Use of screens in children aged less than 6 years in Guipúzcoa. Social characteristics and impact on health

INTRODUCTION

New technologies have become everyday features in children’s lives. Since 1970, the age at which children begin to interact with media on a regular basis has shifted from 4 years to 4 months.¹ For this reason, several health organizations have issued recommendations for the optimal use of screens by minors: the World Health Organization (WHO) recommends no screen time in children aged less than 2 years and a maximum of one hour of screen time a day in children aged 2 to 4 years.² The American Academy of Pediatrics recommends eliminating media exposure for children aged less than 18 months; for children aged 18 to 24 months, very limited media exposure, always with a parent standing by to guide them, and choosing high-quality programming; for children aged 2 to 5 years, limiting screen use to no more than one hour a day; and, when it comes to older children, for parents to establish consistent limits in terms of the amount of screen time and type of content consumed, in addition to ensuring that media use is not displacing sleep, exercise or any other activities essential to health and well-being.³ In Spain, the Asociación Española de Pediatría has developed a “Family Digital Plan” in line with these recommendations.⁴

Given the increase in screen use, there is growing concern in the scientific community about its potential short- and long-term effects on children’s health. This is why screen use should be limited in infants and young children. On one hand, screen use has been associated with an increase in body mass index (BMI) in early childhood and school age⁵; on the other hand, there is evidence of an association between screen use in school-aged children and the development of mental health and developmental disorders.

It should be taken into account that the early years of life (0-8 years) correspond to the period of greatest brain plasticity, when lived experiences have a profound impact on social, cognitive and emotional development. It is also when healthy lifestyle habits, such as eating, physical activity and sleep behaviors, are established.^6,7 Screen use has also been associated with poorer executive function and delays in cognitive, language and psychosocial development.¹

Considering the different variables related to the increase in screen use and given the importance of the child’s immediate environment, we ought to highlight that the family should be the target of intervention by pediatricians.⁸ These providers play a crucial role in helping parents identify suitable digital content as well as tools to assist them in monitoring, limiting and reinforcing what is being learned in front of the screen. Intervention bundles should be developed with the aim of increasing knowledge regarding digital media through counseling sessions or educational materials.⁹ Parents should also be encouraged to co-view age-appropriate digital content with their children to promote learning.¹⁰

The aim of our study was to analyze the screen use habits of children aged less than 6 years in the province of Gipuzkoa and the different variables associated with excessive screen use. Likewise, we sought to determine the proportion of children aged less than 2 years and 2 to 6 years exposed to screens, the association of screen use with socioeconomic and family characteristics, the content viewed by children who use screens and the immediate environment of the child in relation to screen use.

METHODS

Cross-sectional study based on a questionnaire administered to parents during the routine check-ups conducted at ages 6 months, 11-12 months, 15-18 months, 21-24 months, 3-4 years and 6years as part of the Osakidetza (Basque Country Health System) 2021 Healthy Child Program.¹¹ The questionnaire was used to obtain data on family characteristics, including socioeconomic status, screen use and physical activity.

In developing the questionnaire, we took into account the ecological systems theory proposed by Uri Bronfenbrenner,¹² who hypothesized that human development is shaped by the interaction of the organism with the environment. Thus, it is necessary to assess child-related factors (age, sleep and sedentary behaviors), caregiver-related factors (parental age, maternal employment, maternal stress, parental screen time, parental socioeconomic characteristics such as income, occupation, socioeconomic status or ethnicity) and environmental factors. This approach differentiates between the microsystem, or the immediate environment of the child, including the home, and the macrosystem, which represents the sociocultural environment of the child.

We assessed physical activity in young children based on the guidelines on physical activity and sedentary behavior of the WHO.²

To assess socioeconomic status, we used the Income, Education and Crowding Index model (known as “REI” in the original Spanish),¹³ a tool that takes into account the crowding index (inhabitants/number of rooms in the home), parental educational attainment and parental employment.

To assess screen use, we applied the methodology proposed in a study on an epidemiological study on recreational screen use habits conducted in the Balearic Islands in 2021.¹⁴

Table 1 presents the data collection form.

Data collection was carried out between February 1 and June 30, 2023 in the province of Gipuzkoa. Pediatricians and pediatric nurses in Gipuzkoa were invited to participate. An online clinical session was held to invite participation and distribute the questionnaire. Thus, the information reached all pediatricians in the province. At a later time, additional information was provided to those who expressed interest.

Inclusion criteria

The study universe comprised every child aged 6 months to 6 years in Gipuzkoa. We excluded children with moderate-to-severe underlying disease (cancer, recent serious accidental injury, conditions requiring surgery, etc) causing significant physical limitations or requiring hospital admission or home rest in the past three months. We also excluded children with an identified neurological disorder of any kind or in follow-up by pediatric neurology at the outpatient level.

The study was approved by the Research Ethics Committee of the Health Area of Gipuzkoa (Protocol Code: PGG-UPN-2022-01) during the meeting held on October 25, 2022.

Statistical analysis

We performed a descriptive analysis of the different variables. For this purpose, continuous variables were expressed as means and percentages, and categorical variables as absolute frequencies and percentages. In addition, we made comparisons between the two age groups using the Student t test for continuous variables and the chi-square test for categorical variables.

