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Am Fam Physician. 1999;60(7):2177-2180

AAP Policy on Use of Sunscreen in Infants

The American Academy of Pediatrics (AAP) has issued a new policy statement on the dangers of sun exposure to infants. According to the statement, which appeared in the August 1999 issue of Pediatrics, it may be safe to use sunscreen on infants younger than six months of age when adequate shade and clothing are unavailable.

Previously, the AAP did not advise the use of sunscreen on infants. However, there is no evidence that using sunscreen on small areas of an infant's skin causes harm. Avoiding sun exposure and dressing infants in lightweight pants and long-sleeved shirts remain the primary recommendations of the AAP, but when this is not possible, parents should apply a minimal amount of sun-screen to exposed areas of the infant's body, such as the face and back of the hands, to avoid sunburn.

According to the policy statement, children, including infants, are also at increased risk for eye injury from sun exposure. The AAP suggests that infants and children wear hats with a brim and sunglasses that block at least 99 percent of the sun's rays to protect them from retinal damage. Further recommendations from the AAP include the following:

  • Physicians should incorporate advice on sun protection into their health supervision practices.

  • Physicians will rarely see infants and children with melanoma or non-melanoma skin cancer. Therefore, patients at high risk, such as those with a large number of nevi and a family history of melanoma, should be identified and treated in collaboration with a dermatologist.

  • Physicians should encourage schools to adopt safe sun practices, such as shaded playgrounds, allowance of “uniform” hats and outdoor time before 10 a.m.

The AAP also encourages the government and schools to educate the public and raise awareness of the dangers of sun exposure.

Decline in U.S. Cancer Incidence and Deaths

According to the “Annual Report to the Nation on the Status of Cancer, 1998–99, With a Special Section on Lung Cancer and Tobacco Smoking,” the incidence of new cancer cases and the rate of deaths from all cancers combined decreased in the United States between 1990 and 1996. The American Cancer Society, the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention released the report, which was published in the April 21, 1999, issue of the Journal of the National Cancer Institute.

The incidence rate (the number of new cancer cases per 100,000 persons) for all cancers combined declined an average of 0.9 percent per year between 1990 and 1996, with the greatest decrease after 1992, the year in which incidence rates peaked. From 1990 to 1996, the death rate from cancer has fallen an average of 0.6 percent per year.

The greatest decline in the incidence rate was seen among men, who overall have higher rates of cancer than women. From 1990 to 1996, the overall decline in the incidence rate was greater for men than for women, with the largest decrease seen among men who were 25 to 44 years of age and those 75 years and older. Among women, the largest decrease was seen in those 35 to 44 years of age and those 85 years and older. The death rate decreased among men of all ages, with the exception of those 85 years of age and older; this decrease actually influenced the overall decline. The death rate decreased among women younger than 65 years.

The report also includes a special section on lung cancer and tobacco use. Lung cancer accounts for 28 percent of all cancer deaths each year, causing more deaths than any other type of cancer. According to the study, from 1990 to 1996, incidence rates of lung cancer among men decreased an average of 2.6 percent per year, and death rates decreased by about 1.6 percent per year. However, the incidence and death rates of lung cancer have increased among women. In the 1990s, the incidence rate among women increased by about 0.1 percent per year, while the death rate increased by about 1.4 percent.

The report was compiled from incidence data from NCI's Surveillance, Epidemiology, and End Results Program and mortality data from the National Center for Health Statistics.

Reflex Sympathetic Dystrophy Syndrome

Practice guidelines on the diagnosis, treatment and management of reflex sympathetic dystrophy syndrome (RSDS), also known as complex regional pain syndrome, have been written by an interdisciplinary committee appointed by Anthony Kirkpatrick, M.D., Ph.D., director of research at the Reflex Sympathetic Dystrophy Syndrome Association of America (RSDSA).

RSDS is a painful neurologic syndrome that results from a soft tissue injury or minor trauma. It is often underdiagnosed and undertreated. The pain (which is often described as severe, constant, stabbing and burning) and sensitivity to touch that accompany the condition are out of proportion to the original injury.

According to Dr. Kirkpatrick, “The single most important modality for treating the patient with RSDS is education.” The guidelines suggest the use of a detailed algorithm to guide physicians step-by-step through the diagnosis and treatment of the syndrome. The guidelines are written in language that patients will be able to understand, so that persons with RSDS who do not have access to sub-specialists will be able to make informed decisions about their care.

The first edition of the guidelines is available on the RSDSA Web site ( or by calling the RSDSA at 856-795-8845.

HRSA Publication About Universal Newborn Hearing Screening

A publication promoting the early identification of hearing loss has been published by the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA). The 36-page document focuses on 13 areas to be addressed when implementing and operating a successful early identification hearing loss program for newborns. These include choosing equipment, training, financing, managing data and communicating with parents, physicians and hospital staff. A 1993 National Institutes of Health consensus conference recommended that all infants be screened before hospital discharge. The document describes four newborn hearing screening technologies in use that are practical and cost-effective. Free copies of the document are available from the National Maternal and Child Health Clearinghouse at

Problem Drinking in the Workplace

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published a report on alcohol and the workplace (Alcohol Alert No. 44). According to the report, the use of alcohol by U.S. workers can threaten public safety, impair work performance, and result in costly medical and social problems that affect employees and employers. Losses in productivity that were attributed to alcohol cost U.S. businesses an estimated $119 billion in 1995. The report explains that employers are in a unique position to help mitigate some of the factors that lead to problem drinking and have the ability to motivate employees to seek help for problems with alcohol.

