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Yepez CE, Anderson CE, Frost E, Whaley SE, Koleilat M. Sleep Duration Is Associated with Household Food Insecurity and Sugar-Sweetened Beverage Intake Among Women, Infants and Children Participating Children Ages 0-5. Am J Health Promot 2024; 38:492-502. [PMID: 38155440 DOI: 10.1177/08901171231225289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
PURPOSE To determine associations between child and household characteristics and sleep duration among low-income children in Los Angeles County. DESIGN Cross-sectional study. SETTING Survey data collected in 2017 and 2020 in Los Angeles County, California. SAMPLE Special Supplemental Nutrition Program for Women, Infants and Children (WIC) households with children ages 4-60 months. MEASURES Sleep duration for children 4-60 months old (less than recommended (LTR), recommended range, more than recommended (MTR)), household food insecurity (HFI), sociodemographics, and daily servings of sugar-sweetened beverages (SSB). ANALYSIS Multinomial logistic regression, stratified by child age, was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for associations between household/child characteristics and LTR or MTR sleep compared to recommended duration among WIC participating children 4-60 months old. RESULTS The final sample included 3512 children ages 4-23 months and 6035 children ages 24-60 months. In the study population, 32% (3-5 years old) to 44% (4-11months) of children under 5 did not meet the recommended hours of sleep per night. HFI was associated with higher odds of LTR (OR 1.27, CI 1.12-1.45) and MTR (OR 1.46, CI 1.15-1.87) sleep among 24-60 month-old children. Each additional daily SSB serving was associated with higher odds of LTR sleep (4-23 months: OR 1.10, CI 1.02-1.19; 24-59 months: OR 1.12, CI 1.08-1.17). CONCLUSIONS HFI and SSB intake are associated with not getting the recommended amount of sleep among low-income WIC participating children. Nutrition assistance program participants may benefit from receiving information about recommended sleep duration for young children and how to establish sleep routines to optimize sleep duration.
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Affiliation(s)
- Catherine E Yepez
- Public Health Foundation Enterprises (PHFE) WIC, a Program of Heluna Health, City of Industry, CA, USA
| | - Christopher E Anderson
- Public Health Foundation Enterprises (PHFE) WIC, a Program of Heluna Health, City of Industry, CA, USA
| | - Erin Frost
- Department of Public Health, College of Health and Human Development, California State University, Fullerton, CA, USA
| | - Shannon E Whaley
- Public Health Foundation Enterprises (PHFE) WIC, a Program of Heluna Health, City of Industry, CA, USA
| | - Maria Koleilat
- Department of Public Health, College of Health and Human Development, California State University, Fullerton, CA, USA
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Likhitweerawong N, Boonchooduang N, Khorana J, Phinyo P, Patumanond J, Louthrenoo O. Executive dysfunction as a possible mediator for the association between excessive screen time and problematic behaviors in preschoolers. PLoS One 2024; 19:e0298189. [PMID: 38574024 PMCID: PMC10994291 DOI: 10.1371/journal.pone.0298189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/20/2024] [Indexed: 04/06/2024] Open
Abstract
Excessive screen time in children is a growing concern for parents and healthcare providers worldwide because it frequently leads to behavioral problems. Although executive dysfunction is proposed to be one of the contributing factors to maladaptive behaviors, little is known about the link between screen time and behaviors. This study aimed to identify whether executive dysfunction contributes to the negative behaviors of children exposed to excessive screen time. A cross-sectional study was conducted on preschool-aged children from public and private schools in Chiang Mai, Thailand. The parents/guardians of each child completed the questionnaires regarding clinical characteristics and screen time use, the Behavior Rating Inventory for Executive Function-Preschool (BRIEF-P), and the Strengths and Difficulties Questionnaire (SDQ). Children with more than one hour of media exposure per day were considered to have excessive screen time. Multivariable Gaussian regression was analyzed to compare the BRIEF-P and SDQ scores between the excessive and appropriate screen time groups. Causal mediation analysis was performed to examine the effects of total screen time on increasing behavioral problems with executive functioning as a mediator. A total of 1,126 preschoolers were included in the analyses. After controlling for age, sex, socioeconomic status, and maternal education, the excessive screen time group had significantly higher BRIEF-P global executive composite score than the appropriate screen time group (mean difference of global executive composite score = 1.49, 95% CI [0.12, 2.86], and p = 0.033). Concurrently, there were significant differences in externalizing behavior subscales and SDQ total difficulties scores between the excessive and appropriate screen time groups (mean difference of total difficulties score = 0.90, 95% CI [0.29, 1.50], and p = 0.004). A significant average causal mediation effect (ACME) of screen time on behavioral problems mediated through executive functioning was β = 0.28, 95% CI [0.13-0.44], which was more than half of the total effect (54.9%, 95% CI [37.4-100%]). The current study suggests that the increase in behavioral issues in preschoolers might be partly explained by the direct effect of excessive screen time and the mediating effect of impaired executive functioning. Our results may raise concerns about the necessity to limit screen time and monitor for executive function deficits and behavioral problems in young children with high screen time.
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Affiliation(s)
- Narueporn Likhitweerawong
- Department of Pediatrics, Division of Growth and Development, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nonglak Boonchooduang
- Department of Pediatrics, Division of Growth and Development, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jiraporn Khorana
- Department of Surgery, Division of Pediatric Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jayanton Patumanond
- Center of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Orawan Louthrenoo
- Department of Pediatrics, Division of Growth and Development, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Nathanson AI. Sleep and Technology in Early Childhood. Psychiatr Clin North Am 2024; 47:15-26. [PMID: 38302204 DOI: 10.1016/j.psc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Research suggests that technology use is associated with poorer sleep outcomes among children less than 6 years of age. These associations are evident regardless of the type of technology studied, although evening exposure may have the greatest impact compared with technology use during other parts of the day. More work is needed, particularly given that technology use is relatively high among young children. Clinicians should assess patients' technology exposure, including before bedtime, to assess whether sleep issues stem from children's technology use. Moreover, clinicians should educate caregivers about the association between technology use and sleep problems among young children.
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Affiliation(s)
- Amy I Nathanson
- School of Communication, Ohio State University, Columbus, OH 43210, USA.
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Quah PL, Loo BKG, Chia MYH, Chua TBK, Tan TSZ, Chan PC, Tan KH. Adherence to 24-hour integrated activity guidelines among infants, toddlers and preschool children in Singapore. PLoS One 2024; 19:e0298968. [PMID: 38408072 PMCID: PMC10896501 DOI: 10.1371/journal.pone.0298968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
This study examined children's adherence to the Singapore Integrated 24-Hour Activity Guidelines for Early Childhood in infants, toddlers and preschoolers aged 0-6 years. A total of 901 caregivers, comprising 219 infants, 379 toddlers, and 303 preschoolers, provided information regarding their children's physical activity (PA), screen viewing time (SVT), and sleep durations on both weekdays and weekends. Meeting the 24-hour integrated activity guidelines was defined as follows: for infants ≥ 30 minutes per day of tummy time or floor-based play; zero SVT; total sleep of 14-17 hours per day for ages 0-3 months, 12-16 hours per day for ages 4-11 months; for toddlers ≥ 180 minutes of total PA per day; zero SVT under 2 years; <1 hour for ages 2 to less than 3 years; and a total sleep of 11-14 hours per day; for preschoolers ≥ 180 minutes of total PA per day; SVT <1 hour per day; total sleep of 10-13 hours per day for those aged 3-5 years, and 10-11 hours per day for 6-year-olds. Chi-squared tests were used to examine the differences in guideline adherence between weekdays and weekends. Compared to weekdays, during weekends there was a higher proportion of toddlers and preschoolers adhering to the PA guidelines (68.9% vs 50.1%; 78.9% vs 55.4%, respectively, p<0.05), and a lower proportion of toddlers adhering to SVT (38.8% vs 21.8%; p = 0.001). There was a declining adherence to all three activity guidelines as age groups progressed from infants (44.7%) to toddlers (15.8%) and then to preschoolers (9.4%). Concurrently, there was a decrease in adherence to SVT recommendations across the age groups, with adherence rates being highest among infants (83.1%), followed by toddlers (15.8%), and preschoolers (9.4%). Decreasing compliance with all three guidelines, coupled with a corresponding decline in adherence to SVT guidelines as children transition from toddlerhood to preschool age, is a cause for concern. This underscores the need for proactive efforts to educate caregivers about reducing or eliminating SVT among infants and young children.
