Digital screen exposure in infants, children and adolescents: a systematic review of existing recommendations

Abstract

Objectives

This review aimed to synthesise existing recommendations - issued by either United Nations agencies, scientific societies, governmental health authorities, non-profit organisations, or others - on digital screen exposure in infants, children, and adolescents.

Study design

Systematic review.

Methods

A wide search strategy was utilised - including digital databases (PubMed, EMBASE, Web of Science), Google, ChatGPT, reference lists from and grey literature —up to July 2024. Identified documents were categorized by type, issuing institutions, audience, publication year, and age groups. A synthesis of recommendations on screen time quantity was provided, comparing recommendations from the World Health Organization (WHO) with those from other institutions/bodies.

Results

Out of 85,425 records retrieved, 41 documents were identified. Of these, 23 were published by scientific societies, 13 by government/health authorities, two by the WHO, and three by non-profit organisations. In relation to digital screen quantity, most documents aligned: i) for children under 2 years, most documents recommended zero exposure (n = 20/22); ii) for children aged 2–5 years, the majority recommended limiting screen time to 1 h per day (n = 17/21); iii) for children over 5 years and adolescents, the most permissive guidelines suggested a maximum of 2 h per day (n = 8/10). Existing recommendations were either equally strict or more restrictive than WHO guidelines. In regard to the quality of digital screen exposure, 10 key points emerged, along with additional guidance for parents, schools, healthcare professionals, researchers, and industry.

Conclusions

There is consensus on the need to limit the quantity of digital screen time for infants, children and adolescents and to ensure good quality exposure. This alignment provides a strong basis for governments and other bodies to agree on local recommendations, as well as strategies to improve their implementation in practice.

1. Introduction

In recent years, the use of digital devices among children has markedly increased globally, and the time of first exposure is often anticipated in early infancy [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]]. This trend is confirmed by systematic reviews, large surveys, and other studies. A meta-analysis published in 2022, including 63 studies, found that only 25 % of children under 2 years of age and approximately 33 % of children aged 2 to 5 meet the American Academy of Paediatrics (AAP) screen time guidelines, recommending no screen time for children younger than 2 years and less than 1 h per day for children aged 2–5 years [1]. According to the latest Health Behaviours in School-aged Children (HBSC), which is the largest available report, conducted in a sample of 279,117 from 44 countries in Europe, Central Asia, and Canada [2], one in three adolescents maintains continuous online activities. Problematic social media use - defined as a pattern of use characterised by “addiction-like” symptoms - has risen from 7 % in 2018 to 11 % in 2022, with variation observed across different countries; additionally, 12 % were identified as being at risk of problematic gaming [2]. A systematic review including 41,871 children and young adults up to 25 years of age reported that the prevalence of problematic smartphone use - described as a behavioural addiction to smartphones - ranged from 10 % to 30 % in the population under study [13]. Another review confirmed that children as young as 7 years old engaged in some form of online gambling, which is associated with a higher risk of gambling-related harms later in life [14]. Smartphones have become the primary means of internet access, with most children being connected ‘anywhere, anytime’, with a near-constant use of these devices.

Previous reports have highlighted that the increase in the time that children spend online affects other activities. According to the EU Kids Online International Report [3], which reflects data from 25,101 children aged 9–16 collected between 2017 and 2019 19 European countries, the time children spend online has more than doubled compared to three years earlier, with up to 21 % of children spending less time with family, friends or doing schoolwork, because of the time spent online. Moreover, the same report showed that a variable proportion of children - from 7 % to 45 % across Europe - encountered online experiences that bothered or upset them, while 1 in 10 children reported never feeling safe online [3].

Other surveys indicated that student use of digital technology in classrooms and at home can be distracting, disrupting learning [15]. This includes the circulation of sexual messages [15] and pornography, including violent pornography (depicting coercive, degrading or pain-inducing sex acts), with UK surveys reporting that incidental exposure to pornography starts from early ages, such as 7–8 years, and 79 % of children encountered violent pornography – an exposure associated with aggressive/unsafe sex - before the age of 18 [16].

