Qualitative study on the influence of mealtime screen exposure on children’s feeding practices: perspectives from paediatricians and speech-language pathologists in Chennai, Tamil Nadu

Abstract

Objective

This qualitative research study investigates perspectives on the influence of mealtime screen exposure (MTSE) on feeding practices in children through semi-structured interviews with paediatricians and speech-language pathologists (SLPs).

Design

This study used a constructivist paradigm and a qualitative research approach, employing thematic analysis, to understand the research objectives from the lens of practitioners. The researchers used transcripts from semistructured interviews to generate themes.

Setting

This was a multisite, in situ research study conducted in healthcare facilities such as hospitals, private clinics and educational institutions in Chennai, Tamil Nadu, India, between March and April 2023.

Participants

24 participants, 12 SLPs and 12 paediatricians, were interviewed. The researchers selected these participants purposively based on their expertise and experience in dealing with children’s feeding practice-related disorders.

Results

The study identified six themes: limited awareness of MTSE’s effects, cultural expectations on mothers, screen dependency, sensory deprivation, fragile caregiver–child bonding and picky eating tendencies. Key findings reflect a lack of caregiver awareness, sociocultural pressures and the negative developmental impacts of MTSE on children’s feeding practices.

Conclusions

This study highlights the need for increased awareness among primary caregivers and healthcare professionals regarding the risks of prolonged MTSE. Both paediatricians and SLPs unanimously agree that MTSE can adversely affect feeding practices.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study used semistructured interviews that allow for in-depth exploration and reduce social desirability and groupthink bias.

• The study used purposive sampling and thus recruited experts with an average of eleven years of experience, increasing the likelihood of profound insights.

• The interview guide was designed to gain a holistic perspective by accommodating individual, group-level and societal factors influencing mealtime screen exposure (MTSE).

• The study focused only on MTSE issues in urban participants and could not provide insights into issues in rural contexts.

Introduction

The increasing prevalence of children’s screen time use during feeding, a trend we term mealtime screen exposure (MTSE), is a growing concern in Indian households.¹ This engagement with electronic devices such as smartphones, televisions and tablets during feeding times is not only causing feeding and behavioural problems but is also linked to various developmental issues in children.² MTSE, adopted by parents to ease the stress of feeding, is beginning to show significant impacts on children’s eating habits and the development of essential feeding skills, including self-feeding.² Feeding practices refer to the strategies and actions used by parents to (1) nourish (feed) their children, (2) influence their eating habits and (3) regulate their appetite and overall development. These practices are also influenced by the cultural, social and individual drivers of healthy eating behaviours, appetite regulation and child development that play a vital role in fostering eating behaviours in the long term.2,4

One of the critical concerns with MTSE is its effect on eating behaviours. The distractions caused by screens can lead to behavioural feeding disorders, as children may become less aware of the quality and quantity of food they consume.⁵ Studies, including one by Madigan et al, have indicated the association between screen exposure in children and deleterious effects on physical, behavioural and cognitive outcomes.6,8 Furthermore, Robinson et al’s research also highlights that children with elevated levels of MTSE are less likely to develop age-appropriate self-feeding skills than those with less or no MTSE.⁷ These findings underscore the detrimental effects that MTSE can have on children’s eating habits and feeding skill development.

The impact of MTSE extends beyond eating habits into broader developmental concerns and finer sensorimotor delays. A cross-sectional population-based study conducted in Tamil Nadu, India, with 718 children under 5, found that average daily expenditure on excessive screen time was pronounced in 73% of the participants at 2.39 hours. Feeding times were common occasions for such spending. The study established a meaningful relationship between increased ST and developmental delays in many areas of development, including language and communication. Key sociodemographic factors involved maternal screen time and bedtime screen use and were associated with higher ST in children. In essence, these findings insist on the developmental hazards of screen exposure during mealtimes and require primary healthcare interventions to help caregivers better manage children’s ST.⁵ The recommended screen time for infants under 24 months is 0, while for children aged 24–59 months, it should be limited to 1 hour per day.⁸ This excessive screen engagement has been associated with significant communication and cognitive delays in children. The study suggests that reducing screen time is crucial for young children’s development and well-being.⁹ Furthermore, excessive screen time has been linked to developmental issues such as reduced physical activity, obesity risk, cognitive development delays, shorter attention spans and delayed language acquisition.¹⁰ Recent research indicates a correlation between increased screen time and adverse effects on parent–child interaction and physical activity levels.¹⁰