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Affiliation(s)
- Phaik Ling Quah
- Division of Obstetrics & Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Benny Kai Guo Loo
- General Paediatric Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Michael Yong Hwa Chia
- Physical Education & Sports Science, National Institute of Education, Nanyang Technological University, Singapore, Singapore
| | - Terence Buan Kiong Chua
- Physical Education & Sports Science, National Institute of Education, Nanyang Technological University, Singapore, Singapore
| | - Teresa Shu Zhen Tan
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Poh Chong Chan
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Kok Hian Tan
- Division of Obstetrics & Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Wentz EE, Hoose DL, Holliday K, McDonald T, Silsby K, Podvin S, Hirsh A. Knowledge is power: Relationship between professional recommendations, maternal attitudes, and screen time exposure of infants. J Pediatr Nurs 2023; 73:e213-e219. [PMID: 37741715 DOI: 10.1016/j.pedn.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend infants avoid screen media exposure, yet most infants are regularly exposed. This study aimed to explore screen exposure, maternal attitudes regarding screen media effects, and pediatricians' recommendations to better understand widespread screen media use with infants younger than 18 months of age in hopes of informing mitigation efforts. DESIGN AND METHODS Surveys consisting of 10 Likert-style questions were distributed real-time to a purposive sample of 193 mothers with infants 18 months of age or younger in Georgia, Pennsylvania, and New York. RESULTS Seventy-nine percent of infants exceeded AAP/WHO guidelines and 61% of respondents couldn't recall receiving pediatrician recommendations regarding screen exposure for their infant. Mothers with higher levels of education were associated with an accurate reflection of the adverse effects of screen usage on infant development (ANOVA; F = 10.122; df = 3; p < .001). Accurate maternal attitudes regarding adverse effects on infants was associated with less daily screen exposure (Spearman correlation; r = -0.428; p < .001). CONCLUSIONS Findings suggest that knowledge about adverse side effects of screen media usage with infants is associated with less daily exposure; and, that pediatricians may not routinely review guidelines for infants with their families, underscoring the importance of other methods of knowledge dissemination. PRACTICE IMPLICATIONS Nurses, as trusted healthcare providers, can provide counseling on infant screen media usage creating an opportunity for augmented knowledge dissemination across maternal demographics potentially leading to less screen exposure in this vulnerable population.
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Affiliation(s)
- Erin E Wentz
- Upstate Medical University, CHP - Physical Therapy, 750 E. Adams Street NAB 3318, Syracuse, NY 13210, United States of America.
| | - Danielle L Hoose
- Upstate Medical University, CHP - Physical Therapy, 750 E. Adams Street NAB 3318, Syracuse, NY 13210, United States of America
| | - Kathryn Holliday
- Upstate Medical University, CON, 750 E. Adams Street NAB, Syracuse, NY 13210, United States of America
| | - Tara McDonald
- Ivy Rehabilitation Physical Therapy, 23 Burnside Avenue, Apt. B, Cranford, NJ 07016, United States of America
| | - Kristen Silsby
- The Jackson Clinics, 3061 Mount Vernon Avenue, Unit N215, Alexandria, VA 22305, United States of America
| | - Sarah Podvin
- Rochester Hearing and Speech Center, 22 Misty Pine Road, Fairport, NY 14450
| | - Alexandra Hirsh
- Hackensack Meridian Health, 77 Orange Road, Apt. 81, Montclair, NJ 07042, United States of America
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Amos KA, Ogilvie JD, Ponti M, Miller MR, Yang F, Ens AR. Paediatricians' awareness of Canadian screen time guidelines, perception of screen time use, and counselling during the COVID-19 pandemic. Paediatr Child Health 2023; 28:357-361. [PMID: 37744755 PMCID: PMC10517250 DOI: 10.1093/pch/pxad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/17/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives Paediatricians are essential in guiding families on screen time use as digital media becomes increasingly prevalent. While this has been highlighted through the COVID-19 pandemic there is no literature on paediatricians' awareness of Canadian screen time guidelines, or perception of these guidelines during this time. The aim of this study was to assess pediatricians' knowledge, attitudes, and comfort with the Canadian Paediatric Society's (CPS) screen time guidelines, specifically during the COVID-19 pandemic. Methods Our survey was developed by a paediatric resident and paediatric endocrinologist, reviewed by local experts, and sent electronically to members of the CPS Community and Developmental Paediatrics sections. Results All 53 respondents were aware of current CPS screen time guidelines, and the majority self-reported fair to excellent knowledge of guidelines for both age groups (<5 years and school-aged children/adolescents). Over 80% noticed increased screen use during the pandemic, and 98% were somewhat or very concerned about screen use and their patients' health and well-being. Pediatricians reported concerns about associations between increased screen time with worsening behaviour, mental health concerns, obesity, and sedentary lifestyle. The greatest barrier to reducing screen time was perceived insufficient motivation or support from caregivers/families. Conclusions Responding Canadian paediatricians are knowledgeable and comfortable with current screen time guidelines in Canada. Despite this, there is increasing concern with health outcomes associated with screen use. These results highlight paediatricians' important role in counselling patients and may encourage further local advocacy and public education around screen use and associated health risks in children.
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Affiliation(s)
- Kiersten A Amos
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jacqueline D Ogilvie
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
- Division of Developmental Pediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Michelle Ponti
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
- Division of Developmental Pediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Michael R Miller
- Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
- Children’s Health Research Institute, London, Ontario, Canada
| | - Fanyu Yang
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Andrea R Ens
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
- Division of Endocrinology, Department of Pediatrics, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
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7
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Quah PL, Loo BKG, Mettananda S, Dassanayake S, Chia MYH, Chua TBK, Tan TSZ, Chan PC, But BWM, Fu ACC, Wong SMY, Nagano N, Morioka I, Kumar S, Nair MKC, Tan KH. 24 h Activity Guidelines in Children and Adolescents: A Prevalence Survey in Asia-Pacific Cities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6403. [PMID: 37510635 PMCID: PMC10379132 DOI: 10.3390/ijerph20146403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
This study aimed to examine the prevalence of adherence to 24 h activity guidelines in children and adolescents from Asia-Pacific cities. In 1139 children aged 5-18 years, moderate-to-vigorous physical activity (MVPA), screen viewing time (SVT), sleep duration, child weight, height, sex, and age were parent-reported. Descriptive statistics were used to assess the number of guidelines met, and prevalence of adherence to activity guidelines by city and child sex. Prevalence of meeting all three 24 h activity guidelines was low across all countries (1.8-10.3%) (p < 0.05). Children from Thiruvananthapuram, India had the highest [10.3% (95% CI: 6.0-17.0)], while those from Tokyo, Japan had the lowest prevalence [1.8% (95% CI: 0.5-7.0)] of meeting all three guidelines. The highest prevalence of meeting individual MVPA, SVT and sleep guidelines was found in India [67.5% (95% CI: 58.8-75.1)], Kelaniya, Sri Lanka [63.2% (95% CI: 58.7-67.4)] and Kowloon, Hong Kong [59.4% (95% CI: 51.1-65.3)], respectively. Overall, a higher prevalence of boys met all three guidelines, compared to girls [5.9% (95% CI: 4.1-8.1) vs. 4.7% (3.1-6.6), p = 0.32]. The prevalence of adhering to all three activity guidelines was low in all five participating cities, with a higher proportion of boys meeting all guidelines.
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Affiliation(s)
- Phaik Ling Quah
- Division of Obstetrics & Gynaecology, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Benny Kai Guo Loo
- Sports and Exercise Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Sachith Mettananda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya 11600, Sri Lanka
- Colombo North Teaching Hospital, Ragama 11010, Sri Lanka
| | - Senuri Dassanayake
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya 11600, Sri Lanka
| | - Michael Yong Hwa Chia
- Physical Education & Sports Science, National Institute of Education, Nanyang Technological University, Singapore 639798, Singapore
| | - Terence Buan Kiong Chua
- Physical Education & Sports Science, National Institute of Education, Nanyang Technological University, Singapore 639798, Singapore
| | - Teresa Shu Zhen Tan
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore 119074, Singapore
| | - Poh Chong Chan
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore 119074, Singapore
| | - Betty Wai-Man But
- Department of Paediatrics, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | | | | | - Nobuhiko Nagano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo 173-0023, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo 173-0023, Japan
| | - Shyamal Kumar
- NIMS-Spectrum-Child Development Research Centre, Thiruvananthapuram 695123, India
| | - Muttathu K C Nair
- NIMS-Spectrum-Child Development Research Centre, Thiruvananthapuram 695123, India
| | - Kok Hian Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
- Duke-NUS Medical School, Singapore 169857, Singapore
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Kracht CL, Redman LM, Bellando J, Krukowski RA, Andres A. Association between maternal and infant screen time with child growth and development: A longitudinal study. Pediatr Obes 2023; 18:e13033. [PMID: 37005344 PMCID: PMC10337477 DOI: 10.1111/ijpo.13033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Sedentary screen time is an early, modifiable risk factor for obesity and poor child development. OBJECTIVES To examine the relationship between maternal and infant screen time with child growth and development. METHODS Pregnant women were recruited for a cohort study related to maternal and infant development. Screen time was assessed in mothers during pregnancy, and subsequently in children at 3 months, 12 months, and 24 months of age. Child anthropometry was measured, and nuclear magnetic resonance quantified child fat mass. Fat mass index (FMI) was calculated. The Bayley Scales of Infant Development-III were used to assess child development. Linear regression models were used to assess the relationship between screen time and child growth and development, adjusted for covariates and stratified by sex. RESULTS Mother/child dyads (n = 89) were mainly white (92.1%), and half were boys (52%). Both sexes increased screen time between 12 months and 24 months (ps <0.05). Child screen time was positively associated with FMI and negatively associated with development scores. In adjusted models, screen time was positively associated with FMI in boys, and meeting the screen time guideline was associated with lower FMI in girls. CONCLUSION Greater infant screen time was related to higher adiposity. Though few relationships emerged, a cautionary approach to screen time early in life may benefit child health.