According to existing data, exposure to digital devices is most frequently initiated by parents. Surveys conducted in several different countries - such as the US, Australia, UK and EU countries [4,5,[7], [8], [9], [10], [11], [12],17] - show that parents generally resort to digital devices when children are at very early ages, for various reasons: educational purposes, entertainment, keeping their children occupied during household chores, calming, alleviating boredom, facilitating mealtime and sleeping. In a nationally representative survey in the US, by age 2 years, 40 % of children had their own tablet, increasing to 58 % by age 4 [4]. In a survey among 800 families in Italy, exposure to digital devices started with breastfeeding, and 26 % of parents allowed their children to use devices independently between 0 and 2 years, a percentage that rises to 62 % for the 3–5 years age group [10]. Additionally, 35 % of parents of children between 0 and 2 years delegated the task of entertaining their children to devices, for example by reading fairy tales, a percentage that reaches 80 % in the 3–5 age group [10]. Other national surveys conducted in the UK, US and Australia [5,11,12] confirm large use of digital devices from early childhood.

Several systematic reviews indicate that screen exposure can have detrimental effects on various aspects of a child's development and well-being [13,[18], [19], [20], [21], [22]]. A comprehensive review of over thirty systematic reviews and large-scale studies involving thousands of children and adolescents reported that screen time is linked to various negative health outcomes such as myopia, hearing loss, obesity, sleep disturbances, and musculoskeletal problems like back and neck pain [19]. Other systematic reviews reported a dose-dependent relationship between excessive screen use and mental health disorders, including attention-deficit/hyperactivity disorder (ADHD), language delay, and addictive behaviours such as problematic smartphone use, problematic social media use, and problematic online gaming [19] and problematic online gambling [14]. Other reviews pointed out that the observed impact of excessive screen time can become more evident in the long term [18,22]. In infants and children up to eight years, excessive screen time has been shown to negatively impact social interactions, cognitive and executive functions, and language development, disrupt playtime, and impair sleep quality, especially when not coupled with parental engagement [18,21]. In older children and adolescents, excessive screen exposure has been linked to worse educational performance and outcomes [15] and additional negative somatic outcomes, including, besides those previously mentioned, high blood pressure and metabolic disorders [18,22,23].

Education messages from parents, teachers or other caretakers seem to be lacking. According to the EU Kids Online International Report across 19 countries between 1 in 10 and one in four children below 15 years rarely received safety advice from parents, teachers, or friends [3]. Restrictive mediation by parents appears limited, with only a small proportion of children being prohibited from using webcams, downloading content, or accessing social networking sites [3]. In addition, in most countries, up to a third of children reported that their parents had published something about them online without seeking their consent [3]. In the school setting, digital screens are also increasingly used, while little data is available on the awareness of existing recommendations among teachers and school directors.

While numerous entities, including the World Health Organization (WHO), have proposed explicit recommendations on digital screen exposure in the paediatric age group [18,[24], [25], [26], [27], [28]], a systematic review and comparison across existing recommendations was lacking. This systematic review aimed to provide a synthesis of all relevant documents with explicit recommendations on digital screen exposure in infants, children, and adolescents. It has been specifically conducted to inform the new WHO/UNICEF Strategy on Child and Adolescent Health and Wellbeing in the European Region 2026–2030.

2. Methods

2.1. Study design

This systematic review was developed and reported according to PRISMA guidelines [29]. The PRISMA checklist is reported in Supplemental File S1. A protocol for the review was developed before starting the screening of the studies and is available upon request.

2.2. Search question

This review aimed at synthesising existing recommendations by any official bodies - United Nations (UN) agencies, scientific societies, government/health authorities, nonprofit organisations, or others -related to digital screen exposure in children and adolescents (0–19 years), including any device used either at home or at school.

2.3. Search strategy

The search strategy combined searches in digital databases, Google, and artificial intelligence (AI). Regarding digital databases, we searched PubMed, Embase, and Web of Science, covering the period from January 2014 to July 2024. To develop the search strategy, we first examined and compared the search strategies utilised in 18 systematic reviews related to the impact of screen time [18,[30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46]] and incorporated all relevant keywords along with additional specific terms relevant to our research question. In the second step, we refined the search strategy using Boolean operators and keywords from papers retrieved in the previous step. Third, we tested the search strategy to ensure it captured all relevant studies, including those resulting from previous reviews. For each database, the complete final search strategy is detailed in Supplemental File S2. The search was performed without language restrictions and was limited to studies involving human subjects. For two texts originally written in German and Chinese, translation, as well as back translation to further check translation accuracy - were performed using Google Translate. The remaining documents were sourced in their original English versions. All records were imported into the Rayyan software [47] and duplicates removed.

