r e v i e w ar t i c l e · 2019-09-11 · questionnaires tv and 37.9% played barrie rs, parental...

INDIAN PEDIATRICS 773 VOLUME 56__SEPTEMBER 15, 2019

Screen Time in Under-five Children

NIMRAN KAUR1, MADHU GUPTA1, PRAHBHJOT MALHI2 AND SANDEEP GROVER3

From Departments of 1Community Medicine and School of Public Health, 2Pediatrics and 3Psychiatry; Postgraduate Institute ofMedical Education and Research, Chandigarh, India.Correspondence to: Dr Madhu Gupta, Professor, Department of Community Medicine and School of Public Health, PostgraduateInstitute of Medical Education and Research (PGIMER), Chandigarh, India. [email protected]

Context: Screen-viewing in childhood is primarily a mean of entertainment, during the unstructured time. We aimed to review the burdenof the problem, delineate the associated factors and correlates, evaluate the impact of screen-time on the overall health of under-fivechildren, and the interventions to reduce screen-time. Evidence acquisition: Published articles from January 2009 to June 2018 weresearched through PubMed, Clinical Key, Scopus, Embase, and Google Scholar using key Medical Subject Heading words. Results: Theburden of screen-time varied from 21% to 98% in the middle-income, and 10% to 93.7% in the high-income countries. The socialecological model was used to illustrate associated factors and correlates including child, caregiver, micro and macro digital-mediaenvironment related factors. The interventions included increase in the physical activity, reduction in the body mass index, improvingsleep and dietary behaviors etc. The effectiveness of these interventions ranged from 0.3 minutes (standard error 13.3) to -47.16minutes (standard error 2.01). Conclusion: Clinicians should obtain history of screen-time in children, and advise limiting the screenexposure according to the child’s age. There is a need to generate evidence on burden and effectiveness of interventions amongchildren in the Indian settings, owing to the limited data.

Keywords: Digital-media, Obesity, Screen exposure, Sedentary behaviors, Smartphone, Television.

Screen-time or digital-screen exposureis the duration of time spent by theindividual in using electronic/digital media liketelevision (TV), smartphone, tablet or computer

[1]. As per American Academy of Pediatrics (AAP)guidelines [2], children below the age of two years shouldnot have any screen exposure, and screen time of ≥1 hourper day is considered excessive among children aged 2-5years. Also, for the proper growth and development ofchildren, the use of digital-media should be restrictedwhile eating meals, or one hour before sleep.

Excessive screen time is predominantly associatedwith sedentary behaviors in children and adolescents [3].Excessive screen time is considered as one of the majorrole players in causing non-communicable diseases(NCDs) [4] and health risks [5] later in life. A longitudinalstudy reported that there was a rapid increase in TV-timeby one year of age, and children who had screen time <1hour per day at 14 months of age, started watching screensfor >2 hours per day when they are aged 30 months [1]. AJapenese study reported that 29.4% of children of age 18months, 24.5% of age 30 months, and 21% at both ageswatched TV for 4 hours or more per day [6]. Children belowthe age of two years who watched TV for any duration perday, and children aged >2 years who watched TV for >2hours per day were more likely to show a delay in motorskill development [7]. Further, screen time has been

associated with impairments in language development[7,8], and behavioral [6], psychosocial, academic andphysical wellbeing [9].

There is limited published data on the duration ofscreen time, its associated factors and intervention studieson reducing it in the low- and middle-income countries(LMIC). The purpose of this review is to document theburden of screen time, its associated factors andcorrelates, outline the health impact, and summarize theinterventions developed to reduce screen time amongunder-five children.

Search strategy: A literature review of published articlesfrom January 2009 to June 2018 was performed throughsearches in PubMed, Clinical Key, Scopus, Embase, andGoogle Scholar. Medical Subject Headings (MeSH)words used were ‘preschooler’, ‘infant’, ‘kid’, and‘toddler’ for child-related terms; and ‘screen-time’,‘screen-viewing’, electronic media related- ‘electronicmedia’, ‘digital-media’, ‘TV’, ‘smartphone’, ‘mobilephone’ for screen-time related terms. When relevantarticles were identified, cross-references were searchedfor related studies.

Inclusion criteria for a searched article included (i)peer-reviewed article published in English language in thescientific journals; (ii) cross-sectional studies onprevalence of digital-media use, adherence to screen time

RRRRR EEEEE VVVVV IIIII EEEEE W AW AW AW AW A RRRRR TTTTT IIIII CCCCC LLLLL EEEEE


KAUR, et al. SCREEN TIME IN CHILDREN

guidelines, correlates of digital-media use among under-five children; (iii) cohort or case control studiesassessing association between at least one digital-mediagadget and behavioral outcome or demographic correlateamong under-five children; (iv) interventional studies in aschool-, clinic-, hospital-, family-, home-, or community-based setting to reduce screen time as one of theoutcome; and (v) studies measuring (proportion or mean)the use of atleast one type of digital-media gadget (likeTV, computer or videogames etc) by children. The articlesreporting digital-media exposure of caretakers or parentsor diseased children or older children were not included inthe analysis.

Potentially relevant articles were screened by theirtitles, and abstracts. When the abstract was not availableor had incomplete findings, the entire article was retrieved.Articles describing study protocols, reports,dissertations, models and conference abstracts wereexcluded. Data extraction form was used to obtain thestudy information, study design, country, age ofparticipants; exposure i.e., screen-based characteristics(e.g., duration, frequency, pattern, and measurement and/or description of intervention); outcome/health indicators(e.g., measurement type); results (e.g., odds ratio,difference in means); and covariates included in theanalyses (e.g., eating behaviors, emotional outcomes,sleep outcomes, psychological outcomes, nutrition,parental perceptions, parental behaviors, parenting skills,home environment, physical activity of the children).The search was done by two authors, and it was crosschecked by the third author for correctly excluding thestudies. Any discrepancies were resolved by the fourthauthor.

We identified 19,833 articles, 19511 were eitherduplicates or irrelevant, among these 322 articles werescreened based on their title and abstract (Fig. 1). Of the322 studies, 171 articles were excluded based upon theexclusion criteria, and 151 full text articles were assessed.Of these 101 articles were excluded due to a context otherthan the review. Finally, 50 studies were reviewed including14 cross-sectional studies [4,7,8,10-20], on prevalence,associated factors, correlates and consequences ofexcessive digital-media exposure (Table I) [1,6,9,21-28]; 11overlapping studies and two systematic reviews [29,30]on the associated factors, correlates and consequences ofexcessive digital-media exposure [1,6,9,21-28]; 16intervention studies [31-46], three systematic reviews[3,5,47] and four digital-media guidelines [2,48-50] amongunder-five children. Among the 16 interventions studies,two were pilot-RCTs [31,32], four cluster-RCTs [39-42], andten RCTs [33-38,43-46] (Table II). All studies relied on theinformation given by the parents.

BURDEN OF PROBLEM

The results of 14 cross-sectional studies for estimatingthe prevalence are summarized in Table I. Prevalence ofexcess screen time varies from 10% to 93.7% across thehigh-income countries, and 21% to 98% in the middle-income countries. Four out of 14 cross-sectional studiesconsidered screen time more than 2 hours per day asexcessive [4,17,19,20], six used screen time more than >1hour per day as excessive [6,8,11,14,16,24], whereas threestudies reported average screen time [7,12,14,18]. Overall,the screen time ranged from 0.1-5 hours per day amongunder-fives. Younger children (0-2 years) from the middle-income countries [26] and older ones (0-5 years) from thehigh-income countries [14] had screen time of >1 hour perday. The maximum duration of screen time was reportedamong 3-5 years old children in home-based care [16,23].Four studies [4,15,20,24] reported a higher prevalence ofscreen time of >1 hour per day during weekends (25% to63%), as compared to weekdays (10% to 48%). All thestudies measured screen time while watching TV, whichwas perferred over other digital-media devices

FIG. 1 Flow diagram depicting the inclusion and exclusioncriteria for selecting the articles at each stage.

19,833 articles identifided through database searchPubMed 2272; Embase 1149; Clinical key 241

Scopus 145; Google Scholar 16026

19,511 duplicate andirrerelevant articlesexcluded

↓

322 articles screened based on the title and abstract

←

171 articles excluded asthey were from differentage category, or ondiseased children, orestimated caregiversscreen-time, or estimateswere not clearlyinterpreted, or irrelevanttype of article

151 full-text articles assessed for eligibility

101 articles excludeddue to a context otherthan the review 50 articles included

in this review

←→

→



TA

BL

E I

SU

MM

AR

Y O

F P

RE

VA

LE

NC

E S

TU

DIE

S, A

SSO

CIA

TE

D F

AC

TO

RS, C

OR

RE

LA

TE

S O

F S

CR

EE

N T

IME A

MO

NG

CH

ILD

RE

N A

GE

D 0

-5 Y

EA

RS.

