Parental Education for Limiting Screen Time in Early Childhood: A Randomized Controlled Trial.

OBJECTIVE: To assess the impact of focused parental education on limiting screen time in early childhood. METHODS: An open label randomized controlled trial was conducted in a tertiary care hospital in Delhi wherein 120 healthy children aged 9-10 months of age, born at term gestation and appropriate for gestational age (birth weight ≥ 2500 g), attending the immunization clinic reporting for measles-rubella (MR) vaccination were enrolled. Primary caregivers were randomized to either receive 30 minutes of in-person active counselling with pre-designed content including a printed pamphlet targeted at reduction of screen time (Educational group, n = 61) or to receive routine in-person counseling on general health measures (Control group, n = 61). All caregivers were followed up. Primary caregivers in both groups were reinforced telephonically every month for 6 months. At the end of six months, we assessed the proportion of children with screen-time > 1 hour/day and the median duration of screen-time (minutes /day). We also compared both groups in terms of changes in pre-post intervention developmental and behavioral scores (measured with Ages and Stages questionnaires). RESULTS: After 6 months of follow-up, 3% (2/61) children in the Educational group had screen time > 1 hour/day as compared to 53% (32/61) (P < 0.001) in the Control group. Median (IQR) for total screen duration in the Educational group was 35 (30,49) minutes/day compared to 75 (50,90) minutes/day in the Control group (P < 0.001). Children in the Educational group were also observed to have a significant change in behavioral score and fine motor and adaptive skills as compared to controls. CONCLUSION: Parental education starting in infancy is a promising intervention to reduce screen exposure in children; it may also have a positive impact on their developmental and behavioral skills.

Indian Academy of Pediatrics Guidelines on Screen Time and Digital Wellness in Infants, Children and Adolescents.

JUSTIFICATION: Screen-based media have become an important part of human lifestyle. In view of their easy availability and increasing use in Indian children, and their excessive use being linked to physical, developmental and emotional problems, there is a need to develop guidelines related to ensure digital wellness and regulate screen time in infants, children, and adolescents. OBJECTIVES: To review the evidence related to effects of screen-based media and excessive screen time on children's health; and to formulate recommendations for limiting screen time and ensuring digital wellness in Indian infants, children and adolescents. PROCESS: An Expert Committee constituted by the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines. A detailed review document was circulated to the members, and the National consultative meet was held online on 26th March 2021 for a day-long deliberation on framing the guidelines. The consensus review and recommendations formulated by the Group were circulated to the participants and the guidelines were finalized. CONCLUSIONS: Very early exposure to screen-based media and excessive screen time (>1-2h/d) seems to be widely prevalent in Indian children. The Group recommends that children below 2 years age should not be exposed to any type of screen, whereas exposure should be limited to a maximum of one hour of supervised screen time per day for children 24-59 months age, and less than two hours per day for children 5-10 years age. Screen time must not replace other activities such as outdoor physical activities, sleep, family and peer interaction, studies and skill development, which are necessary for overall health and development of the children and adolescents. Families should ensure a warm, nurturing, supportive, fun filled and secure environment at home, and monitor their children's screen use to ensure that the content being watched is educational, age-appropriate and non-violent. Families, schools and pediatricians should be educated regarding the importance of recording screen exposure and digital wellness as a part of routine child health assessment, and detect any signs of cyberbullying or media addiction; and tackle it timely with expert consultation if needed.

Compliance to Prescription of Routine Vitamin D Supplementation in Infants.

We assessed compliance to routine vitamin D supplementation in 330 infants (age 6 wk to 9 mo), who were prescribed supplemen-tation at birth. 137 (41.5%) had received vitamin D supplemen-tation at some point of time till enrolment. Median (IQR) compliance to routine vitamin D supplementation was 66.7% (50%, 83.3%) in those who ever received supple-mentation. Only 29 (8.8%) were receiving appropriate routine vitamin D supple-mentation in terms of dose, frequency and duration. There was low level of reinforcement (35%) from healthcare workers and low parental awareness (34%) of the need of supplementation.

Effect of Faculty Training on Quality of Multiple-Choice Questions.

