New insights about infant and toddler skin: implications for sun protection

Sun Exposure of Preschoolers, Parental Sun Protection Behavior, and Sun Protection Measures at Preschool in Bavaria-Comparison of Two Cross-Sectional Studies of 2010/11 and 2018/19

INTRODUCTION

Children's skin is particularly susceptible to the carcinogenic effects of ultraviolet radiation. Young children are dependent on sun protection measures taken by parents and other caregivers.

OBJECTIVES

The aim of the study is to evaluate parental sun protection behavior and sun protection measures at preschool at two points in time (2010/11 and 2018/19) in Bavaria and to test for a secular trend.

METHODS

Two cross-sectional surveys were carried out. For each survey, more than 4,000 parents of preschoolers completed a self-administered questionnaire about parental sun protection behavior and sun protection measures at preschool. To identify possible associations between parental sun protection behavior and sociodemographic characteristics, logistic regression analysis was carried out.

RESULTS

In the survey of 2018/19, six out of eight sun protection measures are adequately applied by over two-thirds of the parents. Two out of eight sun protection measures are adequately applied by less than one-third of the parents. Those two measures are aligning sun protection to actual UV index and preschoolers wearing sunglasses. The comparison of the study population of the survey of 2010/11 and of 2018/19 shows an improvement in parental sun protection behavior for seven out of eight sun protection measures. In both surveys more than 80% of parents state that preschool staff ensures preschoolers wear sun hats and sunscreen outside on sunny days.

CONCLUSIONS

Future campaigns should focus on the use of sunglasses and promote the UV index, as these sun protection measures are used very little.

Sunscreen Label Marketing Towards Pediatric Populations: Guidance for Navigating Sunscreen Choice

INTRODUCTION

 Sunscreen marketing to specific demographics is largely unregulated. Marketing specifically targeting pediatric populations has the potential to drive consumer behavior. The American Academy of Pediatrics (AAP) and American Academy of Dermatology (AAD) provide recommendations for sunscreen use in children over the age of six months. This study sought to determine if sunscreen products marketed toward pediatric populations align with healthcare guidelines.

MATERIALS AND METHODS

Sunscreens available in major retail outlets in the Philadelphia area were cataloged and reviewed for marketing targeting specific demographics such as "baby", "babies", "children", "kids", "sports", and "active". The products were reviewed for sun protection factor (SPF), broad-spectrum ultraviolet (UV) protection, water resistance, active UV filters, and application method.  Results: Of 410 sunscreens cataloged, 27 were marketed towards "baby" or "babies", 44 towards "children" or "kids", and 71 towards "sports" or "active". All of the sunscreen products reviewed targeting the pediatric population offered water resistance for up to 80 minutes and broad-spectrum UV coverage. Sunscreens targeting "baby" or "babies" aligned most closely with AAP guidelines for sunscreen use in pediatric populations, with 92.6% offering an SPF between 15 to 50 and no products including oxybenzone as a UV filter. However, sunscreens targeting "children", "kids", "sports", and "active" bore a close resemblance to the overall sunscreen profile for all demographics but with a higher percentage of products containing oxybenzone. Oxybenzone was found in 11.4% of "children" and "kids" products and 16.9% of "sports" and "active" sunscreen products, compared to 7.6% of all sunscreen products available, and was also found in most sunscreen products with an SPF of 70 or higher.

CONCLUSION

 Sunscreen products marketed towards "baby" and "babies" tend to align closely with guidelines for sunscreen use in the pediatric population for children over six months of age; however, those with brand marketing towards "children", "kids", "sports", and "active" do not. Limiting recommendations for a sunscreen product with an SPF of 30 to 50 targeting this demographic, however, sufficiently meets guidelines set forth by the AAP and AAD.

Skin maturation from birth to 10 years of age: Structure, function, composition and microbiome

Infant and adult skin physiology differ in many ways; however, limited data exist for older children. To further investigate the maturation processes of healthy skin during childhood. Skin parameters were recorded in 80 participants of four age groups: babies (0-2 years), young children (3-6 years), older children (7-<10 years) and adults (25-40 years). Overall, skin barrier function continues to mature, reaching adult levels of transepidermal water loss (TEWL), lipid compactness, stratum corneum (SC) thickness and corneocyte size by the age of about 6 years. Higher levels of lactic acid and lower levels of total amino acids in the SC of babies and young children further indicate higher cell turnover rates. In all age groups, TEWL and skin surface hydration values remain higher on the face compared with the arm. Skin becomes darker and contains higher levels of melanin with increasing age. The composition of skin microbiome of the dorsal forearm in all children groups is distinct from that in adults, with Firmicutes predominating in the former and Proteobacteria in the latter. Skin physiology, along with the skin microbiome, continues to mature during early childhood in a site-specific manner.

Association between Vitamin D Levels, Puberty Timing, and Age at Menarche

Pubertal development represents the process of physical maturation where an adolescent reaches sexual maturity and attains reproductive function. The effects of vitamin D are mainly mediated by the vitamin D receptor (VDR), which is expressed in almost all body cells, including the ovary and human pituitary gland and animal hypothalamus. Thus, vitamin D has gained great interest as pathogenic factor of pubertal disorders and fertility. This narrative review aimed to provide a broad overview of the available literature regarding the association between vitamin D levels, puberty timing, and age at menarche. A review of the data on the involvement of micronutrient deficiency, as a modifiable cause of pubertal disorders, is important for the prediction and prevention of deficiencies as well as for fertility protection and should be considered a public health priority. Reported data support that vitamin D is a regulator of neuroendocrine and ovarian physiology and, more in detail, a deficiency of vitamin D is involved in altered pubertal timing. Considering the long-term consequences of early pubertal development and early menarche, the detection of modifiable causes is crucial in preventive strategies. Future studies in humans and with an increased scale are needed to elucidate the vitamin D role in sexual maturation and puberty development.

