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CME / CE

Can Kids’ Outdoor Play Reduce Risk for Too Much Screen Time?

  • Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MD
  • CME / CE Released: 3/10/2023
  • Valid for credit through: 3/10/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

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    • Letter of Completion

Target Audience and Goal Statement

This activity is intended for pediatricians, neurologists, family medicine/primary care clinicians, public health and prevention officials, nurses, physician assistants, and other members of the health care team for children using or watching screens.

The goal of this activity is for learners to be better able to describe potential associations of higher screen time at age 2 years with neurodevelopmental outcomes at age 4 years, and whether such associations are mediated by frequency of outdoor play at age 2 years 8 months, based on an analysis from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children.

Upon completion of this activity, participants will:

  • Assess the potential associations of higher screen time at age 2 years with neurodevelopmental outcomes at age 4 years, and mediating effects of outdoor play on these associations, based on an analysis from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children
  • Determine the clinical and public health implications of associations of higher screen time at age 2 years with neurodevelopmental outcomes at age 4 years, and mediating effects of outdoor play on these associations, based on an analysis from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children
  • Outline implications for the healthcare team


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Marcia Frellick has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC 

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships. 

Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / CE

Can Kids’ Outdoor Play Reduce Risk for Too Much Screen Time?

Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / CE Released: 3/10/2023

Valid for credit through: 3/10/2024, 11:59 PM EST

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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.

Outdoor Play Mitigated Poorer Daily Living Scores

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.

Proven Benefits for Outdoor Play

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.

Screen Time Is Increasing

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.

Study Highlights

  • Participants (n=885; 56% male; mean screen time per day, 2.6±2.0 hours) were a subsample of the HBC Study (n=1258).
  • Children were born between December 2007 and March 2012 and followed up from age 1 year 6 months to 4 years, when researchers determined standardized Vineland Adaptive Behavior Scale scores for communication, daily living skills, and socialization domains.
  • The mediating factor was frequency of outdoor play at age 2 years 8 months, with 6 to 7 days/week coded as frequent outdoor play.
  • More screen time at age 2 years was significantly linked to infrequent outdoor play at age 32 months (OR, 2.03; 95% CI, 1.48-2.76).
  • In causal mediation analyses, higher screen time (>1 hour/day) at age 2 years was associated with lower communication scores at age 4 years (nonstandardized coefficient b = −2.32; 95% CI, −4.03 to −0.60).
  • Frequency of outdoor play did not mediate this association.
  • Higher screen time was also associated with lower scores in daily living skills (b = −1.76; 95% CI, −3.21 to −0.31); 18% of this association was mediated by frequency of outdoor play.
  • Frequency of outdoor play was associated with socialization (b = −2.73; 95% CI, −4.39 to −1.06), but higher screen time was not (b = −1.34; 95% CI, −3.05 to 0.36).
  • The associations were not confounded or mediated by factors including sex, parental education, and any autism spectrum disorder symptoms at age 18 months.
  • The investigators concluded that higher screen time at age 2 years was directly associated with poorer communication and daily living skills at age 4 years, but frequency of outdoor play at age 2 years 8 months alleviated it by 18%.
  • This suggests that frequent outdoor play mitigated the association between higher screen time and later suboptimal neurodevelopment, implying potential for intervention.
  • Future research should clarify the nature of these associations and intervention measures, enabling targeted interventions to lower potential risk for screen time, and explore the mechanisms underlying the association between screen time and neurodevelopmental outcomes.
  • Updating guidelines regarding media use and improving adherence to these recommendations is extremely important for children, parents, educators, and researchers.
  • Neurodevelopmental concerns regarding screen use are particularly concerning, given the younger age for first use.
  • In a recent meta-analysis, 75% of children aged younger than 2 years used or watched screens, despite guideline recommendations against any screen time before age 2 years.
  • During the COVID-19 pandemic, children’s outdoor play and physical activity decreased while screen time increased, which did not change once seclusion measures were lifted, potentially increasing risk for neurodevelopmental problems.
  • Outdoor play has proven benefits for physical, mental and developmental health by fostering motor skills and motor planning involved in daily living skills, such as feeding, dressing, and toileting.
  • Mechanisms underlying the association between screen time and communication neurodevelopment may include television viewing reducing attention to parental vocalization, thereby decreasing child vocalization, and/or decreasing parent-child interaction.
  • Study limitations include possible underestimation of screen time by parents and lack of data regarding screen program content, which can modulate the effect of high screen time.
  • In addition, children born in the 2020s may have been exposed to more screen time than those reared in the early 2010s in this study.

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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