To analyze the socioeconomic and family-related variables that could be associated with screen time, we fitted a multivariate linear regression model. We also fitted linear or logistic regression models, according to the type of dependent variable, to analyze whether excessive screen use (defined according to the WHO criteria) was associated with different health outcomes, such as psychomotor development, sleep or physical activity. We adjusted these models for age group. We present the results of linear models in terms of the coefficient with the corresponding 95% confidence interval, and the results of logistic models in terms of the odds ratio (OR).

All the analysis were performed with the R statistical software package.

RESULTS

A total of 281 children were included in the study. Eight were excluded due to insufficient data, so the number of questionnaires included in the analysis was 273: 114 (41.8%) for the group aged between 2 and 6 years and 159 (58.2%) for the group aged less than 2 years. Table 2 summarizes the characteristics of the sample.

Table 3 presents the results of the descriptive analysis of screen use in terms of screen time, appropriateness and the types of content consumed by children.

Subsequently, we fitted linear regression models to assess which factors may have an impact on the mean total screen time. All models were adjusted for age group. Table 4 presents the results of the analysis of the association between family characteristics and socioeconomic variables (child age, country of origin of parents, parental educational attainment and REI socioeconomic index) and screen use, which showed that, on average, children aged 2 to 6 years used screens one more hour a day compared to children aged less than 2 years, with greater screen times in non-Spanish children compared to Spanish children. We also found an association between socioeconomic status and screen use, as screen time was lower in children of families with a higher REI index or higher parental educational attainment.

Furthermore, we analyzed whether the mean screen time was associated with various outcomes, such as sleep duration, sedentary lifestyle habits or language delay. For this purpose, we conducted linear regression analysis or regression analysis with continuous dependent variables, as applicable, the results of which are shown in Table 5.

These models indicated that screen use had an impact on sleep duration both on weekdays and weekends. On the other hand, excessive screen use (any screen time in children under 2 years and more than one hour in children aged 2 to 6 years) had a negative impact on language development and physical activity, with an increase in sedentary habits.

According to the Primary Care Information System of the Ministry of Health, there are 107 pediatric caseloads in Gipuzkoa,¹⁵ of which 23 were included in the study, which therefore yielded data for 21.5% of the total pediatric caseloads. As for the number of children, according to the Basque Institute of Statistics (Eustat),¹⁶ there are a total of 28 242, of who 16 110 reside in the 14 municipalities where the survey took place, which means that we obtained information for 57% of the pediatric population in the age range of interest.

DISCUSSION

We analyzed the most relevant aspects of the potential repercussions of screen use, such as speech delay, reduced sleep duration and sedentary lifestyles, demonstrating their impact on the children included in the study.

We also found an association between the REI socioeconomic index and screen use.

Other aspects, such as the impact on visual acuity, were not analyzed in this study. Previous literature reviews suggest that electronic devices used for visualizing images do not cause organic damage to the visual system but do have an impact in the development of fatigue or eye strain when used inappropriately or without the recommended protective measures,¹⁷ so prolonged use of these devices is not advisable.

We did analyze developmental outcomes, and found an association with language delay, as described in other studies.¹⁸ We hypothesize that this may be due to the consumption of inappropriate contents or contents meant for an adult audience, the displacement of parent-child interactions and a decrease in family functioning.¹

Another aspect analyzed in the study was sleep duration, and we found a reduction in the hours of sleep both on weekdays and in the weekend. There is evidence of an association between screen time and sleep duration and quality, especially with the use of screens in the evening or at night.¹⁹ This was supported by the findings of our study, as a high proportion of children used screens before bedtime.

We also observed an increase in sedentary behavior in children who used screens. This can promote an increase in BMI, as demonstrated by a study conducted in children aged 2 years in which a screen time increase of just one hour a week was associated with an increase in BMI.²⁰

Studies at the primary care level have intrinsic limitations in relation to the resources and time available to conduct them.²¹ On the other hand, this care setting offers the advantage of greater access to the population, enabling the collection of population-based data on specific health care issues, such as excessive screen use in the pediatric population. The obtained data are limited because, for the study to be conducted in the framework of everyday clinical practice, the questions have to be very specific, as an excessively long completion time could be taxing for parents as well as pediatricians and pediatric nurses.

An editorial published in the journal Nutrición Hospitalaria²² remarked on the lack of longitudinal or interventional studies allowing a more accurate assessment of the impact of these behaviors. The authors also stated the need to improve the methodological quality of studies—which are usually based on data collected by means of questionnaires—through the use of objective measures.

Keeping these limitations in mind, our study found that screen use was excessive in our population and associated with unfavorable outcomes in language development, sleep duration and sedentary behavior, which should motivate us to insist on the need to limit screen use in children of any age during routine check-ups in the healthy child program.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article.

FUNDING

Bottom-Up grant from the Department of Health of the Territorial Delegation of Gipuzkoa (2023).

AUTHORSHIP

Author contributions: protocol design and collection of questionnaires (PGG, MDP and NEH), protocol design (ELER), methodological review of protocol and statistical analysis (MMA), data collection (research group).

This study was presented as an oral communication at the 20^th Congress of the Asociación Española de Pediatría de Atención Primaria. Madrid, March 9, 2024.

ABBREVIATIONS

BMI: body mass index · OR: odds ratio · WHO: World Health Organization.

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