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Affiliation(s)
- Chelsea L. Kracht
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808
| | - Leanne M. Redman
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808
| | - Jayne Bellando
- University of Arkansas for Medical Sciences and Arkansas Children’s Nutrition Center, Little Rock, AR 72202
| | - Rebecca A. Krukowski
- University of Virginia, Department of Public Health Sciences, 200 Jeanette Lancaster Way, Charlottesville, VA 22903
| | - Aline Andres
- University of Arkansas for Medical Sciences and Arkansas Children’s Nutrition Center, Little Rock, AR 72202
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Dy ABC, Dy ABC, Santos SK. Measuring effects of screen time on the development of children in the Philippines: a cross-sectional study. BMC Public Health 2023; 23:1261. [PMID: 37380949 DOI: 10.1186/s12889-023-16188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 06/24/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Screen time in young children is discouraged because of its negative effects on their development. However, excessive screen media use has been rising, particularly during the global pandemic when stay-at-home mandates were placed on young children in several countries. This study documents potential developmental effects of excessive screen media use. METHOD This is a cross-sectional study. Participants were 24 to 36 month old Filipino children recruited through non-probable convenience sampling from August to October 2021. Regression analyses were performed to test the association between screen time and changes in scaled scores for skills and behaviors determined from the Adaptive Behavior Scale and to identify factors associated with increased screen media use. RESULTS Increased odds of excessive use of screen media of children by 4.19 when parents watch excessively and 8.56 times greater odds when children are alone compared to watching with a parent or other children. When adjusted for co-viewing, more than 2 h of screen time is significantly associated with decrease in receptive and expressive language scores. The effects on personal skills, interpersonal relationships and play and leisure skills were only statistically significant at 4 to 5 or more hours of screen time use. CONCLUSION The study found that spending no more than 2 h screen time had minimal negative effects on development and that use beyond 2 h was associated with poorer language development among 2 year olds. There is less excessive screen media use when a child co-views with an adult, sibling or other child and when parents likewise have less screen time themselves.
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Affiliation(s)
- Angel Belle C Dy
- Ateneo de Manila University, School of Medicine and Public Health, Ortigas Avenue, Pasig City, 1604, Philippines.
| | - Alane Blythe C Dy
- Ateneo de Manila University, School of Medicine and Public Health, Ortigas Avenue, Pasig City, 1604, Philippines
| | - Samantha Katrina Santos
- Ateneo de Manila University, School of Medicine and Public Health, Ortigas Avenue, Pasig City, 1604, Philippines
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Ponti M. Screen time and preschool children: Promoting health and development in a digital world. Paediatr Child Health 2023; 28:184-202. [PMID: 37205134 PMCID: PMC10186096 DOI: 10.1093/pch/pxac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 09/27/2022] [Indexed: 05/21/2023] Open
Abstract
COVID-19 transformed the family media environment and spurred research on the effects of screen media exposure and use on young children. This update of a 2017 CPS statement re-examines the potential benefits and risks of screen media in children younger than 5 years, with focus on developmental, psychosocial, and physical health. Four evidence-based principles-minimizing, mitigating, mindfully using, and modelling healthy use of screens-continue to guide children's early experience with a rapidly changing media landscape. Knowing how young children learn and develop informs best practice for health care providers and early years professionals (e.g., early childhood educators, child care providers). Anticipatory guidance should now include child and family screen use in (and beyond) pandemic conditions.
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Affiliation(s)
- Michelle Ponti
- Canadian Paediatric Society, Digital Health Task Force, Ottawa, Ontario, Canada
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11
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Kamga Fogno AW, Rouquette A, Gronfier C, Bernard JY, Plancoulaine S. Associations between screen use, outdoor time/daylight exposure and sleep changes during the first COVID-19 lockdown in French children from the ELFE and EPIPAGE2 birth cohorts. CNS Neurosci Ther 2023; 29:1649-1656. [PMID: 36807866 PMCID: PMC10173720 DOI: 10.1111/cns.14128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
AIMS To investigate associations between outdoor and screen time and changes in sleep patterns in children from two nationwide birth-cohorts in the SAPRIS project. METHODS During the first French COVID-19 pandemic lockdown, volunteer parents of children enrolled in the ELFE and EPIPAGE2 birth-cohorts completed online questions about their child's outdoor time, screen time, and changes in sleep duration and quality compared with the pre-lockdown situation. In 5700 children (aged 8-9 years, 52% boys) with available data, we assessed associations between outdoor time, screen time, and sleep changes using multinomial logistic regression models adjusted for confounders. RESULTS Children spent on average 3 h08 outdoors and 4 h34 using screens/day (3 h27 for leisure, 1 h07 for class-work). Sleep duration increased in 36% of children and decreased in 13.4%; sleep difficulties appeared/increased in 22.5% and decreased/disappeared/remained stable in 18.3%. After adjustment, increased screen time, especially for leisure, was associated with increased and decreased sleep duration (OR(95%CI) = 1.03(1.00-1.06) and OR = 1.06(1.02-1.10), respectively). No association was observed between outdoor time and sleep changes after adjustment. CONCLUSIONS Our study adds evidence for the association between high leisure-time screen time and shorter sleep time. It supports current screen guidelines for children, especially during leisure time and for those whose sleep duration is short.
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Affiliation(s)
- Alex Wilfried Kamga Fogno
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
| | - Alexandra Rouquette
- Université Paris-Saclay, UVSQ, Inserm U1018, CESP, Paris, France.,AP-HP Paris-Saclay, Hôpital du Kremlin Bicêtre, Service de Santé Publique et d'Epidemiologie, Le Kremlin Bicêtre, France
| | - Claude Gronfier
- Université Claude Bernard Lyon 1, INSERM, CRNS, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Bron, France
| | - Jonathan Y Bernard
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France.,Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Sabine Plancoulaine
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France.,Université Claude Bernard Lyon 1, INSERM, CRNS, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Bron, France
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12
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Associations of excessive screen time and early screen exposure with health-related quality of life and behavioral problems among children attending preschools. BMC Public Health 2022; 22:2440. [PMID: 36575397 PMCID: PMC9795659 DOI: 10.1186/s12889-022-14910-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Both excessive screen time and early screen exposure have been linked to children's health outcomes, but few studies considered these two exposures simultaneously. The aim of this study was to explore the independent and interactive associations of excessive screen time and early screen exposure with health-related quality of life (HRQOL) and behavioral problems among Chinese children attending preschools. METHODS A cross-sectional study of 4985 children aged between 3 and 6 years was conducted in Chengdu, China. Each parent has finished an online questionnaire regarding their children's screen use, HRQOL, and behavioral problems. Children with screen time over 1 h/day were considered as having excessive screen time. Early screen exposure was defined if the children had started using screen-based media before the age of 2 years. HRQOL was assessed by the Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0), while behavioral problems were confirmed with the 48-item Conners' Parent Rating Scale (CPRS-48). RESULTS Of the 4985 children (2593 boys and 2392 girls) included, the mean age was 4.6 (SD: 1.0) years. After adjustment for confounders and early screen exposure, excessive screen time was significantly associated with worse HRQOL scores in all dimensions and summary scales, as well as each type of behavioral problems (all p values < 0.05). We also found that compared to children with later initiation of screen exposure, those with screen use before the age of 2 years had significantly lower emotional functioning score (β: - 2.13, 95%CI: - 3.17, - 1.09) and psychosocial health summary score (β: - 0.82, 95%CI: - 1.54, - 0.10) of HRQOL, as well as higher risks of conduct problems, learning problems, psychosomatic problems, impulsive-hyperactive, and hyperactivity index, which were independent of excessive screen use. Furthermore, there were significant interactive effects of excessive screen time and early screen exposure on emotional functioning domain of HRQOL scores and conduct problems. CONCLUSION Excessive screen time and early screen exposure are two independent and interactive factors to children's HRQOL and behavioral problems. Our findings support current guidelines to limit screen exposure in children. Appropriate screen use may represent an important intervention target to improve children's HRQOL and reduce their behavioral problems.
