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Counseling Parents and Children on Sun Protection: A National Survey of Pediatricians

Sophie J. Balk, MD^*, Karen G. O’Connor, BS and Mona Saraiya, MD, MPH

^* Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
Division of Health Policy Research, American Academy of Pediatrics, Elk Grove Village, Illinois
Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objective. To describe pediatricians’ attitudes toward skin cancer (SC), sun protection (SP) counseling, and the quantity and content of such counseling and to identify barriers to counseling.

Methods. An American Academy of Pediatrics Periodic Survey was mailed to 1616 randomly selected US members between October 2001 and February 2002. The response rate was 54.6%.

Results. More than 90% of pediatricians agreed that SC is a significant public health problem and that preventing episodic high exposures to the sun during childhood will reduce the risk of adult melanoma. However, only 22.3% of respondents reported counseling most patients in all age groups. Female pediatricians were more likely to counsel most patients; pediatricians located in the South and West and those who practice in hospital/clinic settings were least likely to counsel compared with those in other regions. Approximately half (53%) of pediatricians reported selectively counseling on the basis of patient characteristics The most important SP recommendation named was using a sunscreen with a sun protection factor 15. Only 38% of pediatricians rated SP as very important to their patients’ health compared with other topics such as use of car seats (86%), nutrition (79%), immunization issues (76%), and smoking/avoidance of environmental tobacco smoke (74%). The most frequently named barrier to SP counseling was lack of time (58% reporting).

Conclusions. Although the majority of pediatricians believe that SC prevention is a worthy issue, only a minority reported providing routine SP counseling to most patients in every age group, and most ranked SP lower in importance than other issues. Interventions might include programs and materials to educate patients and pediatricians alike. To have an effect on increasing rates of SC and SC mortality, a broader public health approach is needed as a complement to pediatricians’ counseling efforts.

Key Words: sun protection • skin cancer • melanoma • pediatricians • counseling • prevention • vitamin D

Abbreviations: SC, skin cancer • BCC, basal cell carcinoma • SCC, squamous cell carcinoma • NMSC, nonmelanoma skin cancer • UVR, ultraviolet radiation • SP, sun protection • AAP, American Academy of Pediatrics • SPF, sun protection factor

Skin cancer (SC) is the most common cancer in the United States and is a major cause of morbidity in adults. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC; grouped together as nonmelanoma skin cancer [NMSC]) occur most frequently with >1 million cases each year.¹ These tumors are highly curable if treated; nonetheless, 2200 people died of NMSC in 2002.¹ Melanoma, the third most common SC, occurs mostly in older adults; the median age of diagnosis is 57,² one of the lowest of all cancers. Melanoma is also one of the most common cancers in young adults. Melanoma, therefore, affects most age groups.

Melanoma accounts for 4% of SC cases but causes more than three quarters of SC deaths. Dramatic increases in melanoma incidence and mortality occurred in the last century. An estimated 54 200 new cases were diagnosed and 7600 people died of melanoma in 2002.³ Melanoma is usually curable in early stages, but the prognosis is poor when melanoma has metastasized; efforts to combat melanoma thus have focused on prevention and early detection. Exposure to ultraviolet radiation (UVR) is strongly linked to the development of BCC, SCC, and melanoma.^4–9

SC has its antecedents in childhood and adolescence. Intense exposure to solar UVR during childhood and adolescence in the form of severe, blistering sunburns raises a person’s risk of developing melanoma^4–7 and BCC^8,9 later in life. In contrast, SCC is related to exposure to lower levels of UVR experienced over longer periods of time.

Awareness of sun protection (SP) to prevent SC is promoted by public health organizations, including the Centers for Disease Control and Prevention (www.cdc.gov/ChooseYourCover), the US Environmental Protection Agency (www.epa.gov/sunwise), and the National Council on Skin Cancer Prevention (www.skincancerprevention.org). Another approach to preventing SC involves counseling by physicians and other clinicians. The American Academy of Pediatrics (AAP) recommends that pediatricians incorporate SP counseling into practice.^10,11 Counseling by pediatricians may help to achieve Healthy People 2010 objectives: 1) increase the proportion of people who use at least 1 of the following protective measures that might reduce the risk of skin cancer: avoid the sun between 10 AM and 4 PM, wear sun-protective clothing when exposed to the sun, use sunscreen with a sun protection factor (SPF) of 15, and avoid artificial sources of UV light; and 2) reduce deaths from melanoma to 2.5 per 100 000 people.¹²