Sun-Protective Clothing Worn Regularly during Early Childhood Reduces the Number of New Melanocytic Nevi: The North Queensland Sun-Safe Clothing Cluster Randomized Controlled Trial

Numerous pigmented moles are associated with sun exposure and melanomarisk. This cluster randomized controlled trial aimed to determine if sun-protective clothing could prevent a significant proportion of the moles developing in young children (ACTRN12617000621314; Australian New Zealand Clinical Trials Registry. Twenty-five childcare centers in Townsville (19.25° S), Australia, were matched on shade provision and socioeconomic status. One center from each pair was randomized to the intervention arm and the other to the control arm. Children at 13 intervention centers wore study garments and legionnaire hats at childcare and received sun-protective swimwear and hats for home use, while children at the 12 control centers did not. The 1–35-month-old children (334 intervention; 210 control) were examined for moles at baseline (1999–2002) and were re-examined annually for up to 4 years. Both groups were similar at baseline. Children at intervention centers acquired fewer new moles overall (median 12.5 versus 16, p = 0.02; 0.46 versus 0.68 moles/month, p = 0.001) and fewer new moles on clothing-protected skin (6 vs. 8; p = 0.021 adjusted for confounding and cluster sampling) than controls. Intervention children had 24.3% fewer new moles overall (26.5 versus 35) and 31.6% (13 versus 19) fewer moles on clothing-protected skin than controls after 3.5 years. Sunlight’s influence on nevogenesis is mitigated when children regularly wear UPF 30-50+ clothing covering half their body, implying that increased clothing cover reduces melanoma risk. Sun-protective clothing standards should mandate reporting of the percentage of garment coverage for childrenswear.

Sun-Safe Zones: Investigating Integrated Shading Strategies for Children's Play Areas in Urban Parks

Although Open Space Ratio is a critical control in the Development Approval process, there are no ultraviolet radiation (UVR) protection guidelines for urban parks. This study explores key strategies for shade provision in children's play areas in urban parks, aiming to promote sun-safe play environments against alarming skin cancer trends. The literature review identified primary issues affecting UVR exposure in public venues, and the research comprises a shade audit of Beaton Park in Dalkeith. The methods involved using virtual park modeling and Shadow Analysis simulations to generate the daily average number of hours in shade for each month. Our recommendations based on this analysis are (a) a minimum canopy cover representing 50% of the entire ground cover; (b) a minimum diameter for a shade (umbrella) of about 2.5 times the diameter of the table; and (c) an ideal umbrella height of 90 cm from the table surface. This research proposes a potential nexus between landscape design and a UVR protection framework for child-friendly Sun-safe Zones (SsZ).

Vitamin D deficiency in South-East Asian children: a systematic review

OBJECTIVE

To describe the prevalence and determinants of vitamin D deficiency (VDD) among healthy children aged between 0 and 18 years living in South-East Asia (SEA).

DESIGN

We systematically searched Ovid MEDLINE and Ovid EMBASE for observational studies assessing VDD among healthy children in the SEA region as the primary or secondary outcome from database inception to 6 April 2021. PubMed was used for e-pubs and publications not indexed in Medline. Publications that included abstracts in English were included. We performed a systematic review to describe the prevalence of VDD in SEA children.

RESULTS

Our initial search identified 550 publications with an additional 2 publications from manual screening. Of those, 21 studies from 5 different countries (Thailand, Indonesia, Vietnam, Malaysia and Cambodia) were summarised and included in forest plots. The prevalence of VDD (<50 nmol/L) ranged from 0.9% to 96.4%, with >50% of newborns having VDD, and severe VDD (<30 nmol/L) ranged from 0% to 55.8%. Female sex and urban living were the most common determinants of VDD.

CONCLUSIONS

VDD among healthy children living in the SEA region is common. Efforts to detect VDD and the implementation of preventive measures, including education on safe sun exposure and oral vitamin D supplementation or food fortification, should be considered for key target groups, including adolescent females and pregnant and lactating women to improve the vitamin D status of newborns.

PROTOCOL REGISTRATION NUMBER

This study is registered with PROSPERO (CRD42020181600).

The Crosstalk between Vitamin D and Pediatric Digestive Disorders

Vitamin D is a cyclopentane polyhydrophenanthrene compound involved mainly in bone health and calcium metabolism but also autophagy, modulation of the gut microbiota, cell proliferation, immune functions and intestinal barrier integrity. The sources of vitamin D include sunlight, diet and vitamin D supplements. Vitamin D3, the most effective vitamin D isoform is produced in the human epidermis as a result of sunlight exposure. Vitamin D undergoes two hydroxylation reactions in the liver and kidney to reach its active form, 1,25-dihydroxyvitamin D. Recent studies highlighted a complex spectrum of roles regarding the wellbeing of the gastrointestinal tract. Based on its antimicrobial effect, it was recently indicated that vitamin D supplementation in addition to standard eradication therapy might enhance H. pylori eradication rates. Moreover, it was suggested that low levels of vitamin D might also be involved in the acquisition of H. pylori infection. In terms of celiac disease, the negative effects of vitamin D deficiency might begin even during intrauterine life in the setting of maternal deficiency. Moreover, vitamin D is strongly related to the integrity of the gut barrier, which represents the core of the pathophysiology of celiac disease onset, in addition to being correlated with the histological findings of disease severity. The relationship between vitamin D and cystic fibrosis is supported by the involvement of this micronutrient in preserving lung function by clearing airway inflammation and preventing pathogen airway colonization. Moreover, this micronutrient might exert anticatabolic effects in CF patients. Inflammatory bowel disease patients also experience major benefits if they have a sufficient level of circulating vitamin D, proving its involvement in both induction and remission in these patients. The findings regarding the relationship between vitamin D, food allergies, diarrhea and constipation remain controversial, but vitamin D levels should be monitored in these patients in order to avoid hypo- and hypervitaminosis. Further studies are required to fill the remaining gaps in term of the complex impact of vitamin D on gastrointestinal homeostasis.