Four separate searches were performed in Google, using relevant keywords mentioned in the previous paragraph. Results were systematically reviewed up to and including page 10 (400 total results), as performed in other systematic reviews [48], and in line with existing recommendations for searching on Google [49]. When the search retrieved web pages that were re-directed to another web page (e.g., the webpage of a government, or another organization), we further searched all retrieved websites. The search in Google was performed in English, up to 25^th September 2024. Documents published on any date and in any language were considered for inclusion. Acknowledging that a search conducted in English could limit the type of documents retrieved in Google, we further explored with the WHO Regional Office for Europe the feasibility of a survey among governments of the 53 countries included in the WHO European Region. This option was considered more appropriate after the finalisation of this review, since the review could inform a survey among many countries.

We also used AI scholar mode from ChatGPT 4.0 (2024) and related, to search for supplementary documents [50]. Finally, the reference lists of all relevant documents from electronic medical databases and grey literature were manually reviewed.

2.4. Document selection and data extraction

Inclusion and exclusion criteria are reported in Table 1. The first 1000 records were screened in parallel by two co-authors (MC, SP). Complete alignment on records that met inclusion criteria was reached after the first 500 records; however, an additional 500 records were screened in parallel by two authors to further assess consistency. All remaining titles and abstracts were screened independently by the two co-authors (MC, SP) using Rayyan software. The full texts of all relevant abstracts were retrieved, and eligibility was further assessed by two co-authors (MC, SP); any discrepancy was solved in discussion with other team members (IM, ML). Regular weekly discussion sessions were held to ensure consistency in data selection across pairs of authors.

Table 1.

Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Population	Children and adolescents from 0 to 19 years old	Other populations (older than 19)
Exposure	Screen time	Documents/publications: 1.Not being explicit either on the recommended duration of screen time or on the quality of screen time; 2.Reporting only other types of recommendations (e.g. cybersecurity, physical activity); 3.Reporting the impact of policies, or reporting parental awareness of policies, is beyond the scope of this review; 4.Reporting adherence to existing policies, because this has been reported in another recent review [1]; 5.Reporting the impact of screen time on the health and well-being of children and adolescents, because this has been reported in another recent review (Cullen) [19]; In addition, we excluded: abstracts, posters, study protocols and commentaries.
Type of document/publication	Any document/publication by any official bodies - United Nations agencies, scientific societies, government health authorities, non-governmental organisations, nonprofit organisations, or others - reporting a recommendation, including: guidelines, statements, laws, policies, and others.
Language	Any	–
Countries	Any	–

Data extraction was conducted independently in parallel by two co-authors (VN, MC). A pre-defined data extraction form was developed, tested, and optimized before use. The list of information extracted for each document is reported in Supplemental File S3.

To ensure alignment in data extraction and tabulation, regular discussion sessions were held with a senior co-author (ML).

2.5. Data synthesis

We synthetised the studies’ characteristics in tables and graphs and summarised in the text the characteristics of the included documents using absolute frequencies. The retrieved recommendations were synthesised based on: i) the type of documents, issuing institutions, expected audience, setting, and publication year; ii) the geographic distribution of the issuing institutions categorized by WHO Regions; iii) age group (using the most widely used age categories adopted by the identified documents: children under 2 years; children aged 2–5 years; children older than 5 years up to 19 years (most documents did not further differentiated by children age in this group, or they used very heterogenous categories)). We also provided a comparative synthesis of existing WHO recommendations [27,28] when compared to other recommendations. We also synthesised in text and Table 1) recommendations on quality aspects of screen time exposure; and 2) specific recommendations to distinct audiences, i.e., parents/caretakers, schools, healthcare professionals, researchers, and industry.

