The use of sunscreen in children – what, how and why?

What are the sun’s rays composed of?

Okay, so my aim is not to turn you into physicists but simply not introduce you to the general terminology that is required for you to understand the basic concepts behind the need for sun protection.
The sun’s radiation is the general term used to describe all the three main electromagnetic radiation that reaches the earth:
The visible light spectrum is the electromagnetic segment that the human eye can see during the day.
The infra-red light spectrum – is the only light that is responsible for the sun’s warmth
The ultra-violet light spectrum – this is invisible light that is the main culprit behind the damage that can be caused to our body by the sun (read more below about the component responsible for sunblock in sunscreen).
Let’s focus on the ultraviolet (UV) light for now. UV light have 3 main components and these can be classified according to their wavelength.
UV-A is the main component, it is able to penetrate the atmosphere and reach the earth. Is is able to penetrate the outer layer of our skin and is therefore also associated with the chronic effects of aging of the skin.
UV-B this is a smaller component (involves about 5%), but it plays a significant role in the damage that can be caused to the skin, all the way from burns to skin cancer.
UV-C is mostly absorbed in the layers of the atmosphere and is unable to reach the earth, but due to the ongoing damage to our ozone layer it seems like it is becoming more prominent and will be having a greater effect on us in the future.
Note that the sun is not only dangerous in summer, but also has components that may exhibit dangerous effects during the fall and winter months, as well.

What is the ultra-violet (UV) index?

The UV index is something that we see every time we watch the weather forecast. It is an index calculated to express the level of risk caused by UV lights. It is usually presented in different colours – from green, which expresses a low risk and all the way to purple – extremely high risk. Naturally, during the summer months, there is a higher level of risk that starts in the early morning hours and lasts until the sun sets. With the help of this index, one can plan their day outdoors and avoid outdoor activity (even if it is under full protection), during the high-risk hours. Read more below about avoidance.

Why is sunlight important and necessary?

Minutes before I go on to discuss the dark side of the sun and the harm that it can cause, let me just remind you all that our sunlight is the source of light and life on our planet. It brightens our day, provides us with warmth, is an essential part of photosynthesis (which I could elaborate on forever) and it really is just a vital part of our life on this planet and we could not possibly live without it. Additionally, the sun is our source of energy, it is part of the process of vitamin D formation in our body (remember the post about giving infants vitamin D supplements? Read more here). And it also plays a role in the recovery of certain skin diseases and has a meaningful effect on our mood (some claim there is an association between the absence of sunlight and the development of depression during winter).
But besides all of this, it can bring about detrimental effects and we must learn how to protect ourselves and our children from those effects.

What are some of the negative effects of sunlight?

Sunlight has some potentially harmful short-term and long-term effects. Let me clarify – exposure to sunlight can lead to acute effects, such as burns, and also accumulating damage, that may present later in life, such as skin cancer.

Why am I emphasizing this? Some children are exposed to sunlight on a daily basis, and if we make sure to provide them with protection from a young age, we can avoid the sun’s accumulative damage that may present either in childhood or in adulthood.

Dehydration and heat strokes – this is obvious, an excessive exposure to sunlight without any rest or sufficient fluid intake can cause dehydration or even heat strokes. I know that sometimes this is associated with a mild condition, that improves with bedrest and fluid intake, but dehydration and heat strokes can also lead to life-threatening situations.

Sunburns – sunburns are burns that are caused as a result of exposure to sunlight, especially UV-B rays. It is true that some people have a “tendency” to burn depending on how light their skin-colour is, but all the different skin colours, including dark skin tones, are able to burn in the sun. Sunburns are actually an inflammatory process that occurs in the skin and is caused by the sun’s rays. The process includes vascular expansion, grouping of inflammatory cells, secretion of materials that promote the inflammatory process and cause skin cell damage and with time, accumulative, chronic damage.

What are the different degrees of sunburns that exist?

We can divide these according to their depth, just like we do for other types of burns:
Superficial sunburns – these will look like red lesions, they are painful and tender to touch (we’ve all experienced what it’s like to try and put on a shirt after you’ve been in the sun all day and how every single movement is painful with that shirt on). They usually improve and resolve within a few days.
Superficial partial-thickness sunburns – these are sunburns that include redness and blisters, are painful and tender to touch and take a little longer to heal. They usually take around 1-3 weeks and they heal without scarring.
In both of these, the initial redness first appears after a few hours, is the worst about one day after exposure and then starts improving within 2-3 days. Improvement is ongoing for several days. The healing process includes peeling of the skin and the areas that have darkened. The burns I mentioned above are the more common ones but obviously there is also a third type which includes deeper thickness sunburns that can reach the deeper layers of the skin – these occur less frequently and after a more significant exposure.
They are often accompanied by general signs and symptoms that occur after exposure to the sun, such as headaches, vomiting and a general bad feeling.

