Supplementary Online Content Carter B, Rees P, Hale L, Bhattacharjee D, Paradkar MS. Association between portable screen-based media device access or use and sleep outcomes: a systematic review and meta-analysis. JAMA Pediatr. Published online October 31, 2016. doi:10.1001/jamapediatrics.2016.2341 etable 1. Databases and the Main Search Strategy etable 2. Assessment and Risk of Bias (RoB) etable 3. Characteristics of Included Studies etable 4. Summary of the Results of the Included Studies efigure 1. A Forest Plot of Children With Excessive Sleepiness Comparing Children Who Had Use of a Media Device With Those Who Did Not Have Access to a Device efigure 2. A Forest Plot of Children With Poor Sleep Comparing Children Who Had Access to a Media Device With Those Who Did Not Have Access to a Device efigure 3. A Forest Plot of Children With Excessive Sleepiness Comparing Children Who Had Access to a Media Device With Those Without Access to a Device This supplementary material has been provided by the authors to give readers additional information about their work. 1
etable 1. Databases and the Main Search Strategy Databases searched: British Education Index British Nursing Index CINAHL Cochrane Library ERIC International Bibliography of Social Sciences Medline via Ovid (EMBASE, Medline, Psych INFO) PubMed Science Direct Scopus Web of Science Open Grey Main Search strategy used: (Date limits applied: 01/01/2011 to 15/06/2015) 1 (Mobile phone* OR mobile telephone* OR cell phone* OR cellular phone* OR cellular telephone* OR electronic media* OR smart phone* OR portable media device* OR tablet phone*) (Title, abstract, keywords) 2 (sleep* OR insomnia OR parasomnia OR wakefulness OR awakening) (Title, abstract, keywords) 3 (child* OR adolescen* OR school aged children OR pupils OR students OR teenage* OR young person OR young adult OR pubescent OR juvenile) (Title, abstract, keywords) 4 (1 and 2 and 3) 2
etable 2. Assessment and Risk of Bias (RoB) Eligible studies Methodological quality domains Domains of a Domains Domains of a 1 2 3 4 5 6 7 8 9 10 11 12 13 low RoB unclear RoB high RoB Assessment Adachi-Mejia et al (2014) # * * + * * 8 1 4 Excluded Arora et al (2014) 13 0 0 Good Arora et al (2013) + 12 1 0 Unclear Buxton et al (2015) + * + 10 2 1 Low Chahal et al (2013) + 12 1 0 Unclear Falbe et al (2015) * + 11 1 1 Low Gamble et al (2014) + + 11 2 0 Unclear Gradisar et al (2013) + * * 10 1 2 Low Hysing et al (2015) * + 11 1 1 Unclear Jiang et al (2015) 13 0 0 Good King et al (2014) + 12 1 0 Unclear Kubiszewski et al (2013) + + 11 2 0 Unclear Lemola et al (2015) * + 11 1 1 Low Mak et al (2014) + 12 1 0 Unclear Munezawa et al (2011) + 12 1 0 Unclear Nathan and Zeitzer (2013) & * * * * + 8 1 4 Excluded Pea et al (2012) $ * + * * 9 2 2 Excluded Piero-Velert et al (2014) + + + 10 3 0 Unclear Pieters et al (2014) * + + 9 3 1 Low Redmayne et al (2013) + * + 10 2 1 Low Footnotes: *study did not meet the domain (high RoB); + unclear if the study met the domain (unclear RoB); blank indicates the study met the domain (low RoB). # Adachi-Mejia et al (2014) was excluded because it did not use statistical techniques appropriately, did not present adequate data, reported results that were unclear and was not focused in terms of comparative features assessed. & Nathan and Zeitzer (2013) was excluded as it had a poor response rate (10%). $ Pea et al. (2012) was not clearly focused in terms of the comparative features, the criteria were vague and participants were recruited into cohorts at different times of the year. 3
Methodological quality criteria used in etable 2 1, Were the aims of the study clearly stated? 2, Were the study clearly focused in terms of population selected, comparative features assessed and outcomes considered? 3, Do the authors appear to have conducted a preparatory unbiased literature review to identify the current state of knowledge? 4, Was the choice of the study method appropriate? 5, Were the inclusion criteria explicit? 6, Have the results of the study been clearly presented? 7, Are the data in the tables or graphs and the text consistent? 8, Were all important outcomes/results considered? 9, Was study size considered and is it likely to have affected the results? 10, Was the ascertainment clearly stated? 11, How were the comparison group(s) chosen? 12, Was the comparison group enrolled in same time period and assessed in the same way as the exposed group? 13, Were the statistical methods used appropriately? 4
