Growing up in the ‘60s, I watched a LOT of television with friends and family. We were riveted by shows like “That Girl,” “Rat Patrol” and “Dark Shadows” and we spent countless hours lolling on the living room floor in front of the TV. My Mom used to refer to it as the “Boob Tube” and she was constantly yelling at us to “go outside and play.” Well, as usual, it seems like my Mom was on to something. Today’s electronic babysitter of choice is the iPhone and iPad. But the audience has changed a bit—it’s not just teens and tweens glued to the screens but toddlers and babies, some less than a year-old.

According to new guidelines recently issued by the World Health Organization (WHO), children under five years old must spend less time sitting watching screens, or restrained in prams and seats, get better quality sleep and have more time for active play if they are to grow up healthy. (See the sidebar below for the WHO guidelines at a glance.)

Specifically, for infants less than one year and one-year olds, the WHO recommended no sedentary screen time on electronic devices, such as watching TV and playing computer games. For children three- to four-years of age, sedentary screen time should be no more than one hour. In general, less screen time is better, according to the WHO.

We all know how addictive our devices are, but what are the implications for our eyes, especially for young children whose brains and eyes are still developing?

According to the National Eye Institute, since the 2000s myopia has been accelerating. While genetics play a part in myopia, another contributing factor is eye fatigue caused by increased use of digital devices. Some studies have also pointed to “a lack of developmental cues furnished by natural sunlight or time spent focusing on objects in the distance,” according to Think About Your Eyes.

All of these facts are a great way for ECPs to start the conversation with their patients about the dangers of phones and tablets for young children. The fascination with electronic devices, for adults as well as children, sometimes borders on addiction. We here at VMail Weekend thought it might be helpful for ECPs to get an inside perspective on how these devices are affecting children and what steps can be taken by parents to control children’s screen time so they can grow up healthy and happy. So we reached out to these three experts to get their take on this very complicated subject.


Dr. Nathan Bonilla-Warford
Pediatric Optometrist
Bright Eyes Family Vision Care
New Tampa and Westchase, Florida

I discuss children's screen use every single day in the exam room. Parents feel a great deal of anxiety about screens because on one hand schools, friends and children themselves are encouraging more device use and on the other hand, parents worry that they will harm their children or be judged harshly by family and friends if their kids use devices. It is a very complicated issue that has very few clear-cut answers. Often parents, look to professionals such as pediatricians and optometrists to give direction to their children about screen use.

First, I acknowledge that rigid rule absolutes, such as zero screen time, are not very realistic in our culture today. I talk about the fact that it is not important exactly how many minutes of screen time a child gets, but how they use screens and what else they are missing out on when screen time becomes excessive.

I tell parents that it is less about total screen time, but more about how long the sessions are and how active the children are. Two hours of TV time broken down into 20-minute sections throughout the day is better than one sedentary hour on a phone. I will advise parents that the smaller the screen, the more demanding it is visually.

Unstructured outdoor play is best, but in Florida it gets hot and you worry about UV protection. Large screens like TVs with interactive, movement-based games are the next best thing. Then desktop monitors, followed by laptops, and finally tablets. Phones and smaller devices are the most worrisome because the screens are so small—children will literally hold them a few inches from their eyes and posture is often hunched over with little movement.

Unfortunately, we do not understand all of the effects screen time may be having on our children. Certainly, anything that reduces movement and physical exercise can contribute to obesity and long-term health problems such as diabetes. Exposure to blue light can have a negative effect on circadian rhythm and late night screen use can reduce sleep time.

Specifically, with vision, increases in myopia have been related to indoor time and most screens are used indoors. Some patients can develop accommodative or vergence dysfunction from prolonged use of screen time resulting in headaches, as well as blurry or double vision. In some cases, vision therapy may be needed to resolve these problems.

We are in the middle of a giant worldwide experiment. I feel like parents are much more aware of screen usage than a few years ago, but they still don't feel well-equipped to manage screen use in the house. And (I am guilty here, too), many parents are not always the best role models for their kids, which makes the issue even more complicated.

The single most important thing is that parents participate in screen time (as much as possible) with their kids so they know what their kids are watching and doing and can interact. For example, we have a rule in our house that kids cannot watch YouTube without an adult. It lets us know how much YouTube they are watching, what they are interested in, and if the content is appropriate. As parents, we can control when to turn it off and take them outside.

Finally, the younger the child, the more play and movement should be emphasized by parents over screens.


Dwight Akerman, OD, MBA, FAAO
Chief Medical Editor
Review of Myopia Management

Children under five must spend less time sitting watching screens, or restrained in strollers and seats, get better quality sleep and have more time for active play if they are to grow up healthy, according to new guidelines issued by the World Health Organization (WHO).1

The overall goals of these guidelines are to provide recommendations on the amount of time in a 24-hour day that young children, under 5 years of age, should spend being physically active or sleeping for their health and wellbeing, and the maximum recommended time these children should spend on screen-based sedentary activities or time restrained.