How can you treat a sunburn?

Cold/lukewarm compresses.
Washing blisters that have burst with water and soap to keep the skin from getting infected.
Moisturizing damaged skin with creams and aloe-vera.
If you have large and tender blisters you may cover them with a layer of Vaseline and dressing.
Analgesics as needed to reduce the pain.
There is no need to use any steroidal ointments.

What about all the well-known home-remedies?

I remember the days when I had yoghurt rubbed on my back after a sunburn as a child. It must have been cold and that’s why it was able to provide some relief. Oh, those were the days!
There are a lot of home-remedies out there such as honey and black tea, or cucumbers, but do me a favour – try not to spread everything you have in your fridge on yourself.
Of course, if the burn is deep and covers a larger area of skin or if you have any other general signs or symptoms – see a doctor for an assessment and the need for additional therapy such as fluid replacement, wound dressing and so on.

What kinds of chronic changes can occur to the skin as a result of sun exposure?

It is obvious to all of us that the sun can cause lots of chronic changes. From skin colour changes (such as tanning) to pigmentary lesions called solar lentigines, raised lesions with thicker skin named actinic keratosis, wrinkles and accelerated aging. People that spend hours and hours working in the fields under the strong effects of the sun, without using any sun protection, have darker, wrinkly and more aged skin. In addition, some people suffer from rashes and skin reactions that are specific to sun exposure.

What about tanning in children?

If you don’t mind, I will not be going into the details of my opinion with regards to cosmetics, aesthetics and whether I think tanning looks good on children or adolescents. I think it’s important to keep in mind that tanning is how our body conveys its protective mechanism against UV light. In fact, the skin produces melanin in order to protect our DNA from the harms of radiation and this is expressed in darker skin. I just want to say that those people who like tanning are actually causing themselves harm that some other people may see as cosmetic beauty. But this damage does accumulate. And it can lead to skin cancer. And skin cancer is very very dangerous.
So do me a favor, do not tan. And if your children are teenagers that want to tan in order to look prettier, try to knock some sense into them.

Skin cancer? How is it related to children?

There are different types of skin cancers that are caused by sun exposure, and these include SCC – squamous cell carcinoma, BCC – basal cell carcinoma and malignant melanoma. Skin cancers are caused due to changes in the DNA of skin cells (the genetic material in our cells) because of light radiation.
Fortunately, skin cancers are rare in children because they only occur after accumulative damage and take a while to develop. But I don’t know how to make this any clearer – exposure to excessive sunlight in childhood, repetitive sunburns and certainly burns entailing blisters are a proven risk factor for the development of skin cancer in adulthood.
Make sure to provide your children with maximum protection for a better future. We do so many things to try and prevent and improve their life and sometimes we just neglect this important topic. And this is the reason I started of by saying that giving someone advice about sun protection is probably one of the most important pieces of advice a pediatrician can give to his/her patients.

What about damage to the eyes?

Sunlight accelerates the development of cataracts which is a process that causes cloudiness in the lens of eyes. Also here, avoiding accumulative damage to the eyes in childhood can prevent the development of cataracts in adulthood.

How can one protect themselves from the sun’s radiation?

Now that it is obvious to all of us that it is important to protect ourselves from sunlight, lets talk about how this can be done. Here are the 6 S’s of sun safety:
Shade from the sun when possible. Try to sit in the sun during the safer hours. Consider the UV index and avoid outdoor activities between 10am and 4pm. The UV radiation is lower before and after these hours.
Slap on a wide brimmed hat.
Slide on some quality sunglasses (this is just as important in children, remember what I said about cataracts?).
Slip on a shirt – even if it’s hot, if you are sitting under the sun, it is important to dress wisely and cover your arms and legs. You can even swim in a shirt or swimsuit made of UV-protective material.
Slop on sunscreen (read all about sunscreens below).
Sip on sufficient fluids throughout the day to replace the fluids lost during activity. This is true all year around but especially true during the extra hot days of the year when fluid loss is more significant.

What are sunblock creams made of?

