Caring for Our Children (CFOC)

Chapter 3: Health Promotion and Protection

3.4 Health Protection in Child Care

3.4.5 Sun Safety and Insect Repellent

3.4.5.1: Sun Safety Including Sunscreen

Frequently Asked Questions/CFOC Clarifications

Reference: 3.4.5.1

Date: 02/17/2012

Topic & Location:
Chapter 3
Health Promotion
3.4.5.1: Sun Safety Including Sunscreen

Question:
Why does this standard state that sunscreen should be applied thirty minutes before going outdoors, but the AAP reference listed on page 127 states that sunscreen should be applied 15-30 minutes before going outside?

Answer:
The recommendation of how many minutes prior to going outside sunscreen should be applied was revised from 30 minutes to 15-30 minutes on January 30, 2012, which was after the publication of CFOC, 3rd Edition.

Content in the STANDARD was modified on 8/8/2013.

Caregivers/teachers should implement the following procedures to ensure sun safety for themselves and the children under their supervision:

  1. Keep infants younger than six months out of direct sunlight. Find shade under a tree, umbrella, or the stroller canopy;
  2. Wear a hat or cap with a brim that faces forward to shield the face;
  3. Limit sun exposure between 10 AM and 4 PM, when UV rays are strongest;
  4. Wear child safe shatter resistant sunglasses with at least 99% UV protection;
  5. Apply sunscreen (1).

Over-the-counter ointments and creams, such as sunscreen that are used for preventive purposes do not require a written authorization from a primary care provider with prescriptive authority. However, parent/guardian written permission is required, and all label instructions must be followed. If the skin is broken or an allergic reaction is observed, caregivers/teachers should discontinue use and notify the parent/guardian.

If parents/guardians give permission, sunscreen should be applied on all exposed areas, especially the face (avoiding the eye area), nose, ears, feet, and hands and rubbed in well especially from May through September. Sunscreen is needed on cloudy days and in the winter at high altitudes. Sun reflects off water, snow, sand, and concrete. “Broad spectrum” sunscreen will screen out both UVB and UVA rays. Use sunscreen with an SPF of 15 or higher, the higher the SPF the more UVB protection offered. UVA protection is designated by a star rating system, with four stars the highest allowed in an over-the-counter product.

Sunscreen should be applied thirty minutes before going outdoors as it needs time to absorb into the skin. If the children will be out for more than one hour, sunscreen will need to be reapplied every two hours as it can wear off. If children are playing in water, reapplication will be needed more frequently. Children should also be protected from the sun by using shade and sun protective clothing. Sun exposure should be limited between the hours of 10 AM and 4 PM when the sun’s rays are the strongest.

Sunscreen should be applied to the child at least once by the parents/guardians and the child observed for a reaction to the sunscreen prior to its use in child care.

RATIONALE
Sun exposure from ultraviolet rays (UVA and UVB) causes visible and invisible damage to skin cells. Visible damage consists of freckles early in life. Invisible damage to skin cells adds up over time creating age spots, wrinkles, and even skin cancer (2,4).

Exposure to UV light is highest near the equator, at high altitudes, during midday (10 AM to 4 PM), and where light is reflected off water or snow (5).

COMMENTS
Protective clothing must be worn for infants younger than six months. For infants older than six months, apply sunscreen to all exposed areas of the body, but be careful to keep away from the eyes (3). If an infant rubs sunscreen into her/his eyes, wipe the eyes and hands clean with a damp cloth. Unscented sunblocks or sunscreen with titanium dioxide or zinc oxide are generally safer for children and less likely to cause irritation problems (6). If a rash develops, have parents/guardians talk with the child’s primary care provider (1).

Sunscreen needs to be applied every two hours because it wears off after swimming, sweating, or just from absorbing into the skin (1).

There is a theoretical concern that daily sunscreen use will lower vitamin D levels. UV radiation from sun exposure causes the important first step in converting vitamin D in the skin into a usable form for the body. Current medical research on this topic is not definitive, but there does not appear to be a link between daily normal sunscreen use and lower vitamin D levels (7). This is probably because the vitamin D conversion can still occur with sunscreen use at lower levels of UV exposure, before the skin becomes pink or tan. However, vitamin D levels can be influenced significantly by amount of sun exposure, time of the day, amount of protective clothing, skin color and geographic location (8). These factors make it difficult to apply a safe sunscreen policy for all settings. A health consultant may assist the program develop a local sunscreen policy that may differ from above if there is a significant public health concern regarding low vitamin D levels.

