Dose–Response Associations Between Screen-Based Digital Media Use and Anxiety in Children and Adolescents: A Systematic Review and Three-Level Meta-Analysis

Screen-based digital media use is widespread in childhood and adolescence, but its association with anxiety and dose–response relationship remain uncertain. We systematically reviewed observational studies of participants aged 6–19 years reporting time- or frequency-based screen exposure and anxiety-specific outcomes. PubMed/MEDLINE, Web of Science Core Collection, Scopus, and CNKI were searched through September 2026. Study quality was assessed using the AHRQ checklist or Newcastle–Ottawa Scale. Eligible estimates were synthesized using three-level random-effects meta-analysis and restricted cubic splines. Fifty-seven reports were retained. The primary adjusted dataset included 79 odds-ratio effects from 17 independent studies (pooled OR 1.40, 95% CI 1.26–1.54; I2 = 51.7%). Screen type significantly moderated the association after Holm correction. The dose–response analysis included seven independent studies; the linear component was significant (p = 0.039), whereas nonlinearity was not supported (p = 0.132; wild-cluster p = 0.163). Evidence was predominantly observational and cross-sectional, and dose–response data were limited. Greater screen exposure was associated with higher odds of anxiety, supporting a graded pattern without a discrete threshold. Because the evidence was predominantly observational and cross-sectional, this exposure–response gradient should be interpreted as an association rather than evidence that greater screen use causes anxiety; reverse and reciprocal pathways remain possible. This review was not registered and was funded by two Jiangsu Provincial Education Science Planning projects.