Do children need humans or screen? Institutional-based cross-sectional study

Introduction: Screen exposure is on the rise and has been virtually unavoidable in the post-Covid era. Screen exposure during the critical period of brain development results in delayed language, learning and behaviour problems and subsequent sedentary lifestyle results in non-communicable disease later in life. Objectives: To assess the burden of digital screen exposure and parental perceptions of its effects in children. Method: This institution-based cross-sectional study was conducted among children aged 1-13 years in a tertiary healthcare centre in Puducherry, India, from April 2022 to June 2022. Data were collected using the Digital Screen Exposure Questionnaire (DSEQ), administered by trained Compulsory Rotatory Residential Internship (CRRI) after pilot testing. Results: Our study shows that the prevalence of excessive screen exposure (>1 hour) was 25% during weekdays and 44.9% during weekends. The most common media used was television (TV) in 92.8%, closely followed by smart phones in 90%. Most frequently watched content (>5 times/ week) was random things for enjoyment in 57.8% followed by rhymes in 25.7%; 57.1% had no outside play during weekdays. Mother’s education was the main predictor which influenced the duration of screen exposure in study participants. Conclusions: Our study shows that the prevalence of excessive screen exposure (>1 hour) was 25% _____________________________


Introduction
Children's exposure to digital media is increasing, which is a point of concern as screen time exposure has a major impact on the health of children and also affects the families. Children now have access to more screens and media than ever before, in their room as a television (TV), in their backpacks as tablets and in their hands as their caregiver's or their own smart phones 1 . With the Covid-19 pandemic, children are spending even more time with screens for online learning, entertainment and socialization with friends virtually 2 . Overall, screen time ranged from 0.9 to 3.5 hours/day among under-five year old children and 1-3.1 hours/day among school-aged children. Indian studies showed that children are exposed to screen-based media as early as 2 months of age with the median age of first exposure to screens at 10 months. There is greater use of smart phones (96%) than TV (89%) especially for games and videos 3 . Screen time during holidays (3.9 hours/day) is more than school days (2 hours/ day) among adolescents 4 .
Early childhood is the critical phase in development when the brain is more sensitive to the environment around them. Screens curtail the ability to control impulses and reduce empathy and the ability to read human emotion. It also detracts from activities that help boost their brain power like play and interaction with other children 5 . Hence, excessive screen exposure has been linked to delayed language, learning and behaviour problems 6 . It can cause sleep disturbances by suppressing and disrupting melatonin secretion 7 . Other problems include computer vision syndrome, refractive errors, headaches, body image perception disorders and drug abuse [8][9][10][11] . Due to sedentary life style and the consumption of unhealthy food promoted by advertisements, excessive screen time is considered as one of the major role players in causing non-communicable diseases (NCDs) and health risks later on in life 12,13 .
As per recent Indian Academy of Paediatrics (IAP) guidelines, children below the age of 2 years should not be exposed to any type of screen with the exception of an occasional video call with relatives. Screen time for children between the age of 2 and 5 years should not exceed 1 hour, the less, the better. For older children and adolescents, other than online classes, there should be a maximum of 2 hours screen time. It is important to balance screen time with other activities that include an hour of physical activity (play time), adequate duration of sleep and time for schoolwork, meals, hobbies, and family time 14 . This is similar to World Health Organisation (WHO) and AAP guidelines for screen time 15,16 . Parental awareness of screen time of their children and its effects are crucial to regulate screen media exposure in children.
The above guidelines are updated regularly but are criticized as to be not completely evidence-based. In the outpatient department (OPD) waiting area and in the wards in our institution even after repeated sensitization of the parents, it has been noticed that the parents are voluntarily giving children phones to keep them silent. which emphasizes need-based counselling for the parents There is limited published data from India on the burden of screen exposure, especially its content and context and associated factors using standardized tools, the knowledge of which is essential to formulate policy for screen hygiene in children.

Objectives
We conducted the present study to assess the burden of digital screen exposure and parental perceptions of its effects in children.

Method
This was an institution-based cross-sectional study conducted in a tertiary healthcare centre in Puducherry, India, from April 2022 to June 2022. The institution has an in-patient capacity of 932 beds, with exclusive 100 critical care beds in different specialties.

