Mobile Phones and Health Effects in Children - Epidemiology

Mobile phones and health effects in children epidemiology
Maria Feychting Institute of Environmental Medicine Karolinska Institutet Sweden
Few epidemiological studies on children and adolescents

Well-being, cognition, behavioural problems
A few cross-sectional studies Several cohort studies Three cohort studies on maternal exposure
Cancer
RF-exposure from transmitters and cancer risk (one on base-stations, a few on radio and TV transmitters) Mobile phone use and cancer risk two international studies ongoing, CEFALO and Mobi-Kids
Maria Feychting
18 maj 2011
Well-being, symptoms, depression etc.

Methodological considerations RF-exposure or life-style?
Need to distinguish between potential effects of radiofrequency exposure and a behavior or life-style associated with mobile phone use reversed causality
Psychosocial aspects of mobile phone use, e.g.

demands on availability perceived stressfulness of accessibility being awakened at night
These are confounding factors in a study of RF exposure

Maria Feychting 18 maj 2011 3
Cross-sectional studies
Limitations inherited in the cross-sectional study design
Cannot determine temporality did exposure precede outcome (disease)? Risk of reversed causality outcome (disease) affects exposure
Cannot be used to draw conclusions about cause and effect
Maria Feychting
18 maj 2011
Other limitations
Risk of recall bias prevalent disease affects selfreported exposure
Amount of mobile phone use Distance to base station
Disease is also self-reported Selection bias may be a problem

Concerned persons more likely to participate and more likely to have located the nearest base station and probably more likely to report symptoms or lower wellbeing
Maria Feychting
18 maj 2011
German study (Thomas et al. 2008) showed that 3% among participating adolescents answered dont know on question about distance to base station, compared to 17% among non-participants
German study (Thomas et al. 2008) showed that among participating adolescents in personal measurement study, 12% were concerned about mobile phones, compared to 8% among nonparticipants
Maria Feychting
18 maj 2011
Well-being, symptoms, depression Cross-sectional studies, self-reported

Various health outcomes more common among children and adolescents self-reporting frequent mobile phone and DECT phone use
Sderqvist F, et al. 2008, Heinrich et al. 2011, 2011, e.g. concentration problems, stress, tiredness, sleeping problems, irritation, asthma, hay fever, etc. Generally higher effects in Swedish studies residual confounding? German studies controlled for environmental worries Recall bias and selection bias a problem and confounding!
Other studies have a different aim:

Behaviors associated with mobile phone use increase health problems (tiredness, depression, sleep problems)
Thome et al. 2011, Punamki et al. 2007
Well-being, symptoms, depression Cross-sectional studies, measured exposure

Heinrich et al. 2011, 2011: 1498 children (8-12 years) and 1524 adolescents (13-17 years) participated in an interview and measurement (52% of invited) Exposure assessment using personal dosimetry 24 h Cross-sectional design two types of outcomes:
Chronic well-being measured symptoms over the last 6 months: headache, irritation, nervousness, dizziness, fatigue, fear and sleeping problems Acute symptoms symptoms reported in a diary; exposure in the morning was related to symptoms at noon, exposure in afternoon to symptoms in the evening
No consistent effects found with measured RF exposure

Well-being, symptoms, depression Cohort studies

Thome et al. 2011: psychosocial aspects of mobile phone use and mental health symptoms
High frequency of mobile phone use at baseline was a risk factor for mental health outcomes at 1-year follow-up
Fewer and lower effects than in cross-sectional analyses The risk for reporting mental health symptoms at follow-up was associated with other aspects of mobile phone use e.g. being constantly accessible
Bulck et al. 2007: Calling and text messages very common during nighttime
High frequency of mobile phone use and SMS associated with tiredness
Maria Feychting
18 maj 2011
Cognitive function cross-sectional MoRPhEUS, Australia

Abramson MJ, et al. 2009: Mobile telephone use is associated with changes in cognitive function in young adolescents
Poorer accuracy, faster reaction time, associative learning response time shorter Same results for calls as for SMS unlikely to be RF
Maria Feychting
18 maj 2011
10
Confounding
The exposure of interest: Radiofrequency fields i.e. not other aspects of mobile phone use that may cause changes in the outcome
e.g. cognitive function trained by frequent sending of text messages . these cognitive changes were unlikely due to radiofrequency (RF) exposure.Overall, mobile phone use was associated with faster and less accurate responding to higher level cognitive tasks. These behaviours may have been learned through frequent use of a mobile phone.
Abramson MJ, et al. Mobile telephone use is associated with changes in cognitive function in young adolescents. Bioelectromagnetics 2009;30:678-86.
MoRPhEUS, cohort analysis Mobile phone use and cognitive function

Thomas et al, 2010, one-year follow-up of 236 7th grade students
Cognitive function tests distributed at baseline and follow-up
Measured response times and accuracy
Students with more calls and SMS at baseline showed less reductions in response times at follow-up Students with increased number of calls and SMS showed more reduction in response times at follow-up
Increased number of calls and SMS was mainly among students with low use at baseline
Changes over time may relate to statistical regression to the mean and not be the effect of mobile phone exposure
Behavioral problems cross-sectional

Self-reported mobile phone use at age 7 increased risk of behavioral problems in Danish children
Divan, et al. 2008, 2011
Measured environmental RF increased risk of behavioral problems in children (conduct problems) and adolescents (conduct problems, hyperactivity)
Thomas, et al. 2010
Maria Feychting
18 maj 2011
13
Potential for reversed causality behavioral problems