Pla

ce (n

o.A

utho

r (Ye

ar)

Age

in y

ears

Stud

y de

sign

Stud

y to

olP

reva

lenc

e of

ST

Ass

ocia

ted

fact

ors a

ndof

stud

ies)

[Ref

] (s

ampl

e si

ze)

corr

elat

es o

f ST

Hig

h-in

com

e co

untr

ies

(n=

16)

Aus

tral

ia (n

=3)

Hin

kley

, et a

l.3-

5 (1

004)

Bas

elin

e da

ta o

f a c

ohor

tS

urve

y to

ol w

as u

sed

•Ave

rage

ST

/ day

•Pos

itive

rela

tions

hip

with

age

(201

2) [1

8] s

tudy

kno

wn

as H

ealt

hy to

rec

ord

pare

nts

repo

rt11

2.5

min

(95%

•No

rela

tions

hip

with

gen

der

Act

ive

Pres

choo

l and

on D

M u

se (T

V/ v

ideo

/ DV

DC

I = 1

07.8

–117

.2).

prim

ary

yea

rs w

as u

sed.

view

ing/

ele

ctro

nic

gam

es/

•Maj

orit

y (9

9.4%

)co

mpu

ter u

se) b

y th

e ch

ild.

wat

ched

TV

; 31.

1%co

mpu

ter/

oth

erel

ectr

onic

gam

es;

28.8

% u

sed

com

pute

r/in

tern

et o

ther

than

gam

es

Dow

ning

, et

al.

3-5

(100

)B

asel

ine

data

of a

coh

ort

Sur

vey

tool

was

use

d to

•Mea

n (S

D) s

eden

tary

tim

e•P

aren

tal c

once

rns

abou

t chi

ld’s

(201

7) [1

9] s

tudy

kno

wn

as H

ealt

hyre

cord

par

ents

rep

ort o

nof

chi

ldre

n 30

1.1

(34.

1)se

dent

ary

beha

vior

wer

eA

ctiv

e P

resc

hool

and

DM

use

of (

TV

/ vid

eo/

min

/day

, and

ST

was

108

.5as

soci

ated

with

gir

ls’ S

T.pr

imar

y ye

ars

was

use

d.D

VD

/ el

ectr

onic

(69.

6) m

in/d

ay.

•Inv

erse

rela

tions

hip:

sle

ep d

urat

ion

gam

es /

com

pute

r) b

y th

e•C

hild

ren

spen

t 108

.5to

gir

ls’ s

eden

tary

tim

e an

d bo

ys’ S

T;

child

.(6

9.6)

min

/day

in S

T.Pa

rent

al s

elf-

effi

cacy

; Mat

erna

let

hnic

ity

to c

hild

pre

fere

nces

tose

dent

ary

beha

viou

rs’ a

nd g

irls

’ ST

•No

rela

tions

hip

with

gen

der,

chi

ldpr

efer

ence

s fo

r sed

enta

ry b

ehav

ior.

Bro

wn,

et a

l.4-

5 (4

983)

Dat

a fr

om tw

o w

aves

of

Dat

a w

ere

obta

ined

in•P

ositi

ve re

lati

onsh

ip w

ith

chil

d’s

ST

(201

0) [2

1]th

e L

ongi

tudi

nal S

tudy

of

face

-to-

face

inte

rvie

ws,

to m

othe

rs w

ho w

orke

d pa

rt-t

ime.

Aus

tral

ian

Chi

ldre

nqu

estio

nnai

res

and

(LSA

C).

dia

ries

of t

he c

hild

’s T

Vvi

ewin

g as

repo

rted

the

pare

nt.

Can

ada

(n=

3)C

arso

n, e

t al.

0-5

(746

)C

ross

-sec

tion

al o

nD

ata

obta

ined

from

the

•Mos

t pa

rtic

ipan

ts•P

osit

ive

rela

tion

ship

wit

h ch

ild’

s(2

012)

[10]

part

icip

ants

rec

ruit

edpa

rent

s w

ith

the

help

of

(93.

7%) w

atch

edag

e, p

aren

tal a

ttit

udes

, par

enta

lfr

om th

e H

ealth

y L

ivin

g q

uest

ionn

aire

sT

V a

nd 3

7.9%

pla

yed

barr

iers

, par

enta

l des

crip

tive

nor

ms,

Hab

its

in P

resc

hool

vide

o/co

mpu

ter g

ames

pare

ntal

ST,

TV

in th

e be

droo

m.

Chi

ldre

n pr

ojec

t. .

•Inv

erse

rela

tion

ship

wit

h pa

rent

aled

ucat

ion,

par

enta

l inc

ome,

par

enta

lse

lf-e

ffic

acy.

Paga

ni, e

t al.

2-5(

1314

)L

ongi

tudn

al s

tudy

dat

aP

aren

t rep

orte

d T

V•1

1% c

hild

ren

at 2

9 m

onth

s•P

osit

ive

rela

tion

ship

wit

h vi

ctim

i-(2

010)

[9]

from

the

Que

bec

Lon

gi-

expo

sure

of c

hild

ren

onha

d ST

>2

h/ d

ay.

zati

on b

y cl

assm

ates

, BM

I, a

ge.

tudi

nal S

tudy

of C

hild

wee

kday

s an

d w

eeke

nds.

•23.

4% o

f the

chi

ldre

n at

•Inv

erse

rela

tion

ship

wit

h cl

ass- C

ontd

....



Dev

elop

men

t was

take

n53

mon

ths

had

ST >

2 h/

day.

room

eng

agem

ent,

mat

hfo

r rec

ruiti

ng th

eac

hiev

emen

t, PA

on

wee

kend

s, o

ther

part

icip

ant.

acti

viti

es th

at re

quir

e ph

ysic

al e

ffor

t.

Car

son,

et a

l.4-

5 (1

633)

Cro

ss-s

ecti

onal

stu

dyD

ata

wer

e ob

tain

ed fr

om th

e•4

2% (4

0% fo

r gir

ls a

nd•P

ositi

ve re

latio

nshi

p w

ith g

irls

(201

0) [1

1] d

ata

was

gat

here

d fr

ompa

rent

s w

ith

the

help

of

45%

for b

oys)

of

from

low

soc

io-e

cono

mic

sta

tus

the

Hea

lthy

Liv

ing

ques

tionn

aire

s.pa

rtic

ipan

ts e

ngag

ed in

neig

hbou

rhoo

ds.

Hab

its

in P

resc

hool

>2

h/da

y of

ST

•Chi

ldre

n fr

om lo

w so

cio-

econ

omic

Chi

ldre

n pr

ojec

t (20

05-

•78%

(68%

for

stat

us n

eigh

bour

hood

s us

ed m

ore

2007

). g

irls

, and

80%

for b

oys)

vide

o ga

mes

whe

reas

thos

e fr

omof

chi

ldre

n en

gage

d in

high

soci

o-ec

onom

ic st

atus

>1

h/da

y of

ST.

neig

hbou

rhoo

ds u

sed

mor

eco

mpu

ters

.

Eur

ope

(n=

1)K

ourl

aba,

et a

l.1-

5 (2

374)

‘Gro

wth

, Exe

rcis

e an

dP

aren

ts r

epor

ted

wee

kday

•Ave

rage

ST

1.3

2 h/

day

,•S

igni

fica

nt re

latio

nshi

p w

ith a

ge,

(201

8) [4

]N

utri

tion

Epi

dem

iolo

gica

lan

d w

eeke

nd T

V/ v

ideo

whe

re 2

6% o

f chi

ldre

npa

rent

al T

V v

iew

ing

, the

regi

on o

fS

tudy

in p

re-s

choo

lers

’vi

ewin

g by

the

child

on

bein

gsp

ent ≥

2 h/

day.

resi

denc

e, m

ater

nal l

evel

of

(GE

NE

SIS

stu

dy).

aske

d sp

ecif

ic q

uest

ions

from

32%

of c

hild

ren

aged

educ

atio

n.a

surv

ey to

ol.

• 3-5

y w

atch

ed T

V >

2 h/

day,

whi

ch w

as h

ighe

r,th

an in

chi

ldre

n ag

ed 1

-2 y

.

UK

(n=

2)B

arbe

r, e

t al.

0-3

(155

8)B

orn

in B

radf

ord

(BiB

)Q

uest

ions

wer

e va

lidat

ed75

% o

f chi

ldre

n ag

ed 1

y•P

osit

ive

rela

tion

ship

wit

h T

V(2

017)

[1]

was

a lo

ngitu

dina

l mul

ti-fr

om th

e S

outh

ampt

onex

ceed

ed g

uide

lines

of z

ero

switc

hed

on a

t hom

e, m

othe

r’s

ethn

ic b

irth

coh

ort s

tudy

Wom

en’s

Sur

vey

Que

stio

n-S

T.pe

rcep

tions

on

ST

of c

hild

ren,

(200

7-10

)na

ire

whi

ch is

val

idat

ed fo

rch

ildre

n of

firs

t tim

e m

othe

rs,

adu

lts

mat

erna

l str

ess,

mot

her n

ot b

orn

inth

e U

K.

Jago

, et a

l.3-

10 (2

965)

Cro

ss-s

ecti

onal

Par

ents

rep

orte

d w

eekd

ay•P

osit

ive

rela

tion

wit

h pa

rent

al S

T,(2

012)

and

wee

kend

TV

/ vid

eoac

cess

to D

Mvi

ewin

g by

the

child

on

bein

g• M

ater

nal S

T h

ad s

tron

ger r

elat

ion

aske

d s

peci

fic

ques

tions

from

rela

ted

to c

hild

’s S

T w

hen

com

pare

dsu

rvey

tool

. w

ith

that

of f

athe

r’s.

USA

(n=5

)C

hris

taki

s, e

t al.

