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Journal of Child Health and Pediatric CareVolume 4, Issue 4October–December 2026

Original ResearchOpen access

Early Childhood Screen Time and Expressive Language Development at 24 Months in Kuala Lumpur, Malaysia: A Prospective Cohort Study

Nurul Ain Rosli, MBBS, MPaeds1, Jia Wen Tan, MSc2, Kavitha Ramasamy, MBBS, MMed1, Ahmad Faiz Zulkifli, PhD3, Mei Chin Leong, MBBS, MRCPCH, PhD1,3*

  1. 1Department of Pediatrics, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
  2. 2Speech Sciences Program, Center for Rehabilitation and Special Needs Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
  3. 3Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia

* Corresponding author: Mei Chin Leong, mc.leong@um.example

Received
Revised
Accepted
Published
DOI
10.5555/jchpc.2026.0404.01
Article number
JCHPC-0404-01
License
CC BY 4.0
Cite this article
Article contents
  1. Abstract
  2. 1. Introduction
  3. 2. Materials and Methods
  4. 3. Results
  5. 4. Discussion
  6. 5. Conclusion
  7. Declarations
  8. References
  9. How to cite

Abstract

BackgroundScreen use begins early in infancy in many urban settings, but prospective evidence linking toddler screen time to language development in Southeast Asia is limited.

MethodsWe recruited 642 children at their 12-month well-child visit in six government health clinics in Kuala Lumpur and followed them to 24 months. Screen time was measured with 3-day caregiver time-use diaries at 12 and 18 months. Expressive vocabulary at 24 months was assessed with validated Malay, Mandarin and Tamil adaptations of the MacArthur–Bates Communicative Development Inventories, and late talking was defined as fewer than 50 words or no word combinations. Associations were estimated with modified Poisson and linear regression adjusted for child, family and home language factors.

ResultsA total of 568 children (88.5%) completed the 24-month assessment. Median screen time at 18 months was 1.6 hours per day (IQR 0.8–2.7), and 208 children (36.6%) used screens for 2 hours or more daily. Late talking occurred in 25.0% of children with 2 hours or more of daily screen time compared with 9.8% of those with less than 1 hour (adjusted risk ratio 2.18, 95% CI 1.29–3.67). Each additional hour per day was associated with a 17-word smaller vocabulary (95% CI 10–24). The association was weaker when caregivers usually co-viewed (p for interaction = 0.038).

ConclusionsHigher screen time at 18 months was associated with poorer expressive language at 24 months. Anticipatory guidance during well-child visits should address both the amount of screen use and caregiver engagement during viewing.

1.Introduction

The first 2 years of life are a period of rapid language acquisition, driven largely by the quantity and quality of interaction between children and their caregivers. The World Health Organization recommends no sedentary screen time for children younger than 2 years and no more than 1 hour per day for 2-year-olds [1]. In practice, a large proportion of toddlers worldwide exceed these limits, and exposure has risen sharply with the spread of smartphones and short-form video platforms [2]. In Malaysia, surveys of urban families suggest that many children are introduced to screens before their first birthday, often to calm or feed them [3].

Early expressive language delay matters clinically because it predicts later difficulties with literacy, behavior and school readiness [4]. Screen exposure may affect language by displacing caregiver–child conversation, through background television that reduces the quality of parental speech, and through caregiver device use that interrupts interaction [5]. Much of the evidence, however, comes from cross-sectional studies in high-income Western countries that cannot address reverse causation, and few studies have accounted for multilingual home environments [6].

We therefore examined the prospective association between screen time at 18 months and expressive language at 24 months in a multiethnic cohort in Kuala Lumpur, and explored whether caregiver co-viewing modified this association.

2.Materials and Methods

2.1Study design and setting

This prospective cohort study recruited children attending their 12-month well-child visit at six government health clinics in Kuala Lumpur between March 2024 and February 2025. These clinics provide free child health surveillance and immunization and serve families across a wide range of income levels and ethnic groups.