Paediatricians and speech-language pathologists (SLPs) increasingly notice the detrimental effects of prolonged MTSE exposure in children. The rise of MTSE cases is alarming to healthcare professionals, policy-makers and parents who are trying to resolve this issue quickly and effectively, given its far-reaching implications on children’s health and developmental trajectories.¹¹ This study aims to explore the impact of MTSE on feeding development through qualitative interviews with paediatricians and SLPs, contributing to a better understanding of the real-time issues of MTSE. Given the prevalence and popularity of screens in society, screen time is inevitable¹²; therefore, the study seeks to understand the antecedents and the adverse effects of MTSE and provide practitioners and researchers with insights into this topical issue.

Methods

Researcher characteristics

The research team consisted of a diverse group of qualified professionals, including a postgraduate student in speech-language pathology with 5 years of clinical experience, an SLP with a PhD and 10 years of expertise in the field and a social scientist with a PhD and over 10 years of research experience in qualitative methodologies and sociocultural factors in healthcare. The investigators had no prior professional or personal relationship with the participants, minimising bias. Reflexivity was maintained through ongoing discussions within the research team to recognise and mitigate potential biases arising from the researchers’ professional backgrounds.

Design

Since the study involves building new knowledge on the issues of MTSE from the perspective of healthcare professionals, a qualitative research design with a constructivist paradigm was employed. Constructivist paradigm is typically used to explore participants’ subjective experiences and perspectives about the phenomenon of interest to construct meaning. Semistructured interviews (SSIs) were used, in which participants were invited to express their views and experiences on the problem of MTSE. The interview transcripts were analysed using a thematic analysis process to develop themes.

Interview guide development and validation

Developing the interview guide for SSI was a critical step in the research process. It was formulated following a literature review based on the conceptual framework of feeding practices by Blaney et al.⁴ The framework explains the role of individual, group and societal factors in feeding practices. Individual factors include attributes of the child, caregiver (mother) and child–caregiver dyad. Group factors include the attributes of hospital and health services, home/family, work and community environment. Whereas the societal factors include the attributes of society, culture and economy. Please refer to online supplemental file 1 for more information on how these factors are incorporated as guiding questions in the interview guide. One of the coauthors refined the guide, ensuring its relevance and applicability to the study’s context. A diverse group of professionals further validated the interview guide, including two SLPs, two paediatricians and two social scientists.

Sampling and data collection

Using a purposive sampling technique, SSIs were conducted between March and April 2023 with 24 professionals, comprising 12 SLPs and 12 paediatricians. Since SSIs are conducted individually, the likelihood of groupthink bias and social desirability bias was limited. The respondents were contacted through telephone and face-to-face meetings. The professionals were selected based on their qualifications and experience (a minimum of 5 years as an SLP or paediatric doctor). The SSIs were conducted face to face in the participants’ workplaces or via video conferencing platforms, depending on the participants’ preferences. No participants dropped out or refused participation after recruitment. Each interview lasted 35–45 min and was audio recorded. During these sessions, privacy and confidentiality were maintained. The principal investigator briefed participants on the study’s purpose and obtained written informed consent before the interviews. Data saturation was achieved during the ninth interview with SLPs and the eighth interview with paediatricians. However, additional interviews were conducted to ensure comprehensiveness. Respondents were allowed for informal member checking of the interview summary to see if it reflected what they intended to convey.