Pediatricians may promote SP by counseling parents and children. There have been relatively few surveys of pediatricians’ attitudes and practices regarding counseling on SP,^13,14 however, and only 1 survey of national scope has addressed this topic.¹⁵ In addition, there have been no surveys of pediatricians regarding attitudes and practices about vitamin D supplementation to prevent rickets, a subject of increasing concern as the public adopts SP practices. This national survey was undertaken to determine pediatricians’ attitudes and reported practices regarding counseling on SP and SC prevention.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The survey was the 51st in a series of Periodic Surveys of Fellows conducted by the AAP 3 to 4 times annually on topics of importance to pediatricians, each using a unique random sample of active, US members of the AAP. For this survey, we drew our sample from a list of 51 327 active members of the AAP, including Candidate Fellows and pediatric residents. The 8-page, close-ended questionnaire was designed by the AAP Division of Health Policy Research and the AAP Committee on Environmental Health with input from the National Council on Skin Cancer Prevention. It was approved by the AAP Institutional Review Board and pilot-tested before the study was begun. The original mailing to 1616 members and 5 follow-up mailings to recontact nonrespondents were conducted from October 2001 through February 2002. An introductory letter from the AAP Executive Director and a business-reply envelope accompanied each questionnaire. After 6 mailings, we received 882 completed questionnaires for a response rate of 54.6%.

Survey Questionnaire
Respondents were asked to 1) estimate the number of sunburn cases that they treated in the past 12 months; 2) rate their agreement or disagreement with statements regarding the importance of SC and SP counseling, using a 5-point Likert scale; 3) estimate the percentage (0%, 1%–24%, 25%–49%, 50%–74%, 75%–99%, 100%) of patients/parents with children in several age categories (birth to 6 months, 7 months to 2 years, 3–6 years, 7–9 years, 10–13 years, 14 years) with whom they had discussed SP at least once during the most recent summer months (June, July, and August); 4) select factors used to identify patients/parents who are in need of SP counseling, unless they provided counseling to everyone; 5) select SP practices usually recommended to patients/parents, chosen from a list; 6) rank the SP recommendation that they believe to be most important; 7) rate their agreement or disagreement with possible barriers to offering SP counseling, using a 5-point Likert scale; 8) state whether, when counseling mothers about SP, they recommended vitamin D supplementation for all, some, or none of their infant patients who were breastfed; 9) rate their interest in working with local schools and/or community organizations to promote SP to children; and 10) state whether they used educational materials when counseling on SP. In addition, the survey asked respondents to rank the importance of SP counseling compared with other preventive care topics, using a 1 to 5 scale (1 = very important and 5 = not at all important).

Demographic information about respondents included gender, age, race/ethnicity, region of the United States, practice location, and practice setting. Pediatricians were also asked whether they had a personal or family history of melanoma or NMSC.

Data Analysis
Analyses of questions regarding experience treating sunburn cases, attitudes toward and frequency of SP counseling, and patient education needs are based on 775 pediatricians (88% of all respondents) who provide direct patient care. Questions regarding the specifics of SP counseling are based on 679 respondents (77% of all respondents) who reported discussing SP with at least some parents or patients (hereafter referred to as "patients").

We examined attitudes toward SP counseling; the reported prevalence of SP counseling; importance of counseling; and barriers to counseling by gender, age, race, region of the country, practice location, training status, practice setting, experience with treating sunburn cases, and family history of SC. For analysis purposes, responses to the primary practice setting question were grouped into 3 practice types: 1) those who spend most of their time in solo or 2-physician practice (referred to as "solo practice"); 2) those who spend most of their time in pediatric group practice, multispecialty group practice, or a staff model health maintenance organization ("group practice"); and 3) those who practice in medical schools, hospitals, clinics, or community health centers ("hospital/clinic practice"). Region was categorized into US Census groupings of Northeast, Midwest, South, and West. Respondents were separated into 2 groups on the basis of mean age: <42 years old ("younger") and 42 years old ("older").