EPA provides specific UV Index information by City Name, Zip Code or by State, to view go to http://www.epa.gov/sunwise/uvindex.html.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.1 Medication Administration
6.1.0.7 Shading of Play Area
REFERENCES
  1. American Academy of Pediatrics. 2008. Sun safety. http://www.healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx.
  2. American Academy of Dermatology. 2010. Skin, hair and nail care: Protecting skin from the sun. Kids Skin Health.http://www.kidsskinhealth.org/grownups/skin_habits_sun.html.
  3. Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O’Riordan, H. Koh, G. Colditz. 2005. Sun protection policies and practices at child care centers in Massachusetts. J Comm Health 30:491-503.
  4. Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun protection for children. Dermatology Nurs 17:419-22,431-33.
  5. Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with infants and children. Medic8. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/traveling-safely-with-infants-and-children.
  6. Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. Schultz. 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul Toxicol 27:231-39.
  7. Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce vitamin D production to insufficient levels? British J Dermatology 161:732-36.
  8. Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 122:398-417.
NOTES

Content in the STANDARD was modified on 8/8/2013.

3.4.5.2: Insect Repellent and Protection from Vector-Borne Diseases

Content in the STANDARD was modified on 4/5/2017.

 

Most insects do not carry human disease and most insect bites only cause mild irritation. Insect repellents may be used with children older than 2 months in child care where there are specific disease outbreaks and alerts. As with all pesticides, care should be taken to limit children’s exposure to insect repellents (1). Caregivers/teachers should consult with a child care health consultant, the primary care provider, or the local health department about the appropriate use of repellents based on the likelihood that local insects are carrying potentially dangerous diseases (e.g., local cases of meningitis from mosquito bites). This information should be shared with parents/guardians, and collective decisions made about use.
Insect repellent requires the written permission of parents/guardians and label instructions must be followed. It does not require written permission from a primary care provider.

Repellents containing DEET
Repellents with 10%-30% DEET offer the broadest protection against mosquitoes, ticks, flies, chiggers, and fleas. Caregivers/teachers should read product labels and confirm that the product is 1) safe for children and 2) contains no more than 30% DEET. Most product labels for registrations containing DEET recommend consultation with a physician if applying to a child less than six months of age.
The use of DEET should reflect how much time the child will be exposed to biting insects (2):
  • 10% DEET is generally effective for two hours.
  • 24% DEET is generally effective for five hours.
  • Products with more than 30% DEET should never be used on children.
  • Do not use products that combine insect repellent and sunscreen. This is because sunscreen may need to be re-applied more often and in larger amounts than repellent.
  • If sunscreen is also used, apply sunscreen FIRST. DEET may decrease the SPF of sunscreens by one-third. Sunscreens may increase absorption of DEET through the skin).
Other Types of Insect Repellents
Picaridin and IR3535 are other products registered at the Environmental Protection Agency (EPA) identified as providing repellent activity sufficient to help people avoid the bites of disease carrying mosquitoes (4). Para-menthane-diol (PMD) or pil of lemon eucalyptus products, according to their product labels, should NOT be used on children under three years of age (4,5).

General Guidelines for Use of Insect Repellents with Children
As noted above, insect repellents may be applied to children older than two months. In addition to consulting label instructions, teachers/caregivers may follow these guidelines:
a.    Apply insect repellent to the caregiver/teacher’s hands first.
b.    When applying insect repellent on a child, use just enough to cover exposed skin.
c.    Do not apply under clothing.
d.    Do not use on children’s hands.
e.    Avoid applying to areas around the eyes and mouth.
f.     Do not use over cuts or irritated skin.
g.    Do not use near food.
h.    After returning indoors, wash treated skin immediately with soap and water.
i.     Caregivers/teachers should wash their hands after applying insect repellent to the children in the group.
j.     If the child gets a rash or other skin reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison center (1-800-222-1222) for further guidance (4). If repellent is used on broken skin or an allergic reaction is observed, discontinue use and notify the parent/guardian.
 
Protection from ticks
In places where ticks are likely to be found (6), caregivers/teachers should take the following steps to protect children in their care from ticks:
 
a.    Remove leaf litter and clear tall grasses and brush around homes and buildings and at the edges of lawns;
b.    Place wood chips or gravel between lawns and wooded areas to restrict tick migration to recreational areas;
c.    Mow the lawn and clear brush and leaf litter frequently;
d.    Keep playground equipment, decks, and patios away from yard edges and trees;
e.    Ensure that children wear light colored clothing, long sleeves and pants, tuck pants into socks; and
f.     Conduct tick checks of children when returning indoors (7).

