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Original Investigation
July 12, 2021

Association of High Screen-Time Use With School-age Cognitive, Executive Function, and Behavior Outcomes in Extremely Preterm Children

Betty R. Vohr, MD1; Elisabeth C. McGowan, MD1; Carla Bann, PhD2; et al Abhik Das, PhD3; Rosemary Higgins, MD4,5; Susan Hintz, MD, MS, Epi6; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
Author Affiliations
  • 1Division of Neonatal Medicine, Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence
  • 2Division of Statistical and Data Sciences, RTI International, Research Triangle Park, North Carolina
  • 3Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
  • 4National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, Bethesda, Maryland
  • 5George Mason University, Fairfax, Virginia
  • 6Division of Perinatal Neonatal Medicine, Stanford University, Palo Alto, California
JAMA Pediatr. 2021;175(10):1025-1034. doi:10.1001/jamapediatrics.2021.2041
Key Points

Question  Is increased screen time at early school age associated with an increase in risk of developmental and behavioral problems for extremely premature infants?

Findings  In this cohort study including 414 children who had been born extremely prematurely, high screen time of 2 hours or more per day was associated with an increase in risk of cognitive, executive function, and behavioral problems at early school age among extremely premature children after adjusting for center, male sex, and gestational age, severe retinopathy of prematurity, and social determinants. The maximum number of hours of screen time reported for these children was 40.3 hours per week.

Meaning  These findings suggest that a high level of screen time contributes further to an increase in risk of cognitive, executive function, and behavior outcomes at age 6 to 7 years in extremely premature children, supporting the need for health care professionals to discuss both the benefits and risks of screen time with families and share the American Academy of Pediatrics recommendations.


Importance  Both preterm birth and increased screen time are known to be associated with an increase in risk of developmental and behavioral sequelae. The association between high screen time or a television or computer in the bedroom in early school age and adverse cognitive, executive function, language, and behavior outcomes of extremely preterm children (EPT) is not well understood.

Objective  To assess the association of high screen time with cognition, language, executive function, and behavior of EPT children aged 6 to 7 years; a second objective was to examine the association between high screen time and rates of structured physical activity and weight.

Design, Setting, and Participants  This cohort study was a secondary analysis from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial Neuroimaging and Neurodevelopmental Outcomes school-aged cohort and includes 414 EPT children born between February 1, 2005, and February 28, 2009, and evaluated in between 2012 and 2016 at ages 6 years 4 months to 7 years 2 months. The study was conducted from July 7, 2012, and August 15, 2016, and data were analyzed between December 10, 2018, and April 1, 2021.

Exposures  Cohorts included children exposed to low (≤2 hours per day) vs high (>2 hours per day) amounts of screen time and by the presence (no vs yes) of a television/computer in the bedroom.

Main Outcomes and Measures  In addition to growth parameters, assessments included the Wechsler Intelligence Scale for Children-IV, the Behavior Rating Inventory of Executive Function, the Developmental Neuropsychological Assessment, the Conners 3rd Edition–Parent Short-Form, and the Social Communication Questionnaire.

Results  Of the 414 children included in the analysis, 227 (55%) were boys; mean (SD) birth weight was 870.6 (191) g. A total of 238 children (57%) had high screen time and 266 (64%) had a television/computer in their bedroom. In multivariable linear regressions adjusted for center, male sex, gestational age, and social determinants of health, high screen time was independently associated with the following mean (SE) test score changes: lower full-scale IQ (−3.92 [1.64]; P = .02); an increase in association with deficits in executive functions, including metacognition (8.18 [3.01]; P = .007), global executive function (7.49 [2.99]; P = .01), inhibition (−0.79 [0.38]; P = .03), and Conners 3rd Edition–Parent Short-Form inattention (3.32 [1.67]; P = .047). A television/computer in the bedroom was associated with an increase in inhibition (−0.80 [0.39]; P = .04) and hyperactivity/impulsivity (3.50 [1.75]; P = .046) problems.

Conclusions and Relevance  The findings of this study suggest that high screen time contributes to adverse cognitive, executive function, and behavior outcomes at ages 6 to 7 years in children born at less than 28 weeks. These findings support the need for clinicians to have heightened awareness of the risks for EPT children and discuss both the benefits and risks of screen time with families.

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