Selected questions were examined by the experience of treating sunburn cases: respondents who treated 1 cases of sunburn during the 12 months before the survey were compared with those who had not treated any. Respondents were also grouped by those who reported having a personal or family history of any type of SC and those who did not. Similarly, respondents who discussed SP with 75% of their patients in every age group were compared with those who discussed this topic with less frequency.

Data were analyzed using SPSS 11.5 (SPSS Inc, Chicago, IL). ² tests were performed to compare responses by the practice and personal characteristics as defined. Differences in response rates between groups are noted as statistically significant at the P .05 level. We used a theoretically derived multivariable logistic model that included all independent characteristics included in the questionnaire (age, gender, etc) that might affect practice. Personal history and other characteristics of physicians have been shown to have an effect on counseling practices.^16–19 We hypothesized that there could be a relationship between SP counseling practice and the independent variables listed above, experience treating sunburn, and personal or family history of SC.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Characteristics of Respondents
There were somewhat fewer male compared with female pediatricians (45.5% vs 54.5%). The average age was 42.2 years. Three fourths (74.9%) of pediatricians described themselves as white non-Hispanic; 25.1% identified themselves as belonging to other groups. These and other demographic characteristics are summarized in Table 1. The characteristics of respondents are consistent with those of other recent Periodic Surveys and are representative of the known characteristics (gender, age, and geographic region) of the AAP membership at the time (data not shown). For this survey, respondents were more likely to be female compared with nonrespondents, although mean age and distribution by geographic region were similar. Approximately 80% of board-certified pediatricians are AAP members.

Experience Treating Sunburn Cases
Nearly 6 (58.9%) of 10 pediatricians reported treating 1 sunburn case; 41.1% said that they had no cases. Pediatricians who treated sunburned patients saw an average of 8.3 such cases during the past year. Experience treating sunburn varied by practice characteristics. Male pediatricians, older pediatricians, and those who were generalists were more likely than female pediatricians, younger pediatricians, or those who spent most of their time in a subspecialty to say that they had treated such cases (64.1% male vs 54.8% female [P < .01]; 66.9% 42 years vs 51.6% <42 years [P < .001]; 68.0% generalists vs 29.5% subspecialists [P < .001]). Pediatricians in inner-city practices and hospital/clinic practices were least likely to have treated sunburns (36.6% inner city vs 54.1% urban vs 73.7% suburban vs 75.6% rural [P < .001]; 69.3% solo vs 75.7% group vs 35.7% hospital/clinic [P < .001]). There were no significant differences in treating sunburn on the basis of region.

Attitudes Regarding the Importance of Sun Exposure and SC
Nearly all pediatricians agreed that 1) cumulative sun exposure during childhood increases the risk of SC in adulthood (95.1%), 2) SC is a significant public health problem (93.3%), 3) pediatricians should educate patients on SP (92.9%), and 4) prevention of episodic high exposure to the sun in childhood will reduce the likelihood of developing melanoma in adulthood (91.8%). Most (82.5%) pediatricians did not think that SP counseling should be directed only toward white or light-skinned patients. Three fourths (75.2%) of pediatricians believed that schools should provide comprehensive educational programs about SP at all grade levels; 18.6% were not sure.

In general, attitudes toward SP counseling and risks of SC did not differ by practice characteristics, frequency of treating sunburn cases, personal/family history of SC, or proportion of patients counseled. However, more pediatricians who had treated sunburn cases compared with those who had not (92.8% vs 90.1%; P < .01) and more pediatricians who had personal or family experiences with SC compared with those who did not (95.5% vs 89.8%; P < .05) believed that prevention of episodic high exposures to the sun will reduce children’s likelihood of developing melanoma in later life.

Proportion of Patients Counseled and Factors Associated With Counseling
Most (88.1%) pediatricians reported that they had discussed SP with some (at least 1%) of their patients at least once during recent summer months. Counseling practices varied somewhat by patient age. Approximately 4 of 10 pediatricians said that they discussed SP with 75% of their patients younger than 3 years. Approximately one third reported discussing this topic with most (75%) of their patients of other ages (34.2% discussed with most patients 3–6 years, 31.4% with patients 7–9 years, 31.8% with patients 10–13 years, and 32.6% with patients 14 years). Overall, only 22.3% of pediatricians said that they discussed SP with most (75%) of their patients in every age group.