Breastfeeding and vitamin D

The recent re-emergence of vitamin D deficiency (VDD) and rickets among breastfed infants without adequate sunlight exposure and vitamin D supplementation has been reported worldwide. Breastfed infants are particularly vulnerable to VDD because of the low vitamin D content of breast milk, restricted sunlight exposure, increased pollution, and limited natural dietary sources of vitamin D. The prevalence of VDD in breastfed infants differs vastly between studies and nations at 0.6%-91.1%. The recommended intake of vitamin D for lactating mothers to optimize their overall vitamin D status and, consequently, of their breast milk is 200-2,000 IU/day, indicating a lack of consensus. Some studies have suggested that maternal high-dose vitamin D supplementation (up to 6,400 IU/day) can be used as an alternate strategy to direct infant supplementation. However, concern persists about the safety of maternal high-dose vitamin D supplementation. Direct infant supplementation is the currently available option to support vitamin D status in breastfed infants. The recommended dose for vitamin D supplementation in breastfed infants according to various societies and organizations worldwide is 200-1,200 IU/day. Most international guidelines recommend that exclusively or partially breastfed infants be supplemented with 400 IU/day of vitamin D during their first year of life. However, domestic studies on the status and guidelines for vitamin D in breastfed infants are insufficient. This review summarizes the prevalence of VDD in breastfed infants, vitamin D content of breast milk, and current guidelines for vitamin D supplementation of lactating mothers and infants to prevent VDD in breastfed infants.

Skin Barrier Function in Infants: Update and Outlook

A good understanding of infant skin should provide a rationale for optimum management of the health of this integument. In this review, we discuss the skin barrier function of infants, particularly with reference to the use of diapers and baby wipes. The skin barrier of newborns continues to develop with age. Two years after birth, the barrier properties of infant skin closely resemble those of adult skin. However, several risk factors may contribute to impaired skin barrier and altered skin permeability in infants. Problems may arise from the use of diapers and baby wipes. The skin covered by a diaper is effectively an occluded environment, and thus is vulnerable to over-hydration. To date there has been no published information regarding dermal absorption of ingredients contained in baby wipes. Similarly, dermal absorption of topical ingredients in infants with underlying skin conditions has not been widely explored. Clearly, there are serious ethical concerns related to conducting skin permeation studies on infant skin. However, the increasing availability of non-invasive methods for in vivo studies is encouraging and offers new directions for studying this important patient group.

The Role of the Global Solar UV Index for Sun Protection of Children in German Kindergartens

More than twenty-five years ago, the Global Solar UV index (UVI) was introduced as a simple means of visualizing the intensity of ultraviolet radiation and to alert people to the need for sun protection. In our survey, among directors of 436 kindergartens in southern Germany we investigated the level of awareness and knowledge about the UVI as well as the practical consequences for sun protection in kindergartens. Less than half of the directors (n = 208, 47.7%) had ever heard of the UVI, and only a small minority of them (n = 34, 8.7%) used the daily UVI information to adapt sun protective measures in their kindergartens. Detailed knowledge about the UVI was a rarity among the respondents. The proportion of respondents with self-perceived detailed UVI knowledge was five times higher than the actual knowledge assessed by an in-depth structured interview using open-ended questions about the UVI (14.2% vs. 2.8%). No clear relationship between UVI awareness, knowledge, and use and directors' age and gender was found. The UVI-related variables also showed no association with directors' knowledge of risk factors for skin cancer and their attitudes towards tanned skin. Overall, the results paint a sobering picture regarding the penetration of the UVI into sun protection policies of German kindergartens. Future public health campaigns should aim to increase the awareness and understanding of the UVI as well as its relevance for sun protection of children.

Towards a paradigm shift in environmental health decision-making: a case study of oxybenzone

BACKGROUND

Technological advancements make lives safer and more convenient. Unfortunately, many of these advances come with costs to susceptible individuals and public health, the environment, and other species and ecosystems. Synthetic chemicals in consumer products represent a quintessential example of the complexity of both the benefits and burdens of modern living. How we navigate this complexity is a matter of a society's values and corresponding principles.

OBJECTIVES

We aimed to develop a series of ethical principles to guide decision-making within the landscape of environmental health, and then apply these principles to a specific environmental chemical, oxybenzone. Oxybenzone is a widely used ultraviolet (UV) filter added to personal care products and other consumer goods to prevent UV damage, but potentially poses harm to humans, wildlife, and ecosystems. It provides an excellent example of a chemical that is widely used for the alleged purpose of protecting human health and product safety, but with costs to human health and the environment that are often ignored by stakeholders.

DISCUSSION

We propose six ethical principles to guide environmental health decision-making: principles of sustainability, beneficence, non-maleficence, justice, community, and precautionary substitution. We apply these principles to the case of oxybenzone to demonstrate the complex but imperative decision-making required if we are to address the limits of the biosphere's regenerative rates. We conclude that both ethical and practical considerations should be included in decisions about the commercial, pervasive application of synthetic compounds and that the current flawed practice of cost-benefit analysis be recognized for what it is: a technocratic approach to support corporate interests.

Vitamin D Status Among Children With Juvenile Idiopathic Arthritis: A Multicenter Prospective, Non-randomized, Comparative Study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic autoimmune disease characterized by destructive and inflammatory damage to the joints. The aim in this study was to compare vitamin D levels between children and adolescents, 1-18 years of age, with juvenile idiopathic arthritis (JIA) and a health control group of peers. We considered effects of endogenous, exogenous, and genetic factors on measured differences in vitamin D levels among children with JIA.

METHODS

Our findings are based on a study sample of 150 patients with various variants of JIA and 277 healthy children. The blood level of vitamin D was assessed by calcidiol level. The following factors were included in our analysis: age and sex; level of insolation in three regions of country (center, south, north); assessment of dietary intake of vitamin D; effect of prophylactic doses of cholecalciferol; a relationship between the TaqI, FokI, and BsmI polymorphisms of the VDR gene and serum 25(OH)D concentration.

RESULTS

We identified a high frequency of low vitamin D among children with JIA, prevalence of 66%, with the medial level of vitamin D being within the range of "insufficient" vitamin D. We also show that the dietary intake of vitamin D by children with JIA is well below expected norms, and that prophylactic doses of vitamin D supplementation (cholecalciferol) at a dose of 500-1,000 IU/day and 1,500-2,000 IU/day do not meet the vitamin D needs of children with JIA. Of importance, we show that vitamin D levels among children with JIA are not affected by clinical therapies to manage the disease nor by the present of VDR genetic variants.

CONCLUSION

Prophylactic administration of cholecalciferol and season of year play a determining role in the development of vitamin D deficiency and insufficiency.