Sample size and sampling:
The sample size of 135 was calculated after considering that the prevalence of excessive screen time was 73%, absolute precision of 7.5% with 95% confidence Interval (CI) (calculated by Epi Info version 3.5.4) 1 ; consecutive sampling was applied.
Inclusion criteria: All children aged 1 to 13 years were included.
Exclusion criteria: Sick children and children whose parents were not willing to give consent were excluded.
Data collection: All eligible children in the age group one to 13 years were included in the study. The first participant was selected by simple random sampling technique and the following study participant was selected by systematic random sampling technique. Data were collected using the Digital Screen Exposure Questionnaire (DSEQ), administered by trained Compulsory Rotatory Residential Internship (CRRI) after pilot testing.
DSEQ is an 86-item caregiver reported questionnaire developed by Dr Madhu Gupta, Department of Paediatrics, Postgraduate Institute of Medical Education and Research (PGIMER) from the Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India and it is freely available in the internet 17 . It is not copyright protected and permission was obtained from the author. It has five domains, sociodemographic, screen time exposure and home media environment, level of physical activity, media related behaviours and parental perceptions. It has good face and content validity, internal consistency and test-retest reliability 17 .
Ethical issues: Approval for the study was obtained from the Ethics Committee of Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, India (No. EC/21/2022). Written informed consent was obtained from parents of all participants in addition to oral consent for 8-11year-old children and assent for 12-13-year-old children.
Statistical analysis: Data were entered in the Epi info software version 7.2 and analysis was done using Statistical Package for the Social Sciences (SPSS) software version 24.0. Categorical variables were expressed in percentages and continuous variables in mean and standard deviation. Association between socio-demographic factors and excessive screen time was done by Chi square test. p-value <0.05 was considered statistically significant. Table 1 gives the socio-demographic details of the 140 study participants. The mean age of the study participants was 6.09 years; 16 (11.4%) attended day care for more than 3 days a week. Parents were the caregivers in 131 (93.5%) cases. Table 2 gives the home media environment.    The purpose of using digital media was commonly to watch random things for enjoyment like music, advertisements, baby TV, click photos etc. in 81 (57.8%) rather than for educational purposes; 29 (20.6%) used digital media for homework, 85 (70.7%) for video calling, 73 (52.1%) for learning rhymes, alphabets, 36 (25.7%) to learn mathematics, 106 (75.8%) to watch stories, 33 (23.6%) to learn various sciences online and 67 (47.8%) to watch adult programs (soap operas, news, movies). Around 18 (12%) talked to the characters on screen and 16 (11.4%) acted out story/ role play character while watching the screens. Table 4 shows the media related behaviour of study participants.   Analysing the influence of sociodemographic factors on excessive screen time >1 hour shows that age, gender, residence and socioeconomic status had no influence. Only education of the mother was significantly associated with excessive screen time (p <0.001).

Discussion
Our study shows that the prevalence of excessive screen exposure (>1 hour) was 25% during weekdays and 44.9% during weekends. The most common media used was TV in 92.8%, closely followed by smart phones in 90%. Most frequently watched content (>5 times/ week) was random things for enjoyment (57.8%) followed by rhymes (25.7%); 57.1% had no outside play during weekdays. Except for mother's education, no other socio-demographic factor influenced the duration of screen exposure in study participants.
The burden of excessive screen time was 10-93% in developed countries and 21-98% in developing countries 18 . Criteria for excessive screen time was >2 hours per day in some studies and >1 hour/day in a few studies. The prevalence was also higher during weekends (25-63%) than weekdays (10-48%). A recent study from Tamilnadu by Varadarajan S, et al 1 showed that rates of excessive screen time in children aged less than 2 years was 73.3% and in those more than 2 years was 73%; 24.2% reported more screen time during weekends 1  were not concerned about screen time in children. In our study, only 11.4% believed that it has no negative effects.
Using a validated questionnaire is a strength of the study as it gives a robust estimate of screen media exposure in children. Limitations of the study are that it is an institution-based cross-sectional study and temporarily cannot be maintained; because of the smaller sample size, the findings cannot be generalised. This study has also captured only parental perceptions and not the actual effects of screen exposure in children The results of our study show that screen media exposure is widely prevalent in our region. As tech free zone is virtually impossible, paediatricians need to impart need-based counselling on screen time guidelines and its implications on health and behaviour in children. Interventional strategies like individualizing screen time, discussing with children, home based rules regarding TV turn off time, co-viewing/ co-sharing and supervising the content might promote healthy screen behaviour. Parents also should follow healthy media usage as they model children. Longitudinal studies exploring content and context across various age groups and effect of interventional strategies are required to update guidelines and promote screen hygiene in children.

Conclusions
Our study shows that the prevalence of excessive screen exposure (>1 hour) was 25% during weekdays and 44.9% during weekends. Common media used were TV in 92.8% and smart phones in 90%. Except for mother's education, no other sociodemographic factor influenced the duration of screen exposure in study participants. There was excessive screen exposure in children despite parental perception of its harmful effects