etable 3. Characteristics of Included Studies Study author and year Arora et al, 2013 Arora et al, 2014 Type of study Country United Kingdom United Kingdom Age range 11-18 Mean age ± SD 13.9 ± 2.0 11-13 NA Questionnaires Sent/ Responded/ Analyzed 1043 759 632 1495 1181 738 Response rate (%) Male/ Female Exposure 88 228/ 404 Pre-bedtime use of mobile phones 79 402/ 336 Pre-bedtime use of mobile phones Sleep Outcomes, Timing of outcomes s s Buxton et al, 2015 USA 6-17 11.4 ± 5.0 4072 1441 1103 35.4 565/ 538 Presence of mobile phone/ tablet in bedroom at night, s and weekends Chahal et al, 2015 Falbe et al, 2015 Gamble et al, 2014 Canada 10-11 NA USA 9-13 Australia 11-17 10.6 ± 1.5 15.2 ± 1.4 5597 3687 3396 2456 2061 2048 NA 1184 1184 66 84 NA 1698/ 1698 995/ 1053 384/ 800 Use of mobile phone for chatting/texting at night Presence of device in the bedroom at night Sleeping near small screens at night Mobile phone presence and use in sleep environment and weekend 5
Gradisar et al, 2013 Hysing et al, 2015 Study author and year Jiang et al, 2015 King et al, 2013 Kubiszewski et al, 2013 Lemola et al, 2015 Type of study USA 13-18 NA Norway 16-19 17.0 Country Age range Mean age ± SD China 8-17 11.5 Australia 12-18 France 12-15 Switzer- - land 12-17 14.9 ± 1.5 12.9 ± 1.25 14.8 ± 1.3 NA 05 205 19430 10220 9846 Questionnaires Sent/ Responded/ Analyzed 6590 6247 NA 1360 1287 1287 454 332 332 646 390 362 NA 53 Response rate (%) 94.8 108/ 97 4594/ 5252 Male/ Female 3213/ 3034 94.6 638/ 649 73 156/ 176 61 200/ 162 Frequency of use of mobile phones in an hour before bedtime and presence of mobile phones in sleep environment Use of mobile phones & tablet devices in an hour before bedtime Exposure Duration of mobile phone use after school Ownership of mobile & tablet device Presence of mobile phone in bedroom Use of mobile phone after 8 pm Frequency of mobile phone use in bed for calling/texting at night. Presence of portable devices in sleep environment Sleep Outcomes and weekend Timing of outcomes and weekend 6
Mak et al, 2014 Munezawa et al, 2011 Piero-Velert et al, 2014 Pieters et al, 2014 Redmayne, 2013 Hong Kong 12-20 15.3 ± 1.7 Japan 6-18 NA Spain 12-18 NA Belgium 13-20 New Zealand 16.9 ± 1.5 10-14 12.3 817 792 762 95680 94777 94777 4585 3095 / NA 3282 1936 1916 439 373 373 97 434/ 319 63 65.7 NA 59 48077/ 46700 857/ 1059 85 207/ 165 Use of mobile phones over the entire day Mobile phone use after lights out for calling or texting Duration of mobile phone use Mobile phone use in an hour before sleep -frequency -intensity (duration) Number of calls lasting > 10 minutes made using mobile phone during the day s and weekend 7
Studies etable 4. Summary of the Results of the Included Studies Inadequate sleep quantity Poor sleep quality Excessive daytime Use of portable electronic media devices around the bedtime Arora et al (11) + (β, ) + (β, ) Arora et al (28) + (β, ) Chahal et al (29) + (β, ) Gamble et al (30) o (β, ) + ( ) Gradisar et al (3) + ( ) + (β, ) Hysing et al (31) + ( ) + ( ) Jiang et al (22) + (β) o ( ) + ( ) Kubiszewski et al (33) o ( ) - ( ) + ( ) Lemola et al (25) o ( ) + ( ) Munezawa et al (35) + ($) + ($) + ($) Piero-Velert et al (36) + ($) Pieters et al (26) o ($) + ($) + ($) Presence of portable electronic device in sleep environment Buxton et al (23) + ( ) o ( ) o ( ) Chahal et al (29) + (β, ) Falbe et al (24) + (β) + ( ) Gamble et al (30) + ( ) + ( ) + ( ) Gradisar et al (3) + ( ) o ( ) + ( ) Kubiszewski (33) o ( ) + ( ) + ( ) Lemola et al (25) + ($, ) + ($, ) Key Type of association reported Measure of effect used in the study - Significant negative association Odds ratio (OR) + Significant positive association $ Correlation coefficient (r) o No significant association β Coefficient of linear regression (β) 8
efigure 1. A Forest Plot of Children With Excessive Sleepiness Comparing Children Who Had Use of a Media Device With Those Who Did Not Have Access to a Device
efigure 2. A Forest Plot of Children With Poor Sleep Comparing Children Who Had Access to a Media Device With Those Who Did Not Have Access to a Device Note: The number of participants were not provided by Falbe et al (2015) or Kubiszewski et al (2015), only the results from the statistical analysis are included.
efigure 3. A Forest Plot of Children With Excessive Sleepiness Comparing Children Who Had Access to a Media Device With Those Without Access to a Device Note: The number of participants was not provided by Kubiszewski et al (2015), only the results from the statistical analysis are included.