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PDF, Also Known As Version of Record King’s Research Portal DOI: 10.1001/jamapediatrics.2016.2341 Document Version Publisher's PDF, also known as Version of record Link to publication record in King's Research Portal Citation for published version (APA): Carter, B., Rees, P., Hale, L., Bhattacharjee, D., & Paradkar, M. S. (2016). Association Between Portable Screen-Based Media Device Access or Use and Sleep Outcomes: A Systematic Review and Meta-analysis. JAMA Pediatrics, 170(12), e1-e7. https://doi.org/10.1001/jamapediatrics.2016.2341 Citing this paper Please note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination, volume/issue, and date of publication details. 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Download date: 25. Sep. 2021 Research JAMA Pediatrics | Original Investigation Association Between Portable Screen-Based Media Device Access or Use and Sleep Outcomes A Systematic Review and Meta-analysis Ben Carter, PhD, MSc; Philippa Rees, MPhil, MBBCh; Lauren Hale, PhD, MPH; Darsharna Bhattacharjee, MBChB, MRCPCH; Mandar S. Paradkar, MBBS, DCH, MPH Editorial IMPORTANCE Sleep is vital to children’s biopsychosocial development. Inadequate sleep Supplemental content quantity and quality is a public health concern with an array of detrimental health outcomes. Portable mobile and media devices have become a ubiquitous part of children’s lives and may affect their sleep duration and quality. OBJECTIVE To conduct a systematic review and meta-analysis to examine whether there is an association between portable screen-based media device (eg, cell phones and tablet devices) access or use in the sleep environment and sleep outcomes. DATA SOURCES A search strategy consisting of gray literature and 24 Medical Subject Headings was developed in Ovid MEDLINE and adapted for other databases between January 1, 2011, and June 15, 2015. Searches of the published literature were conducted across 12 databases. No language restriction was applied. STUDY SELECTION The analysis included randomized clinical trials, cohort studies, and cross-sectional study designs. Inclusion criteria were studies of school-age children between 6 and 19 years. Exclusion criteria were studies of stationary exposures, such as televisions or desktop or personal computers, or studies investigating electromagnetic radiation. DATA EXTRACTION AND SYNTHESIS Of 467 studies identified, 20 cross-sectional studies were assessed for methodological quality. Two reviewers independently extracted data. MAIN OUTCOMES AND MEASURES The primary outcomes were inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness, studied according to an a priori protocol. RESULTS Twenty studies were included, and their quality was assessed. The studies involved 125 198 children (mean [SD] age, 14.5 [2.2] years; 50.1% male). There was a strong and consistent association between bedtime media device use and inadequate sleep quantity (odds ratio [OR], 2.17; 95% CI, 1.42-3.32) (P < .001, I2 = 90%), poor sleep quality (OR, 1.46; 95% CI, 1.14-1.88) (P = .003, I2 = 76%), and excessive daytime sleepiness (OR, 2.72; 95% CI, 1.32-5.61) (P =.007,I2 = 50%). In addition, children who had access to (but did not use) media devices at night were more likely to have inadequate sleep quantity (OR, 1.79; 95% CI, 1.39-2.31) (P < .001, I2 = 64%), poor sleep quality (OR, 1.53; 95% CI, 1.11-2.10) (P =.009, I2 = 74%), and excessive daytime sleepiness (OR, 2.27; 95% CI, 1.54-3.35) (P < .001, I2 = 24%). CONCLUSIONS AND RELEVANCE To date, this study is the first systematic review and Author Affiliations: Author meta-analysis of the association of access to and the use of media devices with sleep affiliations are listed at the end of this outcomes. Bedtime access to and use of a media device were significantly associated with the article. following: inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness. An Corresponding Author: Ben Carter, PhD, MSc, Department of integrated approach among teachers, health care professionals, and parents is required to Biostatistics and Health Informatics, minimize device access at bedtime, and future research is needed to evaluate the influence of Institute of Psychiatry, Psychology the devices on sleep hygiene and outcomes. and Neuroscience, King’s College London, Strand, London WC2R 2LS, JAMA Pediatr. doi:10.1001/jamapediatrics.2016.2341 United Kingdom ([email protected] Published online October 31, 2016. or [email protected]). (Reprinted) E1 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a Kings College London User on 11/16/2016 Research Original Investigation Use of Screen-Based Media Devices and Sleep Outcomes leep is crucial to the development of physically and psy- chologically healthy children. Sleep disturbance in child- Key Points hood is known to lead to adverse physical and mental S Question Is there an association between screen-based media health consequences. Short- and long-term detrimental health device access or use in the sleep environment, and sleep quantity outcomes include poor diet, sedentary behavior, obesity, re- and quality? duced immunity, stunted growth, mental health issues (eg, de- Findings A systematic review and meta-analysis showed strong pression and suicidal tendencies), and substance abuse.1-3 and consistent evidence of an association between access to or Despite its importance to health, insufficient sleep and re- the use of devices and reduced sleep quantity and quality, as well sultant daytime sleepiness are prevalent among the pediatric as increased daytime sleepiness. population and increase throughout adolescence.4,5 In the Meaning An integrated approach among teachers, health care United States, 75% of those 17 to 18 years old report insuffi- professionals, and parents is needed to improve sleep hygiene. cient sleep, which is consistent with the findings in other de- veloped countries.6 The American Academy of Pediatrics has highlighted factors, including electronic media device use, early children and adolescents of school age between 6 and 19 years. school start times, and increase in caffeine consumption, that The exclusion criteria were studies of stationary exposures, such contribute substantially to this trend of insufficient and dete- as televisions or desktop or personal computers, or studies in- riorating sleep in the pediatric population.4,5 vestigating electromagnetic radiation. Studies7,8 during the past decade have demonstrated that the use of conventional electronic devices, such as televi- Data Sources and Search Strategy sions, gaming consoles, and computers, negatively affects A search strategy consisting of 24 Medical Subject Headings sleep. Newer portable mobile and media devices, including was developed in Ovid MEDLINE and adapted for other data- smartphones and tablet devices with broader capabilities (eg, bases (eTable 1 in the Supplement). On June 15, 2015, searches internet and social networking), provide a different type of ex- of the published literature were conducted across 12 data- posure because they allow real-time interaction and there- bases, including the British Education Index, Cumulative In- fore continuous stimulation for children, unlike older station- dex to Nursing and Allied Health database, Cochrane Library, ary devices.8 Herein, these newer portable screen-based mobile Educational Resources Information Center, International and media devices are termed media devices. Biography of Social Sciences, Ovid MEDLINE (EMBASE, The presence of media devices is almost ubiquitous among MEDLINE, and PsycINFO), PubMed, Science Direct, Scopus, children: 72% of all children and 89% of adolescents have at and Web of Science. The gray literature was searched using the least 1 device in their sleep environment, with most used near OpenGrey online database. Bibliographies of included stud- bedtime.3,6 Such devices are hypothesized to adversely affect ies and conference abstracts were hand searched, and au- sleep through various pathways.7,8 First, they may nega- thors of included studies were contacted to identify any on- tively influence sleep by directly displacing, delaying, or in- going or unpublished studies. terrupting sleep time. Second, the content can be psychologi- cally stimulating, and, third, the light emitted from devices Device Exposure Categories and Sleep Outcomes affects circadian timing,
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