Analysis

The analysis followed the thematic analysis process outlined by Braun and Clarke¹³ in creating codes and developing themes. First, all interview sessions were transcribed verbatim using Otter.ai software. Second, the data were cleaned and organised for further use by QDA Miner Lite, a qualitative research software. Third, open codes were generated by reading the transcripts by the first author. This process is followed by verifying the applicability and correctness of the codes of the second author in collaboration with the first author. Finally, the second and the third authors combined these codes into themes. Further, the researchers checked the themes to see if they aligned with the research objectives of this study.

Patient and public involvement

None.

Results

The outcome of the thematic analysis is discussed as six themes in the following section.

Theme 1: squinted awareness

The respondents opined that parents and caregivers are unaware of proper feeding practices and the effects of MTSE and often lack guidance on best practices of feeding and development. The caregivers’ awareness about the ill effects of MTSE is limited to visual acuity. The experts observed that most caregivers regret their lack of awareness of other harmful impacts of MTSE on feeding practices when their children exhibit difficulties with feeding and vegetative skills. Experts also observed that caregivers believe that the child’s feeding habit will naturally change when the child is exposed to newer environments such as daycare facilities and schools.

The mothers are not aware. They do not understand because what they think is that the child is going to be at home for four years. Let us do whatever we do. Once they go to school, they will learn in another environment where they have to eat a wide variety of food, and all the children will have different food exposures. - An SLP

Respondents voiced those comprehensive educational initiatives involving parents, healthcare professionals and educators are crucial for mitigating the impacts of MTSE on children’s feeding habits.

Theme 2: culture-imposed burden on mothers

Experts observed that the sociocultural norms exert a considerable influence on MTSE practices. Cultural norms in countries such as India, where it is the sole responsibility of the mother to feed the children, place a heavy burden on her feeding practices. The instances of MTSE are higher in children of working mothers.

The responsibility of feeding the child is solely placed on the mother, creating immense pressure and limited support systems. Moreover, factors such as larger family sizes or working mothers can impact mealtime routines, making it challenging to allocate sufficient time for engaging in feeding interactions with the child. Understanding these cultural and demographic nuances. - A Paediatrician

Participants observed that mothers resort to MTSE habits to cope with stress and compensate for limited familial support. This theme highlights the need for a nuanced approach to social and cultural dynamics to support families in fostering healthier mealtime environments.

Some mothers have reported that allowing screens during meals can help reduce their workload and provide a temporary break, as children become occupied and less demanding during feeding. - A Paediatrician

Paediatricians also observe that economic background does not influence screen time; it is only the size and sophistication of the screen. The experts opined that caregivers’ awareness of the impact of MTSE on children is the key to addressing the issue of MTSE. A paediatrician also reported that ‘the mothers are unaware of the feeding cues, which are signals from the children when they need a feed.’

Theme 3: screen dependency and digital intrusion

Paediatricians opined that children are attracted to screens due to captivating visuals, sounds and animated content, which parents leverage to feed their children and avoid mealtime struggles. Respondents opined that even if children are exposed to screens only during feeding, the screen exposure of children shall cross well beyond the prescribed guidelines of various paediatric associations. Parents appear to use MTSE due to reduced time availability as it helps to manage difficult mealtime behaviours. Respondents underscored that primary caregivers believe that children eat more during MTSE. Caregivers think that MTSE is a reinforcement for effortless feeding. Parents often overestimate their children’s capacity to consume food, which leads to various problems, such as forced feeding.

It is common for mothers to overestimate the quantity of food their child consumes during meals. This can result in wastage and unnecessary pressure on the child. - An SLP

However, once the MTSE habit is established, it is difficult to withdraw due to children’s resistance, who are conditioned to eat only when exposed to screens. SLPs observed that parents are concerned that children may refuse to eat unless their favourite video is playing in the background. Therefore, parents use screens as a distraction to feed children.