2.2Participants

Children were eligible if they were born at 35 weeks' gestation or later, had no known hearing impairment, neurodevelopmental disorder or major congenital anomaly, and had a caregiver able to complete questionnaires in Malay, English, Mandarin or Tamil. Of 731 eligible children approached, 642 were enrolled. Follow-up assessments took place at 18 and 24 months, with telephone reminders and flexible scheduling to reduce attrition.

2.3Exposure and outcome measures

Primary caregivers completed a 3-day time-use diary covering two weekdays and one weekend day at 12 and 18 months, recording the child's screen use in 15-minute intervals by device and content, whether an adult co-viewed, and the duration of background television. Such diaries agree closely with passive device sensing in toddlers [7]. Co-viewing was classified as usual when an adult was present for at least half of the child's recorded screen time. Expressive language at 24 months was assessed with validated Malay, Mandarin and Tamil adaptations of the MacArthur–Bates Communicative Development Inventories (CDI) Words and Sentences form, completed by the caregiver with a trained research assistant [8]. Conceptual vocabulary was scored for children exposed to more than one language. Late talking was defined as an expressive vocabulary of fewer than 50 words or no two-word combinations [9].

2.4Statistical analysis

Screen time at 18 months was categorized as less than 1 hour, 1 to less than 2 hours, and 2 hours or more per day, and was also analyzed continuously. Risk ratios for late talking were estimated with modified Poisson regression, and differences in vocabulary size with linear regression. Models were adjusted for child sex, birth order, ethnicity, maternal education, household income group, multilingual home, childcare attendance, shared book reading and screen time at 12 months. Effect modification by co-viewing was tested with an interaction term. Missing covariate data (less than 4%) were handled by multiple imputation, and inverse probability weighting for loss to follow-up was applied in a sensitivity analysis.

3.Results

Of the 642 enrolled children, 568 (88.5%) completed the 24-month assessment. Those lost to follow-up were more often from lower-income households but had similar screen time at 12 months. Median daily screen time rose from 0.9 hours at 12 months to 1.6 hours (IQR 0.8–2.7) at 18 months, when 208 children (36.6%) used screens for 2 hours or more each day. Smartphones accounted for most screen time, and short-form videos and animated nursery rhymes were the most common content. Children with higher screen time were more likely to come from B40 households, had mothers with less education, were read to less often and had more background television exposure (Table 1).

Table 1. Characteristics of the cohort by daily screen time at 18 months (n = 568)
Characteristic<1 h/day (n = 174)1–<2 h/day (n = 186)≥2 h/day (n = 208)p-value
Male sex86 (49.4)97 (52.2)112 (53.8)0.69
Malay ethnicity102 (58.6)113 (60.8)131 (63.0)0.68
Maternal tertiary education118 (67.8)109 (58.6)96 (46.2)<0.001
Household income in B40 group49 (28.2)67 (36.0)94 (45.2)0.003
Multilingual home71 (40.8)80 (43.0)87 (41.8)0.91
Shared book reading ≥3 days/week112 (64.4)98 (52.7)79 (38.0)<0.001
Attends childcare center63 (36.2)58 (31.2)52 (25.0)0.06
Background television ≥3 h/day21 (12.1)48 (25.8)97 (46.6)<0.001

Values are n (%). B40 refers to households in the bottom 40% of the national income distribution. p-values are from chi-square tests.

At 24 months, 97 children (17.1%) met criteria for late talking. The proportion rose with screen time at 18 months, from 9.8% among children with less than 1 hour per day to 25.0% among those with 2 hours or more (Table 2). After adjustment, children with 2 hours or more of daily screen time had more than twice the risk of late talking and produced 52 fewer words on average than those with less than 1 hour. Each additional hour of daily screen time was associated with a 17-word smaller vocabulary.

Table 2. Association between screen time at 18 months and expressive language at 24 months
Screen time at 18 monthsLate talkers, n (%)Adjusted RR (95% CI)Vocabulary, mean ± SDAdjusted difference, words (95% CI)
<1 h/day (n = 174)17 (9.8)1.00 (reference)214 ± 1180 (reference)
1–<2 h/day (n = 186)28 (15.1)1.42 (0.80–2.52)183 ± 112−22 (−46 to 2)
≥2 h/day (n = 208)52 (25.0)2.18 (1.29–3.67)146 ± 109−52 (−76 to −28)
Per additional hour per day—1.24 (1.10–1.40)—−17 (−24 to −10)

RR, risk ratio; CI, confidence interval; SD, standard deviation. Vocabulary is the number of words produced on the CDI. Models are adjusted for the covariates listed in the statistical analysis. A dash indicates not applicable.