Impact of prenatal and early life environmental exposures on normal human development

The global burden and pattern of disease has changed in recent decades, with fewer early childhood deaths and longer lives complicated by chronic disease. Disruption of normal human growth and development by adverse environmental exposures, especially during foetal development and early postnatal life increase life-long risk of chronic disease. The developmental timing and method of adverse exposure determines the likely impact on health and development. While many organ systems are structurally and functionally mature at birth, the CNS, respiratory and immune systems are not and undergo prolonged periods of postnatal growth and development. As such, these organ systems are vulnerable to adverse effects of both prenatal and postnatal environmental exposures. While the precise mechanisms underlying chronic disease are unknown, epigenetic mechanisms and the induction of oxidative stress are likely to be involved. An understanding of these processes is necessary to develop mitigation strategies aimed at reducing chronic disease prevalence.

Addressing Frequently Asked Questions and Dispelling Myths About Melanocytic Nevi in Children

Melanocytic nevi are congenital or acquired benign melanocytic neoplasms. The reason for the appearance of melanocytic nevi is not precisely known. Melanocytic nevi frequently occur in children, constituting a common reason for consultation in pediatric dermatology clinics. In our experience, many parents and caregivers present doubts and fears based more on popular beliefs than on data with valid scientific evidence. This review answers their frequently asked questions, such as the risk of malignancy, the importance of nevi location, the warning signs of malignant transformation, best prevention strategies, and optimal management, based on the most recent scientific evidence available.

Results of a Primary Skin-Cancer-Prevention Campaign in Early Childhood on Sun-Related Knowledge and Attitudes in Southern Hungary

Simple Summary

Primary skin-cancer-prevention campaigns among young children are important as this is the age when individuals are developing behaviors. Our aim was to evaluate sun-protection knowledge and behavior among caregivers in daycare centers and kindergartens and to determine if educational lectures are positively influential. In daycare centers, we discovered that measures of sun protection (e.g., hat, sunscreen, and shaded areas) are more likely to be available when compared to kindergartens. Knowledge regarding sun safety has improved following our initial presentation, however, not significantly. Sun safety policies did not exist in any of the facilities, presenting an urgent need for their implementation.

Abstract

Avoidance of ultraviolet (UV) exposure in early childhood is important for reducing the lifetime risk of developing skin cancer. The goal of the present prospective, multicenter pilot study was to assess the sun-protection practices in kindergartens and daycare centers and to evaluate sun protection knowledge and behavior among caregivers employed in the surveyed facilities. The study consisted of two parts. A baseline questionnaire was completed by the caregivers in relation to knowledge regarding basic sun protection and sun protection practices of the participating facilities. Afterward, a thirty-minute presentation was hosted in reference to this topic. Six months following the presentation, a follow-up questionnaire was distributed among the caregivers, evaluating the attitude-related and behavioral changes towards children. A total of 153 caregivers from five daycare centers (children between 6 months and 3 years of age) and sixteen kindergartens (children between 3 and 7 years of age) willfully participated in our study. According to our results, the main source of information regarding sun protection originated from different types of media. We found that staying in shaded areas and the use of protective clothing were not frequent in the facilities. Following our presentation regarding skin types and sunscreen use, protective measures improved, but not significantly (p = 0.222). The majority (92.31%) of caregivers distributed the information throughout their environment and also to parents. Sun protection knowledge is necessary; however, motivation among caregivers and parents and involvement of children is also relevant. Hence, a continuous, repetitive educational program regarding sun-smart behavior is deemed essential.

Developing indices to identify hotspots of skin cancer vulnerability among the Non-Hispanic White population in the United States

PURPOSE

Skin cancer is the most common, yet oftentimes preventable, cancer type in the United States. Exposure to ultraviolet radiation from sunlight is the most prominent environmental risk factor for skin cancer. Besides environmental exposure, demographic characteristics such as race, age, and socioeconomic status may make some groups more vulnerable. An exploratory spatial clustering method is described for identifying clusters of vulnerability to skin cancer incidence and mortality based on composite indices, which combine data from environmental and demographic risk factors.

METHODS

Based on county-level ultraviolet data and demographic risk factors, two vulnerability indices for skin cancer were generated using an additive percentile rank approach. With these indices, univariate local Moran's I spatial autocorrelation identified significant clusters, or hotspots, of neighboring counties with high overall vulnerability indices. Clusters were identified separately for skin cancer incidence and mortality.

RESULTS

Counties with high vulnerabilities were spatially distributed across the United States in a pattern that generally increased to the South and West. Clusters of counties with high skin cancer incidence vulnerability were mostly observed in Utah and Colorado, even with highly conservative levels of significance. Meanwhile, clusters for skin cancer mortality vulnerability were observed in southern Alabama and west Florida as well as across north Alabama, north Georgia and up through the Tennessee-North Carolina area.

CONCLUSIONS

Future skin cancer research and screening initiatives may use these innovative composite vulnerability indices and identified clusters to better target resources based on anticipated risk from underlying demographic and environmental factors.

[Challenges in neonatal dermatology : An introduction]

In order to support dermatologists' interest for the fascinating area of neonatal dermatology, we provide (1) an introduction to the specifics of skin barrier in premature and full-term neonates as well as their clinical implications and (2) an example of age-dependent differential diagnoses and approach to a facial vascular stain in a neonate.

Adherence to supplemental vitamin D intake and infant weight gain: a retrospective cohort study in rural southwestern China

Objectives

We tested the hypothesis that vitamin D supplementation is associated with early body mass index (BMI) patterns.

Methods

Using retrospective longitudinal data of infants and toddlers in a 2-year follow-up study, we identified BMI-for-age Z score (BAZ) growth trajectories using latent class growth modeling (LCGM) analysis. Logistic regression models were adopted to investigate the impact of vitamin D supplementation on BAZ patterns.

Results

Five BAZ trajectories were derived using LCGM. Higher intake of vitamin D supplement was significantly associated with lower odds of rapid weight gain or mild undernutrition in the first 2 years (odds ratios: 0.60–0.83 for class 2: early rapid growth; 0.69–0.82 for class 3: early weight loss, late rapid growth; 0.83–0.89 for class 4: suboptimal growth). Adherence to 400 IU Vitamin D ≥ 1 year was significantly associated with less likelihood of being in class 3 (odds ratio 0.17).