Bivariate analysis found that female pediatricians were more likely than male pediatricians to report counseling 75% of their patients in every age group (25.3% vs 19.0%; P < .05). Pediatricians in the Northeast and Midwest compared with the South and the West were more likely to routinely counsel most patients in every age group (27.7% Northeast vs 26.6% Midwest vs 18.0% South vs 16.8% West; P < .05), as were pediatricians in suburban practices compared with other practice settings (10.5% inner city vs 19.1% urban vs 31.1% suburban vs 22.2% rural; P < .001). Those in hospital/clinic practices were least likely to counsel (33.7% solo vs 28.7% group vs 9.2% hospital/clinic; P < .001). Pediatricians who had completed their training were more likely to counsel compared with residents (24.9% postresidents vs 8.1% residents; P < .001). Pediatricians who treated 1 sunburn case were more likely to counsel 75% of patients compared with pediatricians who treated no cases (27.4% vs 14.0%; P < .001). There were no differences in the proportion of pediatricians who counseled 75% of their patients by pediatricians’ race or personal/family history of NMSC or melanoma. Analysis of responses to the first and second mailings compared with responses from the later mailings showed no differences in those who counsel 75% of all age groups, those who counsel selectively, and in the percentage of respondents who reported sunburn cases.

Multivariate logistic regression analysis (Table 2) revealed that the factor associated with increased likelihood of counseling the majority of all patients was female gender: female pediatricians were nearly twice as likely as male pediatricians to counsel. The factors that decreased the likelihood of counseling were practicing in a hospital/clinic setting and being located in the South or the West. Neither experience with treating sunburn cases nor having a family history of SC had a significant independent effect on counseling.

SP Recommendations
Nearly all (98.5%) pediatricians recommended the use of SPF 15 sunscreen when counseling patients. Most reported telling patients to avoid the sun during peak hours (72.4%) and to wear a hat with a brim (69.4%). Six of 10 encouraged patients to seek shade whenever possible and to wear a long-sleeved shirt or other protective clothing when exposed to the sun (59.7% and 57.1%, respectively). Fewer than half (46.5%) discussed avoiding use of sun lamps or tanning salons, and fewer than 10% advised patients to consult the UV index. Table 4 lists the percentage of pediatricians who choose each SP practice as their number 1 recommendation.

Younger pediatricians and those in hospital/clinic settings were more likely to say that lack of adequate professional training is a barrier (23.1% <42 years vs 16.6% 42 years [P < .01]; 16.7% solo vs 15.3% group vs 28.9% hospital/clinic [P < .01]), as is the lack of a reminder system (39.3% <42 years vs 26.7% 42 years [P < .01]; 29.9% solo vs 26.9% group vs 42.1% hospital/clinic [P < .01]). Lack of written information on SP/SC was a barrier named by more pediatricians in hospital/clinic practices (solo 42.3% vs group 30.0% vs hospital/clinic 47.4%; P < .01).

Recommendations for Vitamin D Supplementation
When counseling mothers of infants on SP, 31.8% of pediatricians reported recommending supplementation with vitamin D for some breastfed infants, and 23.2% did so for all breastfed infants; 39.7% of pediatricians did not recommend vitamin D supplements for breastfed infants. Among those who recommended supplements for selected patients (n = 208), 66.3% did so for breastfed infants with little sun exposure, and 63.9% did so for breastfed infants of color; 11.9% recommended vitamin D supplements for other breastfed infants.

Educational Needs
One fourth (24.9%) of pediatricians reported using patient education materials on SP. Nearly all (96.2%) of these pediatricians used brochures; 21.2% used posters, and 2.2% used videos.

Seven (73.3%) of 10 pediatricians said that they were interested in additional education on SP, such as information on SP recommendations (83.4%), how to choose a sunscreen (78.9%), childhood exposure and risks of SC in adulthood (75.2%), advising adolescents on SP (68.9%), and vitamin D supplementation (63.6%). Approximately half said that they would like more information on the effects of UVR (42.1%) and the UV index (46.6%). Forty-four percent said that they were interested in learning more about tanning salons. Some pediatricians expressed interest in working with local schools and/or community organizations to promote SP: 11.7% said that they were very interested, and 44.0% said that they were somewhat interested in doing so; 44.4% expressed no interest.