BACKGROUND: Multiple-choice question (MCQ) is frequently used assessment tool in medical education, both for certification and competitive examinations. Ill-constructed MCQs impact the utility of the assessment and thus the fate of examinee. We conducted this study to ascertain whether a short training session for faculty on MCQ writing results in desired improvement in their item-writing skills. METHODS: A 1-day workshop on constructing high-quality MCQs was conducted for the faculty as a before-after design, following training session of 3 h duration. 28 participants wrote preworkshop (n = 133) and postworkshop (n = 137) MCQs, which were analyzed and compared for 17 item-writing flaws. A mock test of 100 MCQs (selected by stratified random sampling from all the MCQs generated during the workshop) was conducted for MBBS-passed students for item analysis. RESULTS: Item-writing flaws reduced following the training (15% vs. 27.7%, P < 0.05). Improvement mainly occurred in quality of options; heterogeneity dropped from 27.1% prior to the workshop to 5.8% postworkshop. The proportion of MCQs failing the cover test remained similarly high (68.4% vs. 60.6%), and there was no improvement in writing of the stem before and after the workshop. The item analysis did not reveal any significant improvement in facility value, discriminating index, and proportion of nonfunctioning distractors. CONCLUSION: A single, short-duration faculty training session is not good enough to correct flaws in writing of the MCQs. There is a need of focused training of the faculty in MCQ writing. Courses with a longer duration, supplemented by repeated or continuous faculty development programs, need to be explored.

Screen Time in Indian Children by 15-18 Months of Age.

OBJECTIVE: To determine the prevalence and practices of exposure to screen-based media in children by 15-18 months of age. METHODS: This observational descriptive study was conducted from March to August, 2019. Mothers of 370 healthy developmentally normal children (15-18 months of age) were enrolled during their visit to immunization clinic of a medical college affiliated hospital. Parental response to a semi-structured questionnaire was recorded to assess the initiation, frequency and duration of screen exposure, and related parental perceptions. RESULTS: 369 (99.7%) children were exposed to screen-based media till 18 months of age, starting from median (IQR) age of 10 (8, 12) months. Smartphone and television were being viewed by 354 (96%) and 328 (89%) children, respectively. Screen time was >1 hour/day in 328 (88.7%) and >2 hours/day in 209 (56.5%) children (median (IQR): 120 (80, 180) minutes/d). Most (72%) parents were not concerned with their child's screen time. CONCLUSION: Almost all young children seem to be exposed to screen-based media by 18 months of age in the urban setting. Extensive use of screen-based media by young children calls for formulation of guidelines on toddlers' screen use and their dissemination to parents.

Sunlight Exposure and Vitamin D Status in Breastfed Infants.

OBJECTIVE: To correlate the sunlight exposure in first 6 months to vitamin D status at 6 months of age in predominantly breastfed infants; and to quantify the sunlight exposure required to achieve serum 25(OH)D level >20 ng/mL, by 6 months of age. DESIGN: Design: Prospective cohort. SETTING: Tertiary-care hospital predominantly catering to urban poor population in Delhi. PARTICIPANTS: 132 healthy infants, delivered at term, and predominantly breastfed were enrolled at 6-8 weeks of age. Of these, 100 infants were available for final evaluation at 6 months of age (mean (SD) follow-up: 126 (17) days). METHODS: Baseline maternal vitamin D (serum 25(OH)D) levels were obtained at enrolment. The mothers were asked to maintain a daily record of duration of sunlight exposure, timing of exposure, and body surface area exposed, for the infant, on a pre-designed proforma, till the child was 6 months of age. Infant's serum 25(OH)D was measured at 6 months of age. MAIN OUTCOME MEASURES: Cumulative Sun Index was calculated as a composite measure of overall duration/time/body surface area exposed to sunlight; and correlated with the infant serum 25(OH)D after adjusting for baseline maternal serum 25(OH)D levels, season of exposure, and skin color of the infant. Sun index for exposure in morning (before 10 am) and afternoon (10 am-3 pm) were also correlated to vitamin D status. RESULTS: Of 100 mother-infant pairs completing the study, 90 mothers had vitamin D deficiency (serum 25(OH)D <12 ng/mL). The median duration of exposure of infants to sunlight was 17 min per week, on 6% of body surface area. Vitamin D levels of 67 (67%) infants at 6 months were less than 12 ng/mL and another 23% had insufficient levels (12-20 ng/mL). Cumulative sun index correlated positively to infant's serum 25(OH)D level at 6 months of age (r= 0.461, P<0.001). Increment in afternoon sun index by 1 unit increased the serum 25(OH)D level by 1.07 ng/mL (95% CI 0.37, 1.78; P= 0.003). A minimum 30 minute weekly afternoon sunlight exposure, between 10 am and 3 pm, over 40% body area (infant clothed in diapers, in prone position) for at least 16 weeks, was estimated requirement to achieve sufficient vitamin D levels (>20 ng/mL) by 6 months of age. CONCLUSION: There is a significant positive correlation between afternoon sunlight exposure and infant's vitamin D levels, independent of maternal vitamin D status. Randomized controlled trials are suggested to explore the effectiveness of this simple intervention to prevent or treat vitamin D deficiency in children.