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13
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Mortazavi SAR, Tahmasebi S, Parsaei H, Taleie A, Faraz M, Rezaianzadeh A, Zamani A, Zamani A, Mortazavi SMJ. Machine Learning Models for Predicting Breast Cancer Risk in Women Exposed to Blue Light from Digital Screens. J Biomed Phys Eng 2022; 12:637-644. [PMID: 36569561 PMCID: PMC9759638 DOI: 10.31661/jbpe.v0i0.2105-1341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/02/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND Nowadays, there is a growing global concern over rapidly increasing screen time (smartphones, tablets, and computers). An accumulating body of evidence indicates that prolonged exposure to short-wavelength visible light (blue component) emitted from digital screens may cause cancer. The application of machine learning (ML) methods has significantly improved the accuracy of predictions in fields such as cancer susceptibility, recurrence, and survival. OBJECTIVE To develop an ML model for predicting the risk of breast cancer in women via several parameters related to exposure to ionizing and non-ionizing radiation. MATERIAL AND METHODS In this analytical study, three ML models Random Forest (RF), Support Vector Machine (SVM), and Multi-Layer Perceptron Neural Network (MLPNN) were used to analyze data collected from 603 cases, including 309 breast cancer cases and 294 gender and age-matched controls. Standard face-to-face interviews were performed using a standard questionnaire for data collection. RESULTS The examined models RF, SVM, and MLPNN performed well for correctly classifying cases with breast cancer and the healthy ones (mean sensitivity> 97.2%, mean specificity >96.4%, and average accuracy >97.1%). CONCLUSION Machine learning models can be used to effectively predict the risk of breast cancer via the history of exposure to ionizing and non-ionizing radiation (including blue light and screen time issues) parameters. The performance of the developed methods is encouraging; nevertheless, further investigation is required to confirm that machine learning techniques can diagnose breast cancer with relatively high accuracies automatically.
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Affiliation(s)
| | - Sedigheh Tahmasebi
- MD, Breast Cancer Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Parsaei
- PhD, Department of Medical Physics and Engineering, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- PhD, Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdorasoul Taleie
- MD, Breast Cancer Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Faraz
- MSc, Department of Medical Physics and Engineering, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rezaianzadeh
- PhD, Department of Epidemiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Atefeh Zamani
- PhD, Department of Statistics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Zamani
- PhD, Department of Medical Physics and Engineering, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohammad Javad Mortazavi
- PhD, Department of Medical Physics and Engineering, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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14
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Caffarelli C, Santamaria F, Piro E, Basilicata S, Delle Cave V, Cipullo M, Bernasconi S, Corsello G. New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine. Ital J Pediatr 2022; 48:189. [PMID: 36435791 PMCID: PMC9701393 DOI: 10.1186/s13052-022-01374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.
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Affiliation(s)
- Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci 14, Parma, Italy.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ettore Piro
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valeria Delle Cave
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marilena Cipullo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Giovanni Corsello
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
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15
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Loo BKG, Okely A, Taylor R, Novotny R, Wickramasinghe P, Müller-Riemenschneider F, Waqa G, Pulungan A, Kusuda S, Tan KH. Asia-Pacific consensus statement on integrated 24-hour activity guidelines for the early years. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 32:100641. [PMID: 36785856 PMCID: PMC9918766 DOI: 10.1016/j.lanwpc.2022.100641] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/07/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022]
Abstract
Background Early childhood is a vital period for development and growth. Promoting beneficial lifestyle behaviours in early childhood can help optimise children's health, development and learning, shape their behaviours in adulthood and offer the best protection against future non-communicable diseases (NCDs). In the Asia-Pacific region, NCDs are significant causes of healthcare burden and mortality. Furthermore, there is also a high prevalence of adverse metabolic risk factors and unhealthy lifestyle behaviours among these children. Method Representatives from 19 Asia-Pacific nations and/or jurisdictions developed a consensus statement on integrated 24-hour activity guidelines for the early years using the GRADE-ADOLOPMENT framework. Findings These guidelines apply to all infants, toddlers and pre-schoolers below 5 years of age. The guidelines aim to provide a holistic and practical approach to lifestyle activities by framing physical activity, sedentary behaviour and sleep within a 24-hour period. Dietary patterns were included as they play an integral role in metabolic health and energy balance. Interpretation Aligned with the World Health Organization's Global Action Plan for the Prevention and Control of NCDs through health promotion interventions in early life, through cultivating healthy lifestyle behaviours in the children's early years, we aim to provide children with the best start in life and reduce the burden of future NCDs in the Asia-Pacific region. Funding Funded by Integrated platform for research in advancing metabolic health outcomes of women and children.
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Affiliation(s)
- Benny Kai Guo Loo
- Sport and Exercise Medicine Service, KK Women’s and Children’s Hospital, Singapore,Corresponding author. Department of Paediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
| | - Anthony Okely
- School of Health and Society, University of Wollongong, Sydney, New South Wales, Australia
| | - Rachael Taylor
- Department of Medicine, University of Otago, Dunedin, Otago, New Zealand
| | - Rachel Novotny
- Department of Human Nutrition, Food and Animal Sciences, University of Hawaiʻi at Mānoa, Honolulu, HI, USA
| | | | | | - Gade Waqa
- School of Public Health and Primary Care, Fiji National University, Suva, Fiji
| | - Aman Pulungan
- Endocrinology Division, Child Health Department, Faculty of Medicine, Universitas Indonesia – Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Mitaka, Tokyo, Japan
| | - Kok Hian Tan
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
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16
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Landsem IP, Cheetham NB. Infant sleep as a topic in healthcare guidance of parents, prenatally and the first 6 months after birth: a scoping review. BMC Health Serv Res 2022; 22:1135. [PMID: 36076290 PMCID: PMC9454198 DOI: 10.1186/s12913-022-08484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background This scoping review focuses on infant sleep-related factors and themes that are relevant when health practitioners provide preventive health services to expectant and new parents. Methods A systematic literature search in CINAHL, PubMed, and PsycINFO, published in 2010 or later, identified 1661 records. The search was further narrowed to focus on sleep in healthy term-born infants until the second half of the first year of life. A blinded review by both authors covered 136 papers, of which 43 papers were reviewed in the full text. Finally, 38 articles were included in the data extraction. Results The analysis process showed that the selected studies formed three main information categories: 11 studies thematised safe infant sleep issues, 10 studies described design and findings from sleep-related intervention studies, and 17 studies focused on different parent-child interactive aspects that may influence the quality and duration of infant sleep in the first six months of life. The main finding is that knowledge about early infant sleep is very complex, and includes both child, parent, and environmental factors. Several studies have shown that the concepts and factors related to safe infant sleep also influence the development of healthy infant sleep patterns. Thus, these aspects are interwoven with each other and should be addressed together in communication with parents. Conclusions Health practitioners with different professional backgrounds need to search for an agreement on when and how different aspects of sleep-related knowledge should be communicated to new and expectant parents to enable the design of national follow-up programs. Parents want coherent and personalized services regarding infant sleep issues that may allow them to choose sleeping arrangements, routines, and behaviors that fit in with their sociocultural attitudes and traditions. Many different sources and formats may be used to empower parents regarding infant sleep issues. Studies have described the use of group or individual meetings, videos, and written materials. The key issue is the importance of consistent and seamless knowledge-based services.
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Affiliation(s)
- Inger Pauline Landsem
- The Arctic University of Norway, The Health Research Faculty, Institute of Health and Caring Science, Hansine Hansens veg 18, 9019, Tromsø, Norway. .,Child and Adolescent Department, University Hospital of North Norway, Sykehusvegen 38, 9019, Tromsø, Norway.
| | - Nina Bøhle Cheetham
- The Arctic University of Norway, The Health Research Faculty, Institute of Health and Caring Science, Hansine Hansens veg 18, 9019, Tromsø, Norway
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17
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Fogno A, Rouquette A, Gronfier C, Bernard J, Plancoulaine S. Relations entre usage des écrans, exposition à la lumière naturelle et sommeil chez les enfants en France pendant le premier confinement consécutif à l’épidémie SARS-CoV-2. MÉDECINE DU SOMMEIL 2022. [PMCID: PMC9170532 DOI: 10.1016/j.msom.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Lee G, Kim S. Relationship between Mother’s emotional intelligence, negative parenting behaviour, Preschooler’s attachment instability, and smart device overdependence. BMC Public Health 2022; 22:752. [PMID: 35421976 PMCID: PMC9008395 DOI: 10.1186/s12889-022-13171-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/30/2022] [Indexed: 11/12/2022] Open
Abstract
Background As smart device overdependence among preschoolers could adversely affect their overall development, it is essential to understand the related factors of such overdependence. Mothers have a large influence on preschoolers; however,, the relationship between mothers’ emotional intelligence, negative parenting behaviour, preschoolers’ attachment instability, and smart device overdependence remain unclear. This study aims to develop and test a structural model to explain smart device overdependence among preschoolers. Methods The study collects and analyses data from January to May 2021 from 283 mothers raising children aged 3–6 years in South Korea. Questionnaires regarding mothers’ emotional intelligence and negative parenting behaviour, as well as preschoolers’ attachment instability and smart device overdependence, were used to collect data. The data were analysed by SPSS23.0 and AMOS 23.0 software and a structural equation model was constructed; p ≤ 0.05 was taken as significant. Results Mothers’ emotional intelligence had a direct negative relationship with mothers’ negative parenting behaviour (β = − 0.44) and an indirect negative relationship with preschoolers’ attachment instability (β = − 0.25) and preschoolers’ smart device overdependence (β = − 0.24). Mothers’ negative parenting behaviour had a direct positive relationship with preschoolers’ attachment instability (β = 0.56) and both direct and indirect positive relationships with preschoolers’ smart device overdependence (β = 0.55). Preschoolers’ attachment instability had a direct positive relationship with preschoolers’s smart device overdependence (β = 0.46). Conclusions Mothers’ emotional intelligence, negative parenting behaviour, and preschoolers’ attachment instability are associated with preschoolers’ vulnerability to smart device overdependence. These results are shown that more attention is needed to these variables in order to reduce preschoolers’ overdependence on smart devices. Additionally, we propose to develop and provide interventions based on these results.