Conclusions

Among infants and toddlers aged 0 to 2 years, dietary supplementation of vitamin D is insufficient in rural areas of China. Insufficient vitamin D intake was found to be associated with suboptimal BAZ growth at early stages. Effective collaboration is needed between pediatricians and caregivers, to assure adherence to the nutritional guideline.

The prevalence and determinants of vitamin D deficiency in Indonesian infants at birth and six months of age

Background

Vitamin D deficiency in infants has been associated with an increased risk of a number of diseases but there are limited data on the prevalence and determinants of vitamin D deficiency from tropical settings with high infant morbidity and mortality.

Objective

To determine the prevalence and determinants of vitamin D deficiency in infants at birth and at six months of age in Yogyakarta province, Indonesia.

Design

Serum vitamin D of eligible infants was measured in cord blood at birth and at six months of age. Factors associated with vitamin D deficiency (serum 25-hydroxyvitamin D <50 nmol/L) were collected prospectively monthly from birth and concentrations measured by liquid chromatography-tandem mass spectrometry. Independent risk factors were identified by multiple logistic regression.

Results

Between December 2015 to December 2017, 350 maternal-newborn participants were recruited and followed up. Vitamin D deficiency was detected in 90% (308/344) of cord blood samples and 13% (33/255) of venous blood samples at six months. Longer time outdoors (≥2 hours per day) and maternal multivitamin intake containing vitamin D during pregnancy were protective against vitamin D deficiency at birth (AOR: 0.10, 95% CI: 0.01–0.90 and AOR: 0.21, 95% CI: 0.06–0.68, respectively). Risk factors for vitamin D deficiency at six months included lower cumulative skin-sun exposure score (AOR: 1.12, 95% CI: 1.04–1.20), severe vitamin D deficiency at birth (AOR: 7.73, 95% CI: 1.20–49.60) and exclusive breastfeeding (AOR: 2.64, 95% CI: 1.07–6.49) until six months. Among exclusively breast fed (EBF) infants, a higher skin-sun exposure score was associated with reduced vitamin D deficiency risk.

Conclusion

In equatorial regions, the role of ‘safe’ morning sun exposure in infants and mothers in populations with medium to dark brown skin pigmentation and effective interventions to prevent vitamin D deficiency in newborns and EBF infants, need further consideration and evaluation.

The UVR Filter Octinoxate Modulates Aryl Hydrocarbon Receptor Signaling in Keratinocytes via Inhibition of CYP1A1 and CYP1B1

Ultraviolet radiation (UVR) is a consistent part of the environment that has both beneficial and harmful effects on human health. UVR filters in the form of commercial sunscreens have been widely used to reduce the negative health effects of UVR exposure. Despite their benefit, literature suggests that some filters can penetrate skin and have off-target biological effects. We noted that many organic filters are hydrophobic and contain aromatic rings, making them potential modulators of Aryl hydrocarbon Receptor (AhR) signaling. We hypothesized that some filters may be able to act as agonists or antagonists on the AhR. Using a luciferase reporter cell line, we observed that the UVR filter octinoxate potentiated the ability of the known AhR ligand, 6-formylindolo[3,2-b]carbazole (FICZ), to activate the AhR. Cotreatments of keratinocytes with octinoxate and FICZ lead to increased levels of cytochrome P4501A1 (CYP1A1) and P4501B1 (CYP1B1) mRNA transcripts, in an AhR-dependent fashion. Mechanistic studies revealed that octinoxate is an inhibitor of CYP1A1 and CYP1B1, with IC50 values at approximately 1 µM and 586 nM, respectively. In vivo topical application of octinoxate and FICZ also elevated CYP1A1 and CYP1B1 mRNA levels in mouse skin. Our results show that octinoxate is able to indirectly modulate AhR signaling by inhibiting CYP1A1 and CYP1B1 enzyme function, which may have important downstream consequences for the metabolism of various compounds and skin integrity. It is important to continue studying the off-target effects of octinoxate and other UVR filters, because they are used on skin on a daily basis world-wide.

Ultraviolet filters in sunscreen products labeled for use in children and for sensitive skin

BACKGROUND

The active ingredients in sunscreen products are ultraviolet (UV) filters, many of which are known potential allergens. The use of sunscreen in younger children and individuals with sensitive skin requires special attention, since absorption and allergen sensitization are of concern.

OBJECTIVE

This study aims to evaluate the ultraviolet filters in sunscreen products labeled specifically for "kids" or as "sensitive/hypoallergenic" and compare these to general sunscreen products.

METHODS

From December 2017 to March 2018, the ingredient labels on commercially available sunscreen products in Bangkok, Thailand, were analyzed.

RESULTS

Two hundred and forty-six sunscreen products were examined. Of these, twenty products (8.1%) were marketed for "kids." Forty-one products (16.6%) were labeled as "sensitive" or "hypoallergenic." Ethylhexyl methoxycinnamate (EHMC) and benzophenone-3 (BP3) were less prevalent in products for children [(P = .004) and (P = .029), respectively]. Eighty-five percent of sunscreen products labeled for kids contained at least one chemical UV filter. There was no significant difference between BP3, butyl methoxydibenzoylmethane (BMDM), and octocrylene (OCR) in products labeled for sensitive skin compared to products with no specific labels. Moreover, methylene bis-benzotriazolyl tetramethylbutylphenol (MBBT) was more commonly found in products for sensitive skin than in nonsensitive products (P = .001).

CONCLUSIONS

Common allergenic UV filters were found in sunscreens labeled as sensitive and for children. Regulations for displaying these specific labels should be established for improved benefits and safety to allergy-prone skin.

Sunburn-related variables, secular trends of improved sun protection and short-term impact on sun attitude behavior in Italian primary schoolchildren: Analysis of the educational campaign "Il Sole Amico" ("The sun as a friend")

Sun protection early in life is an essential issue for primary prevention of skin cancers. The Il Sole per Amico was an educational campaign among 66 Italian primary schools. A total of 12,188 questionnaires were completed at baseline. Overall, 9.4% children reported >1 sunburn during the last year and 44.7% parents a use of sunlamps. Independent factors associated with sunburns were: age, lower level of parents' education, light eye and skin color, freckles, nevi on arms, intense sun exposure during the last year, sporadic use of sunscreens, and parental use of sunlamps. A total of 7280 (59.7%) questionnaires were completed at the end of the educational intervention. No significant difference was documented about behavior between the pre- and post-intervention periods. A significant reduction was instead found in both prevalence of recent sunburns and total number of sunburn episodes after comparison with the data obtained by identical questionnaire in the same geographic areas in the "Sole Si Sole No" project in 2001.