Parents find it difficult to withdraw screen time during meals once it has been established. They face resistance and protests from their children when trying to implement screen-free mealtimes. - A Paediatrician

Parents may resort to using screens to distract children from the food they dislike, which can hinder the child’s willingness to try new foods or develop a diverse palate - An SLP

Some experts discussed that MTSE habits are prevalent even though mothers are aware of the harmful impacts of MTSE. Such mothers face the dilemma between physical health and overall child development as MTSE is a motivating factor to consume more food. The respondents reflected that mothers prioritise physical health (observed in the short term) over comprehensive child development, which takes years to observe. This phenomenon indicates a lack of long-sightedness among the primary caregivers.

Mothers may not become fully aware of their child’s feeding development until they reach around 2.5 to 3 years old. It is often when the child faces a struggle with self-feeding or demonstrates aversion to different foods that mothers become conscious of potential feeding issues and seek solutions - A Paediatrician

Theme 4: sensory deprivation

Paediatricians opined that excessive MTSE can disrupt children’s natural feeding processes and routines. It can result in a child’s inability to recognise hunger.

They will not feel solidity while having mealtime during screen time, they will not know what they are eating, and if we ask them, they are not ready to tell us that they want something - A Paediatrician

MTSE can significantly affect a child’s sensory development and feeding skills. Paediatricians and SLPs have expressed concerns over impaired chewing and swallowing and inadequate sensory experiences of the food, such as visual gratification, texture and taste awareness, affecting overall physical and mental well-being.

With the screen in front of them, the child hardly pays attention to the food. They eat mechanically without truly experiencing the taste, texture, and aroma of the meal. - An SLP

The focus of the paediatricians is on the physical and nutritional well-being of the children, whereas the SLPs focus on the impact of MTSE on social and emotional bonding. SLPs reflected that the communication between the primary caregiver and the child is minimal, leading to poor engagement and a lack of responsive feeding.

Mentally, the child becomes oblivious to their surroundings and loses interest in their immediate environment. - An SLP

Theme 5: tenuous caregiver–child bond

Respondents noted that the emotional connection and the child’s familial involvement are augmented during the mealtime interactions between the caregivers and the child. The cognitive and affective stimulations during the interaction are crucial for optimal emotional and social intelligence. They also opined that emotional connection requires complete and undivided attention among caregivers and children. Mealtime allows individuals to engage in meaningful conversations and affective sharing, enhancing familial belongingness. Respondents stated that MTSE hinders the interaction between the child and the caregivers, resulting in fragile emotional bonding. The limited opportunities for real-time communication and emotional expressions can hinder social interactions, good physical health and emotional regulation.

The presence of mobile phones during meals distracts parents from connecting with their children. Instead of fostering strong parent-child relationships and creating a positive mealtime environment, screen time creates barriers to meaningful interaction and bonding.

Theme 6: picky eating

Respondents pointed out that parental struggles with feeding intensify with MTSE, affecting the child’s dietary habits. Reliance on digital distractions for feeding complicates nutritional intake and exhibits unhealthy eating patterns. The experts underscored that children underappreciate food textures and tastes and thereby lack enjoyment of food. Audiovisual content from screens overshadows the perceptual appreciation of the food. This may also lead to aversion to certain food types, textures and tastes.

Many children develop picky eating habits and exhibit strong preferences for specific types of foods, often favouring solid and whole foods over softer textures. It is common for them to express dislike for certain fruits and grains. Surprisingly, these picky eaters generally have no aversion to snacks or crunchy foods, further emphasising the complexity of their meal preferences. - An SLP

Respondents also noted that the child may associate the gratification from audio-visual stimuli with the characteristics of the food. This may result in the child seeking only specific food types that affect balanced nutrition. This habit may persist even as children grow older.

