Screen use and children and adolescents’ physical health assessed as musculosceletal pain, headache and eye health: an umbrella review
Systematic review
|Published
Vi utarbeidet en paraplyoversikt som undersøkte assosiasjonen mellom skjermtid og fysisk helse målt som muskel-skjelettsmerter, hodepine og øyehelse hos barn og ungdom i alderen 0 til 19 år.
Key message
Screen use can have both positive and negative consequences for the health of children and adolescents, but the results from studies are not consistent. We conducted an umbrella review examining the association between screen time and physical health measured as musculoskeletal pain, headaches and eye health in children and adolescents aged 0 to 19 years.
We identified six relevant systematic reviews that we assessed for quality using AMSTAR 2. Four were of moderate quality, and two were of low quality. Two reviews investigated the association between screen time and musculoskeletal pain including headaches, and four examined the association between screen time and eye health. The included studies were mainly cross-sectional.
Based on what the reviews reported, we found:
- Possibly a positive association between screen time, usually over at least 3 hours per day, and musculoskeletal pain in general, and low back pain.
- Possibly a positive association between screen time and headaches in boys, boys and girls combined, but not in girls alone.
- It is uncertain whether there is a positive association between screen time and the prevalence of myopia.
- Possibly a positive association between screen time and Dry Eyes Disease. For Digital Eye Strain, the results were uncertain.
- It is uncertain whether increased screen time during the COVID-19 pandemic was associated with increased progression of myopia.
Knowledge gaps: We lack high-quality systematic reviews that have examined the effects and consequences of screen time on musculoskeletal pain and eye health. Prospective studies with (long-term) follow-up and randomised studies with control groups are needed to assess causality.
Summary
Introduction
Children and adolescents use digital screens in most settings. Screen use can have both positive and negative consequences for health and development, but the results from studies are not consistent. On behalf of the Screen Use Committee, we have conducted an umbrella review on the effects and consequences of screen use on physical health in children and adolescents (0 to 19 years old), summarizing the latest systematic reviews aiming to answer these questions.
Objective
The objective was to answer the following questions: How does digital screen time affect the physical health of children and adolescents (0-19 years old), measured as musculoskeletal pain, headaches, and eye health?
Method
We conducted a systematic literature search in Medline, PsycINFO, Embase, and Episte-monikos in December 2023. Two project members independently assessed the title and abstract of the references, and then evaluated relevant systematic reviews in full text against the inclusion criteria. We included systematic reviews examining screen use and the physical health of children and adolescents (0-19 years old) measured as musculoskeletal pain, headaches, and eye health. Two project members independently assessed the quality of the relevant systematic reviews using the AMSTAR 2 checklist. One member extracted results, and another member verified the extraction. For musculoskeletal pain, we extracted results on musculoskeletal pain in general, lower back pain, neck pain, shoulder/arm pain, and headaches. For eye health, we extracted results for myopia, Dry Eye Disease, Digital Eye Strain, as well as myopia measured during the COVID-19 pandemic compared to before the pandemic. We also aimed to extract data for subgroups of the population based on age group, functional ability, socioeconomic status, biological gender, sexual orientation, and ethnic/cultural minority status. Age classification was sparsely reported, and there was no reporting for the other subgroups. We assessed the certainty of the evidence using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). Certainty levels are divided into four categories: high, moderate, low, and very low certainty.
Results
We identified 13 relevant systematic reviews and included the six newest and highest-quality ones addressing the outcomes. We also compared the primary studies included in all 13 reviews to assess the extent and overlap of included primary studies. Two systematic reviews examined the association between screen time and musculoskeletal pain and headaches: we rated one as low quality and one as moderate quality. Four systematic reviews examined the association between screen time and eye health: we rated one as low quality and three as moderate quality. The included primary studies were mainly cross-sectional. This means that we can only ascertain whether screen time and the outcomes are correlated/associated, not about causal relationship.
Musculoskeletal pain and headaches:
A positive association was reported between screen time (usually above 3 hours per day) and musculoskeletal pain in general, lower back pain, and headaches. The positive association for headaches was reported for boys and boys and girls combined, but not for girls alone. The age group was 11 to 19 years old. We assessed the certainty of the evidence in these results as low.
For the association between screen time and neck pain or shoulder and elbow pain, the results were uncertain, with reports of both a positive association and little or no association in the primary studies. We assessed the certainty of the evidence as very low.
Eye health:
One review reported little or no association between screen time and myopia in a meta-analysis of prospective studies in children and adolescents aged 3 to 19 years old. We assessed the confidence in the result as low. In the meta-analyses of cross-sectional studies, the association was positive, but these results were uncertain, and we have very certainty of the evidence. The authors reported that smartphone use could be associated with an increased risk of myopia, but there was insufficient and conflicting evidence for the relationship between screen use and myopia.
One review found a positive association between one hour of increased screen time per day and Dry Eyes Disease (DED) in children aged 7 to 12 years old. For participants with DED who stopped screen use for four weeks, the DED rate decreased by 100% compared to 13.3% in those diagnosed with DED but continued screen use for four weeks. We have low certainty of the evidence.
One review reported a positive association between screen time of over three to four hours per day and Digital Eye Strain in adolescents aged 13 to 22 years old. The authors of the review did not provide estimates. We assessed the certainty of the evidence as very low. The results are therefore uncertain.
One review reported on the progression of myopia and increased screen time during the COVID-19 pandemic compared to before the pandemic in children aged 5 to 18 years, but it is uncertain whether the increased screen time was associated with an increased degree of myopia.
Discussion
We have systematically summarized systematic reviews examining screen use and the physical health of children and adolescents measured as musculoskeletal pain and eye health. We focused on the latest reviews of highest methodological quality and excluded systematic reviews of critically low methodological quality. However, even the best systematic review cannot provide more reliable conclusions than what the available and included studies show. A systematic review of high quality may include poorly conducted studies, and a review of critically low methodological quality may include the best studies. Nevertheless, we assume that we have included the most relevant reviews, which in turn have included the most relevant primary studies, since we compared which primary studies were included in the reviews that had the same research question, population, and outcome.
The aim of the umbrella review was to investigate the effects and consequences of screen use for children and adolescents aged 0-19 years and for several subgroups of the population. The included primary studies in the reviews were almost exclusively cross-sectional studies that could not assess causality, i.e., whether one leads to the other. Therefore, the documentation is limited and deficient. We identified the following knowledge gaps:
- Relevant systematic reviews of high quality with sufficient information on population and outcomes were lacking.
- Primary studies with control groups with low risk of systematic biases where it was possible to draw conclusions about causality were lacking. This was a significant and substantial deficiency.
- We intended to perform subgroup analyses of several subgroups of the population such as functional ability, socioeconomic status, biological gender, sexual orientation (LGBTQ+), and ethnic/cultural minority status, but this was not possible since these data were not presented in the studies. Sorting by age groups was also intended, but was sparsely investigated.
Conclusion
We have systematically included and summarized results of systematic reviews examining screen use and the physical health of children and adolescents measured as musculoskeletal pain, headaches, and eye health. We identified only systematic reviews of low and moderate methodological quality that mainly included cross-sectional studies. Therefore, the documentation can only inform about correlation and association between screen time and the outcomes, not causality. The results from the included systematic reviews indicated a possible association between screen time and musculoskeletal pain in general, low back pain, and headaches. As a rule, the age of the children and adolescents was between 10 and 20 years. For the association between screen time and myopia, the results were uncertain. In these analyses, the age range was between 3 and 19 years. Systematic reviews of high methodological quality summarizing well-controlled prospective studies examining causality are lacking and should be further investigated.
