State of the science on prevention and screening to reduce melanoma incidence and mortality: The time is now.

Answer questions and earn CME/CNE Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic, and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet radiation increases melanoma risk. Unprecedented antitumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma-associated deaths. This article reviews the state of the science on prevention and early detection of melanoma and current areas of scientific uncertainty and ongoing debate. The US Surgeon General's Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors-health care, government, education, business, advocacy, and community-to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the United States. CA Cancer J Clin 2016;66:460-480. © 2016 American Cancer Society.

Clinical counseling on sun protection and indoor tanning avoidance: A survey of current practices among U.S. health care providers.

Clinicians can play a role in skin cancer prevention by counseling their patients on use of sun protection and indoor tanning avoidance. We used data from the 2016 DocStyles, a web-based survey of U.S. primary care providers, to examine skin cancer prevention counseling practices among 1506 providers. In 2018, we conducted logistic regression analyses to examine factors associated with regularly providing counseling. Almost half (48.5%) of all providers reported regularly counseling on sun protection, and 27.4% reported regularly counseling on indoor tanning. Provider characteristics associated with regular counseling included having practiced medicine for at least 16 years (sun protection: adjusted prevalence ratio [aPR] = 1.27, 95% confidence interval [CI] = 1.15, 1.41; indoor tanning: aPR = 1.38, 95% CI = 1.17, 1.63), having treated sunburn in the past year (sun protection: aPR = 1.78, 95% CI = 1.46, 2.17; indoor tanning: aPR = 2.42, 95% CI = 1.73, 3.39), and awareness of U.S. Preventive Services Task Force recommendations (sun protection: aPR = 1.73, 95% CI = 1.51, 2.00; indoor tanning: aPR = 2.70, 95% CI = 2.09, 3.48). Reporting barriers to counseling was associated with a lower likelihood of regularly counseling on sun protection (1-3 barriers: aPR = 0.82, 95% CI = 0.71, 0.94; 4+ barriers: aPR = 0.80, 95% CI = 0.69, 0.93) and indoor tanning (1-3 barriers: aPR = 0.72, 95% CI = 0.57, 0.91; 4+ barriers: aPR = 0.61, 95% CI = 0.47, 0.78). Barriers to counseling included lack of time (58.1%), more urgent health concerns (49.1%), and patient disinterest (46.3%). Although many providers report regularly counseling patients on skin cancer prevention, most report serious barriers to providing such counseling. Additional research could explore strategies to integrate compelling and informative skin cancer prevention counseling into current provider practices.

Consumer products as sources of chemical exposures to children: case study of triclosan.

PURPOSE OF REVIEW: Consumer products are often overlooked as sources of children's exposures to toxic chemicals. Various regulatory bodies have developed lists of chemicals of concern that can be found in products contacted by children. However, this information has not been summarized for health practitioners. This review organizes such chemicals and products into four categories, with the antibacterial agent triclosan used to illustrate the potential risks to children from a common ingredient in consumer products. RECENT FINDINGS: Biomonitoring, house dust, indoor air, and product testing document children's exposures to a wide variety of chemicals. An increasing number of epidemiology studies have shown associations between these exposures and health effects in children. Triclosan is an example of a chemical contained in high contact products (e.g., soaps, lotions, and toothpaste) not necessarily designed for children. Triclosan exposure in children has been associated with increased responsiveness to airway allergens, with it also capable of endocrine disruption. However, the utility and necessity of this chemical in consumer products has not been demonstrated in most cases. SUMMARY: Triclosan and the other examples provided show that a changing marketplace with little regulatory oversight of chemical uses can lead to unanticipated exposures and potential health risks to children.

Pediatricians' perspectives on indoor tanning.

This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanning among adolescents, as well as their awareness of current legislation that restricts youth access to tanning beds.

Preventing Excessive Noise Exposure in Infants, Children, and Adolescents.

Noise affects people of all ages. Noise-induced hearing loss, a major problem for adults, is also a problem for young people. Sensorineural hearing loss is usually irreversible. Environmental noise, such as traffic noise, can affect learning, physiologic parameters, sleep, and quality of life. Children and adolescents have unique vulnerabilities. Infants and young children must rely on adults to remove them from noisy situations; children may not recognize hazardous noise exposures; teenagers often do not understand consequences of high exposure to music from personal listening devices or attending concerts and dances. Personal listening devices are increasingly used, even by small children. Environmental noise has disproportionate effects on underserved communities. This statement and its accompanying technical report review common sources and effects of noise as well as specific pediatric exposures. Because noise exposure often starts in infancy and effects are cumulative, more attention to noise in everyday activities is needed starting early in life. Pediatricians can potentially lessen harms by raising awareness of children's specific vulnerabilities to noise. Safer listening is possible. Noise exposure is underrecognized as a serious public health issue in the United States. Greater awareness of noise hazards is needed at a societal level.