Infant skin care: updates and recommendations

PURPOSE OF REVIEW

Neonatal skin acclimates rapidly to dry, aerobic conditions at birth and skin function gradually matures throughout infancy. Gentle skin care practices support the ongoing development and function of newborn skin. This article reviews research updates and current skin care recommendations for full-term infants, premature infants, and infants born with severe cutaneous manifestations of genetic skin disorders.

RECENT FINDINGS

Although safe early bathing of full-term infants with environmental controls is possible, delaying the first newborn bath for 12-24 h of life offers benefits of increased parental bonding and breastfeeding success. Swaddled bathing every 4 days is an effective bathing strategy for premature neonates. Among infants with a family history of atopic dermatitis, regular application of bland skin moisturizers reduces their risk of developing the disease. For newborns with erosive or blistering genetic skin conditions, use of specialized wound dressings and emollients promotes wound healing and helps limit skin damage. Environmental control with humidified incubators helps prevent life-threatening hypernatremic dehydration among babies born with collodion membranes; however, affected infants can tolerate breaks outside of the humidifier to promote parent-infant bonding.

SUMMARY

This article reviews infant skin care recommendations relevant to pediatric practice. Research to further optimize newborn skin care is ongoing, particularly, for the special populations of premature neonates and infants born with severe skin disease.

High Birth Weight, Early UV Exposure, and Melanoma Risk in Children, Adolescents, and Young Adults

BACKGROUND

Melanoma, the deadliest form of skin cancer, is the second most common cancer diagnosed before age 30. Little is known about potentially modifiable or intervenable risk factors specific to developing melanoma at a young age. The objective was to determine if high birth weight or higher early-life ultraviolet (UV) radiation exposure would be associated with increased risk of melanoma in young patients.

METHODS

Population-based, case-control study of 1,396 cases of melanoma diagnosed before age 30 in 1988-2013 and 27,920 controls, obtained by linking cancer registry data to birth records in California.

RESULTS

High birth weight (>4,000 g) was associated with 19% higher risk of melanoma (OR = 1.19; 95% CI = 1.02, 1.39), while low birth weight (<2,500 g) was associated with 41% lower risk (OR = 0.59; 95% CI = 0.43, 0.82), compared with normal birth weight (2,500-4,000 g); dose-response per 1,000 g increase was also evident (OR = 1.24; 95% CI = 1.13, 1.36). All quartiles of birthplace UV greater than the lowest quartile were associated with increased melanoma risk. The strongest relation between birthplace UV and melanoma was for 15-19 years of age at diagnosis.

CONCLUSIONS

High birth weight and high early-life UV exposure may be important independent risk factors for melanoma diagnosis before age 30. The implication is that adopting skin-protective behaviors as early as infancy could be important for primary prevention of melanoma in younger people. However, research that accounts for early-life behavioral patterns of skin protection during infancy is needed to advance our understanding of how birth weight and early-life UV may influence the development of early-onset melanoma.

Newborn Skin Care

The skin serves as a unique barrier from the outside world and undergoes critical changes during its development and maturation. This article reviews evidence-based recommendations for the routine care of newborn skin that should be integrated into the pediatrician's practice. [Pediatr Ann. 2019;48(1):e11-e15.].

Vitamin D in pediatric age: consensus of the Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Federation of Pediatricians

Vitamin D plays a pivotal role in the regulation of calcium-phosphorus metabolism, particularly during pediatric age when nutritional rickets and impaired bone mass acquisition may occur.Besides its historical skeletal functions, in the last years it has been demonstrated that vitamin D directly or indirectly regulates up to 1250 genes, playing so-called extraskeletal actions. Indeed, recent data suggest a possible role of vitamin D in the pathogenesis of several pathological conditions, including infectious, allergic and autoimmune diseases. Thus, vitamin D deficiency may affect not only musculoskeletal health but also a potentially wide range of acute and chronic conditions. At present, the prevalence of vitamin D deficiency is high in Italian children and adolescents, and national recommendations on vitamin D supplementation during pediatric age are lacking. An expert panel of the Italian Society of Preventive and Social Pediatrics reviewed available literature focusing on randomized controlled trials of vitamin D supplementation to provide a practical approach to vitamin D supplementation for infants, children and adolescents.

Sun-related knowledge and attitudes of primary and secondary schoolchildren in western Switzerland

Switzerland, particularly its western region, has the highest incidence of melanoma in Europe. Although the risk of melanoma increases with sun overexposure during childhood, sun-related knowledge and attitudes of Swiss children are scarcely documented. We report the first investigation of the knowledge of the danger of ultraviolet radiation, attitudes towards a suntan and parental influence of schoolchildren in western Switzerland. All fifth, eighth and eleventh graders (average ages of 9, 12 and 15, respectively) in the 18 primary (fifth grade, n=431) and secondary (eighth and eleventh grades, n=837) public schools of La Chaux-de-Fonds were surveyed during regular school classes. The response rate was 91% (1154/1268). Sun-related knowledge was high overall. Eight out of 10 children knew about the risk of skin cancer and recognized the most susceptible phototype. Knowledge increased significantly with age. Girls, older children, fair-skinned participants and those who preferred a tanned skin obtained the highest knowledge score. The main source of information on ultraviolet radiation and sun protection was their parents (76%), followed by the school (11%) and the media (9%). Multivariate logistic regression analyses identified higher sun-related knowledge, lower familial socioprofessional status and skin phototypes III-IV to be associated with a tan-seeking attitude. Parental sensitization (56%) and encouragement (61%) towards sun protection were more common among fair-skinned children and those of higher familial socioprofessional status. The high awareness of the risk of skin cancer among Swiss schoolchildren does not translate into appropriate attitudes. Community-wide intervention programmes involving parents, teachers, peers and primary care clinicians could be considered for Swiss prevention campaigns to improve children's sun behaviour and change their current pro-tan attitude.