Co-viewing modified the association (p for interaction = 0.038). Among children with 2 hours or more of daily screen time, late talking occurred in 35 of 112 (31.3%) who mostly viewed alone and in 17 of 96 (17.7%) who usually viewed with a caregiver (Figure 1). Results were similar after inverse probability weighting for loss to follow-up and after excluding children who attended childcare.

Figure 1. Proportion of late talkers at 24 months by daily screen time at 18 months, stratified by usual caregiver co-viewing. Error bars show 95% confidence intervals.

4.Discussion

In this multiethnic urban cohort, more than a third of toddlers used screens for 2 hours or more daily at 18 months, and higher screen time was associated with a greater risk of late talking and smaller expressive vocabularies at 24 months. The association followed a dose–response pattern, persisted after adjustment for socioeconomic and home language factors, and was independent of screen time at 12 months, which makes it less likely to reflect early developmental differences alone.

The weaker association among children who usually co-viewed is consistent with evidence that joint media engagement, in which adults label, question and expand on content, can partly offset lost conversational interaction [10]. Background television, common among children with high screen time, has been linked to fewer words spoken by parents and may contribute to the association [11]. Conceptual vocabulary scoring was important in a multilingual city such as Kuala Lumpur, where single-language measures can underestimate bilingual children's vocabulary and inflate apparent delay [12]. Our findings support brief counseling on screen use at routine well-child visits, an approach that has shown promise in Malaysian primary care [13].

4.1Limitations

Screen time was reported by caregivers, and social desirability may have led to underreporting, although diaries are less prone to this bias than global estimates. The CDI is a parent-report measure and was not supplemented by direct assessment. Residual confounding by unmeasured aspects of caregiver interaction is likely, and because the cohort was drawn from government clinics in one city, the results may not apply to rural or private-sector populations.

5.Conclusion

Higher screen time at 18 months was associated with poorer expressive language at 24 months in urban Malaysian toddlers, and the association was weaker when caregivers co-viewed. Anticipatory guidance during well-child visits should encourage families to limit screen use before age 2 years and, when screens are used, to watch and talk together.

Declarations

Ethics approval
The study was approved by the Medical Research Ethics Committee of Universiti Malaya Medical Centre (protocol 2023112-13156) and registered with the National Medical Research Register of the Ministry of Health Malaysia (NMRR ID-23-02817-KPL).
Consent to participate
Written informed consent was obtained from a parent or legal guardian of every participating child.
Funding
This study was funded by the Fundamental Research Grant Scheme of the Ministry of Higher Education Malaysia (grant FRGS/1/2023/SKK06/UM/02/7). The funder had no role in the design, conduct or reporting of the study.
Conflict of interest
The authors declare no competing interests.
Data availability
De-identified data are available from the corresponding author on reasonable request, subject to approval by the ethics committee.
Author contributions
MCL conceived the study and obtained funding. NAR, KR and MCL designed the protocol. NAR and JWT coordinated recruitment and assessments, and JWT trained assessors in CDI administration. AFZ led the statistical analysis with NAR. NAR drafted the manuscript, and all authors critically revised it and approved the final version.
Acknowledgments
We thank the families who took part, and the nurses and medical officers of the participating health clinics.

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Copyright and license

© 2026 The Author(s). Published by Scholix Publishers. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original authors and source are credited.

How to cite this article

Rosli, N. A., Tan, J. W., Ramasamy, K., Zulkifli, A. F., & Leong, M. C. (2026). Early Childhood Screen Time and Expressive Language Development at 24 Months in Kuala Lumpur, Malaysia: A Prospective Cohort Study. Journal of Child Health and Pediatric Care, 4(4), Article JCHPC-0404-01. https://doi.org/10.5555/jchpc.2026.0404.01

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