Behavioral problems may be associated with a lifestyle
Likely to increase own mobile phone use Likely to increase time spent in environments where mobile phone use is more common, e.g. cafs, clubs, public transportation higher environmental exposure Truancy more common more time to spend on the phone
May lead to false positive results the outcome may increase exposure Difficult to determine when the condition started
Reversed causality potential problem also in cohort and case-control studies with insufficient latency period
Maternal exposure during pregnancy

Effects on behavioral problems at age 7, in two publications on Danish cohort study
Divan et el. 2010, Divan et al. 2011 Retrospective self-reported assessment of mobile phone use
Both publications report increased risk

Highest risk with both prenatal and postnatal phone use combined OR=1.5 (95% CI 1.4-1.7) Strong hereditary component, over 80% heritability mothers who were early mobile phone users possibly different Extensive confounding control Lower risks in more recent birth cohorts residual confounding?
Example of confounding Maternal smoking during pregnancy

Lambe et al., 2006: Maternal smoking during pregnancy and school performance at age 15:
Increased risk of poor school performance related to maternal smoking, with dose-response However, if mother smoked in her first pregnancy but not in her second, the sibling was also at increased risk
Cnattingius et al., 2011: Maternal smoking during pregnancy and suicidal acts in young offspring
Increased risk of suicidal acts related to maternal smoking, with dose-response With sibling controls discordant for the outcome no association was found with maternal smoking during pregnancy
Maternal exposure during pregnancy and child development

Divan et al. 2011, in press, cohort study of 41,000 Danish children
No effect on developmental milestones at age 6 and 18 months
Vrijheid et al. 2010, cohort study of 530 Spanish children

Little evidence of adverse effects on neurobehavioral development at age 14 months
Maria Feychting
18 maj 2011
17
Transmitters and cancer risk

Studies with individually predicted RF field strength from radio- and TV towers have not found increased risk of childhood leukemia
(reviewed in Schuz J, Ahlbom A. Rad Prot Dosim, 2008)
UK case-control study of exposure from mobile phone base stations during pregnancy and childhood cancer
Distance from nearest base station Total power output Modelled power density
No associations were found for any cancer type

Elliot et al. 2010
Mobile phone use and childhood brain tumour risk

Two ongoing international case-control studies: CEFALO MOBI-KIDS
Maria Feychting
18 maj 2011
19
CEFALO - An international case-control study on brain

tumours in children and adolescents and mobile phone use
Denmark, Norway, Sweden, Switzerland

All cases of brain tumours in children aged 7-19 are identified during a 4 year period
Close collaboration with paediatric oncology and neurosurgery clinics Regular search in population based Cancer registries Study period: April/May 2004 to 2008
2 controls per case selected randomly from the general population

Data collection
Personal interviews with child and parent(s) Exposure information:
Detailed questions about mobile phone use: frequency, duration, laterality and type (voice or messaging), handsfree, and use of cordless phones Questions about other potential risk factors Information from registries (mobile phone operators, medical birth registries)
Collection of saliva samples

Stored at Karolinska Biobank, Stockholm
Maria Feychting
18 maj 2011
21
CEFALO
In total, >400 cases of brain tumours and >900 population based controls are eligible for inclusion Participation rates are high, >80% among cases and >70% among controls Analyses have been finalized, manuscript submitted
Maria Feychting
18 maj 2011
22
Brain tumour incidence in Sweden 1970-2008

Age 10-24 years, per 100 000, age standardized
6
4 Men Women
Source: Swedish Cancer Registry National Board of Health and Welfare

18 maj 2011 23
Maria Feychting
19 70 19 72 19 74 19 76 19 78 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08
Research strategies
Prospectively collected exposure information
To avoid recall bias
Sufficient latency periods to avoid reversed causality Cross-sectional observational studies not recommended
Large, well-designed, well-controlled human experimental studies probably more informative for acute effects Cohort studies with prospective data for long-term effects
For behavioral outcomes frequent follow-up needed
Monitor brain tumour incidence time trends

Information from high quality cancer registers, international collaborations to minimize random fluctuations

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Mobile phones and health effects in children epidemiology

Maria Feychting Institute of Environmental Medicine Karolinska Institutet Sweden

Few epidemiological studies on children and adolescents

Well-being, symptoms, depression etc.

Psychosocial aspects of mobile phone use, e.g.

These are confounding factors in a study of RF exposure

Cannot be used to draw conclusions about cause and effect

Disease is also self-reported Selection bias may be a problem

Well-being, symptoms, depression Cross-sectional studies, self-reported

Other studies have a different aim:

Well-being, symptoms, depression Cross-sectional studies, measured exposure

No consistent effects found with measured RF exposure

Well-being, symptoms, depression Cohort studies

Cognitive function cross-sectional MoRPhEUS, Australia

MoRPhEUS, cohort analysis Mobile phone use and cognitive function

Behavioral problems cross-sectional

Potential for reversed causality behavioral problems

Maternal exposure during pregnancy

Both publications report increased risk

Example of confounding Maternal smoking during pregnancy

Maternal exposure during pregnancy and child development

Vrijheid et al. 2010, cohort study of 530 Spanish children

Transmitters and cancer risk

No associations were found for any cancer type

Mobile phone use and childhood brain tumour risk

CEFALO - An international case-control study on brain

Denmark, Norway, Sweden, Switzerland

2 controls per case selected randomly from the general population

Collection of saliva samples

Brain tumour incidence in Sweden 1970-2008

Source: Swedish Cancer Registry National Board of Health and Welfare

Monitor brain tumour incidence time trends

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