0-5

(168

)C

ross

-sec

tion

alR

esea

rch

staf

f wen

t to

the

Mea

n S

T/ d

ay fo

r chi

ldre

nT

he c

hild

ren

atte

ndin

g ho

me-

base

d(2

009)

[12]

enro

lled

child

-car

e pr

ogra

ms

in d

ay c

are

was

3.4

h in

child

-car

e pr

ogra

ms h

ave

mor

eto

fill

up

the

surv

ey to

ol w

ithho

me-

base

d pr

ogra

ms,

as

prop

ensi

ty to

wat

ch T

V o

n an

the

help

of t

he s

taff

at c

hild

com

pare

d w

ith

1.2

h in

aver

age

day

than

thos

e in

cen

ter-

care

pro

gram

s.ce

nter

-bas

ed p

rogr

ams.

base

d pr

ogra

ms.

fold

s (P

<0.

001)

.

Con

td...

.

Pla

ce(n

o.A

utho

r (Ye

ar)

Age

in y

ears

Stud

y de

sign

Stud

y To

olP

reva

lenc

e of

ST

Ass

ocia

ted

fact

ors a

ndof

stud

ies)

[Ref

] (s

ampl

e si

ze)

corr

elat

es o

f ST

Fro

m p

re-p

age.

..



Asp

lund

, et a

l.0-

5 (3

14)

Cro

ss-s

ecti

onal

A s

elf-

adm

inis

tere

d su

rvey

•53%

chi

ldre

n m

et A

AP

•Pos

itive

rela

tions

hip

with

age

,(2

015)

[13]

ques

tion

nair

e pa

rent

s on

DM

guid

elin

es o

n ST

vie

win

g,pa

rent

al S

T a

nd b

elie

fs re

gard

ing

ST,

use

(TV

/ vid

eo g

ames

/ com

-•5

6% m

et A

AP

guid

elin

es•N

egat

ive

rela

tions

hip

with

no

TV

pute

r/ c

ell-

phon

es a

nd o

ther

for n

o T

V in

the

child

’sdu

ring

din

ner,

hea

lthy

pare

ntal

DM

dev

ices

) by

chil

dren

.be

droo

mbe

liefs

, acc

ess

to T

V a

t hom

e.•O

nly

29%

met

bot

h•N

o re

lati

onsh

ip w

ith

chil

d’s

guid

elin

es.

ethn

icit

y, c

hild

’s B

MI c

ateg

ory,

•Chi

ldre

n w

ere

mor

e lik

ely

pare

nt’s

age

, par

ent’s

eth

nici

ty,

to m

eet t

he g

uide

lines

ifT

V in

the

child

’s b

edro

om, s

urve

yth

ey h

ad <

2 T

Vs

in th

eir

lang

uage

.ho

mes

, din

ner w

itho

ut T

V,

or re

stri

cted

par

enta

l ST.

Em

ond,

et a

l.C

ross

-sec

tiona

lA

n on

line

surv

ey w

as g

iven

to•C

hild

ren

wat

ched

mea

n•P

ositi

ve a

ssoc

iatio

n w

ith g

reat

er(2

018)

[14]

2-5

(385

)pa

rent

whe

re th

ey r

epor

ted

(SD

) 31.

0 (2

3.8)

h/w

eek

hous

ehol

d D

M u

se w

ithi

n 1

h of

upon

DM

use

of t

heir

chi

ldre

n o

f D

Mbe

dtim

e (P

<0.

01) i

n a

dose

-•4

6% u

sed

DM

gad

gets

depe

nden

t man

ner.

with

in 1

h o

f be

dtim

e•4

1% u

sed

DM

gad

gets

inth

eir b

edro

oms.

Tand

on,

et a

l.2-

5 (1

0700

)E

arly

Chi

ldho

od L

ongi

-P

aren

ts r

epor

ted

the

DM

•66%

of c

hild

ren

exce

eded

•Chi

ldre

n in

hom

e-ba

sed

(201

1) [2

2]tu

dina

l Stu

dy-B

irth

use

(TV

/ DV

D/ v

ideo

>2h

/day

gui

delin

es o

f ST.

care

had

the

max

imum

ST

Coh

ort

wat

chin

g tim

e) o

f the

•70%

of c

hild

ren

in H

ead

(5.5

h/d

ay),

foll

owed

by

child

ren.

Star

t exc

eede

d >

2 h/

day

ST.

pare

ntal

car

e on

ly (4

.4 h

/•T

he a

vera

ge S

T fo

rda

y), h

ead

star

t (4.

2 h/

day)

child

ren

was

3.5

h/d

ayan

d c

hild

-car

e ce

nter

s (3

.2 h

/day

).•N

o re

lati

onsh

ip w

ith

hous

ehol

din

com

e, c

hild

’s ra

ce/e

thni

city

, chi

ld’s

gend

er,

prim

ary

lang

uage

and

mot

her’

s ed

ucat

ion,

em

ploy

men

tst

atus

, mar

ital

sta

tus,

pri

mar

yla

ngua

ge.

Fulto

n, e

t al.

2-5

(286

1)C

ross

- sec

tion

al T

he 1

999-

Com

pute

rize

d in

terv

iew

s•7

1% o

f chi

ldre

n (2

-5 y

)•N

o re

latio

nshi

p w

ith o

verw

eigh

t/(2

009)

[15]

2006

dat

a of

Nat

iona

lw

ere

adm

inis

tere

d to

par

ent/

view

ed T

V fo

r ≤2h

/day

.ob

esit

yH

ealt

h an

d N

utri

tion

guar

dian

rep

orte

d th

e D

M•4

5% o

f chi

ldre

n re

port

ed•P

osit

ive

rela

tion

ship

wit

hE

xam

inat

ion

Surv

ey(T

V/ c

ompu

ter)

use

d by

no c

ompu

ter u

se o

n th

eM

exic

an-A

mer

ican

eth

nici

tyw

as u

sed

to s

elec

tch

ildre

n.pr

evio

us d

ay.

•Neg

ativ

e re

latio

nshi

p w

ith n

on-

pare

nts.

hisp

anic

bla

ck e

thni

city

Con

td...

.

Pla

ce(n

o.A

utho

r (Ye

ar)

Age

in y

ears

Stud

y de

sign

Stud

y To

olP

reva

lenc

e of

ST

Ass

ocia

ted

fact

ors a

ndof

stud

ies)

[Ref

] (s

ampl

e si

ze)

corr

elat

es o

f ST

Fro

m p

re-p

age.

..



Japa

n (n

=1)

Che

ng, e

t al.

0-3

(479

)C

ohor

t stu

dy d

ata

Par

ent r

epor

ted

DM

usa

ge•2

9% (a

ged

18 m

os)

•Pos

itiv

e as

soci

atio

n w

ith

TV

(201

0) [6

]an

alyz

ed fr

om J

apan

(TV

) of t

he c

hild

ren

wat

ched

TV

≥4

h/da

y,ex

posu

re a

t you

ng a

ge w

ithC

hild

ren’

s st

udy.

24.5

% c

hild

ren

(age

d 30

hype

ract

ivit

y–in

atte

ntio

n, c

hild

ren

mos

), a

nd 2

1% a

t bot

h ag

es.

of lo

w in

com

e gr

oups

•Neg

ativ

e re

latio

nshi

p w

ithpr

osoc

ial b

ehav

ior i

n ol

der c

hild

ren

Kor

ea (n

=2)

Bye

on, e

t al.

2 (1

778)

Nat

iona

l cro

ss- s

ectio

nal

Par

ent q

uest

ionn

aire

s th

roug

h•T

he a

vera

ge T

V v

iew

ing

•Pos

itive

rela

tions

hip

with

lang

uage

(201

5) [8

] s

urve

yco

mpu

ter

assi

sted

per

sona

ltim

e of

chi

ldre

n w

as 1

.21

h/de

lay

inte

rvie

w w

ere

used

to g

athe

rda

y.da

ta o

n D

M u

sage

by

thei

r• A

bout

44%

chi

ldre

n ha

dch

ildre

n. S

T b

etw

een

1-2

h/da

y.

Cha

ng, e

t al.

2-5

(400

)A

par

t of t

he In

tern

et-

Sur

vey

tool

was

use

d to

•On

wee

kday

s, 4

8% o

f•A

bout

65%

of c

hild

ren

wer

e(2

018)

[23]

Coh

ort f

or U

nder

stan

ding

gath

er in

form

atio

n fr

omch

ildre

n w

atch

ed T

V fo

rex

pose

d to

TV

bef

ore

2 ye

ars.

of in

tern

et a

ddic

tion

Ris

kth

e pa

rent

/ rep

orte

d th

e >

1 h/

day.

•Bef

ore

1 ye

ar o

f age

, 12.

2% o

ffa

ctor

s/ R

escu

e in

Ear

lyD

M u

se (T

V v

iew

ing)

of

•On

wee

kend

s, 6

3.1%

child

ren

wer

e us

ing

smar

tpho

nes

live

liho

od (I

-CU

RE

) stu

dy.t

heir

chi

ldre

n. w

atch

ed T

V fo

r >1

h/da

y,fo

r the

firs

t tim

e.•2

3.4%

of c

hild

ren

used

•31%

of t

he c

hild

ren

wer

e us

ing

thei

r sm

artp

hone

s fo

rsm

artp

hone

s be

fore

2 y

ears

.>

1 h/

day.