These are products that contain blockers that either reflect or absorb UV lights. There are two types of blockers – mineral/physical blockers or chemical/organic blockers.
Mineral/physical blockers – these are non-organic products that reflect or physically spread UV light. They remain on the skin but are not absorbed by the skin, and by doing so cause minimal irritation to the skin and are considered safe products.
Chemical/organic blockers – these are organic products that absorb UV light with the help of a chemical process. These are absorbed into the skin but the amount that is absorbed and its effects are not very clear and haven’t been researched thoroughly. Their absorbance into the skin can also lead to allergies and local reactions as a result of sun exposure when they have been applied to the skin. Oxybenzone is a common chemical in these products and one of the main culprits behind allergic inflammatory reactions in the skin. Additionally, its association with estrogenic hormonal influences on laboratory animal models has been questioned. It has also been associated with environmental damage to coral reefs.

What is SPF?

SPF is the acronym for Sun Protection Factor which is a measure of the intensity of protection that products have against UVB (only). How is this measured? The intensity of radiation required to cause a superficial burn on skin that has had the product applied to it, versus skin without any product, is tested under laboratory conditions. The higher the SPF value, the more protection it offers against the same radiation intensity. Note that the value does not indicate how long you can spend in the sun or anything of that sort. The higher the value, the longer it will take for the skin to get burnt when exposed to sunlight. This means – the higher the value is, the better it is.
As for UVA protective indices – these don’t really exist. Some European products have all sorts of indices for measuring the ration between UVB and UVA protection, but this isn’t very properly classified.

Dr Efi – how do I select the best sunblock cream for my child?

The American Academy of Dermatology recommends choosing sunscreen that contains the following:

• SPF 30 or higher.
• Broader spectrum – that is protective against UVB and UVA.
• Water and sweat resistant – waterproof products are able to retain their SPF 40-80 minutes after being in the water. Water resistant products are even better.
• A nice texture to allow for better compliance.
• And I’ll just add to this and say – that just like for any other cosmetic product – choose the one that suits your child’s skin the best.

And just like we tend to read the label on food products that we give our children because it is important for us to know what they contain, I would also recommend looking over the label on sunscreen before applying it on your child. Purchase creams that are of high quality and contain safe blockers, contain all the features mentioned above and are suitable for your child’s specific skin.
Everyone, but every single person out there needs to wear sunblock! Both children and their parents. Especially those with lighter coloured skin tones, freckles and moles but also people with darker coloured skin.

How is sunscreen applied?

It sounds a bit trivial, but it is still important to take special care when applying sunscreen so as to reach it maximum effect. Here are some basic rules – apply it generously, apply it prior to sun exposure, apply it on all the exposed areas and repeat application as needed.
Apply generously – in order to enjoy the maximum SPF protection that the product offers, you need to apply enough. What is a sufficient amount? If you want to be precise, it is about 2mg/cm of skin. Okay, there is really no need to push it and take accurate measurements, but it comes down to about 6-9 spoons of cream for an adult. It is always better to apply too much than too little.
Timing – just like everything else in life, timing here is of the essence as well. It is important to apply the cream about 15-30 minutes prior to exposure to allow for it to produce the required protective layer. I know it is not really realistic to get to the pool, apply cream on your kids and then expect them to wait for 30 minutes. My best piece of advice would be to apply some before leaving the house and then some more when you get to your destination.
Apply it on all the exposed areas of skin – don’t forget the face, the palms of the hands and feet, the ears and neck.
Repeat application – applying cream once is not enough. Remember that even waterproof products eventually wash off in water. And so, make sure to repeat the application every 1.5-2 hours. Especially if the kids tend to leave the pool, dry themselves off using a towel and then go back in. Remember that the cream will get wiped off as well. We tend to forget this because the kids are just enjoying themselves and having fun, but it is really important to try and make an effort to remember.
Stick to the 6 S’s of “Sun Safety” as well. Sunscreen does not replace all of those.

Do I need to apply sunscreen on my baby as well?

Let me start by saying that babies need sun protection as well. Exposing babies under the age of 6 months to the sun is not advised and it is best to protect them by avoiding the sun altogether, sticking to the shaded areas and covering them in long clothed. This is both due to the sun’s potential damage to their skin and also because their thin skin may be sensitive to all these different types of products which tend to get absorbed into the skin. Nonetheless, if you have no choice but to expose them to the sun, I recommend applying a thin layer of sunscreen.

To summarize, this is a very important topic. There aren’t too many options out there for things that we, as parents, can do for our children to prevent them from developing potential damage in their childhood or adulthood. We put so much effort into trying to provide them with a better future and we really have to make sun safety one of these efforts and we must insist on it.

All in all, it is a pretty simple task. Stay safe my friends!