Screen Use and Mental Health Symptoms in Canadian Children and Youth during the COVID-19 Pandemic

Importance: Longitudinal research on specific forms of electronic screen use and mental health symptoms in children and youth during COVID-19 is minimal. Understanding the association may help develop policies and interventions targeting specific screen activities to promote healthful screen use and mental health in children and youth. Objective: To determine whether specific forms of screen use (television [TV] or digital media, video games, electronic learning, and video-chatting time) were associated with symptoms of depression, anxiety, conduct problems, irritability, hyperactivity, and inattention in children and youth during COVID-19. Design, Setting, and Participants: A longitudinal cohort study with repeated measures of exposures and outcomes was conducted in children and youth aged 2 to 18 years in Ontario, Canada, between May 2020 and April 2021 across 4 cohorts of children or youth: 2 community cohorts and 2 clinically referred cohorts. Parents were asked to complete repeated questionnaires about their children\u27s health behaviors and mental health symptoms during COVID-19. Main Outcomes and Measures: The exposure variables were children\u27s daily TV or digital media time, video game time, electronic-learning time, and video-chatting time. The mental health outcomes were parent-reported symptoms of child depression, anxiety, conduct problems and irritability, and hyperactivity/inattention using validated standardized tools. Results: This study included 2026 children with 6648 observations. In younger children (mean [SD] age, 5.9 [2.5] years; 275 male participants [51.7%]), higher TV or digital media time was associated with higher levels of conduct problems (age 2-4 years: β, 0.22 [95% CI, 0.10-0.35]; P \u3c.001; age ≥4 years: β, 0.07 [95% CI, 0.02-0.11]; P =.007) and hyperactivity/inattention (β, 0.07 [95% CI, 0.006-0.14]; P =.04). In older children and youth (mean [SD] age, 11.3 [3.3] years; 844 male participants [56.5%]), higher levels of TV or digital media time were associated with higher levels of depression, anxiety, and inattention; higher levels of video game time were associated with higher levels of depression, irritability, inattention, and hyperactivity. Higher levels of electronic learning time were associated with higher levels of depression and anxiety. Conclusions and Relevance: In this cohort study, higher levels of screen use were associated poor mental health of children and youth during the COVID-19 pandemic. These findings suggest that policy intervention as well as evidence-informed social supports are needed to promote healthful screen use and mental health in children and youth during the pandemic and beyond

Nutritional risk in early childhood and parent-reported school concerns

Objective: To determine if nutritional risk in early childhood is associated with parent-reported school concerns. Design: A prospective cohort study conducted through the TARGet Kids! primary care research network (2011-2018). Nutritional risk was measured between 18 months and 5 years of age using validated parent-completed NutriSTEP® questionnaires with eating behaviour and dietary intake subscores (0 = lowest and 68 = highest total nutritional risk score). Parent-reported school concerns were measured at school age (4-10 years of age) and included: speech and language; learning; attention; behaviour; social relationships; physical coordination; fine motor coordination and self-help skills and independence. The primary outcome was any parent-reported school concerns, and individual school concerns were used as secondary outcomes. Multiple logistic regression models were conducted adjusting for clinically relevant confounders to assess the relationship between nutritional risk and school concerns. Setting: Toronto, Canada. Participants: Children aged 18 months to 10 years. Results: The study included 3655 children, 52 % were male, mean NutriSTEP® score was 14·4 (sd 6·4). Each 1 sd increase in NutriSTEP® total score was associated with a 1·18 times increased odds of school concerns (adj OR: 1·18, 95 % CI 1·07, 1·28, P = 0·0004), and high nutritional risk was associated with a 1·42 times increased odds of school concerns (adj OR: 1·42, 95 % CI 1·13, 1·78, P = 0·002). Conclusions: Nutritional risk in early childhood was associated with school concerns. Nutritional interventions in early childhood may reveal opportunities to enhance school outcomes.</p

Haemoglobin thresholds to define anaemia from age 6 months to 65 years:estimates from international data sources

Background: Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. Methods: In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6–23 months, 24–59 months, 5–11 years, and 12–17 years, and adults aged 18–65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. Findings: We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5–105·3) in 924 children aged 6–23 months, 110·2 g/L (109·5–110·9) in 1874 children aged 24–59 months, and 114·4 g/L (113·6–115·2) in 1839 children aged 5–11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3–123·1) in 1741 female adolescents aged 12–17 years and 128·2 g/L (126·4–130·0) in 1103 male adolescents aged 12–17 years. In pooled analyses of adults aged 18–65 years, the fifth centile was 119·7 g/L (90% CI 119·1–120·3) in 3640 non-pregnant females and 134·9 g/L (134·2–135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5–111·0) in the first trimester (n=772) and 105·9 g/L (104·0–107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. Interpretation: Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. Funding: World Health Organization and the Bill &amp; Melinda Gates Foundation.</p