Comparative analysis of nutritional guidelines for vitamin D

Vitamin D is essential for calcium and bone homeostasis. Humans are largely dependent on UVB-radiation-induced photosynthesis of vitamin D, as few foods contain vitamin D. However, the same radiation that produces vitamin D is also carcinogenic, albeit with a long lag time, and causes DNA damage. In view of the increasing life expectancy, avoiding excessive sun exposure is prudent. Several groups of people have a shortfall between their requirements for vitamin D and their combined endogenous synthesis and intake from natural foods, and therefore need vitamin D supplementation. Governments and scientific societies are regularly updating their recommendations for intake of vitamin D, especially for groups that should (infants) or prefer to (especially elderly individuals) avoid direct sunlight. An overview of such guidelines is presented in this Review. A fairly large consensus exists that all infants should receive 400 international units (IU) (10 μg) daily during their first year of life and that elderly individuals should have access to vitamin D supplementation (at recommended dosages varying from 400 IU to 800 IU daily in most governmental guidelines but at higher dosages in other guidelines). All guidelines unanimously agree that serum levels of 25-hydroxyvitamin D (25OHD) <25 nmol/l (10 ng/ml) should be avoided at all ages. Children and adults who have limited sun exposure should receive vitamin D supplementation, but the recommended doses vary widely (from 200 IU to 2,000 IU daily), in line with disagreement regarding the minimal desirable serum concentration of 25OHD (which varies from 25 nmol/l to >100 nmol/l).

From the shop to the drain - Volatile methylsiloxanes in cosmetics and personal care products

Organosiloxanes are widely used in the formulation of a broad range of cosmetic and personal care products (PCPs), including creams and lotions, bath soaps, shampoo and hair care products to soften, smooth, and moisten. In fact, the intensive and widespread use of organosiloxanes combined with their lipophilic nature, makes them interesting targets for future research, particularly in the toxicology area. This study focused on determining the concentration levels of these compounds in the bestselling brands of PCPs in the Oporto region (Portugal), allowing the estimation of dermal and inhalation exposure to siloxanes and the evaluation of the quantities released to the environment "down-the-drain" and to air. To accomplish this task, a QuEChERS technique ("Quick, Easy, Cheap, Effective, Rugged, and Safe") was employed to extract the siloxanes from the target PCPs, which has never been tested before. The resulting extract was analysed by gas chromatography-mass spectrometry (GC-MS). The limits of detection varied between 0.17 (L2) and 3.75ngg(-1) (L5), being much lower than any values reported in the literature for this kind of products. In general, satisfactory precision (<10%) and accuracy values (average recovery of 84%) were obtained. 123 PCPs were analysed (moisturizers, deodorants, body and hair washes, toilet soaps, toothpastes and shaving products) and volatile methylsiloxanes were detected in 96% of the samples, in concentrations between 0.003μgg(-1) and 1203μgg(-1). Shampoo exhibited the highest concentration for cyclic and aftershaves for linear siloxanes. Combining these results with the daily usage amounts, an average daily dermal exposure of 25.04μgkgbw(-1)day(-1) for adults and 0.35μgkgbw(-1)day(-1) for baby/children was estimated. The main contributors for adult dermal exposure were body moisturizers, followed by facial creams and aftershaves, while for babies/children were body moisturizers, followed by shower gel and shampoo. Similarly, the average daily inhalation exposure was also estimated. Values of 1.56μgkgbw(-1)day(-1) for adults and 0.03μgkgbw(-1)day(-1) for babies/children were calculated. An estimate of the siloxanes amount released "down-the-drain" into the sewage systems through the use of toiletries was also performed. An emission per capita between 49.25 and 9574μgday(-1) (mean: 1817μgday(-1)) is expected and shampoo and shower gel presented the higher mean total values (1008μgday(-1) and 473.3μgday(-1), respectively). In the worst-case scenario, D5 and D3 were the predominant siloxanes in the effluents with 3336μgday(-1) and 3789μgday(-1), respectively. Regarding the air emissions per capita, values between 8.33 and 6109μgday(-1) (mean: 1607μgday(-1)) are expected and D5 and D6 were the predominant siloxanes.

Significance of antenatal glucocorticoid exposure for pressure injury prevalence in neonates

AIMS

Studies have highlighted that antenatal steroids could have an effect on neonatal skin maturation. This study examined if there was a relationship between the administration of antenatal glucocorticoids for mothers and the skin injuries in their neonates. Data from skin injury audit were extracted from the neonatal database and analyzed to determine differences in the prevalence of neonates with pressure injuries [cases] whose mothers had received antenatal steroids, compared to those without pressure injuries [control].

RESULTS

Of 247 neonates audited, 77 [31%], had documented pressure injuries, 170 [69%] had no documented injury. The median birth weight and gestation were 1400 g [IQR 893-2268 g] and 30.3 weeks [IQR 26.3-40.0 weeks] respectively. Of the neonates born less than 34 weeks, 80% were exposed to antenatal steroids and were equally distributed across patient genders. Within the 77 cases, 53 [66%] were exposed to antenatal steroids compared to controls in which 88 [53%] had not. The effect between cases and controls was not statistically significant [χ2 = 2.81, P = 0.09]. However a difference was noted between genders, as female neonates benefited from the exposure to steroids [OR = 0.317, 95% [CI 0.105-0.956], p value -0.041].

CONCLUSION

Antenatal glucocorticoids appear to be beneficial in reducing pressure injury prevalence in female neonates.

Evolution of sun-protection measures for children

BACKGROUND

The prevention of melanoma can be significantly improved by targeting information directly towards the subpopulation of children and, as a means to achieve it, towards young parents.

OBJECTIVES

The objective of this analysis was to determine the evolution over time of the sun-protection measures adopted by parents for their young children.

METHODS

The Edifice Melanoma survey was based on telephone interviews of a representative sample of 1502 subjects aged ≥18 years. This particular analysis focuses on 864 adults whose children are exposed to the sun for more than 10 days a year. We compared the characteristics and attitudes of two sub-groups of parents with regard to sun protection of young children: current-day behaviour of parents with children <15 years and behaviour in the past of parents whose children are now ≥15 years.

