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

Educational Objective
To assess the association of high screen time with cognition, language, executive function, and behavior of extremely preterm children aged 6 to 7 years.
1 Credit CME
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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Article Information

Accepted for Publication: April 26, 2021.

Published Online: July 12, 2021. doi:10.1001/jamapediatrics.2021.2041

Corresponding Author: Betty R. Vohr, MD, Division of Neonatal Medicine, Department of Pediatrics, Women & Infants Hospital of Rhode Island, 101 Dudley St, Providence, RI 02905 (bvohr@wihri.org).

Author Contributions: Drs Bann and Das full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analyses.

Concept and design: Vohr, Higgins, Hintz.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Vohr, McGowan, Bann.

Critical revision of the manuscript for important intellectual content: Vohr, McGowan, Das, Higgins, Hintz.

Statistical analysis: Bann, Das.

Obtained funding: Das, Hintz.

Administrative, technical, or material support: Higgins, Hintz.

Supervision: Higgins.

Conflict of Interest Disclosures: Dr Vohr reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) during the conduct of the study. Dr Bann reported receiving grants from the NICHD during the conduct of the study. Dr Das reported receiving grants from the National Institutes of Health cooperative agreement grant during the conduct of the study. Dr Hintz reported receiving grants from the NICHD NRN during the conduct of the study. No other disclosures were reported.

Funding/Support: The National Institutes of Health (M01 RR30, M01 RR32, M01 RR39, M01 RR54, M01 RR59, M01 RR64, M01 RR80, M01 RR70, M01 RR633, M01 RR750, M01 RR997, UL1 RR25008, UL1 RR25744, UL1 TR442), the NICHD (U10 HD21364, U10 HD21385, U10 HD21373, U10 HD27851, U10 HD27856, U10 HD27880, U10 HD27904, U10 HD34216, U10 HD36790, U10 HD40461, U10 HD40492, U10 HD40689, U10 HD53089, U10 HD53109, U10 HD53119, and U10 HD53124) and the National Heart, Lung, and Blood Institute (NHLBI) (via co-funding) provided grant support for the NRN’s Extended Follow-up at School Age for the Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial (SUPPORT) Neuroimaging and Neurodevelopmental Outcomes (NEURO) Cohort.

Role of the Funder/Sponsor: Although the NICHD staff had input into the study design, conduct, analysis, and manuscript drafting, the comments and views of the authors do not necessarily represent the views of the NICHD. Data collected at participating sites of the NICHD Neonatal Research Network NRN were transmitted to Research Triangle Institute International, the data coordinating center for the network, which stored, managed, and analyzed the data for this study.

Group Information: The members of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network are listed in the Supplement.

Additional Contributions: We thank the children and their parents who participated in this study.

Additional Information: Extended Follow-up at School Age for the SUPPORT NEURO Cohort: NCT00233324.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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