Mid

dle-

inco

me

coun

trie

s (n=

5)

Chi

na (n

=2)

Lin

, et a

l.0-

3 (1

50)

Cro

ss-s

ecti

onal

Sur

vey

tool

was

use

d to

•Chi

ldre

n <

2 y

wat

ched

TV

•Pos

itiv

e re

lati

onsh

ip w

ith

(201

4) [7

]ga

ther

info

rmat

ion

from

>0

h/ d

ay, a

nd c

hild

ren

(≥2

dela

yed

cogn

itive

dev

elop

men

t,ca

regi

vers

abo

ut D

M (T

V,

year

s) w

ho w

atch

ed >

2 h/

lang

uage

dev

elop

men

t, m

otor

-sm

artp

hone

, iP

ad, a

ndda

y w

ere

mor

e li

kely

tode

velo

pmen

t, ty

pe o

f car

e ta

ker

com

pute

r) O

f the

ir c

hild

ren.

show

a d

elay

in m

otor

ski

ll•N

egat

ive

rela

tions

hip

with

deve

lopm

ent.

Mat

erna

l edu

cati

on•C

hild

ren

(0-2

y) w

atch

edan

ave

rage

of 6

7.4

min

/day

of T

V.

Wu,

et a

l.3-

6(20

2)E

xplo

rato

ry q

uant

itat

ive

A v

alid

ated

que

stio

nnai

re• P

osit

ive

rela

tion

ship

wit

h(2

016)

[17]

stud

y (C

hine

se) w

as d

evel

oped

toan

tisoc

ial b

ehav

iour

car

toon

s,ga

ther

dem

ogra

phic

s of t

heco

gniti

ve d

evel

opm

ent,

func

tiona

lch

ildre

n, p

aren

ts, a

nd h

ome

deve

lopm

ent.

envi

ronm

ent a

nd p

atte

rn o

f•S

igni

fica

nt r

elat

iosh

ip w

ith c

hild

’spa

rent

-chi

ld a

nd c

hild

’sag

e, c

hild

’s g

ende

r, p

aren

t’s a

ge, Con

td...

.

Pla

ce(n

o.A

utho

r (Ye

ar)

Age

in y

ears

Stud

y de

sign

Stud

y To

olP

reva

lenc

e of

ST

Ass

ocia

ted

fact

ors a

ndof

stud

ies)

[Ref

] (s

ampl

e si

ze)

corr

elat

es o

f ST

Fro

m p

re-p

age.

..



DM

use

by

the

pare

nts.

num

ber o

f ch

ildre

n in

the

fam

ily,

par

enta

l em

ploy

men

t sta

tus,

fam

ily

inco

me,

loca

tion

of th

e co

mpu

ter.

Indi

a (n

=1)

Ver

ma,

et a

l.6

mo

-2 y

rsP

rosp

ecti

veT

he c

hild

ren

wer

e ob

serv

ed a

t• N

egat

ive

rela

tion

with

ach

ievi

ng(2

018)

[24]

(100

)an

inte

rval

of t

wo

year

s ti

llco

gniti

ve m

ilest

ones

they

att

ain

two

year

s of

age

–•N

o re

latio

nshi

p w

ith a

chie

ving

Sur

vey

tool

was

use

dph

ysic

al m

iles

tone

s.

Mal

aysi

a (n

=1)

Lee

, et a

l.4-

6 (8

35)

A p

art o

f the

Sou

th E

ast

Que

stio

nnai

re w

ere

adm

inis

-•2

7% o

f chi

ldre

n (2

5.7%

• Few

(27%

) chi

ldre

n ex

ceed

ed d

aily

(201

6) [1

6]A

sian

Nut

riti

on S

urve

yste

red

to th

e pa

rent

s/ c

areg

iver

surb

an, 3

2.7%

rura

l) h

adST

reco

mm

enda

tions

.(S

EA

NU

TS)

that

gat

here

d in

form

atio

n on

daily

ST

of

>2

h/da

y.• I

n ru

ral a

reas

, les

ser b

oys

(24.

1%)

DM

use

d by

chi

ldre

n.•O

nly

24.1

% b

oys

from

in c

ompa

riso

n to

the

girl

s (4

6.2%

)ru

ral a

reas

had

ST

of <

1 h/

had

ST o

f <1

h.da

y in

com

pari

son,

46.

2%•N

o re

lati

onsh

ip w

ith

the

area

of

girl

s.re

side

nce,

eth

nic

grou

p, h

ouse

hold

inco

me,

and

mat

erna

l edu

catio

n.et

hnic

gro

ups,

hou

seho

ld in

com

e,m

ater

nal e

duca

tion

•Boy

s had

sign

ific

antly

hig

her S

T.

Tha

iland

(n=

1)R

uang

dara

gano

n,0-

2 (2

60)

A p

art o

f the

Pro

spec

tive

Pare

nt w

ere

inte

rvie

wed

face

-•C

hild

ren

aged

6 m

o (9

8%),

•Pos

itive

rela

tions

hip

with

age

;et

al.

(200

9) [2

5]C

ohor

t Stu

dy o

f Tha

ito

-fac

e an

d on

the

tele

phon

e to

1 y

(95.

3%) a

nd 2

ypa

rent

s be

liev

edth

at T

V v

iew

ing

Chi

ldre

n (P

CT

C),

that

gath

er in

form

atio

n on

(96.

7%) w

atch

ed T

V.

was

ben

efic

ial t

o ch

ild’s

eve

lopm

ent.

follo

wed

up

child

ren

from

repo

rted

DM

(TV

vie

win

g) in

•Abo

ut 2

2% o

f chi

ldre

n•N

o re

lati

onsh

ip w

ith

dela

yed

birt

h to

2 y

ears

of a

ge.

child

ren.

(1 y

) spe

nt ≥

2 h/

day

on T

V,

lang

uage

dev

elop

men

t, N

umbe

r of

and

38.4

% o

f 2-y

ear-

old

hous

ehol

d T

V, T

V in

chi

ld’s

bed

room

child

ren

wat

ched

TV

≥2

h/da

y.•T

he m

ean

(SD

) ST

was

1.23

(1.4

2) h

/d (

1 ye

ar o

ld)

and

1.69

(1.5

6) h

/day

(2 y

ear o

ld).

ST:

scre

en t

ime;

TV:

tel

evis

ion;

DM

: di

gita

l m

edia

; PA

: ph

ysic

al a

ctiv

ity.

Pla

ce(n

o.A

utho

r (Ye

ar)

Age

in y

ears

Stud

y de

sign

Stud

y To

olP

reva

lenc

e of

ST

Ass

ocia

ted

fact

ors a

ndof

stud

ies)

[Ref

] (s

ampl

e si

ze)

corr

elat

es o

f ST

Fro

m p

re-p

age.

..



Con

td...

.

TA

BL

E I

I S

UM

MA

RY

OF I

NT

ER

VE

NT

ION

ST

UD

IES O

N S

CR

EE

N T

IME IN

CH

ILD

RE

N A

GE

D 0

-5 Y

EA

RS

Pla

ce (N

o. o

fA

utho

r(Ye

ar)

Age

inSt

udy

Sam

ple

Inte

rven

tion

grou

p pa

ckag

eC

ontr

ol g

roup

End

poin

tsM

ean

diffe

renc

e in

ST

inst

udie

s)[R

ef]

year

sde

sign

size

pac

kage

inte

rven

tion

vers

us c

ontr

olar

m (

95%

CI)

Aus

tral

iaH

inkl

ey,

et a

l.2-

3P

ilot

-22

Gro

up s

essi

ons,

fam

ily-

base

d ac

tivi

ties

,Fa

mili

es ju

st re

ceiv

edST

-31.

2 m

inut

es/d

ay (S

E=

20.3

,(n

=1)

(201

5) [

32]

RC

T p

robl

em-s

olvi

ng, a

nd c

halle

nges

dis

-us

ual h

ealth

ser

vice

s.In

terv

al: -

70.9

9, 8

.59)

cuss

ed in

six

sess

ions

. Soc

ial c

ogni

tive

and

Fam

ily

Sys

tem

s th

eori

es w

ere

used

.

Can

ada

Bir

ken,

et a

l.2-

4R

CT

351

Cou

nsel

ing

pare

nts,

par

ties,

chi

ldPa

rent

s re

ceiv

edM

ean

tota

l-7

min

utes

/day

(SE

=15

.56,

(n=

2)(2

012)

[46]

invo

lvem

ent a

nd T

V tu

rn-o

ff ti

me

but n

ost

anda

rd c

ouns

elin

gw

eekd

ay a

ndIn

terv

al: -

37.5

0, 2

3.50

).fo

llow

-up

was

don

e. T

he S

ocia

l cog

nitiv

efr

om tr

aine

d pe

r-w

eeke

nd S

T.th

eory

was

use

d.so

nnel

on

med

ia u

se.

The

y w

ere

give

n m

edia

guid

elin

es p

ublis

hed

byth

e C

anad

ian

Pedi

atri

cS

ocie

ty

Hai

nes,

et a

l.2-

5R

CT

121

Mot

ivat

iona

l coa

chin

g at

hom

e an

d by

Fam

ilies

wer

e m

aile

dSl

eep

dura

tion,

-32.