Importance of SP Counseling
Table 6 shows the percentage of pediatricians who ranked SP as "very important" compared with the other topics that pediatricians are expected to address during health maintenance visits and the mean scores for importance. Although all listed topics were rated as important or fairly important, pediatricians were less likely to rate SP as "very important" compared with other topics. The mean score for SP (2.0) ranked as one of lesser importance.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Our survey indicates that the large majority of respondents agree that SC is an important public health issue with roots in childhood and that preventing episodic high exposures to the sun can help to prevent SC. Reported counseling behavior, however, was not consistent with respondents’ attitudes: a minority of respondents reported counseling most patients, defined as 75% of patients, and only 22% of respondents reported routinely counseling patients in all age groups. More counseling was reported for children in younger age groups, perhaps because there are more health maintenance visits scheduled at younger ages, allowing for more opportunities to discuss SP. A majority of respondents reported selectively counseling on the basis of patient characteristics.

Female pediatricians were more likely to counsel most patients on SP; this finding is consistent with other studies demonstrating that female pediatricians are more likely than male pediatricians to counsel patients on preventive health topics.^16,17 Pediatricians in the West and South and those in hospital or clinic settings were least likely to provide counseling. It is easy to comprehend why pediatricians in hospital and clinic settings were less likely to provide SP counseling to most patients: parents who use these settings often have many urgent needs with which to contend. It is harder to explain the finding that pediatricians in the South and West were less likely to provide counseling, because many parts of these areas are sunny and warm.

Approximately half of the pediatricians reported counseling on the basis of patient characteristics such as white or light-skinned coloring, tendency to sunburn, or family history of SC. This result makes sense given that there is a higher risk of all skin cancers in individuals with light skin and light eyes, and melanoma risk increases with a family history of melanoma and with blistering sunburns in childhood. Excessive sun exposure can have deleterious health effects to the skin, eyes, and immune system of any person, however, so it is important to educate all parents and patients about SP.

Contrary to other data showing that personal and professional exposure to health risks leads to higher rates of counseling,^18,19 personal and family history of skin cancer and cases of sunburn treated in this study were not significantly related to counseling the majority of patients. The number of cases of sunburn seen was not significantly related to area of the country, yet pediatricians in the West and South were less likely to counsel. Although suburban and rural pediatricians were more likely to see cases of sunburn, they were not significantly more likely to counsel compared with pediatricians in inner-city and urban areas. Furthermore, SP was not considered to be as important as other issues to be covered in preventive care visits, as indicated by the mean score assigned to SP compared with other topics and by the percentage of pediatricians who rated the subject "very important" as compared with other topics.

Sunscreen was the most frequently recommended SP method and the method ranked as most important by the large majority of respondents. Sunscreen is the most widely used method of SP.^20,21 Clinical trials^22,23 have demonstrated that sunscreen use can reduce the incidence of actinic keratoses, the precursor lesions of SCC. One randomized clinical trial showed that sunscreen also reduces SCC.²⁴ No randomized controlled clinical trials have shown that sunscreen can prevent melanoma. Sunscreen users have been found to have a higher risk of melanoma and BCC and higher numbers of nevi.²⁵ This may be explained by the possibility that fair-skinned people who are at high risk for developing skin cancer are more likely than dark-skinned people to use sunscreens. In addition, some investigators have hypothesized that people who use sunscreens may spend more time in the sun.²⁶ Such people do not sunburn as readily as do nonusers of sunscreen and may be exposed to other parts of the sunlight spectrum responsible for the development of BCC and melanoma. Despite these concerns, sunscreen is recommended by the AAP,¹⁰ the American Academy of Dermatology,²⁷ the American Cancer Society,²⁸ and the National Council on Skin Cancer Prevention.²⁹ Sunscreen use is viewed not as the sole or main strategy for preventing adverse effects but as 1 part of an overall program of sun avoidance. Because there is no advantage to sunburning, sunscreen is recommended when a child will be in the sun long enough to sunburn.¹⁰