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19
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Effects of Screen Viewing Time on Sleep Duration and Bedtime in Children Aged 1 and 3 Years: Japan Environment and Children's Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073914. [PMID: 35409594 PMCID: PMC8997461 DOI: 10.3390/ijerph19073914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023]
Abstract
This study aimed to clarify the effects of television/digital versatile disc (TV/DVD) viewing time and portable electronic device (PED) usage time on sleep duration and bedtime and the difference between the effects of TV/DVD and PED on sleep. The effect of TV/DVD viewing time or PED usage time on sleep duration and bedtime was analyzed using a multiple logistic regression analysis adjusted for covariates. A total of 74,525 participants were included in the analysis, using data from Japan Environment and Children’s Study. TV/DVD viewing was not associated with short sleep duration, but PED usage was associated with short sleep duration. In addition, the risk of short sleep duration increased as PED usage time increased. We also investigated the effects of sleep habits at age 1 year on sleep at age 3 years. This study showed that late bedtime at age 1 year posed a significant risk of late bedtime at age 3 years. In summary, particular caution should be paid to PED use from a child’s health perspective, and sleep habits should be focused on bedtime from the age of 1 year.
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20
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Thompson LA, Liberty R, Corr A. "Does your baby watch TV?": The associations between at-home TV watching and laboratory challenge cortisol are different for young infants and their mothers. Dev Psychobiol 2022; 64:e22236. [PMID: 35191526 DOI: 10.1002/dev.22236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/24/2021] [Accepted: 12/05/2021] [Indexed: 11/07/2022]
Abstract
This longitudinal study examined associations between at-home TV watching and the biological stress response (cortisol) during a laboratory infant cognitive challenge task in 240 3- and 5-month infants and their mothers. Cortisol levels were lower in mothers of 5-month-old infants whose infants were exposed to TV at home, compared to mothers of infants that were not TV-exposed. Cortisol patterns were different across three laboratory sampling intervals for 3-month-old infants as a function of TV watching, revealing a sharp increase in laboratory cortisol only for infants who were exposed to TV at home. In contrast, there was no effect of TV exposure in 5-month-old infants' cortisol. Infant temperament and demographic measures were included as control variables in regression models to predict maternal and infant cortisol. At 3 months, for the T3 cortisol sampling interval, and at 5 months across all three sampling intervals, maternal cortisol levels were significantly predicted by infant TV exposure after accounting for variance due to these control variables. Our findings show the strong influence of the infant TV-exposure factor in the biological stress response of mothers of young infants, and suggest that infant TV exposure may influence self-regulation in 3-month-old infants.
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Affiliation(s)
- Laura A Thompson
- Clinical Psychology Program, Fielding Graduate University, Las Cruces, New Mexico, USA.,Psychology Department, New Mexico State University, Las Cruces, New Mexico, USA
| | - Rebecca Liberty
- Clinical Psychology Program, Fielding Graduate University, Las Cruces, New Mexico, USA
| | - Alora Corr
- Clinical Psychology Program, Fielding Graduate University, Las Cruces, New Mexico, USA
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21
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Widyastari DA, Kesaro S, Rasri N, Saonuam P, Katewongsa P. Learning Methods During School Closure and Its Correlation With Anxiety and Health Behavior of Thai Students. Front Pediatr 2022; 10:815148. [PMID: 35419324 PMCID: PMC8995846 DOI: 10.3389/fped.2022.815148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/23/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The sequential waves of epidemic spread of COVID-19 in Thailand have caused periodic closures of schools, and exposed students to different learning methods that require multiple adjustment strategies. This study aimed to examine how different learning methods may correlate with anxiety and health behavior (e.g., physical activity, active play, screen time, sleep) of primary and secondary school students in Thailand. METHODS Thailand Report Card (TRC) Data (2021) was employed. The sample of the TRC was drawn by multi-stages random sampling stratified by region, district, urban/rural, school size, sex, and age to ensure national representativeness. A total of 6,078 Thai primary (64%) and secondary (36%) school students were included in the analysis. RESULTS About two-thirds (66.4%) of the sample experienced a shift from traditional classroom to fully online learning, 6.9% experienced partial online instruction, 23.6% received handouts or written assignments, and 3.1% resumed traditional classroom learning. Compared to fully online learning, students who experienced traditional classroom (onsite) teaching were 37.8% less likely to report moderate-to severe anxiety (OR 0.6; p-value 0.021). There was no significant correlation between school closure-induced anxiety with overall physical activity (PA) and active play, but anxiety was significantly associated with screen time and sleep duration. Receiving handouts/written assignments only as the learning method was significantly correlated with PA, but two methods (handouts and onsite/traditional classroom) was significantly correlated with active play. Students who experienced classroom learning were also more likely to comply with recommended durations of screen time and sleep. CONCLUSION Although online learning was probably the most convenient choice during COVID-19 containment measures in Thailand, this method did not provide sufficient opportunity for PA and play. Online learning also encouraged an excessive use of screen media, and disrupted sleeping patterns. Online learning also pressured Thai students to make various adjustments in their daily routines that may have further aggravated anxiety.
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Affiliation(s)
- Dyah Anantalia Widyastari
- Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand.,Thailand Physical Activity Knowledge Development Centre (TPAK), Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand
| | - Sarocha Kesaro
- Thailand Physical Activity Knowledge Development Centre (TPAK), Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand
| | | | | | - Piyawat Katewongsa
- Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand.,Thailand Physical Activity Knowledge Development Centre (TPAK), Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand
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22
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Eric O. The negative effects of new screens on the cognitive functions of young children require new recommendations. Ital J Pediatr 2021; 47:223. [PMID: 34742324 PMCID: PMC8572488 DOI: 10.1186/s13052-021-01174-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/23/2021] [Indexed: 11/10/2022] Open
Abstract
Television studies have shown that some negative effects of screens could depend on exposure time, but more importantly on the characteristics of the child, the type of content viewed, and the context in which it is viewed. Studies on newer screens show that these factors are still valid but new ones now play a negative role: portable screens increase the duration of exposure and lowered the age at which exposure begins. More worryingly, new screen persuasive designs and dark patterns largely used incite more frequent use, attracting the attention of children and parents, resultantly interfering deeply in parent/child relationships. In this text we suggest that current academic recommendations have to be more broadly shared but also that new recommendations are needed: especially to advise parents not to let their screen interactions compete with real interactions with their child which are the core of learnings (especially language) and emotional regulations but also of their security.
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Affiliation(s)
- Osika Eric
- Department of Pediatrics, Saint Camille Hospital, 2 Rue des Pères Camilliens, 94360, Bry-sur-Marne, France.
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23
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Byrne R, Terranova CO, Trost SG. Measurement of screen time among young children aged 0-6 years: A systematic review. Obes Rev 2021; 22:e13260. [PMID: 33960616 PMCID: PMC8365769 DOI: 10.1111/obr.13260] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/16/2022]
Abstract
The impact of screen-based devices on children's health and development cannot be properly understood without valid and reliable tools that measure screen time within the evolving digital landscape. This review aimed to summarize characteristics of measurement tools used to assess screen time in young children; evaluate reporting of psychometric properties; and examine time trends related to measurement and reporting of screen time. A systematic review of articles published in English across three databases from January 2009 to April 2020 was undertaken using PROSPERO protocol (registration: CRD42019132599) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured screen time as outcome, exposure, or confounder in children 0-6 years. The search identified 35,868 records, 1035 full-text articles were screened for eligibility, and 622 met inclusion criteria. Most measures (60%) consisted of one to three items and assessed duration of screen time on a usual day. Few measures assessed content (11%) or coviewing (7%). Only 40% of articles provided a citation for the measure, and only 69 (11%) reported psychometric properties-reliability n = 58, validity n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of published articles increased from 28 to 71. From 2015, there was a notable increase in the proportion of articles published each year that assessed exposure to mobile devices in addition to television. The increasing number of published articles reflects increasing interest in screen time exposure among young children. Measures of screen time have generally evolved to reflect children's contemporary digital landscape; however, the psychometric properties of measurement tools are rarely reported. There is a need for improved measures and reporting to capture the complexity of children's screen time exposures.