4 m

inut

es/d

ay (S

E(2

013)

[44]

phon

e, e

duca

tiona

l mat

eria

ls, T

V c

ontr

oled

ucat

iona

l mat

eria

lsT

V v

iew

ing

=20

.98,

Inte

rval

: -73

.48,

8.6

8)de

vice

, inc

entiv

es, a

nd te

xt m

essa

ges.

focu

sed

on c

hild

and

BM

I.Fo

llow

-up

was

don

e. S

ocia

l-ec

olog

ical

deve

lopm

ent.

mod

el.

Eur

ope

Yilm

az, e

t al.

2-6

RC

T41

2Fa

mily

inte

rven

tion,

cou

nsel

ing

calls

and

Fam

ilies

just

rece

ived

Mea

n S

T v

iole

nt-4

7.2

min

utes

/day

(SE

=2.

01,

(n=

4)(2

015)

[38]

educ

atio

nal m

ater

ial g

iven

to p

aren

ts. N

ous

ual h

ealth

serv

ices

.be

havi

ors,

lang

uage

Inte

rval

: -51

.10,

-43.

22)

follo

w-u

p w

as d

one.

The

Soc

ial c

ogni

tive

deve

lopm

ent,

theo

ry w

as u

sed.

toba

cco

smok

ing,

BM

I in

child

ren

and

sede

ntar

ybe

havi

or.

Pude

r, e

t al.

3-5

RC

T65

2M

ulti-

dim

ensi

onal

cul

tura

lly ta

ilore

dT

he c

hild

ren

did

not

Aer

obic

-fitn

ess,

-13.

4 m

inut

es/d

ay (S

E 5

.94,

(201

1) [4

0] li

fest

yle

inte

rven

tion

, and

ada

pted

for t

here

ceiv

e an

y ne

w in

for-

BM

I, m

otor

agi

lity,

Inte

rval

: -25

.04,

-1.7

6)bu

ilt e

nvir

onm

ent o

f the

pre

scho

ol c

lass

.m

ativ

e m

ater

ial.

The

yba

lanc

e, p

erce

ntag

eco

ntin

ued

thei

r reg

ular

body

fat,

wai

st c

ircu

m-

scho

ol c

urri

culu

m.

fere

nce,

PA

, eat

ing

habi

ts,

ST, s

leep

, psy

cho-

logi

cal h

ealth

, and

cogn

itive

abi

litie

s.

Gri

eken

, et

al.

5C

lust

er 6

37L

ifes

tyle

cou

nsel

ing,

que

stio

nnai

res,

All

par

ents

att

ende

dD

urat

ion

of o

utsi

de-1

.6 m

inut

es/d

ay (S

E =

6.63

,(2

015)

[34]

RC

Tbe

havi

or c

hang

e, a

nd h

ome

envi

ronm

ent

wel

l-ch

ild

visi

ts. T

hey

play

, or T

VIn

terv

al: -

14.5

5,11

.43)

mod

ific

atio

ns w

ith fo

llow

-up.

ASE

mod

el,

rece

ived

gen

eral

info

r-vi

ewin

g.



prec

autio

n pr

oces

s m

odel

, ela

bora

tion

mat

ion

abou

t nut

ritio

nlik

elih

ood

mod

el, a

nd th

e st

ages

of c

hang

ean

d ph

ysic

al a

ctiv

ity.

mod

el.

Lat

omm

e, e

t al.

4-6

Clu

ster

243

4H

ealth

edu

catio

n fo

r par

ents

, and

chi

ldre

n,K

inde

rgar

tens

rece

ived

Com

pute

r/ v

ideo

-In

terv

entio

n gr

oup:

Les

ser

(201

7) [3

5]R

CT

and

cla

ssro

om e

nvir

onm

ent.

Fol

low

-up

regu

lar s

choo

ling

curr

i-ga

mes

use

on

wee

k-ac

cent

uatio

n in

com

pute

r/w

as d

one.

culu

m. T

he in

terv

entio

nda

y an

d w

eeke

nd.

vide

o-ga

mes

use

s on

wee

kday

mat

eria

l aft

er c

ompl

etio

nin

(+5.

48 m

inut

es/d

ay)

of th

e in

terv

enti

on.

whe

reas

con

trol

gro

up (+

8.89

min

utes

/day

). I

nter

vent

ion

grou

p on

wee

kend

, (+

9.46

min

utes

/ day

) whe

reas

, con

trol

(+15

.43

min

utes

/day

)

New

Skou

teri

s, e

t al.

2-4

RC

T10

4P

aren

ts a

nd c

hild

ren

atte

nded

wee

kly

The

par

ents

did

not

Nut

ritio

n, P

A, a

nd-1

0.3

min

utes

/day

(SE

=8.

2,Z

eala

nd(2

015)

[45]

wor

ksho

ps o

n nu

trit

ion,

PA

and

beh

avio

rs,

rece

ive

any

heal

th in

for-

beha

vior

s, a

long

Inte

rval

: -26

.37,

5.7

7)in

clud

ing

guid

ed a

ctiv

e pl

ay, a

nd h

ealth

ym

atio

n. T

hey

wer

e gi

ven

wit

h S

T.sn

ack

tim

e. F

ollo

w-u

p w

as d

one.

the

inte

rven

tion

pack

age

afte

r the

com

plet

ion

ofth

e st

udy

dura

tion

.

USA

(n=8

)Fi

tzgi

bbon

, et a

l.2-

5R

CT

618

The

inte

rven

tion

deliv

ered

by

clas

sroo

mPa

rent

s re

ceiv

ed in

for-

PA, n

utri

tion

and

-27.

8 m

inut

es/d

ay (S

E =

13.9

2,(2

011)

[42]

teac

hers

. Die

t pla

n, a

nd h

ealth

edu

catio

nm

atio

n up

on g

ener

alto

tal S

T.In

terv

al: -

55.8

, -0.

52)

for t

each

ers a

nd p

aren

ts. S

ocia

l cog

nitiv

ehe

alth

con

cept

s.th

eory

, and

sel

f-de

term

inat

ion

theo

ry.

No

foll

ow-u

p w

as d

one.

Fitz

gibb

on, e

t al.

2-5

RC

T15

7Sc

hool

-bas

ed a

nd fa

mily

-bas

ed c

ompo

-Pa

rent

s rec

eive

d in

for-

BM

I and

ST.

15.6

min

utes

/day

(SE

25.

71,

(201

3) [4

3]ne

nts

used

. Soc

ial c

ogni

tive

The

ory,

Hea

lthm

atio

n up

on g

ener

alIn

terv

al: -

34.7

9, 6

5.99

)B

elie

f Mod

el a

nd S

elf-

dete

rmin

atio

nhe

alth

con

cept

s.th

eory

. Fol

low

-up

was

don

e.

Fos

ter,

et a

l.C

omm

unit

y m

eeti

ngs,

par

ent h

ealt

hP

aren

t-ch

ild

dyad

sST

, BM

I,T

he in

terv

enti

on g

roup

sho

wed

(201

5) [4

1]2-

5R

CT

educ

atio

n, a

nd c

onsu

ltatio

ns a

long

with

atte

nded

com

mun

ity

child

’s g

row

th,

decr

easi

ng S

T fr

om a

mea

n of

foll

ow-u

p.m

eeti

ngs.

The

y go

t the

nutr

itio

n, a

nd3.

3 ho

urs/

day

(Int

erva

l: 2

.3,

Eat

Pla

yGro

wT

M c

urri

-qu

alit

y of

life

.4.

2) a

t 6 m

onth

s to

2.1

hou

rs/

culu

m to

teac

h he

alth

yda

y (I

nter

val:

1.5

, 2.7

) at 1

2-ha

bits

.m

onth

fol

low

-up.

Tave

ras,

et a

l.3-

5C

lust

er 4

75Fa

mily

cou

nsel

ling,

hea

lth e

duca

tion,

Chi

ldre

n re

ceiv

ed u

sual

Tota

l TV

/vid

eo-2

1.6

min

utes

/day

(SE

8.4

1,(2

011)

[33]

RC

Tm

otiv

atio

nal i

nter

view

ing,

and

smal

lpe

diat

ric

care

acc

ordi

ngvi

ewin

g, T

V in

the

Inte

rval

: -38

.8, -

5.12

)

Fro

m p

re-p

age.

..

Pla

ce (N

o. o

fA

utho

r(Ye

ar)

Age

inSt

udy

Sam

ple

Inte

rven

tion

grou

p pa

ckag

eC

ontr

ol g

roup

End

poin

tsM

ean

diffe

renc

e in

ST

inst

udie

s)[R

ef]

year

sde

sign

size

pac

kage

inte

rven

tion

vers

us c

ontr

olar

m (

95%

CI)

Con

td...

.



ince

ntiv

es. C

hron

ic c

are

mod

el. N

o fo

llow

-to

the

curr

ent s

tand

ards

bedr

oom

, BM

I,up

was

don

e.of

car

e. fo

od fr

eque

ncy,

food

con

sum

ptio

n,an

thro

pom

etri

csan

d PA

.

Zim

mer

man

,3-

53-5

Pil

otFa

mili

es w

ritte

n m

ater

ials

and

four

mon

thly

The

par

ents

rece

ived

A si

gnif

ican

t red

uc-

-37.