3. Results

3.1. Results of the search strategy

The database searches yielded 85,425 records. After removing duplicates and title and abstract screening, 39 records were retained for eligibility assessment and full-text review, among which 16 documents were included. An additional 51 records were identified through Google searches (n = 35), citation searching (n = 10), and ChatGPT (n = 7), and following the eligibility assessment, 25 were included. Therefore, overall, 41 documents were included in this systematic review (Fig. 1). The list of included documents is provided in Supplemental File S4.

Fig. 1.

PRISMA study flow diagram.

Notes: ∗All records were excluded by humans and no automation tool was used.

3.2. Key characteristics of included recommendations

The included documents (Supplemental File S4) were published between 2011 and 2024 (Fig. 2). Concerning the publication type, the documents were identified by authors as follows: 19 guidelines; 10 recommendations; six statements (either position statements or consensus statements), and six other documents (one guidance, one critical review, one law, one policy brief, one technical report [51], and one standard) (see Fig. 2, Panel A).

Fig. 2.

Key characteristics of included recommendations, by year of publication.

Notes:

¹Fig. 2, Panel A:. Among the statements, we included two policy statements, two position statements, one consensus statement, and one additional statement. The “other types” category included all types of documents identified with a frequency of ≤2, namely: one advisory document, one critical literature review, one law, one policy brief, one report, and one standard (only 1 document identified for each type).

²Fig. 2, Panel B: The category “government authorities” included 11 documents published by government health authorities and two from other government bodies. One document was published by a scientific society (American Academy of Paediatrics), in collaboration with a professional organization (American Public Health Association) and the National Resource Center For Health and Safety In Child Care and Early Education [58].

³ Recommendations extracted from the official website of the Irish National Health Service and from the German website “Screen free until 3” did not provide the exact publication date, so they were not included in the figure.

Abbreviations: n. = absolute numbers; WHO= World Health Organization.

The recommendations on digital exposure were mostly given either as stand-alone recommendations (n = 26), of which few (n = 7) included also minor indications of physical activity or sleep-related habits, or in the context of recommendations primarily focused on physical activity (n = 12). The three exceptions were: a Taiwanese law [52], which broadly addresses children's rights and well-being; the National Sleep Foundation's recommendations [53], which focuses exclusively on screen exposure and sleep; the Australian “Evidence-based guidelines for wise use of electronic games by children”, which addresses e-games selectively [54].

Among the included documents, 23 were published by scientific societies, 13 by government/health authorities, two from the WHO, and three from non-profit organisations (Fig. 2, Panel B). When looking at this category over time, the first recommendations were issued by scientific societies, with the first being released in 2011 by the Canadian Society for Exercise Physiology (CSEP) [55]. The first retrieved recommendations from government authorities were issued in 2016 in the USA and Germany [56,57], with the number of recommendations from governments increasing over time.

The institutions releasing the document were geographically based in five different WHO Regions: 14 were based in WHO Americas Region (i.e. Canada, USA); 13 in WHO European Region (i.e. Denmark, France, Germany, Ireland, Italy, Switzerland, UK); 10 in WHO Western Asia Region (i.e. Australia, China, New Zealand, Singapore, Taiwan); three in WHO South-Est Asia Region (i.e. India); one in WHO African Region (i.e. South Africa). However, no document self-identified as specific to any country or audience. The expected audience broadly included caregivers, health professionals, schools, and industry.

Among the included documents, 18 were specifically oriented towards the home setting, 7 to the school setting, 12 to both home and school settings, and 4 did not make explicit a particular setting (Fig. 2, Panel C). When looking at this category over time, the recommendations targeting more than one setting seemed to increase over time (Fig. 2).

3.3. Recommendations on screen time duration by age group

For children in the 0–2 years age group, 22 documents were considered. Four documents were excluded because they included recommendations specific only to the educational setting for children 0–2 years, four were not specific to this age group, and 11 made recommendations on media content quality or recommended that “screen time should be limited” without further details on exposure quantity for this age group. Among the 22 included documents, nearly all (n = 20) recommended that children under 2 years of age should spend zero time on digital devices. The remaining two documents recommended less than 1 h per day in children under 2 years or a further division in age groups (zero screen time under 1 year, 1 h for those aged 1–2 years) (Fig. 3, A).