Picky eating tendencies may emerge when children associate screens with comfort or familiarity, leading to a reluctance to deviate from preferred foods or routines. - An SLP

Paediatricians suggested that age-appropriate food consistencies are also affected by MTSE. Even at older ages, a child can still prefer food with a pureed consistency and exhibit inappropriate behaviours such as throwing tantrums when food of the desired consistency is not presented. This behaviour forces parents to relent to their children’s needs, disregarding the overall child’s development and physical health.

Discussion

This study centred on the effects of MTSE on children’s feeding practices and developmental outcomes, focusing on insights from paediatricians and SLPs, who play pivotal roles in managing paediatric feeding disorders. These professionals consistently highlighted MTSE as a detrimental practice, underlining its triggers, immediate consequences and broader implications on child development and family dynamics. The study highlights the complex relationship between screen dependency for feeding and its consequences, such as sensory deprivation and the breakdown of the caregiver–child bond. Figure 1 outlines the key themes related to MTSE and its impacts.

Figure 1. Mealtime screen exposure (MTSE): antecedents and consequences.

Professionals perceive that caregivers’ lack of awareness about the effects of MTSE and the culturally imposed burden on mothers during feeding practices are triggering factors that lead to the introduction of screens during mealtimes.¹⁴ Additionally, this research underscores the lack of awareness among parents and caregivers regarding the harmful effects of MTSE, resulting in increased screen usage during mealtimes.¹⁵ Caregivers choose to use screens as a convenient solution for managing mealtime chaos. They believe that screen time facilitates the child’s consumption of enough food without resistance to eating. The sociocultural pressure surrounding the overidentification of mothers as being responsible for feeding children is an important influencer of MTSE.¹⁶ Consequently, introducing MTSE leads to screen dependency and digital intrusion in mealtime interactions.^{17 18} Paediatricians and SLPs also emphasised the role of the extended family and not only the mothers in dealing with the MTSE issues. More participation in feeding the children by other family members, such as the father and grandparents, would provide much-needed support to the mother, deterring MTSE habits. Promoting mindful practices among family members can reduce MTSE’s adverse effects on children’s development and feeding behaviours. For example, screen-free family meals can enhance emotional dynamics, foster meaningful interactions and promote healthy eating. Research shows that reducing screen use during meals leads to deeper connections among family members, mitigating screen dependency and improving the overall mealtime experience.^{19 20}

Recurring MTSE sets a conditioned response for children, in which they associate screen exposure with mealtime. Professionals widely acknowledge that this can lead to increased adamic behaviour in children, such as insisting on screens to consume food. The most important concern of MTSE is picky eating behaviour in children. The observations also shed light on the negative impact of MTSE on food consumption choices, eating behaviours and overall developmental milestones, encompassing sensorimotor skills and cognitive development.^{20 21} Introducing MTSE reduces interest and loss of focus in eating among children. This lack of interest in food intake and portion size can lead to overeating or inadequate nutrient intake, which in turn contributes to obesity or malnutrition. Prolonged screen exposure impedes children’s ability to effectively communicate hunger or food preferences, making it more difficult to establish a balanced feeding environment.²²

Parental choice to use MTSE limits meaningful engagement and compromises the quality of interactions between the child and caregiver, which is essential for emotional and social development.^{23 24} The caregiver–child interaction is pivotal in transitioning from reflexive to responsive feeding behaviour. However, caregivers often fail to recognise the child’s feeding development and hunger cues, primarily focusing on quantity rather than quality. The interviews shed light on this issue, with professionals noting that parents resist changing food consistency, fearing that their child will resist the changes. Consequently, they continue to provide the same food in large quantities. Caregivers adhere to regular feeding schedules and may neglect the child’s ability to communicate hunger, an important developmental milestone that emerges from birth. For instance, as children grow and become more aware of their surroundings, they start associating specific foods with their hunger and learn to communicate these preferences. However, this crucial communication is affected by the MTSE.