1 m

inut

es/d

ay (S

E 1

6.9,

et a

l. (2

011)

[31]

RC

Tne

wsl

ette

rs, p

hone

or e

mai

l, pa

rent

scu

es o

f pro

mot

ion

oftio

n in

com

mer

cial

Inte

rval

: -68

.64,

-5.5

6)en

cour

aged

thei

r chi

ldre

n, a

nd th

e re

sear

chth

eir c

hild

’s s

afet

y in

cont

ent v

iew

ing

staf

f enc

oura

ged

the

pare

nts.

Soc

ial

seve

ral a

reas

. The

se(2

9 m

inut

es/d

ayco

gniti

ve th

eory

and

beh

avio

r cha

nge

wer

e no

t spe

cifi

c to

[-4.

6-63

], a

nd p

osi-

mod

el w

as u

sed.

No

follo

w-u

p w

as d

one.

DM

.tiv

ely

chan

ged

out-

com

e ex

pect

atio

ns.

Men

doza

, et a

l.3-

5C

lust

er16

0C

urri

culu

m fo

r stu

dent

s in

the

clas

sroo

m,

Pare

nts r

ecei

ved

info

r-T

V v

iew

ing

and

-25.

3 m

inut

es/d

ay (I

nter

val

(201

6) [3

6]R

CT

and

staf

f tra

inin

g on

the

day

prog

ram

usi

ngm

atio

n up

on g

ener

alse

dent

ary

tim

e.- 4

5.2,

-5.4

)th

e So

cial

Cog

nitiv

e T

heor

y.he

alth

con

cept

s.

Kno

wld

en,

et a

l.4-

6R

CT

57G

roup

-by-

tim

e in

tera

ctio

n w

as d

etec

ted

The

par

ents

rece

ived

aC

hild

PA

, sug

ar-f

ree-

0.3

min

utes

/day

(SE

=13

.3,

(201

5) [3

9]fo

r chi

ld fr

uit a

nd v

eget

able

con

sum

ptio

nkn

owle

dge-

base

d pr

og-

bev

erag

e co

nsum

-In

terv

al: -

26.3

7, 2

5.77

)us

ing

Soci

al c

ogni

tive

theo

ry. T

elep

hone

ram

. It i

ncor

pora

ted

edu-

ptio

n, a

nd S

T.co

unse

lling

and

onl

ine

surv

eys w

ere

catio

nal s

essi

ons

for

cond

ucte

d.pa

rent

s on

chi

ld d

evel

op-

men

t. Te

leph

one

coun

-se

lling

and

onl

ine

surv

eys

wer

e co

nduc

ted.

Eps

tein

, et a

l.4-

7R

CT

70W

eekl

y tim

e bu

dget

s for

med

ia u

se, a

ndC

hild

ren

rece

ived

free

Mea

n T

V v

iew

ing,

In th

e co

ntro

l gro

up, t

he m

ean

(200

8) [3

7]al

tern

ativ

es to

sed

enta

ry b

ehav

ior,

mon

thly

acce

ss to

TV

, com

pute

rsan

d co

mpu

ter

(SD

) num

ber o

f hou

rs o

f ST

new

slet

ter,

TV

allo

wan

ce, p

aren

tal s

kills

,an

d m

oney

for p

artic

i-ga

mes

wee

kday

decr

ease

d by

5.2

(11.

1) h

ours

/an

d re

war

ds fo

r chi

ldre

n. N

o fo

llow

-up

was

patin

g in

the

tria

l. T

hean

d w

eeke

nd.

wee

k w

here

as, i

n in

terv

entio

ndo

ne.

par

ents

rece

ived

gen

eral

grou

p de

clin

ed b

y 17

.5 (7

.0)

pare

ntin

g ti

ps.

hour

s/w

eek;

rem

aine

d ab

out t

hesa

me

at 2

4 m

onth

s.

ST:

scre

en-t

ime;

TV

: te

levi

sion

; R

CT:

ran

dom

ized

con

trol

tri

al;

PA:

phys

ical

act

ivit

y; B

MI:

bod

y m

ass

inde

x.

Fro

m p

re-p

age.

..

Pla

ce (N

o. o

fA

utho

r(Ye

ar)

Age

inSt

udy

Sam

ple

Inte

rven

tion

grou

p pa

ckag

eC

ontr

ol g

roup

End

poin

tsM

ean

diffe

renc

e in

ST

inst

udie

s)[R

ef]

year

sde

sign

size

pac

kage

inte

rven

tion

vers

us c

ontr

olar

m (

95%

CI)



[11,12,14,15,17,19-21,24]. Three studies also reported theaverage screen time from using smartphone [17,20,24] andfive studies on computer usage [11,12,14,15,19,21]separately or along with the TV. However, they have notdocumented the screen time of these gadgets separately,and have provided the aggregated time.

The differences in the prevalence rate of excessivescreen time among under-fives can also be attributed to theassociated factors like, digital-media environment[14,17,18,23], parental behaviors [1,4,12–14,17] andgovernment regulations [2,48–50]. The preference of TVover other digital-media devices is evident among under-fives [11,12,14,15,17,19–21,24]. A systematic reviewreported that computers are preferred by older children [5].All the studies have reported screen time throughwatching TV; in addition, a pevious [19] and some recentstudies have measured screen time on using computers,smartphone, iPad, or hand-held games [7,11,12,17,24].However, the screen time from watching TV far exceedsthan that from new-age gadgets. Earlier the device isintroduced, there is an increased propensity toexaggerated use with an increase in age [8,24,26].

FACTORS ASSOCIATED WITH INCREASED SCREEN TIME

Twenty-eight studies including 14 cross-sectionalstudies, 11 overlapping studies, 3 systematic reviews[1,3,4,6–30] and one guideline [2] were reviewed todocument the factors associated with screen time. Asystematic review identified 36 correlates of children (0-8years) specifically with mobile screen exposure [29].

Another review identified 33 correlates in children underthe age of three years [30]. Both these systematic reviewshave used bio-ecological model to explain variouscorrelates at five levels: (i) child biological anddemograpic factors; (ii) family biologic and demographicfactors; (iii) family structure; (iv) behavioral factors; and(v) socio-cultural/environmantal factors. These reviewsreported the associations with screen time to be eitherpositive, negative or none. We have used the socialecological model [10,19] to explain all the 40 factors (23from 28 studies and 17 additional factors from systematicreviews) to be associated with digital-media exposureamong children at four levels. As per this model, there isan interplay (bidirectional) of the factors affecting thebehaviors at four levels including intrapersonal level(child-related factors), interpersonal level (caregiver-related factors), immediate environmental level (child careenvironment) and macro-environment level (socio-cultural environment) [12,14,30]. We have clubbed thechild and family level behavioral factors with child andfamily factors, respectively (Fig. 2).

Intrapersonal: Child-related Factors

At intrapersonal level, the factors associated with digital-media exposure include child’s demographic, behavioraland biological factors. As the child grows older, hisscreen time accentuates [4,6,11,14,26]. Hyperactivity-inattention [6], daily sleep duration, and sedentarypreferences [12] were found to be positively associatedwith a child’s digital-media exposure. Boys were morehyperactive [6] and watching more screens [14] in

Fig. 2 The interactions of associated factors and correlates of screen-time among under-five children using the Social-Ecologicalmodel.



comparison to girls. However, three studies did not reportany gender-based differences in screen time [11,12,23].Another study concluded that the child’s demographicfactors [23] have no associations with child’s digitalmedia exposure.

Interpersonal: Caregiver-related Factors

These factors play a role during interactions between theparent/caregiver and the child. Paternal age [12], timespent on work by mothers [22], maternal stress [1,30],parental screen time [1,4,13,14,17,29,30], mother’s place ofdelivery [1,15], and shorter breastfeeding [30] werepositively related to child’s screen time. Children of first-time mothers had increased in screen time [1]. Parentalincome [14], parent’s occupation [29], socioeconomicstatus of the family [6,15], maternal ethnicity [12],maternal body mass index [30], decreased level ofeducation [7,14] and physical activity [29] of the parents’/caregivers were negatively associated with averagedigital-media exposure of the child. Parents’ perceptions[1,17], attitudes, beliefs towards the importance of digital-media exposure and the amount of time they spent withthe child [29] played a pivotal role in a child’s digital-media exposure. Mother’s relational and personal well-being, parent’s sex, country of birth [29], and cognitivestimulation at home [30] were also associated with child’sscreen time. However, there were no associationsreported with parental demographic characteristics[23], ethnicity of the family [17,23], two-parenthousehold, number of children at home, or non-parentalchild-care [30].

Immediate Environment

Digital media micro-environment

The digital-media micro-environment is the homeenvironment within which the family lives i.e., the microdigital-ecosystem of the house. The access to digital-media gadgets [13,14,17,29,30], screen time rules at home[12,14], TV switched-on in the background at home[1,14,17], home-based care [16,23], parenting skills [14],computers placed outside the child’s bedroom and TV onduring dinner [29], infant crying duration and heavy TVuse [30] are positively related to digital-media exposure inchildren. Parental self-efficacy [12], and type of care [29]were negatively associated with screen time of the child.The TV time/content restrictions had no association withthe child’s screen time [30].