Other SP methods frequently recommended by respondents were avoiding the sun during peak hours, wearing a hat, seeking shade, and wearing clothing. Wearing clothing has been shown to reduce the number of nevi²⁵; nevi are considered a risk factor for the development of melanoma. It is concerning that fewer than half of pediatricians reported discussing the avoidance of sun lamps or tanning salons. Every day, an estimated 1 million people visit these salons; between 12 and 24 million are regular users.³⁰ A 1992 survey of 220 teenagers showed that 33% of girls and 16% of boys had been to a tanning salon at least once.³¹ Current evidence suggests a causal relationship between exposure to artificial UVR and melanoma.^32,33 The National Institute of Environmental Health Sciences has concluded that sunlamps and tanning beds are carcinogenic.³⁴ It is also noteworthy that very few pediatricians advised patients to consult the UV index.

Sun protection was given a low priority score relative to other prevention areas. This finding is concerning given current rates of NMSC and the rapidly increasing rates of melanoma, including its increasing occurrence in young adults. It has been said that physicians who see children tend to do little or nothing about SC prevention because they may not make the connection between sun exposure early in life and the occurrence of SC later in life.³⁵ Our data suggest that other factors may be at play: lack of time, lack of materials, and a perception that counseling falls on deaf ears because many parents and patients do not wish to comply with SP measures. Recent data support the last concern: a nationwide survey of 10 000 teenagers aged 12 to 18 revealed that 83% reported having 1 or more sunburns during the previous summer, with approximately one third reporting 3 or more sunburns. Furthermore, nearly 10% had used a tanning bed during the previous year; 24% of older girls (15–19) reported using a tanning bed. Only 34% of teenagers reported routinely using sunscreen.³⁶

Supplying pediatricians with educational materials for themselves and for their patients should enable them to better provide education. The AAP publishes a patient education brochure³⁷ that may help to reinforce messages delivered by pediatricians. Development of patient education materials could be coordinated with other organizations such as the American Academy of Dermatology and the Skin Cancer Foundation. Materials can be used to augment brief counseling during health maintenance visits, which are frequent during the first 2 years of life; the topic can be brought up in the spring and summer months or when a child will be traveling to sunny places. Reminder systems could be of additional help in increasing SP counseling; reminder/recall systems have been successful in increasing vaccination rates.³⁸ Although educational materials were requested by a majority of pediatricians, our results suggest that certain groups of pediatricians may need special targeting: younger pediatricians and those in hospital or clinic practices might benefit from use of reminder systems and additional professional training.

Successful interventions to increase counseling done by pediatricians have been described.¹³ There are as yet few data, however, to demonstrate that counseling by pediatricians can change the behavior of parents and children with regard to their SP practices. In a survey conducted in Florida, children’s caregivers who were counseled by pediatricians on SP had greater knowledge about SP and were more likely to report regular use of sunscreen for their child, compared with those who were not counseled.³⁹ The US Preventive Services Task Force recently concluded that "the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer." The US Preventive Services Task Force also concluded that counseling parents may increase the use of sunscreen for children but that there was little evidence to determine whether counseling influenced the adoption of other sun-protective behaviors.⁴⁰ Despite the dearth of data about the effectiveness of counseling by pediatricians, it seems reasonable to recommend that pediatricians continue to counsel parents and children to avoid sun exposure while data about the effectiveness of such counseling continue to emerge.

In addition to office-based interventions, pediatricians can play a role in the community and schools. For example, pediatricians could participate in community efforts to encourage schools and parents to have shaded playgrounds and policies for sun safety. The state of California is considering banning teenagers from attending tanning salons⁴¹ and has policies in place to allow schools to encourage children to wear hats while they are outside.⁴² Pediatricians and their office staff might want to look at research-tested materials that can be used in the office (cancercontrolplanet.cancer.gov/sun_safety.html).