Predictive Validity of the Infant Toddler Checklist in Primary Care at the 18-month Visit and School Readiness at 4 to 6 Years

Objective: The American Academy of Pediatrics recommends developmental surveillance and screening in early childhood in primary care. The 18-month visit may be an ideal time for identification of children with delays in language and communication, or symptoms of autism spectrum disorder (ASD). Little is known about the predictive validity of developmental screening tools administered at 18 months. Our objective was to examine the predictive validity of the Infant Toddler Checklist (ITC) at the 18-month health supervision visit, using school readiness at kindergarten age as the criterion measure. Methods: We designed a prospective cohort study, recruiting in primary care in Toronto, Canada. Parents completed the ITC at the 18-month visit. Teachers completed the Early Development Instrument (EDI) when the children were in Kindergarten, age 4-6 years.We calculated screening test properties with 95% confidence intervals (CIs). We used multivariable logistic and linear regression analyses adjusted for important covariates. Results: Of 293 children (mean age 18 months), 30 (10.2%) had a positive ITC including: concern for speech delay (n=11, 3.8%), concern for other communication delay (n=13, 4.4%), and concern for both (n=6, 2.0%). At follow-up (mean age 5 years), 54 (18.4%) had overall EDI vulnerability, 19 (6.5%) had vulnerability on the 2 EDI communication domains. The ITC sensitivity ranged from 11%-32%, specificity from 91%-96%, false positive rates from 4%-9%, PPV from 16%-35%, NPV from 83%-95%. A positive ITC screen and ITC concern for speech delay were associated with lower scores in EDI communication skills and general knowledge (β= −1.08; 95% CI: −2.10, −0.17; β= −2.35; 95% CI: −3.63, −1.32) and EDI language and cognitive development (β= −0.62; 95% CI: −1.25, −0.18; β= −1.22; 95% CI: −2.11, −0.58).  Conclusions: The ITC demonstrated high specificity suggesting that most children with a negative ITC screen will demonstrate school readiness at 4-6 years, and low false positive rates, minimizing over-diagnosis. The ITC had low sensitivity highlighting the importance of ongoing developmental surveillance and screening. </p

Children’s screen use and school readiness at 4-6 years: prospective cohort study

Background The primary aim of this study was to determine if screen use in early childhood is associated with overall vulnerability in school readiness at ages 4 to 6 years, as measured by the Early Development Instrument (EDI). Secondary aims were to: (1) determine if screen use was associated with individual EDI domains scores, and (2) examine the association between screen use and EDI domains scores among a subgroup of high screen users. Methods This prospective cohort study was carried out using data from young children participating in a large primary care practice-based research network in Canada. Logistic regression analyses were run to investigate the association between screen use and overall vulnerability in school readiness. Separate linear regression models examined the relationships between children’s daily screen use and each separate continuous EDI domain. Results A total of 876 Canadian participants participated in this study. Adjusted logistic regression revealed an association between increased screen use and increased vulnerability in school readiness (p = 0.05). Results from adjusted linear regression demonstrated an association between higher screen use and reduced language and cognitive development domain scores (p = 0.004). Among high screen users, adjusted linear regression models revealed associations between increased screen use and reduced language and cognitive development (p = 0.004) and communication skills and general knowledge domain scores (p = 0.042). Conclusions Screen use in early childhood is associated with increased vulnerability in developmental readiness for school, with increased risk for poorer language and cognitive development in kindergarten, especially among high users.</p

The Association between Early Childhood and Later Childhood Sugar-Containing Beverage Intake: A Prospective Cohort Study

Sugar-containing beverages (SCBs) are a major source of sugar intake in children. Early life intake of SCBs may be a strong predictor of SCB intake later in life. The primary objective of this study was to evaluate if SCB intake (defined as 100% fruit juice, soda, and sweetened drinks) in early childhood (≤2.5 years of age) was associated with SCB intake in later childhood (5-9 years of age). A prospective cohort study was conducted using data from the TARGet Kids! primary care practice network (n = 999). Typical daily SCB intake was measured by parent-completed questionnaires. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression. A total of 43% of children consumed ≥0.5 cups/day of SCBs at ≤2.5 years and this increased to 64% by 5-9 years. Daily SCB intake, compared to no daily intake, at ≤2.5 years was significantly associated with SCB intake at 5-9 years (adjusted OR: 4.03; 95% CI: 2.92-5.55) and this association was much stronger for soda/sweetened drinks (adjusted OR: 12.83; 95% CI: 4.98, 33.0) than 100% fruit juice (OR: 3.61; 95% CI: 2.63-4.95). Other early life risk factors for SCB intake at 5-9 years were presence of older siblings, low household income, and shorter breastfeeding duration. Daily intake of SCBs in early childhood was strongly associated with greater SCB intake in later childhood. Early life may be an important period to target for population prevention strategies. </p