RESULTS

Present-day parents are more likely than those of previous generations to systematically or often use hats (96% vs. 90%, P < 0.01), protective clothes (92% vs. 84%, P < 0.01), sunscreen (89% vs. 80%, P < 0.01) and sunglasses (63% vs. 44%, P < 0.01) for their children. Systematic application of sunscreen is also more frequent today than several years ago as reported by 81% of present-day parents vs. 74% of those in the past (P < 0.05). Cream is reapplied every 2 h by 41% of present-day parents, compared to 33%, in the past (P < 0.05).

CONCLUSIONS

The attitude of parents towards sun protection for their children has improved over the past decade.

The consequences for human health of stratospheric ozone depletion in association with other environmental factors

Ozone depletion, climate and human health.

Sun protection training based on a theater play for preschoolers: an effective method for imparting knowledge on sun protection?

Sun protection in childhood is important to reduce the risk of developing skin cancer later in life. The "Periods-of-Life-Program" for primary prevention of skin cancer introduces a combination of individual and environmental interventions for the preschool period. Within this pilot study, an intervention group received cognitive-behavioral and environmental interventions. A control group had solely received the environmental intervention, and a wait-control group received no intervention. Nursery school children (n = 80, 3 to 6 years of age) of four nursery schools were randomly assigned to these groups on school level. The ability of the cognitive-behavioral intervention (a theater play) to enhance sun protection knowledge was examined. The theater play improved knowledge over all age groups (p < .05 η(2) = .06). Age-specific analyses showed better results for children aged 5 to 6 (p < .05 η(2) = .20) compared to children aged 3 to 4 years (p = .17 η(2) = .04). In combining cognitive-behavioral and environmental interventions, the "Periods-of-Life-Program" is a promising strategy for primary prevention of skin cancer.

Determinants of inadequate parental sun protection behaviour in their children--results of a cross-sectional study in Germany

OBJECTIVE

Unprotected sun exposure especially during childhood is a risk factor for skin cancer. A combined use of sun protection measures is recommended to protect children. However, the prevalence and determinants for combined use have been scarcely studied in children. The objective of this study was to identify determinants of parental sun protection behaviour.

METHODS

A cross-sectional survey was performed in five regions in Bavaria (Germany) during school entrance health examination (2010/2011). Parents of 4579 children (47% female, aged 5-6 years) completed a self-administered questionnaire (response 61%).

RESULTS

Most children were regularly protected with single measures (shade (69%), clothes (80%), hat (83%), sunscreen (89%), sunglasses (20%)). However, regarding regular and combined use, >50% of children were inadequately protected. Larger family size, lower household equivalent income, darker skin and sunburn history were associated with inadequate use of different sun protection measures. The less frequent use of one sun protection measure was associated with less frequent use of the others. Child's sex, migration background, parental education and sun exposure showed inconsistent results regarding the different sun protection outcomes.

CONCLUSION

Based on our results a regular, combined and correct use of multiple sun protection for children should be promoted independent of sociodemographic characteristics. Priority of shade, clothes and hat before sunscreen should be clarified.

Ultraviolet Radiation and the Skin

Ultraviolet radiation (UVR) has many interactions with the skin, which are explored in detail in this review. Both ultraviolet A (UVA) and ultraviolet B (UVB) wavelengths are absorbed by chromophores in the skin, resulting in important biologic effects. Exposure to UVR can result in sunburn, immediate and delayed skin pigmentation, photoaging, and immunosuppression. In addition, exposure to UVA and UVB is an important risk factor for melanoma, squamous cell carcinoma, and basal cell carcinoma. Because endogenous vitamin D synthesis requires UVB, concerns have been raised about the possibility that photoprotection might contribute to vitamin D deficiency; however, vitamin D supplementation is a safer and more reliable method for maintaining adequate vitamin D levels than UVR exposure. Protection from UVR is critical and involves several factors. These elements include sun avoidance during peak hours of UVR exposure (10 am to 2 pm), proper application of a broad-spectrum sunscreen with adequate sun protection factor, and wearing protective clothing, a wide-brimmed hat, and protective eyewear. Indoor tanning is a high-risk activity that is likely contributing to recent increases in melanoma and nonmelanoma skin cancer in young women, and efforts are ongoing to ban minors from engaging in indoor tanning.

Current principles of sunscreen use in children

PURPOSE OF REVIEW

Physicians need to be prepared to counsel patients on why and how to protect themselves from damaging ultraviolet (UV) radiation, including the proper use of sunscreens. In this article, we review the interplay between UV radiation, sunscreens and the skin, highlighting current controversies and recommendations surrounding sunscreen use.

RECENT FINDINGS

An important concept is that excessive UV exposure has long-term damaging effects on the skin beyond the immediate sunburn. Recent discoveries of the role of UVA radiation in skin cancer development have set high standards for broad-spectrum coverage to be met by sunscreens. Current evidence does not support an association between sunscreen use and melanoma, systemic toxicity or vitamin D deficiency. Although sunscreen application is the most common modality for sun protection, many people do not use it correctly. Regular sunscreen use during childhood and adolescence can significantly reduce lifetime incidence of skin cancer; therefore, targeting children in pediatric offices regarding unprotected UV exposure may be a practical approach.

SUMMARY

Sunscreens continue to be a major method of photoprotection among the public, offering numerous benefits that clearly outweigh potential risks; however, optimizing the use of sunscreens, especially among children and adolescents, remains a major challenge.

Sun protection, probiotics and parental smoking cessation

PURPOSE OF REVIEW

This article addresses three areas where new research demonstrates the potential to impact the health of children and adolescents: sun protection, probiotic use, and parental smoking cessation.

RECENT FINDINGS

Skin cancer rates are rising, and sun exposure in childhood and exposure to tanning beds are important preventable risk factors. Research on the use of probiotics to treat a variety of intestinal and nonintestinal diseases is expanding. By counseling parents about smoking cessation, pediatricians can assist in decreasing childhood exposure to harmful second-hand and third-hand smoke.

SUMMARY

New research on probiotic use in children shows its potential in prevention and treatment of common childhood illnesses. By finding ways to educate patients and parents on the dangers of ultraviolet radiation and smoke exposure, pediatricians can improve both short-term and long-term health of their patients.