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Affiliation(s)
- Rebecca Byrne
- School of Exercise and Nutrition Sciences, Faculty of Health, Centre for Children's Health Research (CCHR)Queensland University of Technology (QUT)South BrisbaneQueenslandAustralia
| | - Caroline O. Terranova
- School of Exercise and Nutrition Sciences, Faculty of Health, Centre for Children's Health Research (CCHR)Queensland University of Technology (QUT)South BrisbaneQueenslandAustralia
| | - Stewart G. Trost
- School of Exercise and Nutrition Sciences, Faculty of Health, Centre for Children's Health Research (CCHR)Queensland University of Technology (QUT)South BrisbaneQueenslandAustralia
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Emond JA, O'Malley AJ, Neelon B, Kravitz RM, Ostbye T, Benjamin-Neelon SE. Associations between daily screen time and sleep in a racially and socioeconomically diverse sample of US infants: a prospective cohort study. BMJ Open 2021; 11:e044525. [PMID: 34168024 PMCID: PMC8231048 DOI: 10.1136/bmjopen-2020-044525] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To determine the associations between screen media use and sleep throughout infancy (3-12 months). DESIGN Prospective Nurture birth cohort. SETTING North Carolina, USA, 2013-2015. PARTICIPANTS Women enrolled in their second to third trimester, completed a phone interview after birth, and completed home visits at 3, 6, 9 and 12 months post partum. PRIMARY AND SECONDARY OUTCOME MEASURES Women reported the usual hours their infants slept during the day and night and their infants' usual use of five screen media activities at 3, 6, 9 and 12 months post partum. Adjusted mixed-effects regression analyses modelled the associations between infant screen time and sleep outcomes while disaggregating the between-infant and within-infant effects. RESULTS Among 558 mother-infant dyads, 374 (67.0%) infants were black and 304 (54.5%) households earned <$20 000 per year. Half (254, 50.2%) of the infants engaged with screens at 3 months of age, while 326 (72.9%) engaged at 12 months. The median value of the average daily screen time over the study period was 50 (IQR: 10-141) min. Infant screen time was inversely associated with night-time sleep duration only when considering between-infant effects (adjusted beta: -2.9; 95% CI -5.9 to 0.0; p=0.054 for log-transformed screen time). Effects were stronger for television+DVD viewing specifically (adjusted beta: -5.2; 95% CI -9.1 to -1.4; p<0.01 for log-transformed television+DVD time). For example, an infant who averaged 1 hour of television+DVD viewing over the study period slept, on average, 9.20 (95% CI 9.02 to 9.37) hours per night by 12 months compared with 9.60 (95% CI 9.41 to 9.80) hours per night for an infant with no screen time over the study period. There were no significant within-infant effects between screen time and night-time sleep, and screen time was not associated with daytime sleep or night-time awakenings. CONCLUSIONS Screen time during infancy was inversely associated with night-time sleep duration; however, causal associations remain uncertain. TRIAL REGISTRATION NUMBER NCT01788644.
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Affiliation(s)
- Jennifer A Emond
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - A James O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
- The Dartmouth Institute, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Richard M Kravitz
- Division of Pediatric Pulmonary and Sleep Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Truls Ostbye
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
| | - Sara E Benjamin-Neelon
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kim SY, Han S, Park EJ, Yoo HJ, Park D, Suh S, Shin YM. The relationship between smartphone overuse and sleep in younger children: a prospective cohort study. J Clin Sleep Med 2021; 16:1133-1139. [PMID: 32248898 DOI: 10.5664/jcsm.8446] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVES Younger children and adolescents are exposed to various smart devices in the modern world, and their use of smart devices is rapidly increasing worldwide. Although smart devices have often been considered to have negative effects on sleep of children and adolescents, such effects have not been studied among younger children. Sleep is considered particularly important for learning and memory, and also has implications for emotional regulation and behavior. Therefore, this study was conducted to examine the effects of smartphone overuse on sleep in 5- to 8-year-old children. METHODS Participants were from the Kids Cohort for Understanding of Internet Addiction Risk Factors in Early Childhood (K-CURE) Study, an observational prospective cohort study in Korea. Smartphone screen time and total sleep time were assessed using parental questionnaires. Sleep problems of children were assessed using the Children's Sleep Habits Questionnaire (CSHQ). Analysis of covariance was used to examine the association between smartphone overuse and sleep habits in children. All statistical analyses were conducted using SPSS version 21.0 (IBM Corporation, Armonk, NY). RESULTS Total sleep time of the smartphone overuse group (smartphone use over 1 hour daily) was shorter than that of the control group (F = 6.362, P < .05). Children in the smartphone overuse group showed statistically significant higher scores in the CSHQ total score and nocturnal awakening subscale score (P < .05). CONCLUSIONS Excessive smartphone use was related to shorter total sleep time in children. Use of a smartphone was also associated with significant reductions in the quality of sleep in younger children.
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Affiliation(s)
- So Yeon Kim
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sora Han
- Department of Psychology, Sungshin Women's University, Seoul, Republic of Korea
| | - Eun-Jin Park
- Department of Psychiatry, Inje University, Ilsan Paik Hospital, Goyang, Korea
| | - Hee-Jeong Yoo
- Department of Psychiatry, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dasom Park
- Department of Psychology, Sungshin Women's University, Seoul, Republic of Korea
| | - Sooyeon Suh
- Department of Psychology, Sungshin Women's University, Seoul, Republic of Korea
| | - Yun Mi Shin
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
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26
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Zhang Z, Sousa-Sá E, Pereira JR, Okely AD, Feng X, Santos R. Correlates of Sleep Duration in Early Childhood: A Systematic Review. Behav Sleep Med 2021; 19:407-425. [PMID: 32496141 DOI: 10.1080/15402002.2020.1772264] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE This systematic review aimed to summarize correlates of sleep duration in children under 5 years of age. METHODS Six electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, SPORTDiscus, and Scopus) were searched from inception to May 2019. Observational studies and intervention studies reporting cross-sectional results from baseline data were considered. Data were extracted using a predesigned form and potential correlates were categorized following a sociological framework. RESULTS One-hundred and sixteen studies, representing 329,166 children, met the inclusion criteria, with a high risk of bias in 62 included studies. A total of 83 correlates of sleep duration were identified. Among the associations studied four or more times, correlates of nap duration were child's age and nighttime sleep onset/bedtime; correlates of nighttime sleep duration were household income, parent marital status, parental adiposity level, nighttime sleep duration at younger age, nighttime sleep onset/bedtime, nighttime sleep wakeup time, and frequency of current bedtime routine; correlate of total sleep duration was screen time. CONCLUSIONS Young children from low-income households, single families, or having overweight parents may be at risk for short sleep duration. Promoting healthy sleep duration from an early age appears essential. Effective practices may include encouraging an earlier bedtime, limiting screen time, and establishing a regular bedtime routine. The absence of consistent evidence in the psychological, cognitive, and emotional domain as well as the physical environmental domain warrants further research.
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Affiliation(s)
- Zhiguang Zhang
- Early Start, Faculty of Social Sciences, University of Wollongong, Australia
| | - Eduarda Sousa-Sá
- Early Start, Faculty of Social Sciences, University of Wollongong, Australia.,Illawarra Health and Medical Research Institute, Australia
| | - João R Pereira
- Early Start, Faculty of Social Sciences, University of Wollongong, Australia.,CIDAF (Uid/dtp/04213/2016), University of Coimbra, Coimbra, Portugal
| | - Anthony D Okely
- Early Start, Faculty of Social Sciences, University of Wollongong, Australia.,Illawarra Health and Medical Research Institute, Australia
| | - Xiaoqi Feng
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Australia.,Population Wellbeing and Environment Research Lab (PowerLab), School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, Australia
| | - Rute Santos
- Early Start, Faculty of Social Sciences, University of Wollongong, Australia.,Research Centre in Physical Activity, Health and Leisure, University of Porto, Porto, Portugal.,Universidade Lusófona de Humanidades e Tecnologia, Lisboa, Portugal
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Quante M, Redline S. Touchscreen devices-impact on 24-hour sleep in "cyber" babies. Sleep 2021; 44:6158961. [PMID: 33709151 DOI: 10.1093/sleep/zsab023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mirja Quante
- Department of Neonatology, University of Tuebingen, Tuebingen, Germany
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Covolo L, Zaniboni D, Roncali J, Mapelli V, Ceretti E, Gelatti U. Parents and Mobile Devices, from Theory to Practice: Comparison between Perception and Attitudes to 0-5 Year Old Children's Use. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073440. [PMID: 33810306 PMCID: PMC8037713 DOI: 10.3390/ijerph18073440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 11/22/2022]
Abstract
Pediatrics associations recommend avoiding the use of mobile devices (MDs) in children aged 0–2 years and limiting them to one hour per day for children aged 3–5 years. This study aimed to explore public risk perception on MDs use by children aged 0–5 years and attitudes of parents to children’s use. Participants were recruited on a voluntary basis by social media using a self-administered survey. The study included 3115 participants, most of whom were parents of children aged under 5 years (n = 1901; 61%). Most of the respondents (74%) considered that MDs use could be harmful for children’s health. The awareness on a correct use did not always translate into avoiding MDs use as recommended, especially in parents of children aged 0–2 years. Half of the sample (54%) received or sought information on risks related to MDs use. The most consulted information sources were the web (78%), and pediatricians in only 22% of cases. Understanding the determinants of parents’ risk perception and behavior is necessary to design effective family-based interventions in order to guide parents to a moderate and more careful use of MDs by their children. To do so, public health actions must aim to strengthen awareness about conscious use of MDs.