How to Remove a Tick (8):
It is important to remove the tick as soon as possible. Use the following steps:
a.   If possible, clean the area with an antiseptic solution or soap and water. Take care not to scrub the tick too hard. Just clean the skin around it;
b.   Use blunt, fine tipped tweezers or gloved fingers to grasp the tick as close to the skin as possible;
c.   Pull slowly and steadily upwards to allow the tick to release;
d.   If the tick’s head breaks off in the skin, use tweezers to remove it like you would a splinter;
e.   Wash the area around the bite with soap;
f.    Following the removal of the tick, wash your hands, the tweezers, and the area thoroughly with soap and warm water.

Take care not to do the following:
a.    Do not use sharp tweezers.
b.    Do not crush, puncture, or squeeze the tick’s body.
c.    Do not use a twisting or jerking motion to remove the tick.
d.    Do not handle the tick with bare hands.
e.    Do not try to make the tick let go by holding a hot match or cigarette close to it.
f.     Do not try to smother the tick by covering it with petroleum jelly or nail polish.
RATIONALE
Mosquitoes and ticks can carry pathogens that may cause serious diseases (i.e., vector-borne diseases such as West Nile virus and Lyme disease) (7).
Zika is a mosquito-borne virus that usually causes mild illness that lasts from several days to a week. The mosquito that spreads Zika virus is found everywhere in the world including the United States. Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects (9). Information and recommendations regarding Zika are rapidly evolving. Please visit the Centers for Disease Control and Prevention (CDC) Zika updates page for the most recent information: http://www.cdc.gov/zika/index.html (9). 
COMMENTS
Insect repellents should be EPA-registered and labeled as approved for use in the child’s age range.
Aerosol sprays are not recommended. Pump sprays are a better choice. Regardless of the type of spray used, caregivers/teachers should spray the insect repellent into her/his hand and then apply to the child. It is not recommended to directly spray the child with the insect repellent to prevent unintentional injury to eyes and mouth. Preschool children, toddlers, and infants should not apply insect repellent to themselves. School age children can apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly.
Parents/guardians should be notified when insect repellent is applied to their child since it is recommended that treated skin is washed with soap and water.
If a product gets in the eyes, flush with water and consult the poison center at 1-800-222-1222.
Several resources are available on reducing exposure to ticks and mosquitoes based on habits, protective attire, and insect repellent use. The following resources offer detailed information on preventing exposure to ticks and mosquitoes in early care and education settings:
  • Preventing Tick Bites on People by the Centers for Disease Control and Prevention at http://www.cdc.gov/lyme/prev/on_people.html.
  • UCSF California Childcare Health Program’s (CCHP) Health and Safety Note for child care centers:
1. Integrated Pest Management: Mosquitoes: http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/ipm_mosquitoes.pdf
2. CCHP IPM Handout for Family Child Care Homes: Mosquitoes: http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/Mosquitoes_FCCH_IPM.pdf
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.4.5.1 Sun Safety Including Sunscreen
5.2.8.1 Integrated Pest Management
REFERENCES
  1. National Pesticide Information Center. 2015. Pesticides and children. http://npic.orst.edu/health/child.html. 
  2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Center for Disease Control and Prevention. 2015. Chapter 2 - Protection against mosquitos, ticks, & other anthropods. https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/sun-exposure. 
  4. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2015. West nile virus: Insect repellent use and safety. http://www.cdc.gov/westnile/faq/repellent.html.
  5. Centers for Disease Control and Prevention. 2016. Avoid bug bites. https://wwwnc.cdc.gov/travel/page/avoid-bug-bites. 
  6. Centers for Disease Control and Prevention. 2015. Geographic distribution of ticks that bite humans. https://www.cdc.gov/ticks/geographic_distribution.html. 
  7. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2010. Lyme disease: Protect yourself from tick bites.http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.
  8. Centers for Disease Control and Prevention. 2015. Tick removal. https://www.cdc.gov/ticks/removing_a_tick.html. 
  9. Centers for Disease Control and Prevention. 2016. About zika. https://www.cdc.gov/zika/about/index.html. 
  10. ADDITIONAL REFERENCE:

    U.S. Environmental Protection Agency. 2016. Find the insect repellent that is right for you. https://www.epa.gov/insect-repellents/find-insect-repellent-right-you.
     
NOTES

Content in the STANDARD was modified on 4/5/2017.