Digital media macro-environment

The socio-cultural, geographical and environment factorsare the macro-environmental factors that affect the digital-media usage of the family. These represent the macro

digital-ecosystem of the community surrounding thehouse. Interactions at the macro-digital ecosystem cannotbe controlled and may vary from region-to-region. Theplace of residence [4,15,20,29,30], season (winter) [30] andthe government services that are available in that area [2]affect the digital media exposure of the children. A studyreported that boys of rural areas had higher screen timethan in the urban areas [20]. Another study reported that itwas higher among girls belonging to lower socioeconomicstatus as compared to those of higher status [15].

CONSEQUENCES OF INCREASED ST

The consequences of augmented screen time may beearly/preliminary and late/long-standing [1,4,6-12,14-26,28]as shown in Fig. 3. Early consequences are consideredas those that are reported during under-five developmentperiod among infants, toddlers and preschoolers; and lateare those that are reported after this period.

The watching of indiscriminate media content [9],especially if unsupervised [2], might hamper a child’sbehavioral outcomes. Moreover, restricting children in oneposition for >1 hour has additional negative healthoutcomes [2]. Sedentary behaviors related to screen timeamong children might be induced by the parents [1,12,18]as they are the role models for the children [1,4,12], or dueto the parents’ perceptions about the importance of screentime [12,14,26], physical environment-induced (access,presence of bedroom TV, number of gadgets at home etc.)[1,4,12,14,15,17,20]. However, it is reported that not alldigital media is bad as a child’s level of physical activity[47], skill development [28], gain in knowledge [21] earlylearning, cognitive and functional development [10]improved with specific contingent videos. AmericanAcademy of Pediatrics 2016 guidelines [2] reinforce thatone-to-one interaction may, in turn, lead to improvedparent-child engagement, and quality of social interactionfor healthy development.

Early Consequences

The child’s frequency of TV watching was found to besignificantly associated with delayed motor skills,cognitive [7] and language [7,8] development. Thecontent of TV has a detrimental effect on cognitivedevelopment [7]. A Japanese study observed thatchildren aged 30 months, had increased chances of beinghyperactive/inattentive due to excessive TV-viewing [6].Augmented digital media usage leads to reduced sleep,which in turn leads to increased TV exposure that seemsto have a wider impact on the sleep quality [12]. Greaterhousehold chaos leading to excessive screen time is alsorelated to disrupted nighttime sleep [18]. An Indian studyreported a delay in achieving cognitive milestones of



FIG

. 3 A

ssoc

iatio

ns a

nd c

onse

quen

ces

of e

xces

sive

scr

een

time

in u

nder

-fiv

e ch

ildre

n.



children (below 2 years) with respect to digital mediaexposure [25]. There are less parent-child interactions [27]and increased chances of conflicts [13] when the parents’attention is absorbed. Children try to mimic their parentalscreen time behaviors [1,4,14,17] and/or the programsthey watch on screens [10]. Child’s aggressive [6,10] andantisocial behaviors [10] are related to augmented screentime. Due to a lack of positive role models, andindiscriminate watching of media content, children mighthave behavioral problems [10].

Late Consequences

Long-standing consequences of digital media use predictworsened behavioral outcomes in the children when theygrow older [26]. Development path of the childrenexposed to excessive digital-media may lead to unhealthyadolescence [9]. In the school, they are less likely to getengaged, and may be prone to victimization [9]. Childrenwith accentuated screen time have a predominantlyhigher prevalence of overweight [22], obesity [19] andNCDs [3].

INTERVENTION STRATEGIES

The setting for delivering the interventions was mainly atfamily [31,32,35-37,39,43,44], and/or home level[31,38,40,43-45], with a few at school [34,35,41,42,46], orclinic- [39,43], or community-level [33]. Most of theinterventions were based on behavior change theoriessuch as; social cognitive theory [31,32,34,35,38,42,44],social determination theory [34,35] family systems theory[32], social ecological model [36], health belief model [35],chronic care model [39], attitude social influence self-efficacy model, precaution process model, elaborationlikelihood model, the stages of change model [40] or none[33,37,41,43,46]. The intervention packages specificallyfocused on increasing the information related to digital-media, by holding counseling sessions or usingeducational material. Educational materials were mostlyshared with parents [31-33,36-41,43,45], followed byteachers [34,35,42,46] children [37,46] and communitymembers [33]. Seven studies had focused primarily onscreen time reduction [31,32,38,39,41-43], and six studies[33,35-37,40,41] additionally included a follow-up with theparticipants post-intervention to assess the adherence tothe intervention. Some studies had interventions toincrease the physical activity [34,37,40,45,46] and reducethe sedentary time [42], body mass index [33,35,36,44,46],sedentary behavior [42,44], violent behaviors, tobaccosmoking, [44], and modify the eating behaviors ofchildren [33,34,37,45,46]. The reduction in screen timeamong under-five children varied from 0.3 (SE=13.3)minutes to 47.16 (SE=2.01) minutes in the high-incomecountries. The most effective intervention strategy was

theory-based and delivered at the family level [44]. Thechild’s knowledge regarding engagement in screen-basedactivities [31,34-36,42,43,45,46], home-based rulesregarding TV turnoff time [38], and the alternatives usedby parents for reducing digital-media use had asignificant effect on reducing the screen time. Thecomparator group in most of the studies received theusual health care services except in two studies, wheresession on media use were held and national guidelineson media use among children were shared. [33,45] .

Intervention studies to reduce screen time has beenreported from high-income countries only [31-46]. (WebTable II). There is no published intervention studies fromLMICs. The intervention strategy of utilizing a child’sknowledge to engage in sedentary behavior [31,34-36,42,43,45,46] was found to be effective in reducing theexcessive ST. Also, primary caretaker’s role to mediate[31,33,36-41,43,44] the digital media exposure amongchildren was central in regulating the screen time.

CONCLUSIONS

The results of this review have highlighted that there is ahigh prevalence of excessive screen time among under-fivechildren in the high - and middle-income countries. Thereare several health impacts of excessive screen timeincluding emotional, sleep, behavioral issues impairing thegrowth and cognitive development of under-five children.Most of the high-income countries have made guidelinesfor limiting the excessive digital-media usage for all agegroups including Canada [48], Australia [50], and Itlay [49]while, several LMICs have no such guidelines. Thefindings of this review might be useful for thepolicymakers in formulating such guidelines in thesecountries.

Based upon the results of this review, we recommendthat pediatricians should explore the history of screen timefrom the parents of all under-five children visiting them inthe clinics and about the digital-media home environment,and advise to not to use digital gadgets for children lessthan 2 years and limit it to one hour for children age 2-5years. The policy-makers and associations like IndianAcademy of Pediatrics should formulate guidelines onpermissible limits of screen time among children. As, thereis a paucity of data on the prevalence of screen timeamong under-fives from LMICs, such studies should beplanned to understand the cultural context of screen timeuse in these settings. Also, culturally appropriateinterventions to reduce the same in the LMICs should bedesigned. Such studies are of utmost importanceconsidering the worsening mental [5-7,10] and physicalhealth of children [4,5,9], and to prevent NCDs.

Acknowledgement: Dr. Kamal Kishore, Lecturer, Department of



Biostatistics, PGIMER for providing technical inputs in themethods of this review.Contributors: MG: contributed to the methods and discussionsection; NK, MG: jointly conceived the idea; NK, MG, SG, PM:assessed the studies for inclusion in the review; NK, MG:extracted the data; SG, PM: contributed in describing the relatedtext of the studies; NK: wrote the first draft of the manuscript.All the authors provided technical inputs to improve theintellectual content of the manuscript and approved the finalversion of manuscript.Funding: None; Competing interest: None stated.

REFERENCES

1. Barber SE, Kelly B, Collings PJ, Nagy L, Bywater T,Wright J. Prevalence, trajectories, and determinants oftelevision viewing time in an ethnically diverse sample ofyoung children from the UK. Int J Behav Nutr Phys Act.2017;14:88-99.

2. Reid Chassiakos Y, Radesky J, Christakis D, Moreno MA,Cross C. Children and adolescents and digital media.Pediatrics. 2016;138:e20162593-e.

3. Pearson N, Biddle SJH. Sedentary behavior and dietaryintake in children, adolescents, and adults. Am J Prev Med.2011;41:178-88.

4. Kourlaba G, Kondaki K, Liarigkovinos T, Manios Y.Factors associated with television viewing time in toddlersand preschoolers in Greece: The GENESIS study. J PublicHealth. 2009;31:222-30

5. Davey S, Davey A. Assessment of smartphone addiction inIndian adolescents: A mixed method study by systematic-review and meta-analysis approach. Int J Prev Med.2014;5:1500-11.

6. Cheng S, Maeda T, Yoichi S, Yamagata Z, Tomiwa K;Japan Children’s Study Group. Early television exposureand children’s behavioral and social outcomes at age 30months. J Epidemiol. 2010;20:S482-9.

7. Lin LY, Cherng RJ, Chen YJ, Chen YJ, Yang HM. Effectsof television exposure on developmental skills amongyoung children. Infant Behav Dev 2015;38:20-6.

8. Byeon H, Hong S. Relationship between television viewingand language delay in toddlers: evidence from a Koreanational cross-sectional survey. PLoS One.2015;10:e0120663.

9. Pagani LS, Fitzpatrick C, Barnett TA, Dubow E.Prospective associations between early childhoodtelevision exposure and academic, psychosocial, andphysical well-being by middle childhood. Arch PediatrAdolesc Med. 2010;164:425-31.

