Myopia and screen time in children: epidemic proportions

Myopia has emerged as a critical public health issue in recent years, with compelling evidence demonstrating an alarming increase in its occurrence among the younger population [1]. This epidemic is particularly pronounced in Southeast Asian countries, where myopia rates have skyrocketed to unprecedented levels of 80%–90% among children who finish high school [1, 2]. This dramatic surge not only poses immediate challenges for vision care but also raises serious concerns about long-term ocular health and economic impacts [3]. The rapid spread of myopia in these regions serves as a stark warning, highlighting the urgent need for global attention and intervention to address this growing public health threat. The persistent upward trend in myopia includes Europe, where a study showed that 47.2% of 20-year-olds have myopia, against only 13.9% in the 1960s [2]. A part of that increase regards severe myopia, a spherical equivalent of −6 or more, which is a clinically relevant problem. High myopia is associated with an increased risk of ocular complications and irreversible visual impairment [2].

This increase in the occurrence of myopia definitely relates to lifestyle changes, in particular the use of hand-held devices, the underlying genetic factors being rather stable. Major behavioral risk factors include the high frequency of continuous near work activities, in particular of hand-held smart devices, and reduced outdoor exposure during childhood. In contrast, most studies show a significant effect of outdoor exposure against myopia when children are exposed for at least 2 hours a day [4]. For example, a population-based Taiwanese program promoting 2 hours of outdoor activities per weekday for kindergarten children was shown to lead to a decline in myopia prevalence among preschoolers from 15.5% in 2014 to 8.4% in 2016. Policy measures are therefore needed and may help to contain the myopia epidemic, including prevention by lifestyle modifications and early detection, and mitigation of progression using corrective lenses.

International guidelines on screen time focus on the consequences for the mental and socio-emotional health of children, with limited attention for the impact related to optimal physical development, like reducing myopia. Their current focus mostly pertains to the balancing of screen time with other activities such as physical activity, social interaction, and adequate sleep to promote optimal child development and health. Of these, the WHO guidelines recommend the following rule, 0-1-2 [2]:

0: Until the age of 2, no screen time for infants (<1 year) and or 1-year-olds.

1: No more than 1 hour for 2-year-olds, with less time preferred. No more than 1 hour of screen time per day for 3–4-year-olds, either.

2: Limit sedentary screen time to 2 hours for children aged 5 and above.

The American Academy of Pediatrics supports this 0-1-2-rule and has developed the Family Media Use Plan for children older than 5.

Worldwide, various countries try to implement age-specific strategies and guidelines on screen use based on state-of-the-art research. However, approaches vary due to a lack of consensus on criteria. Should a guideline be focused on near-screen usage or screens in general, or on social media, and should the cultural context be taken into consideration, in rule and estimates of impact? Countries like Australia and Sweden follow the WHO guidelines and have added regulations on mobile phones being banned until a certain age, for example, Australia until the age of 16 years at school and for use of social media and France planning to ban mobile phones until the age of 15 years. In short, the issue is acknowledged as a problem, but policy approaches vary considerably.

One may wonder whether we need uniform rules across all countries given the variation in contexts, but in any case, we need to strive for the most effective approach of this major public health issue. Knowledge on the impact of screen time on youth health has increased, and similarly has awareness on this subject. The above considerations indicate that the WHO guideline should be reconsidered. Picking the best of the WHO, and the current Dutch and German approaches, we propose (i) an extension into older ages building on the 3-6-9-12 rule, (ii) incorporating a daily outdoor time of 2 hours into screen time guidelines, (iii) for every 20 minutes of screen time, children should look away for 20 seconds [2, 5], see Fig. 1. The latter could well be integrated into device algorithms. These issues definitely deserve further action at the European level, given the epidemic nature of the issue.

Figure 1.

Picking the best of WHO, German and Dutch rules to guide screentime in children.

In a further European approach, the first step should be to address the measures to be taken by healthcare professionals, targeting parents and youth. A second step could be to introduce guidelines on smartphone use and education on social media at schools, as youth spend most of their daily time at school. Finally, we would recommend (inter)national policy measures on the age-specific initiation of smartphone use and use of social media in general. Ideally, these two steps could be taken in parallel, and should be monitored.

Digital technology is here to stay but the impact on the health of future generations is a subject of concern. We think this requires urgent public health action, in the direction as suggested, to contain the myopia epidemic.

Conflict of interest: None declared.

Funding

None declared.

Data availability

All the data included in our study are from published studies.