Preventing Excessive Noise Exposure in Infants, Children, and Adolescents.

Noise exposure is a major cause of hearing loss in adults. Yet, noise affects people of all ages, and noise-induced hearing loss is also a problem for young people. Sensorineural hearing loss caused by noise and other toxic exposures is usually irreversible. Environmental noise, such as traffic noise, can affect learning, physiologic parameters, and quality of life. Children and adolescents have unique vulnerabilities to noise. Children may be exposed beginning in NICUs and well-baby nurseries, at home, at school, in their neighborhoods, and in recreational settings. Personal listening devices are increasingly used, even by small children. Infants and young children cannot remove themselves from noisy situations and must rely on adults to do so, children may not recognize hazardous noise exposures, and teenagers generally do not understand the consequences of high exposure to music from personal listening devices or attending concerts and dances. Environmental noise exposure has disproportionate effects on underserved communities. In this report and the accompanying policy statement, common sources of noise and effects on hearing at different life stages are reviewed. Noise-abatement interventions in various settings are discussed. Because noise exposure often starts in infancy and its effects result mainly from cumulative exposure to loud noise over long periods of time, more attention is needed to its presence in everyday activities starting early in life. Listening to music and attending dances, concerts, and celebratory and other events are sources of joy, pleasure, and relaxation for many people. These situations, however, often result in potentially harmful noise exposures. Pediatricians can potentially lessen exposures, including promotion of safer listening, by raising awareness in parents, children, and teenagers. Noise exposure is underrecognized as a serious public health issue in the United States, with exposure limits enforceable only in workplaces and not for the general public, including children and adolescents. Greater awareness of noise hazards is needed at a societal level.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach.

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

A pediatrician's guide to climate change-informed primary care.

Despite the urgency of the climate crisis and mounting evidence linking climate change to child health harms, pediatricians do not routinely engage with climate change in the office. Each primary care visit offers opportunities to screen for and support children burdened with risks to health that are increasingly intense due to climate change. Routine promotion of healthy behaviors also aligns with some needed-and powerful-solutions to the climate crisis. For some patients, including those engaged in athletics, those with asthma and allergies, or those with complex healthcare needs, preparedness for environmental risks and disasters worsened by climate change is a critical component of disease prevention and management. For all patients, anticipatory guidance topics that are already mainstays of pediatric best practices are related closely to needed guidance to keep children safe and promote health in the setting of compounding risks due to climate change. By considering climate change in routine care, pediatricians will be updating practice to align with evidence-based literature and better serving patients. This article provides a framework for pediatricians to provide climate-informed primary care during the structure of pediatric well child and other visits.

E-Cigarettes and Other Electronic Nicotine Delivery Systems (ENDS).

Electronic nicotine delivery systems and vaping devices are now the most commonly used forms of tobacco consumed by youth and young adults. A variety of chemicals and toxicants released during inhalation have harmful systemic effects and effects on the lung. The known and potential health consequences are particularly alarming. There is concern that use of these devices will create a new generation of life-long smokers with nicotine and polysubstance addiction. Beyond the concerning chronic health effects of regular use, there is a recent epidemic of severe, acute lung disease termed e-cigarette, or vaping product use-associated lung injury, (EVALI), associated with high morbidity and mortality. These issues demand immediate public health attention. Healthcare providers play key roles in limiting the exposure of youth and young adults to these products by providing evidence-based counseling to patients and families, and by advocating for regulations to protect against childhood initiation and continuation of use.

Counseling on Sun Protection and Indoor Tanning.

BACKGROUND: The US Preventive Services Task Force recommends clinical counseling for individuals ages 10 to 24 years to decrease skin cancer risk. METHODS: A national, random sample of US American Academy of Pediatrics members practicing primary care in 2002 (response rate 55%) and 2015 (response rate 43%). Surveys explored attitudes and experiences regarding sun protection counseling; indoor tanning questions were added in 2015. χ2 tests compared demographics and counseling responses across years, and multivariable logistic regression models examined counseling predictors. RESULTS: More pediatricians in 2015 (34%) than in 2002 (23%) reported discussing sun protection during recent summer months with ≥75% of patients. This pattern held across all patient age groups (each P <.001). Female and suburban pediatricians counseled more; those in the South and West counseled less. More pediatricians in 2015 than in 2002 named time as a barrier. Sun protection ranked lowest among preventive topics in both years. In 2015, approximately one-third of pediatricians reported discussing indoor tanning at least once with 10 to 13 year-old patients; approximately half discussed this with older adolescents. Most (70%) did not know if their states had laws on minors' indoor tanning access; those stating they knew whether a law existed counseled more. CONCLUSIONS: Although improved, sun protection counseling rates remain low. Indoor tanning counseling can be improved. Because early-life exposure to UV radiation increases risk and clinician counseling can positively impact prevention behaviors, pediatricians have an important role in skin cancer prevention; counseling may save lives. Time constraints remain a barrier.