Fig. 3.

Recommendations on digital screen exposure duration, by age group

Notes:

¹Fig. 3, Panel B: 1 out of 3 documents in the “Recommended <30 min Per day” category recommended less than 30 min per day for children aged 3–6 years old.

²Fig. 3 Panel C: Half (5 out of 10) documents did not specify different recommendations by different age subgroups in between this large group of ages (5 and 19 years), while the remaining half of documents used different categories: i) one document recommends <1 h per day for children aged 6–11 years; ii) one document recommends <2 h per day for children aged 5–10 years, but did not specify a time for children aged 10–18 years; iii) one document recommended a maximum of 30–45 min per day for children aged 6–9 years, 45 min per day for children aged 9–12 years, and 1–2 h per day for adolescents aged 12–16 years; iv) one document recommended a maximum of 1 h per day for children aged 8–16 years; v) one document recommended a maximum of 30–45 min per day for children aged 6–10 years.

³ The presence of the WHO logo indicates in which category the WHO recommendations belong to (WHO recommends to keep exposure to minimum).

Abbreviations: h = hour per day; min. = minutes; WHO= World Health Organization; yo: years old.

For children aged 2–5 years, a total of 21 documents were retrieved, after excluding four documents specific to educational settings, four focused on other age groups, and 12 that did not specify a recommended screen time duration for this age group. Among the 21 included documents, most (n = 17) advised limiting screen time to 1 h per day. One recommended zero screen time, and three recommended a maximum of 30 min per day (Fig. 3, B).

For children over 5 years of age and/or adolescents, we identified 10 documents after excluding those not targeting this age group (n = 10), those that did not specify an actual screen time duration for children above 5 years (n = 17), and those specific to educational settings (n = 4). Among the 10 included documents, there was either no further specification by age subgroup, or large variability in the age groups considered, so this age group could not be further sub-grouped. However, for all documents, the recommendations on digital screen quantity were in the range of 30 min (for the most restrictive guidance) to 2 h (for the less restrictive guidance) (Fig. 3, panel C and the accompanying notes).

3.4. Comparison with the WHO recommendations

The WHO guidelines [27], recommended no screen time for children under 1 year of age, limited screen time to less than 1 h per day for children aged 1–5 years, and reduced screen time “at a minimum” for children over 5 years old and adolescents (in Fig. 3, the WHO recommendations are graphically identified by the WHO logo).

When compared to the WHO guidelines [27] most of the other recommendations were either stricter in terms of time exposure suggested or aligned. Specifically, in the first age group (Fig. 3, Panel A), 20 publications were more restrictive: 18 recommended no screen time for children under 2 years old, and two advised against screen time for children under 18 months. For children aged 2–5 years, 16 publications aligned with the WHO guidelines, while four were stricter. For children over 5 years and adolescents, while the WHO guidelines only recommended reducing screen time “at a minimum”, eight other publications provided more detailed guidance on time limits.

3.5. Recommendations on digital screen time quality

Among the 41 documents retrieved, 25 documents, besides providing a recommendation on screen time, also provided a recommendation on the quality of screen exposure. These recommendations were highly similar to one another. A narrative synthesis of these recommendations resulted in 10 key points, provided in Table 2. More detailed results are reported in Supplemental File S5.

Table 2.

Recommendations on digital screen time quality.

DO

1.Choose age-appropriate formats and pay attention to the content

2.Choose high-quality interactive programming allowing an active (and not passive) use of digital technology

3.Choose media content that promotes socially-positive values

4.Use media devices to support learning, only if the educational content is appropriate (or certified)

5.Prefer active e-games to sedentary e-games

6.After watching digital media content, take time to discuss with your child what you've seen together

DO NOT

7.Expose the child to digital media as “background noise”

8.Choose media content that contains advertisements

9.Choose media content that contains violence (e. g. physical or psychological)

10.Choose media content that contains sounds that further create dependence

3.6. Recommendations to specific audiences

Among the documents included, 35 reported recommendations for specific audiences, and specifically, 26 documents provided targeted recommendations for parents/caretakers, nine for teachers (among which four were entirely dedicated to the educational setting), seven for paediatricians, four for industry stakeholders, and three for researchers. A narrative synthesis of these recommendations, which to a large extent aligned across different documents, is provided in Table 3. More detailed results are reported in Supplemental File S5.