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Affiliation(s)
- Loredana Covolo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Public Health and Human Sciences, University of Brescia, 25123 Brescia, Italy; (E.C.); (U.G.)
- Correspondence:
| | - Daniela Zaniboni
- Post-Graduate School of Public Health, University of Brescia, 25123 Brescia, Italy; (D.Z.); (J.R.)
| | - Jacopo Roncali
- Post-Graduate School of Public Health, University of Brescia, 25123 Brescia, Italy; (D.Z.); (J.R.)
| | - Valentina Mapelli
- Degree Course in Health Assistance, University of Brescia, 25123 Brescia, Italy;
| | - Elisabetta Ceretti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Public Health and Human Sciences, University of Brescia, 25123 Brescia, Italy; (E.C.); (U.G.)
| | - Umberto Gelatti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Public Health and Human Sciences, University of Brescia, 25123 Brescia, Italy; (E.C.); (U.G.)
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29
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Durham K, Wethmar D, Brandstetter S, Seelbach-Göbel B, Apfelbacher C, Melter M, Kabesch M, Kerzel S. Digital Media Exposure and Predictors for Screen Time in 12-Month-Old Children: A Cross-Sectional Analysis of Data From a German Birth Cohort. Front Psychiatry 2021; 12:737178. [PMID: 34912248 PMCID: PMC8668323 DOI: 10.3389/fpsyt.2021.737178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Early exposure to digital media may affect the physical and cognitive development in young children. The American Academy of Pediatrics and national guidelines recommend no digital media use at all under the age of 18 months. The aim of our study was to determine the actual exposure to digital media in 12-month-old infants and to reveal potential risk factors for screen time. Methods: In this prospective cross-sectional survey, data was collected from the KUNO Kids birth cohort study using parent-report questionnaires regarding the media exposure of the study child. We determined age at first contact with different digital media, mean screen time on an average weekday, and the influence of major demographic and socioeconomic factors. Results: Data for screen time analysis was available for 630 children. In summary, 45% of children had already been exposed to digital media by their first birthday. The most frequent first digital media exposure was the TV (33.0%) followed by smartphones (16.9%), both most commonly exposed to around the age of 8 months. On a regular weekday, 20% of the children spent 0.5-1 h in front of a TV and 9% were exposed to a smartphone for the same time frame, compared to 31% of joint parent-child media use. Predictors for screen time were having one sibling, less living space per person, and excessive TV use in the household, the latter of which doubled the chance of the child being exposed to digital media. Conclusion: A proportion of 10% of 1-year-old children were already regularly exposed to digital media. The TV remains the most predominant device but new media, particularly smartphones, might be catching up. Our study provides further support that family TV time is a major predictor of infant screen time. Pediatric recommendations should be re-evaluated in the light of the actual exposure to digital media already in infancy and parents should be proactively counseled regarding possible effects on child development.
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Affiliation(s)
- Kira Durham
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - David Wethmar
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany.,WECARE Research and Development Campus Regensburg, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Birgit Seelbach-Göbel
- University Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- WECARE Research and Development Campus Regensburg, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany.,Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Melter
- Department of Pediatrics, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Michael Kabesch
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Sebastian Kerzel
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
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30
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Abstract
Research suggests that technology use is associated with poorer sleep outcomes among children less than 6 years of age. These associations are evident regardless of the type of technology studied, although evening exposure may have the greatest impact compared with technology use during other parts of the day. More work is needed, particularly given that technology use is relatively high among young children. Clinicians should assess patients' technology exposure, including before bedtime, to assess whether sleep issues stem from children's technology use. Moreover, clinicians should educate caregivers about the association between technology use and sleep problems among young children.
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Affiliation(s)
- Amy I Nathanson
- School of Communication, Ohio State University, Columbus, OH 43210, USA.
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31
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Lim MTC, Ramamurthy MB, Aishworiya R, Rajgor DD, Tran AP, Hiriyur P, Kunaseelan S, Jabri M, Goh DYT. School closure during the coronavirus disease 2019 (COVID-19) pandemic - Impact on children's sleep. Sleep Med 2020; 78:108-114. [PMID: 33422812 DOI: 10.1016/j.sleep.2020.12.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the sleep habits of school-going children before and during school closure in the national lockdown period (called 'Circuit Breaker' or CB in Singapore) due to the COVID-19 pandemic. METHODS Cross-sectional, anonymous, online, population-based survey questionnaire was administered to parents aged 21 years and above with children aged between 3 and 16 years attending pre-school, primary or secondary school (equivalent to kindergarten, middle and-high school) and residing in Singapore. Sleep duration in relation to various daily activities including academic activities, physical exercise, and screen time was evaluated pre-CB and during CB. RESULTS Data from 593 participants were analyzed. Pre-CB, the overall mean (SD) sleep duration of the study population was 9.01 (1.18) hours on weekdays and 9.99 (0.94) hours on weekends. During CB, mean (SD) sleep duration overall was 9.63 (1.18) hours. Although children generally went to bed later (mean 0.65 h later), they woke up even later during CB (mean 1.27 h later), resulting in longer sleep duration (mean increase of 0.35 h). This was most evident in secondary school children (mean increase of 0.70 h). Children attending private schools (which had later start times) had increased sleep duration (mean 10.01 (SD 0.89) hours pre-CB and 10.05 (SD 0.93) hours during CB) compared to public schools (mean 9.05 (SD 0.91) pre-CB and 9.49 (SD 1.22) hours during CB). CONCLUSIONS School closure from the COVID-19 pandemic resulted in longer sleep duration in school-going children. Early school/academic activity start times had a significant impact on limiting children's sleep duration.
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Affiliation(s)
- Michael Teik Chung Lim
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Mahesh Babu Ramamurthy
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Ramkumar Aishworiya
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Dimple D Rajgor
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Anh Phuong Tran
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | | | - Shangari Kunaseelan
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Majid Jabri
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Daniel Yam Thiam Goh
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore.
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Li C, Cheng G, Sha T, Cheng W, Yan Y. The Relationships between Screen Use and Health Indicators among Infants, Toddlers, and Preschoolers: A Meta-Analysis and Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7324. [PMID: 33036443 PMCID: PMC7579161 DOI: 10.3390/ijerph17197324] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/04/2022]
Abstract
Evidence suggests that excessive screen time in early childhood is related to children's physical and mental health. This study aimed to review the relationships between screen media use and several health indicators in infants, toddlers, and preschoolers. A systematic search was conducted by two independent reviewers on PubMed, Web of Science, Embase, and Cochrane Library to identify the eligible studies, with an end date of 13 August 2019. Included studies (published in English) were peer-reviewed and met the determinate population (children aged 0-7 years with screen media exposure and related health outcomes). The AHRQ, NOS, and the Cochrane Handbook were used to evaluate the cross-sectional study, cohort study, and RCT, respectively. A meta-analysis and narrative syntheses were employed separately. Eighty studies (23 studies for meta-analysis) met the inclusion criteria for the systematic review. Strong evidence of the meta-analysis suggested that excessive screen time was associated with overweight/obesity and shorter sleep duration among toddlers and preschoolers. Excessive screen use was associated with various health indicators in physical, behavioral, and psychosocial aspects. Better-quality research on newer media devices, on various kinds of contents in young children, and on dose-response relationships between excessive screen use and health indicators are needed to update recommendations of screen use.
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Affiliation(s)
- Chao Li
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (C.L.); (G.C.)
| | - Gang Cheng
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (C.L.); (G.C.)
| | - Tingting Sha
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha 410008, China;
| | - Wenwei Cheng
- Third Xiangya Hospital of Central South University, Changsha 410000, China;
| | - Yan Yan
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (C.L.); (G.C.)