Comprehensive evaluation of indoor tanning regulations: a 50-state analysis, 2012.

Teenage use of indoor tanning has reached epidemic proportions. There is no federal ban on teen use; rather, it is left to each state to determine policy. We conducted a state-by-state analysis using data from each state's statutes and regulations and supplementary information from the National Conference of State Legislatures. First, we refined an earlier 35-item instrument to now include 56 items that extensively measures age bans, parental involvement, warnings/information, enforcement, and operating requirements. To grade each tanning law, we developed a uniform scoring system with a goal of providing performance data for future comparisons. As of August 2012, 13 states had no tanning facility statute or regulation for minors. In states with some regulations, teen bans are lax-nearly uniformly, most young children under the age of 14 can legally tan with or without suboptimal parental consent or accompaniment laws. Strong Food and Drug Administration involvement can simplify and unify the inconsistencies that exist among states' indoor tanning laws. Until consistent regulations are promulgated and enforced, such an instrument can provide a benchmark for state investigations into the deficiencies and progress of their laws, as well as facilitate direct comparison between states for research and educational purposes.

Severe obstructive sleep apnea in a child with melanocortin-4 receptor deficiency.

Obstructive sleep apnea (OSA) is a highly prevalent medical condition in obese children and is associated with significant neurocognitive, cardiovascular and metabolic derangements. Monogenic forms of obesity resulting from disruption of the leptin-melanocortin pathways have become more notable in recent years and distinguish between various obese phenotypes. However, the association of such disorders with OSA is not well established in children or adults. In this report, we describe a 23-month-old female with morbid obesity and OSA, who was found to carry a defect in the melanocortin-4 receptor (MC4R) pathway. This report emphasizes the genetic basis of obesity related to MC4R deficiency and OSA in children.

Teens and indoor tanning: a cancer prevention opportunity for pediatricians.

In October 2011, California became the first US state to ban indoor tanning for minors under age 18 years. Vermont followed in May 2012. Increasingly, scientific evidence shows that artificial tanning raises the risk of skin cancer, including melanoma, a common cancer in adolescents and young adults and the type most likely to result in death. The World Health Organization, the American Academy of Pediatrics, the American Academy of Dermatology, the American Medical Association, and other organizations strongly recommend legislation to ban minors under age 18 from indoor tanning. Several nations have banned teen tanning. Yet, tanning in salons is still a prevalent practice in the United States, especially among teen girls, where rates for the oldest teens approach 40%. There is no federal legislation to restrict minors from salon tanning. More than 60% of states have some kind of legislation regarding minors' use of tanning salons, but only California and Vermont have passed complete bans of indoor tanning for minors. The Indoor Tanning Association, an industry advocacy group, has vigorously opposed legislative efforts. Pediatricians can play key roles in counseling families and with legislative efforts. In this update, we review the prevalence of salon tanning, association with skin cancer risk, tanning addiction, the roles of the federal and state governments in regulation and legislation, and responses to arguments created by industry to oppose legislation. Preventing exposure to artificial tanning may save lives, including young lives, and is a key cancer prevention opportunity for pediatricians.

Ultraviolet radiation: a hazard to children and adolescents.

Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Yet, people continue to sunburn, and teenagers and adults alike remain frequent visitors to tanning parlors. Pediatricians should provide advice about UVR exposure during health-supervision visits and at other relevant times. Advice includes avoiding sunburning, wearing clothing and hats, timing activities (when possible) before or after periods of peak sun exposure, wearing protective sunglasses, and applying and reapplying sunscreen. Advice should be framed in the context of promoting outdoor physical activity. Adolescents should be strongly discouraged from visiting tanning parlors. Sun exposure and vitamin D status are intertwined. Cutaneous vitamin D production requires sunlight exposure, and many factors, such as skin pigmentation, season, and time of day, complicate efficiency of cutaneous vitamin D production that results from sun exposure. Adequate vitamin D is needed for bone health. Accumulating information suggests a beneficial influence of vitamin D on many health conditions. Although vitamin D is available through the diet, supplements, and incidental sun exposure, many children have low vitamin D concentrations. Ensuring vitamin D adequacy while promoting sun-protection strategies will require renewed attention to children's use of dietary and supplemental vitamin D.