Table 3.

Recommendations on digital screen time, specific to the target audience.

	DO	DO NOT
Recommendations for parents/caretakers	•Be a model for the child, consciously setting limits to your own media use •Create a “family media plan” tool to establish limits for screen time exposure (both of quantity and quality) •Actively consider the many alternatives to screen media, such as: talking with your child, involving your child in what you do, doing physical activities indoors or outdoors, and enjoying nature •Preserve time free from screen use (up to set digital free days or activities) •Create screen-free zones in the house •Always supervise digital use, either by co-viewing with the child or using parental control •Plan time (at least 30 min) for games and conversation after using screen media •Be aware of digital addiction •Actively make digital devices less attractive: covering the TV helps reduce your child's awareness of it; the black and white mode on the smartphone makes it less attractive to your child •Stay updated with international recommendations, tips and tricks •Legally requiring parents to monitor their children (Taiwan) a	•Overuse digital devices in front of your child •Use smartphones or other digital devices during meals, and at any time you are talking/listening with your child •Use digital devices just to keep the child busy, or as pacifiers •Allow screen media and distracting noises to run in the background •Allow the child to penalise physical activity and sleep over screen time •Use screens in the child's bedroom •Let the child use digital screens when alone, particularly in the bedroom, to prevent social isolation •Leave mobile screen devices and the remote control where they can be reached by the child
For teachers/schools	•Be guided by developmentally appropriate teaching practices for the selection of classroom digital materials •Advise children and parents/caretakers about home media use •Cooperate with parents/caretakers to create a realistic and structured timetable, blending online and offline activities •Minimise homework on the digital screen •Encourage students to have at least 1 h outdoors every day •Favour social interaction and confrontation among students •Be aware of digital addiction •Stay updated with international recommendations	•Allow students to carry digital devices to school •Exceed the total maximum exposure to digital screen time of 60 min (for primary schools) and 120 min (secondary schools) •Underestimate the impact of excessive screen time, in particular when of poor quality, on the child's health, wellbeing and development
For healthcare professionals (including paediatricians)	•Start counselling parents/caretakers on screen time habits in the early phases •Help children and parents/caretakers understand the benefits and risks of digital exposure, focusing both on quantity and quality •Help parents/caretakers understand that through interaction and resonance by the parents, knowledge and feelings are conveyed to children, and this is disturbed by the distraction of digital media •Help parents/caretakers develop a “family media plan” tool to establish limits for screen time exposure (both of quantity and quality) •Promote a healthy lifestyle, by educating parents/caretakers, children and adolescents on the importance of physical activities, good sleep and social interactions •Early recognise signs of problematic screen use and digital addiction, in children and parents, and advise accordingly.	•Use the screen to constantly or routinely distract the child during the examination •Underestimate the impact of excessive screen time, in particular when of poor quality, on the child's health, wellbeing and development
For members of industry	•Provide clear information on the nature and content of digital programs, including gameplay •Develop appropriate interfaces for children •Develop digital content which is child-friendly and socially positive •Scientifically evaluate educational products, or avoid making educational claims •Collaborate with researchers to develop evidence-based products	•Use advertising and unhealthy messages
For researchers	•Further conduct research to help build evidence to understand what can constitute a “healthy use of digital technology”, including further researching to document the impact of digital screen exposure on child health, in the short and long term, and the impact of the use of different digital technologies in learning settings •Promote larger dissemination of research findings

^aThe “The Protection of Children and Youths Welfare and Rights Act” (Taiwan) legally requires parents to monitor their children to prevent them from “using electronic products for an unreasonable amount of time, causing harm to their physical and mental health.” [52].

Notably, some recommendations from governments were particularly strict on parental roles. For example, the “Protection of Children and Youths Welfare and Rights Act” enacted in Taiwan, legally requires parents to monitor their children to prevent them from “using electronic products for an unreasonable amount of time, causing harm to their physical and mental health.” [52].