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Tombeau Cost K, Korczak D, Charach A, Birken C, Maguire JL, Parkin PC, Szatmari P. Association of Parental and Contextual Stressors With Child Screen Exposure and Child Screen Exposure Combined With Feeding. JAMA Netw Open 2020; 3:e1920557. [PMID: 32022883 DOI: 10.1001/jamanetworkopen.2019.20557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Parents may use screen exposure or screen exposure combined with feeding for infants and toddlers to alleviate their own stress. OBJECTIVE To evaluate the association of individual and contextual stressors with child screen exposure (CSE) and CSE combined with feeding (CSE+F) in children aged 7 to 18 months as measured by parent-reported use and variation in quantity of CSE and CSE+F. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, population-based study drew parent-child participants from TARGet Kids, a network of primary health care research settings throughout Toronto, Ontario, Canada, between November 1, 2011, and July 31, 2018. The included children were aged 7 to 18 months. Exclusion criteria were health conditions affecting growth, acute conditions, chronic conditions, severe developmental delay, and families who were unable to communicate in the English language. Data were analyzed from April 1, 2019, to July 31, 2019. EXPOSURES Parenting stress, child age, child negative affectivity, family living arrangements, and family income were assessed with parent-completed questionnaires. MAIN OUTCOMES AND MEASURES The primary outcome was CSE and the variation in CSE, which represented the amount of background and engaged use of screens (television, videos or DVDs, video games, computers, and mobile devices) in a typical week. The secondary outcome was CSE+F, which represented the frequency of breakfast, lunch, dinner, and snack consumption during screen exposure in a typical week. Both CSE and CSE+F were assessed with the parent-completed Nutrition and Health Questionnaire; Infant Behavior Questionnaire, Revised Very Short; and Parenting Stress Index, Short Form. RESULTS The final sample size was 1085 children for the analysis of CSE and 1083 children for the analysis of CSE+F. Among 914 respondents, the children's mean (SD) age was 11.6 (2.3) months, and 478 (52.3%) were male. Among 910 respondents, 839 (92.2%) were mothers, with a mean (SD) age among 873 respondents of 34.4 (4.2) years. In a typical week, 581 of 779 children (74.6%) were reported to have any CSE, and 321 of 874 children (36.7%) had some CSE+F. Higher parenting stress levels (odds ratio [OR], 1.01; 95% CI, 1.00-1.02; P = .04) and older child age (OR, 1.43; 95% CI, 1.01-2.03; P = .04) were associated with CSE. Higher parenting stress levels (incidence rate [IR], 1.00; 95% CI, 1.00-1.01; P = .002) and lower household income (IR, 1.26; 95% CI, 1.10-1.45; P = .01) were associated with increased CSE. Older child age (OR, 1.79; 95% CI, 1.35-2.38; P < .001) and lower household income (OR, 2.54; 95% CI, 1.72-3.74; P < .001) were associated with CSE+F. Lower household income (IR, 1.21; 95% CI, 1.03-1.42; P = .02) was associated with increased CSE+F. CONCLUSIONS AND RELEVANCE This study found that parenting stress, income, and child age were associated with CSE, and child age and household income were associated with CSE+F. Given these findings, interventions to improve parental coping mechanisms may decrease child screen exposure.
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Affiliation(s)
| | - Daphne Korczak
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alice Charach
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catherine Birken
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sick Kids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Pediatrics, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sick Kids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Paediatric Outcomes Research Team, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter Szatmari
- Centre for Addiction and Mental Health, Department of Psychiatry, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Associations between early-life screen viewing and 24 hour movement behaviours: findings from a longitudinal birth cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:201-209. [PMID: 32004497 DOI: 10.1016/s2352-4642(19)30424-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/02/2019] [Accepted: 12/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Screen viewing is a sedentary behaviour reported to interfere with sleep and physical activity. However, few longitudinal studies have assessed such associations in children of preschool age (0-6 years) and none have accounted for the compositional nature of these behaviours. We aimed to investigate the associations between total and device-specific screen viewing time at age 2-3 years and accelerometer-measured 24 h movement behaviours, including sleep, sedentary behaviour, light physical activity, and moderate-to-vigorous physical activity (MVPA) at age 5·5 years. METHODS The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study is an ongoing longitudinal birth cohort study in Singapore, which began in June 2009. We recruited pregnant women during their first ultrasound scan visit at two major public maternity units in Singapore. At clinic visits done at age 2-3 years, we collected parent-reported information about children's daily total and device-specific screen viewing time (television, handheld devices, and computers). At 5·5 years, children's movement behaviours for 7 consecutive days were measured using wrist-worn accelerometers. We assessed the associations between screen viewing time and movement behaviours (sedentary behaviour, light physical activity, MVPA, and sleep) using Dirichlet regression, which accounts for the compositional nature of such behaviours. This study is active but not recruiting and is registered with ClinicalTrials.gov, NCT01174875. FINDINGS Between June 1, 2009, and Oct 12, 2010, 1247 pregnant women enrolled and 1171 singleton births were enrolled. 987 children had parent-reported screen data at either 2 or 3 years, of whom 840 attended the clinic visit at age 5·5 years, and 577 wore an accelerometer. 552 children had at least 3 days of accelerometer data and were included in the analysis. Total screen viewing time at age 2-3 years had a significant negative association with sleep (p=0·008), light physical activity (p<0·0001), and MVPA (p<0·0001) in relation to sedentary behaviour at age 5·5 years. Compared with children who spent 1 h or less per day screen viewing at age 2-3 years, children who screen viewed for 3 h or more per day at 2-3 years engaged in more sedentary behaviour (439·8 mins per day [≤1 h screen viewing time] vs 480·0 mins per day [≥3 h screen viewing time]), and less light physical activity (384·6 vs 356·2 mins per day), and MVPA (76·2 vs 63·4 mins per day) at age 5·5 years. No significant differences in time spent sleeping were observed between the groups (539·5 vs 540·4 mins per day). Similar trends were observed for television viewing and handheld device viewing. INTERPRETATION Longer screen viewing time in children aged 2-3 years was associated with more time spent engaged in sedentary behaviour and shorter time engaged in light physical activity and MVPA in later childhood. Our findings indicate that screen viewing might displace physical activity during early childhood, and suggest that reducing screen viewing time in early childhood might promote healthier behaviours and associated outcomes later in life. FUNDING Singapore National Research Foundation, and Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR).
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Chen B, Bernard JY, Padmapriya N, Yao J, Goh C, Tan KH, Yap F, Chong YS, Shek L, Godfrey KM, Chan SY, Eriksson JG, Müller-Riemenschneider F. Socio-demographic and maternal predictors of adherence to 24-hour movement guidelines in Singaporean children. Int J Behav Nutr Phys Act 2019; 16:70. [PMID: 31438965 PMCID: PMC6704617 DOI: 10.1186/s12966-019-0834-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/13/2019] [Indexed: 03/09/2023] Open
Abstract
PURPOSE Integrated 24-Hour Movement Guidelines provide specific recommendations on screen viewing (SV), moderate-to-vigorous physical activity (MVPA) and sleep to improve health of children and youth. However, few studies have examined whether these guidelines are met in young children, particularly in Asia. We evaluated adherence to integrated and individual guidelines and its predictors in 5.5-year-old Singaporean children. METHODS Growing Up in Singapore towards Healthy Outcomes (GUSTO) is a mother-offspring birth cohort study. At age 5.5 years, child SV was reported by parents. Movement behaviours (MBs) were measured continuously using wrist-worn accelerometers over 7 consecutive days and nights. For accelerometer data including ≥3 days with ≥16 h/day we estimated mean (±SD) daily MVPA, SV and nighttime sleep duration across the week. Adherence to integrated (Canadian/Australian) guidelines was defined as meeting all individual guidelines: ≥60 min of MVPA/day, ≤2 h of screen time/day, and 9-11 h of sleep/night. Socio-demographic and maternal predictors collected at pregnancy enrolment and at 26-28 weeks' gestation were examined by multivariable logistic regression. RESULTS Of 864 children followed up age 5.5 years, 547 (63.3%) had both valid ActiGraph and questionnaire data (51.7% boys and 58.3% Chinese ethnicity). Children averaged 101.9 (± 88.7) min/day SV, 67.3 (± 23.7) min/day MVPA and 480.6 (± 57.2) min/night sleep. Few children met integrated guidelines. Specifically, the proportions of children who met none, SV, MVPA, sleep and integrated guidelines were 11.2, 70.2, 59.6, 13.7 and 5.5%, respectively. Multivariable analysis showed that maternal activity and television (TV) viewing were associated with meeting integrated guidelines (insufficiently vs. highly active (OR [95% CI]): 0.11 [0.01, 0.95]; 2-3 vs. ≥ 3 h TV: 3.52 [1.02, 12.22]). Examining higher adherence to individual guidelines, Chinese ethnicity, younger maternal age and lower maternal TV and sleep time were associated with greater SV; male sex, Malay ethnicity, higher birth order and higher maternal activity level were associated with greater MVPA; and older maternal age was associated with adherence to sleep guideline. CONCLUSIONS Beyond individual behaviours, consideration of the full spectrum of MBs may be important to improve children's health. However, few Singaporean children adhere to integrated 24-h movement guidelines. Maternal behaviours as early as during pregnancy could be important targets for future interventions aiming to promote these MBs in children.
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Affiliation(s)
- Bozhi Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
| | - Jonathan Y. Bernard
- Inserm, Centre for Research in Epidemiology and StatisticS (CRESS), Research team on Early life Origins of Health (EAROH), Villejuif, France
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
| | - Natarajan Padmapriya
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Jiali Yao
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
| | - Claire Goh
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
| | - Kok Hian Tan
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Fabian Yap
- Duke-NUS Medical School, Singapore, Singapore
- Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Yap-Seng Chong
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Lynette Shek
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Paediatric Allergy, Immunology & Rheumatology, Khoo Teck Puat - National University Children’s Medical Institute, National University Health System, Singapore, Singapore
| | - Keith M. Godfrey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Shiao-Yng Chan
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Johan G. Eriksson
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
- Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Centre, Berlin, Germany
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