10. Carson V, Janssen I. Associations between factors withinthe home setting and screen time among children aged 0-5years: a cross-sectional study. BMC Public Health.2012;12:539.

11. Carson V, Spence JC, Cutumisu N, Cargill L. Associationbetween neighborhood socioeconomic status and screentime among pre-school children: a cross-sectional study.BMC Public Health. 2010;10:367.

12. Christakis DA, Garrison MM. Preschool-aged children’stelevision viewing in child care settings. Pediatrics.2009;124:1627-32.

13. Asplund KM, Kair LR, Arain YH, Cervantes M,Oreskovic NM, Zuckerman KE. Early childhood screentime and parental attitudes toward child television viewingin a low-income latino population attending the specialsupplemental nutrition program for women, infants, andchildren. Child Obes. 2015;11:590-9.

14. Emond JA, Tantum LK, Gilbert-Diamond D, Kim SJ,Lansigan RK, Neelon SB. Household chaos and screenmedia use among preschool-aged children: A cross-sectional study. BMC Public Health. 2018;18:1210.

15. Fulton JE, Wang X, Yore MM, Carlson SA, Galuska DA,Caspersen CJ. Television viewing, computer use, and BMIamong U.S. children and adolescents. J Phys Act Health.2009;6:S28-35.

16. Lee ST, Wong JE, Ong WW, Ismail MN, Deurenberg P,Poh BK. Physical Activity Pattern of MalaysianPreschoolers: Environment, Barriers, and Motivatorsfor Active Play. Asia Pacific J Public Health.2016;28:21S–34S.

17. Wu CST, Fowler C, Lam WYY, Wong HT, Wong CHM,Loke AY. Parenting approaches and digital technology useof preschool age children in a Chinese community. Italian JPediatr. 2014;40:44.

18. Hinkley T, Salmon J, Okely AD, Crawford D, Hesketh K.Preschoolers’ physical activity, screen time, andcompliance with recommendations. Med Sci Sport Exerc.2012;44:458-65.

19. Downing KL, Hinkley T, Salmon J, Hnatiuk JA, HeskethKD. Do the correlates of screen time and sedentary timediffer in preschool children? BMC PublicHealth. 2017;17:285.

20. Jago R, Stamatakis E, Gama A, Carvalhal IM, Nogueira H,Rosado V, et al. Parent and child screen-viewing time andhome media environment. Am J Prev Med. 2012;43:150-8.

21. Brown JE, Broom DH, Nicholson JM, Bittman M. Doworking mothers raise couch potato kids? Maternalemployment and children’s lifestyle behaviours and weightin early childhood. Soc Sci Med. 2010;70:1816-24.

22. Tandon PS, Zhou C, Lozano P, Christakis DA.Preschoolers’ total daily screen time at home and by type ofchild care. J Pediatr. 2011;158:297-300.

23. Chang HY, Park E-J, Yoo H-J, Lee JW, Shin Y. Electronicmedia exposure and use among toddlers. PsychiatryInvestig. 2018;15:568-73.

24. Verma S, Suman N, Verma P. Effect of electronic gadgetson cognitive milestones of children below 2 years of age.International Archives of Integrated Medicine. 2018;5:52-4.

25. Ruangdaraganon N, Chuthapisith J, Mo-suwan L,Kriweradechachai S, Udomsubpayakul U, ChoprapawonC. Television viewing in Thai infants and toddlers: Impactsto language development and parental perceptions. BMCPediatr. 2009;9:34.

26. Kirkorian HL, Pempek TA, Murphy LA, Schmidt ME,Anderson DR. The impact of background television onparent-child interaction. Child Dev. 2009;80:1350-9.

27. Russo-Johnson C, Troseth G, Duncan C, Mesghina A. Alltapped out: Touchscreen interactivity and young children’sword learning. Front Psychol. 2017;8:578.



28. Kirkorian HL, Choi K, Pempek TA. Toddlers’ wordlearning from contingent and noncontingent video on touchscreens. Child Dev. 2016;87:405-13.

29. Paudel S, Jancey J, Subedi N, Leavy J. Correlates of mobilescreen media use among children aged 0-8: a systematicreview. BMJ Open. 2017;7:e014585.

30. Duch H, Fisher EM, Ensari I, Harrington A. Screen time usein children under 3 years old: A systematic review ofcorrelates. Int J Behav Nutr Phys Act. 2013;10:102.

31. Zimmerman FJ, Ortiz SE, Christakis DA, Elkun D. Thevalue of social-cognitive theory to reducing preschool TVviewing: A pilot randomized trial. Prev Med (Baltim).2012;54:212-8.

32. Hinkley T, Cliff DP, Okely AD. Reducing electronic mediause in 2–3 year-old children: feasibility and efficacy of theFamily@play pilot randomised controlled trial. BMCPublic Health. 2015;15:779.

33. Taveras EM. Randomized Controlled Trial to ImprovePrimary Care to Prevent and Manage Childhood Obesity.Arch Pediatr Adolesc Med. 2011;165:714-22.

34. van Grieken A, Renders CM, Veldhuis L, Looman CW,Hirasing RA, Raat H. Promotion of a healthy lifestyleamong 5-year-old overweight children: health behavioroutcomes of the ‘Be active, eat right’ study. BMC PublicHealth. 2014;14:59.

35. Latomme J, Cardon G, De Bourdeaudhuij I, Iotova V,Koletzko B, Socha P, et al. Effect and process evaluation ofa kindergarten-based, family-involved intervention with arandomized cluster design on sedentary behaviour in 4- to6- year old European preschool children: The ToyBox-study. PLoS One. 2017;12:e0172730.

36. Mendoza JA, Baranowski T, Jaramillo S, Fesinmeyer MD,Haaland W, Thompson D, et al. Fit 5 kids TV reductionprogram for latino preschoolers. Am J Prev Med.2016;50:584-92.

37. Epstein LH, Roemmich JN, Robinson JL, Paluch RA,Winiewicz DD, Fuerch JH, et al. A randomized trial of theeffects of reducing television viewing and computer use onbody mass index in young children. Arch Pediatr AdolescMed. 2008;162:239-45.

38. Yilmaz G, Demirli Caylan N, Karacan CD. An interventionto preschool children for reducing screen time: Arandomized controlled trial. Child Care Health Dev.2015;41:443-9.

39. Knowlden AP, Sharma M, Cottrell RR, Wilson BRA,Johnson ML. Impact evaluation of enabling mothers toprevent pediatric obesity through web-based education andreciprocal determinism (EMPOWER) randomized controltrial. Health Educ Behav. 2015;42:171-84.

40. Puder JJ, Marques-Vidal P, Schindler C, Zahner L, NiedererI, Burgi F, et al. Effect of multidimensional lifestyleintervention on fitness and adiposity in predominantlymigrant preschool children (Ballabeina): Clusterrandomised controlled trial. BMJ. 2011;343:d6195.

41. Foster BA, Aquino C, Gil M, Flores G, Hale D. Arandomized clinical trial of the effects of parent mentors onearly childhood obesity: Study design and baseline data.Contemp Clin Trials. 2015;45:164-9.

42. Fitzgibbon ML, Stolley MR, Schiffer LA, BraunschweigCL, Gomez SL, Van Horn L, et al. Hip-Hop to Health Jr.Obesity Prevention Effectiveness Trial: Post interventionresults. Obesity (Silver Spring). 2011;19:994-1003.

43. Fitzgibbon ML, Stolley MR, Schiffer L, Kong A,Braunschweig CL, Gomez-Perez SL, et al. Family-basedhip-hop to health: Outcome results. Obesity (SilverSpring). 2013;21:274-83.

44. Haines J, McDonald J, O’Brien A, Sherry B, Bottino CJ,Schmidt ME, et al. Healthy habits, happy homes:randomized trial to improve household routines for obesityprevention among preschool-aged children. JAMA Pediatr.2013;167:1072-9.

45. Skouteris H, Hill B, McCabe M, Swinburn B, Busija L. Aparent-based intervention to promote healthy eating andactive behaviours in pre-school children: Evaluation of theMEND 2-4 randomized controlled trial. Pediatr Obes.2015;11:4-10.

46. Birken CS, Maguire J, Mekky M, Manlhiot C, Beck CE,DeGroot J, et al. Office-based randomized controlled trialto reduce screen time in preschool children. Pediatrics.2012;130:1110-5.

47. Peng W, Crouse JC, Lin J-H. Using active video games forphysical activity promotion: A systematic review of thecurrent state of research. Health Educ Behav. 2013;40:171-92.

48. Tremblay MS, LeBlanc AG, Carson V, Choquette L,Connor Gorber S, Dillman C, et al. Canadian SedentaryBehaviour Guidelines for the Early Years (aged 0-4 years).Appl Physiol Nutr Metab. 2012;37:370-80.

49. Bozzola E, Spina G, Ruggiero M, Memo L, Agostiniani R,Bozzola M, et al. Media devices in pre-school children:The recommendations of the Italian Pediatric Society. Ital JPediatr. 2018;44:69.

50. Department of Health and Aging. Get up and Grow:Healthy Eating and Physical Activity for Early Childhood.Canberra, ACT: Australian Government; 2010. Availablefrom:http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#npa05. Accessed March 20, 2019.

r e v i e w ar t i c l e · 2019-09-11 · questionnaires tv and 37.9% played barrie rs, parental...

Documents