Some entities proposed practical tools for supporting parents. For example, the American Academy of Pediatrics developed a tool to help families create a “family media plan” to set healthy screen time limits and promote balanced digital media use within the household [58,59]. The use of this tool is also endorsed by other scientific societies [60].

4. Discussion

This systematic review provides an up-to-date synthesis of recommendations on digital screen exposure for children aged 0–19 years. We retrieved 41 documents, mostly from scientific institutions and governments. Overall, existing recommendations are substantially aligned. Most documents recommend against screen time for infants under 2 years old, with recommendations to limit it to a maximum of 1 h per day for children aged 2 to 5, and to 2 h (according to the most permissive recommendations) for the older age group (up to 19 years). The alignment among existing recommendations, when combined with existing evidence that most children exceed recommended screen time [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13],17,23,26,30,35,36,39,43], clearly points to a significant gap between recommendations and practices and calls for action to increase intersectoral action on adherence to clear and consistent recommendations.

Low adherence to existing recommendations may be due to different factors, including gaps in evidence synthesis and dissemination, broad and rapid societal changes in behaviours, commercial pressure, and lack of explicit regulations. The “digital transformation” is relatively a new challenge, potentially including both positive and negative effects, affecting both the adults and children. As this is a rapidly evolving social phenomenon, existing evidence, including systematic reviews documenting the potential negative impact of excessive screen time exposure [13,14,[18], [19], [20],22,23,[30], [31], [32], [33], [34], [35], [36],[38], [39], [40],[42], [43], [44], [45],48] may still be largely unknown, unclear or confusing to many, as indicated by previous studies [10]. Similarly, existing recommendations, despite being released by many different bodies, as highlighted by this review, may have been poorly communicated, promoted and implemented, due to several different factors, including the recent COVID-19 pandemic, which led to increased digital screen exposure and encouragement of digital technology to facilitate learning and to provide access to health care advice [61]. All these aspects, together with the commercial interest in digital media, may explain the existence of different approaches among different institutions, including both technical and regulatory bodies. More efforts in evidence synthesis, as well as in evidence dissemination, are needed to further communicate this new knowledge to all relevant stakeholders to foster an intersectoral approach.

It's important to acknowledge that over-exposure to digital screens is not a phenomenon marginalised in the paediatric age, but also affects the adult population. In 2024, the global average of screen time in adults aged 25–54 years was about 6–7 h per day [53]. Clearly, even for adults, the quality of screen time can vary a lot. As emphasised in many documents in this review, adults-including parents/caretakers, teachers and health professionals - need to be more aware of their role as models of behaviour, and setting limits both for them as adults, and for the younger generations. The Family Media Plan suggested by several Scientific Societies [59,60] can be a practical tool supporting adults to set health habits with respect to digital devices.

In terms of specific regulations, this review identified 13 recommendations by government/health authorities, showing that actions are being taken at the political/regulatory level. To be effective, regulatory action needs to be monitored and the industry held to account. Government plans should provide clarity, not only on screen time, but on how they will safeguard children from online harms through engagement with the digital sector on regulation. To track action across countries, Chung and Lee (2022) [66] propose a public health model aimed at monitoring excessive and addictive use of the internet and digital media, built on the WHO's Global Information System on Alcohol and Health (GISAH) [67], including a list of specific indicators, designed to monitor the policies adopted across different countries (e.g., surveillance and monitoring systems, sales and revenue, written policies, and prevention services).

We acknowledge as limitations of this review that the number of recommendations by government/health authorities may be largely underestimated (and how well they have been implemented), due to language barriers. In the future, other methods such as a consultation or a survey among countries, may be utilised to better estimate how many countries currently have adopted a recommendation on digital screen time exposure in the paediatric age, in response to concerns about children and adolescents' mental health, and their safety in the digital environment. Regulations also rapidly change over time. For example, during the last months of writing this review, two other relevant regulations were released. The Australian government implemented a ban requiring social media providers to take appropriate measures to prevent children below the minimum age of 16 from creating their own accounts [62]. At the same time, the European Commission has initiated proceedings to determine if TikTok violated the Digital Services Act (DSA) regarding minors' protection, advertising transparency, data access, and managing risks associated with addictive features and harmful content [63]. Meanwhile, Instagram has created special accounts for teenagers to protect their online safety [64].