Several factors may lead to alcohol-related problems in the workplace. These include the workplace culture, feelings of alienation in the work-place, the availability and accessibility of alcohol, limited supervision, and awareness and enforcement of alcohol policies in the workplace.

Performance problems related to alcohol are caused not only by drinking at work but also by heavy use of alcohol outside of work. Employee drinking is often associated with frequent absenteeism, arriving late to work or leaving early, doing poor work, doing less work and arguing with coworkers.

The entire report can be found on the NIAAA Web site ( Copies are also available at no charge by writing the NIAAA Publications Distribution Center, attn: Alcohol Alert, P.O. Box 10686, Rockville, MD 20849-0686.

Progestin-Only Emergency Contraception

The U.S. Food and Drug Administration approved the first progestin-only pill developed to prevent pregnancy after a contraceptive accident or unprotected sex. The Plan B package contains two 0.75-mg tablets of levo norgestrel. One pill is to be taken within 72 hours of unprotected sex, and the second pill is taken 12 hours later.

The manufacturer states that Plan B should not be used as a routine form of contraception because it is not as effective as most contraceptives and does not protect against sexually transmitted diseases. It has an 89 percent reduction in risk of pregnancy following a single act of unprotected sex. Results from two studies indicate that Plan B is more effective and better tolerated than the older Yuzpe regimen.

More information about Plan B can be found on the Plan B Web site at

Tool Kit Available to Help Physicians Address Noncompliance in Patients

To help physicians address the growing problem of noncompliance in patients, the American Heart Association (AHA) has made available a free kit of health care materials called “America's Hidden Health Threat Professional Toolkit,” a folder of materials for use with patients. Materials in the kit include the AHA primary and secondary cardiovascular disease guidelines, a scientific statement on the multilevel compliance challenge, a compliance poster and a sample patient education sheet. Free copies of the tool kit and the patient booklet, “Knock Out America's Hidden Health Threat,” can be requested by calling 800-AHA-USA1. Patient education sheets and other items can be obtained on the compliance section of the AHA Web site ( ).

Measles Vaccination in HIV-Infected Children

Children with human immunodeficiency virus (HIV) have had high mortality rates attributable to measles but, until recently, measles vaccine was thought to be safe for these children. According to a new American Academy of Pediatrics (AAP) policy statement, written by the Committee on Infectious Diseases and the Committee on Pediatric AIDS and published in the May 1999 issue of Pediatrics, severely immunocompromised HIV-infected children should not receive the measles vaccination. Because a protective immune response often does not develop in severely immunocompromised HIV-infected children after immunization and some risk of severe complications exists, these children should not be vaccinated.

Further recommendations from the AAP policy statement include the following:

  • HIV-infected children, adolescents and young adults without evidence of severe immunosuppression should receive the measles-mumps-rubella (MMR) vaccine. The first dose should be given at 12 months of age, and the second dose may be administered as early as 28 days after the first dose. If an outbreak occurs in the community, the MMR vaccination is recommended for infants as young as six months of age when exposure to natural measles is likely. Children vaccinated before 12 months of age should be revaccinated with MMR at 12 months, and an additional dose may be administered as soon as 28 days later.

  • All members of the household of an HIV-infected person should receive the measles vaccine unless they are infected with HIV and severely immunosuppressed, were born before 1957, have been diagnosed with measles by a physician, have laboratory evidence of immunity to measles, have had age-appropriate immunizations or have a contraindication to the measles vaccine.

  • If they are exposed to wild-type measles, all HIV-infected children and adolescents, and children of unknown infection status born to HIV-infected women should be given immune globulin prophylaxis, regardless of their degree of immunosuppression or measles immunization status.

Additional information about measles immunization in HIV-infected children is available in the AAP policy statement.

AHA Policy Statement on Very Low Fat Diets

According to a science advisory from the American Heart Association (AHA), there is evidence for and against the use of very low fat diets. Results from a few clinical trials suggest that very low fat diets are associated with reduced risk of cardiovascular disease, but many unanswered questions remain that make population-wide recommendations of such diets premature.

Current dietary guidelines from the AHA and the National Cholesterol Education Program recommend restricting fat consumption to a maximum of 30 percent of daily caloric intake. With the exception of the World Health Organization Study Group, which recommends that 15 percent of total calories be derived from fat, current guidelines do not specify a lower limit on fat intake. Recommending a lower limit is controversial, because while a very low fat diet (one in which 15 percent or less of total calories are derived from fat) may reduce cardiovascular risk and body weight, it may also produce harmful effects on certain subgroups in the population.

For certain persons, such as those with hypertriglyceridemia or hyperinsulinemia, the elderly or the very young, the risk for elevated triglyceride levels, decreased HDL cholesterol levels and nutritional inadequacy must be considered. The nutritional adequacy of very low fat diets depends on individual food choices. These diets can include nutrient-dense foods such as fruits, vegetables, whole grains, and low-fat or fat-free dairy products, or they may consist of more recent varieties of fat-free and low-fat alternatives to traditionally high-fat foods, such as snacks and desserts.

At this time, no health benefits and possible harmful effects can be predicted from adherence to very low fat diets in certain subgroups. A single reprint of the AHA science advisory (reprint No. 71-0143) is available by calling 800-242-8721 or by writing the AHA at Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596.

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Copyright © 1999 by the American Academy of Family Physicians.

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