer7-11 yet little information is available about the first five years.11 Children spend more time outdoors than adults7 and there is compelling evidence that childhood is a particularly vulnerable time for the
photocarcinogenic effects of the sun.8 Due to this extended time outside, the average child receives approximately three times the annual UVB dose of adults.8 Since even one sunburn in childhood may increase the risk for malignant melanoma, 12 g reater effort needs to be directed towards preventing sunburn at an early age. A recent report by the National Health and Medical Research Council5 reviewed the primary prevention activities of different groups of people in Australia and overseas. The studies have found that adolescents (secondary school ages) tended to spend more time in the sun than other age groups and their use of sun protection methods was relatively low. Children (primary school ages) both in Australia and overseas exhibited higher levels of sun protection while spending considerable time in the sun. Sun exposure among infants and pre-school age children is largely dependent on the discretion of adult care providers.13 For example, Grob et al.9 found the sun protective habits of mothers predictive of the level of sun exposure in children. In their study, 33% of their sample of three-year-olds received levels of sun exposure unsuitable for their skin phenotype. Jarrett, Sharp and McLelland14 found that children under one year old tended to be well protected from the harmful effects of the sun. However, protection against the sun declined with age. It was found that skin type did not affect a child’s likelihood of wearing a shirt, sun-cream or hat,
(Aust N Z J Public Health 2000; 24: 178-184)
Submitted: June 1999 Revision requested: October 1999
Correspondence to: Dr Warren Stanton, Centre for Health Promotion and Cancer Prevention Research, University of Queensland Medical School, Herston Road, Herston, Queensland 4006. Fax: (07) 3365 5540.
Accepted: January 2000
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Prevention of skin cancer for infants and young children during autumn/winter
suggesting that the increased risk of sunburn was not perceived by mothers. Given the importance of intermittent and total cumulative exposure in the development of skin cancer (in all seasons), and the fact it can be prevented by adhering to correct sun safety practices, especially during childhood, there has been relatively little research to investigate children’s exposure levels and parents’ behaviours towards protecting their young children from the sun. In particular, there is very little information available about primary prevention of skin cancer for children in the 1-4 year age group. During summer months there is very little variation in ultraviolet (UV) levels around Australia, but during winter higher levels of UVB are recorded in northern areas of Australia.15-16 Monthly doses of UVR received by children do not change substantially from summer to winter and exceed occupational limits specified for Australia.17 This parallels marked differences in the incidence of melanocytic and non-melanocytic skin cancers at various latitudes,18-19 indicating a need to monitor sun exposure and primary prevention activities during winter months in these areas. This paper outlines the results of a survey conducted in Ipswich (Queensland) and the immediate area to: • determine very young children’s history of sunburn and the prevalence of primary prevention behaviours; • examine the relationship of sun-safe behaviours with their mothers’ personal sun protection; • investigate the association of different primary prevention behaviours with factors such as socio-demographic characteristics, susceptibility to sunburn, sun exposure and history of sunburn; and • provide comparative data for a study of primary prevention behaviour during summer.
Method Sample As exposure levels and primary prevention behaviours were expected to be different across the 0-4 years age group, two samples were selected for the study, namely infants and toddlers. Infants were defined as those who were below one year of age. Toddlers were defined as those who were 2-4 years old. It has been estimated that 1,500 children are born every six months in West Moreton District.20 From birth cohorts of six-month duration, the names of 250 toddlers’ parents (representing one month of births) were randomly selected and contacted over a period of three months. Selection of 200 names of infants’ parents were needed to achieve a similar size sample to that obtained for toddlers. From these lists of addresses and phone numbers, contact could not be made within three attempts for 53% of the mothers. Among the remaining eligible sample of 215, 38% refused participation in the study and the mothers of 133 children (65 infants and 68 toddlers) were interviewed, resulting in a response rate of 62%. An acceptable level of statistical power (0.8) with this size sample enabled detection of an effect size of 0.2 with p0.05).
Procedure The 46-item questionnaire was designed to gather information on children’s sun exposure and mothers’ levels of sun- safe behaviours, in particular, primary preventive measures adopted by parents for their children during autumn and winter. These measures included the use and type of sunscreen, types of clothing, use of headwear and footwear. In addition, a series of eight questions was asked with a view to rating the relative effectiveness of various sun protection measures, for example, wearing a cap, wide-brimmed hat or staying in shade (coded as ‘not effective’, ‘neutral’ or ‘effective’). Measures to gather information on phenotypic characteristics and sun exposure history of the young children included skin colour, susceptibility to sunburn, and ability to tan, number of times the child has been (a) pink and a bit red, or (b) sore and tender as a result of sunburn, number of days outside last week between 10 am and 2 pm, and time spent in the sun on the last occasion outside. Further questions addressed the parents’ same sun-safe behaviour for themselves (coded as ‘never’, ‘rarely’, ‘sometimes’, ‘usually’ or ‘always’). Demographic information collected as part of the survey included age, gender, marital status, education, employment status and country of birth of parents. In order to ensure that the questionnaire was a valid and reliable instrument, questions were drawn from existing projects being conducted throughout Queensland and Australia.22-23 Some questions were developed in consultation with health professionals with extensive knowledge in the field, and were pilot tested. Data collection occurred during autumn and winter (March to August) when there are high levels of UVB recorded in Queensland). All mothers were sent introductory letters informing them about the sun exposure survey. Those who did not have a telephone and were interested in being involved in the survey, were asked to contact the West Moreton Public Health Unit. Mothers
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Stanton et al.
Table 1: Relationship between the history of sunburn, winter sun exposure and age group of children. Infants (%) (n=65)
Toddlers (%) (n=68)
Total (%) (n=133)
Been pink or red as a result of the sun none 1-3 times 4 or more times
63.1 36.9 0.0
17.6 57.4 25.0
39.8 47.4 12.8
Been sore and tender as a result of the sun No Yes
84.6 15.4
66.2 33.8
75.2 24.8
Number of times outside between 10am and 2pm last week None Once Several times Every day
46.9 15.6 29.7 7.8
14.9 23.9 34.3 26.9
30.5 19.8 32.1 17.6
Time in the sun on the last occasion outside 15 minutes or less More than 15 minutes
55.4 44.6
19.1 80.9
36.8 63.2
χ2
36.39a
Odds Ratio (95%CI) 8.0b (3.6-17.8)
2.8 (1.2-6.5) 6.06a 5.0b (2.2-11.6)
19.05a 18.79a
5.3 (2.4-11.4)
Notes: (a) Significant at p0.05). A history of sunburn was significantly associated with current at-risk behaviour. That is, children who spent more than 15 minutes in the sun on the last occasion outside were more likely to have a history of being pink or red (χ2=11.6, p