This review, by highlighting recommendations specific to different stakeholders - including parents/caretakers, teachers, healthcare professionals, industry, and researchers-emphasises the need for a comprehensive intersectoral policy and practice approach to regulating digital screen exposure among children, adolescents, and adults. This aligns with a recent Digital Environment Fact Sheet developed by the WHO European Regional Office [65] which outlines successful governance policies for the digital era, centred on two key aspects. Firstly, these policies must prioritise the protection of children and adolescents as they engage with digital media. This can be achieved through regulatory frameworks that ensure the availability of age-appropriate content and reduce harmful marketing practices by the industry. Secondly, it is essential to increase awareness among the whole population of a healthy balance between their digital and offline lives. The WHO European Regional Office, advises countries to “introduce screen time policies in line with WHO guidelines on sedentary behaviour” [65]. This review highlights that recommendations published by other institutions align closely with, or are even more restrictive than, those by WHO [27,28], reflecting a broad consensus among scientific and governmental institutions, and providing a solid foundation for UN agencies, governments and other bodies to come together and agree on one set of recommendations, as well as strategies to increase their implementation. Clear recommendations underpinned by strong regulation, is needed to protect children.

The next crucial step is for policymakers and researchers to focus on implementing practical, measurable actions to effectively adhered to screen time recommendations. Combined intersectoral approaches that focus on increasing knowledge of existing guidance, strengthening regulatory frameworks, promoting healthy lifestyles, creating positive models and alternatives, and actively engaging children, parents/caretakers, educators, healthcare professionals, and the industry may be needed to achieve a change in current trends.

5. Conclusions

Children and adolescents are increasingly exposed to digital screens from a very early age, and previous systematic reviews show that this can lead to negative consequences for their development and well-being. This review highlights that the majority of recommendations by international and national agencies are substantially aligned on the maximum screen time, in terms of quantity and quality. This consensus together, with the evidence on non-adherence to screen time guidelines and the associated detrimental effects, calls for urgent action to strengthen the implementation of consistent screen time recommendations. Furthermore, the progressive inclusion of tailored guidance for different target groups – such as parents, educators, healthcare professionals, and policymakers – emphasises the need for an intersectoral approach in which all stakeholders collaborate to effectively translate these recommendations into practices.

What this study adds

• •This systematic review represents the first comprehensive synthesis of existing recommendations regarding digital screen exposure in children and adolescents.
• •The review highlights that a large number of recommendations (n = 41) are substantially aligned on the maximum screen exposure recommended in terms of quantity. Many documents (n = 25) also reported indications on the quality of screen time, and specific recommendations for parents/other caretakers, teachers, healthcare professionals, and members of industry, underscoring the need for a comprehensive intersectoral approach.

Implications for policy and practice

• •The alignment among existing recommendations on digital screen time, together with the evidence on nonadherence to scree time guidelines and the associated detrimental effects, calls for urgent action to strengthen the implementation of consistent screen time recommendations at different levels, including at school, and among parents.
• •National plans should include clear recommendations on digital screen exposure, aimed at safeguarding the health of infants, children and adolescents. Combined approaches that focus on increasing knowledge of existing recommendations, promoting a healthy digital lifestyle, creating positive models and alternatives, strengthening regulatory frameworks (and monitoring them), and actively engaging parents/carers, educators, healthcare professionals, and the industry are needed to protect children.

Ethical approval

Not applicable to this study, being this study a review of existing recommendations.

Availability of data

Data are available upon reasonable request to the corresponding author.

Disclaimer

The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Author statements

ML conceptualised the review and provided overall supervision of this review. MC and SP designed the initial search strategy, with significant contributions from IM and ML. MC and SP conducted the study screening for eligibility, while MC and VN performed data extraction. MC synthesised the extracted data, with substantial input from IM and ML. VN and MC drafted the first version of this review, with major inputs from ML. All authors reviewed and approved the final version for publication.

Fundings

This work was supported by the Italian Ministry of Health, through the contribution given to the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste - Italy.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article: