Clinical Context

A total of 75% of children aged younger than 2 years watch or use screens, including televisions, video games, tablets, and smartphones. These infants may be at increased risk for delayed language development, inattention problems, emotional problems, defiant behaviors, and poorer reading and academic performance through preschool and childhood.

Guideline recommendations are to avoid screen use for children aged younger than 18 months and to limit it to 1 hour daily for children aged younger than 2 years, but adherence to these guidelines is low. Outdoor activities have been inversely associated with sedentary time and screen time in children and positively associated with later cognitive, social, and emotional skills.

Study Synopsis and Perspective

Watching a screen more than an hour a day as a toddler is directly linked to poorer communication and daily living skills at age 4 years, but outdoor play may lessen some of the effects, new research suggests.^[1]

The results point to outdoor play as a potential targeted intervention to counter suboptimal brain development in young children who are watching screens at increasingly younger ages.

The findings were published online in JAMA Pediatrics.

The researchers first investigated whether higher screen time (more than 1 hour a day on a device or watching television) at age 2 years is associated with neurodevelopmental outcomes at age 4 years.

They found that the 885 children in the sample from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children who had more screen time had lower scores on communication and daily living skills than children who watched less than an hour a day.

Scores were based on the Vineland Adaptive Behavior Scale according to parent responses to questions. The children included were born between December 2007 and March 2012 and were followed from age 18 months to age 4 years.

After finding the connection between screen time and lower scores, the researchers investigated whether outdoor play (at least 30 minutes a day) introduced at a 2 years and 8 months made a difference. They considered 6 or 7 days per week frequent outdoor play.

The researchers found that the outdoor play intervention mitigated 18% of the association between high screen time and lower daily living scores but did not mitigate the lower communication scores.

They also found that more screen time at age 2 years was significantly linked with infrequent outdoor play at age 32 months (odds ratio, 2.03; 95% confidence interval, 1.48-2.76).

The associations were consistent after taking into account factors including a child’s sex, parental education, and any autism spectrum disorder symptoms at age 18 months.

The authors noted that neurodevelopment concerns with screen use are particularly troubling, as the age for use is getting younger.

A recent meta-analysis found that 75% of children younger than 2 years use or watch screens, even though guidelines recommend against any screen time before 2 years.^[2]

In addition, the “COVID-19 pandemic led to children having higher screen time, less outdoor play, and lower physical activity levels, putting them at a potentially increased risk for neurodevelopmental problems,” the authors note.

“What is concerning is that data show screen time has not decreased after seclusion measures were lifted,” they add.

Jennifer Cross, MD, assistant professor and section chief for developmental pediatrics at Weill Cornell Medicine, New York, who was not part of the study, said that the mitigation properties of outdoor play were something she had not seen before, but the concept makes sense.

“The overwhelming evidence is that screen time is not helpful for young children under the age of 2,” she said.

Outdoor play, in contrast, has proven benefits.

“Physical activity has been shown to be good for physical and mental health, so there’s no reason to believe it wouldn’t be good for 2-and-a-half-year olds,” Dr Cross said. “It’s also good for developmental health. You want them to be engaged in imaginative play and be interactive.”

“[Outdoor play] gets them away from screens and gives them an opportunity to experience another environment and work on their motor skills and motor planning,” she added. “Exercise will change, briefly, the way our brains process information.”

Dr Cross added that a lot of motor skills are involved in daily living skills, such as feeding, dressing, and toileting.

The authors acknowledge that screen time may be underestimated by parents. They also note that they did not have access to what children were watching on the screens.

“This should have been collected because the effect of high screen time differs depending on the type of program,” the authors write.

They add that children born in the 2020s may have been exposed to more screen time than the children reared in the early 2010s studied in this research.

Dr Cross said that screen use in the 2020s may be higher than estimated here, and higher in certain populations globally, so it is not easy to tell whether the intervention in this study would have the same mitigating effect on a real-world population.

However, she said, the effect of outdoor play is always going to be helpful for brain development, and there is no downside.

“Exercise is just as important for little kids as it is for grown-ups,” she said.

The authors and Dr Cross have disclosed no relevant financial relationships.

JAMA Pediatr. Published online January 23, 2023.

Clinical Implications

• Higher screen time at age 2 years was directly associated with poorer communication and daily living skills at age 4 years.
• Frequent outdoor play mitigate the association between higher screen time and later suboptimal neurodevelopment, implying potential for intervention.
• Implications for the Health Care Team: The healthcare team should be aware of the potential benefits of frequent outdoor play and the possibility that it could mitigate effects of higher screen time in children.

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