Expecting overburdened physicians to be a main source of education may be unrealistic. Pediatricians are expected to deliver many important messages on numerous topics in a short period of time. Therefore, to have an effect on skin cancer incidence and mortality, sustained public health campaigns are needed to change the norms that result in excess sun exposure.³⁵ Current fashion and beauty norms result in widespread notions that a tan is healthy and beautiful and that burning is not dangerous. The SunWise School Program developed by the US Environmental Protection Agency is an example of a successful school-based educational campaign. SunWise is a national environmental and health education program for sun safety of children in primary and secondary schools (grades K–8). An analysis of pre- and postprogram data from >4000 students showed significant increases for knowledge and intended behavior. Attitudes regarding the healthiness of a tan also decreased significantly. Brief, standardized SP education can be interwoven efficiently into existing school curricula and result in increases in knowledge and positive intentions for SP. A multidimensional community-based SC prevention program conducted in 10 towns in New Hampshire resulted in increases in the proportion of children in the intervention group with at least some SP⁴³ with changes persisting over time.⁴⁴ The Centers for Disease Control and Prevention has concluded that "schools can play a substantial role in protecting students from unnecessary exposure to UV, thereby reducing their future risk for skin cancer. A comprehensive school approach to skin cancer prevention includes policies, environmental change, educational curricula, family involvement, professional development, integration with health services, and evaluation."⁴⁵

Recommendations Regarding Vitamin D
This survey was undertaken before the promulgation of 2003 AAP guidelines regarding vitamin D supplementation.⁴⁶ Those guidelines recommend that all breastfed infants receive supplementation with 200 international units of vitamin D. Supplementation also is recommended for nonbreastfed infants who ingest <500 mL of vitamin D–fortified formula per day. The guidelines were developed because of growing concerns about rickets resulting from inadequate intake of vitamin D and decreased exposure to sunlight.

Almost one third of respondents to this survey reported recommending supplementation with vitamin D for some breastfed infants in their practice, and one quarter did so for all breastfed infants; almost 40% did not recommend vitamin D supplements for breastfed infants. These survey results provide baseline data that may be useful to monitor pediatricians’ future practices regarding vitamin D supplementation.

Strengths and Limitations of Study
This survey assessing the attitudes, counseling practices, and educational needs of pediatricians regarding SP is 1 of few studies of nationwide scope on this important public health issue. The response rate of almost 55%, although relatively low, is similar to the response rate for other studies of this nature,⁴⁷ and the large number of respondents provides an adequate sample size for analysis. Strengths of this study include that it provides new information about counseling broken down by the age of patients, collects important correlates of counseling such as attitude and demographic characteristics, and collects information about selective counseling.

Although the mean age and distribution by geographic region of nonrespondents are similar to those of respondents, there is a higher proportion of female pediatricians among respondents. The generalizability of our results may be limited because of the unknown impact of nonresponse bias and because some pediatric care is provided by pediatricians who are not AAP members and by other clinicians such as family practitioners. In addition, data on counseling practices are based on pediatrician report and not on patient-based encounters.

	CONCLUSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
This nationwide study revealed that pediatricians believe that SC and SP are important issues to the health of patients and that they believe that childhood sun exposure affects SC risk. A majority of pediatricians selectively counsel on the basis of patient characteristics. Only a minority counsel most patients in every age group. Female pediatricians counsel more compared with male pediatricians; pediatricians in hospitals and clinics and in the South and West counsel less. Time constraints are the main barrier to counseling. Educational materials and other interventions should be helpful in increasing counseling, but a broader public health approach is needed as a complement to pediatricians’ counseling role.

SC deaths are small in number compared with deaths from other forms of cancer. These deaths are particularly tragic, however, because they often occur in younger people and because they are largely preventable through avoidance of UVR, as well as through early detection. Clearly, a sustained public health effort is needed to combat the rising incidence of and deaths from SC in the United States.

	ACKNOWLEDGMENTS

 
This work was supported by the American Academy of Pediatrics. We thank Andrew D. Racine, MD, PhD, for helpful review of the manuscript and Sanford Sharp for assistance with data collection and analysis. We also thank the pediatrician participants.

	FOOTNOTES

 
Accepted Jul 1, 2004.

Reprint requests to (S.J.B.) 1621 Eastchester Rd, Bronx, NY 10461. E-mail: sbalk{at}montefiore.org

The views expressed are those of the authors and do not represent policies of the American Academy of Pediatrics.

	REFERENCES

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