Interviews with SLPs and paediatricians revealed that sensory deprivation is an adverse impact of MTSE. Screens, especially with advertising or selective content, can limit children’s food preferences and discourage them from trying new foods. This study’s findings are consistent with previous research that indicates screen time offers fewer enriching experiences than real-time experiences.²⁵ The professionals also noted that exposure to screens at an early age could cause atypical sensory processing, such as hypersensitivity, hyposensitivity or sensory seeking. This observation is supported by a cohort study that suggests early digital screen exposure, specifically before age 2, is linked to atypical sensory processing in children.²³

Paediatricians and SLPs hold different perspectives on the effects of excessive screen time on feeding practices. Paediatricians focus on nutritional deficiencies and physical development issues, while SLPs emphasise communication and feeding development. Both professionals are concerned about the lack of physical activity, responsive feeding and behavioural feeding disorders that can result from prolonged screen exposure in children. During the interview, important suggestions were made regarding family dynamics and the role of all caregivers in setting a positive example during mealtime. It is crucial to dispel misconceptions that screens contribute to children’s learning and behavioural regulation. Children often imitate adult behaviours, so prioritising screens over engagement inadvertently teaches them to do the same. Professionals strongly recommend highlighting the role of all caregivers in modelling positive mealtime behaviour to reduce dependence on screens.2426,28

Specifically, the study emphasises the significant role that paediatricians and SLPs play in integrating awareness of screen time into their assessments and treatments. More importantly, as the primary point of contact for introducing oral feeding in children, paediatricians can play a pivotal role in raising awareness among caregivers regarding the detrimental effects of MTSE. Additionally, they can advocate for natural alternatives to MTSE during the child’s developmental period. An inherent part of paediatric counselling should involve informing caregivers about the potential drawbacks of MTSE early on, particularly during oral feeding, to instil awareness and encourage healthier feeding practices from the beginning.

The study also emphasises the significance of collaboration among healthcare professionals, educators and policy-makers when addressing the complex issues related to MTSE and its effects on children’s health. An awareness campaign focused on reducing MTSE could be highly advantageous. This initiative may be effectively supported by parenting counsellors, gynaecologists and various support groups that educate caregivers about the importance of balanced screen use. Adopting an interdisciplinary approach that promotes positive mealtime practices and assists caregivers in nurturing healthy child development is essential for effectively addressing the challenges associated with MTSE.

The study examines the impact of MTSE on feeding practices and child development, focusing on its antecedents, influences, impact and related challenges, and broader implications for child well-being. The themes developed from the open codes provide a direction for further research and bolster the connections between factors influencing MTSE and its impact. Like most studies, this study also has limitations. For instance, the study focuses on paediatricians and SLPs operating from urban locations; therefore, it may not have captured the sociocultural dynamics concerning MTSE in rural locations. While the study identifies potential challenges of MTSE, they have not been validated using quantitative data. Large cohort studies need to be conducted to make meaningful policy decisions. However, this study could become a harbinger of new research.

Conclusion

Screen time is an inescapable aspect of modern family life, and its impact on young children’s overall development depends on how it is managed. This study highlights the critical need to raise awareness among caregivers about the negative effects of MTSE. It emphasises the importance of shared responsibility in following screen time guidelines, as suggested by Gupta et al.⁸ It is essential to thoughtfully navigate the digital realm, ensuring our children prosper in an age dominated by screens. This qualitative study builds connections among the factors influencing and impacting MTSE, which needs to be validated with quantitative/panel data studies. In conclusion, this research sheds light on the multifaceted impacts of MTSE and stresses the importance of a concerted effort to limit and mitigate its effects. Collaboration among healthcare professionals and caregivers is essential for addressing the impacts of MTSE. Enhancing caregiver awareness and promoting effective communication can create a healthier environment for children navigating the challenges of the digital landscape and ensure their well-being in today’s rapidly changing world.

Data availability statement

Data are available on reasonable request.