The primary audiences for these guidelines are policymakers in ministries of health, education and /or social welfare, persons working in NGOs and early childhood development services, and those providing advice and guidance to caregivers, such as optometrists, nurses, GPs, pediatricians, and occupational therapists.
Currently, over 23 percent of adults and 80 percent of adolescents are not sufficiently physically active. If healthy physical activity, sedentary behavior, and sleep habits are established early in life, this helps shape habits throughout childhood, adolescence and into adulthood.

The pattern of overall 24-hour activity is key: replacing prolonged restrained or sedentary screen time with more active play, while making sure young children get enough good-quality sleep. Quality sedentary time spent in interactive non-screen-based activities with a caregiver, such as reading, storytelling, singing, and puzzles, is crucial for child development.

Applying the recommendations in the WHO guidelines during the first five years of life will contribute to children’s motor and cognitive development, lifelong health, and may reduce the incidence of myopia in children.

Managing a Child’s LIfestyle
​

Myopia is becoming increasingly prevalent in the U.S. and globally. Managing a child’s lifestyle and visual habits is essential because:
  • Increasing myopia can lead to serious eye health problems later in life such as myopic macular degeneration, glaucoma, cataracts, and retinal detachment.2
  • As children’s eyes grow and myopia increases, their dependency on spectacles increases.
  • In younger children, myopia progresses more quickly because their eyes are growing at a faster rate, resulting in higher levels of myopia and increased eye pathology risks later in life.
  • Higher levels of myopia and dependency on spectacles can reduce the ability of children to participate in sports and other activities.
Advising Parents and Caregivers

Optometrists should advise parents and caregivers of children to:
  • Apply the WHO guidelines for children under 5 years of age.
  • Ensure that children over the age of five spend more time outdoors and less time on digital devices. Recommend outdoor sport and play of at least 2 hours per day in total, spread between outdoor school activity and after school.
  • Take breaks every 20 minutes by looking across the room for 20 seconds when using a computer or reading.
  • Children should not spend more than three hours a day—in addition to school time—on close work such as reading, homework or screen-time.
  • Monitor eyesight and eye health in children with yearly complete eye exams.
To learn more about myopia, go to Review of Myopia Management at https://reviewofmm.com/, a leading source of clinical, practice management, market and research info on myopia for ECPs.

References
1World Health Organization. (2019). Guidelines on physical activity, sedentary behavior and sleep for children under 5 years of age.
2 Holden, B. A., Fricke, T. R., Wilson, D. A., Jong, M., Naidoo, K. S., Sankaridurg, P., ... & Resnikoff, S. (2016). Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology, 123(5), 1036-1042.



Dr. Gary Gerber
Chief Dream Officer
The Power Practice
Founder of Treehouse Eyes

Parents come to Treehouse Eyes on a daily basis talking about screen time and wanting us to essentially tell their kids to limit their use. Our sole focus at Treehouse Eyes is childhood myopia, and the jury is still out as to whether excessive screen time directly correlates to increasing myopia. We tell the parents that while it’s not conclusive that excess use is bad (speaking strictly about myopia, not the other known issues), there are enough other reasons to limit time and only use devices when doing meaningful work.

One of the big challenges in teasing out if myopia is on the rise because of screen time is separating out the other potentially confounding factors—like acknowledging that the screens are being used indoors and are being used at a short distance. So, if screen time contributes to myopia, is it the excess accommodative demand or lack of outdoor light? At the moment, no one knows for sure, but there’s enough evidence to suggest that regardless of ocular consequences, kids benefit by spending more time outside.


Read More About It


A Dark Consensus About Screens and Kids Begins to Emerge in Silicone Valley
The people who are closest to a thing are often the most wary of it. Technologists know how phones really work, and many have decided they don’t want their own children anywhere near them. A wariness that has been slowly brewing is turning into a regionwide consensus: The benefits of screens as a learning tool are overblown, and the risks for addiction and stunting development seem high. The debate in Silicon Valley now is about how much exposure to phones is O.K.

To Grow Up Healthy, Children Need to Sit Less, Play More and Limit Screen Time
“What we really need to do is bring back play for children,” said Dr. Juana Willumsen, World Health Organization focal point for childhood obesity and physical activity. “This is about making the shift from sedentary time to playtime, while protecting sleep."

Is ‘Digital Addiction’ a Real Threat to Kids
As we worriedly watch our children navigate the ever-changing digital landscape, there’s a great deal of talk these days about “digital addiction.” But several experts say we should teach kids to think of screens as something to handle in moderation, like food, rather than something without any healthy place in our lives, like meth or heroin.


Age-Appropriate Screen Time Limitations for Toddlers and Pre-Schoolers
When a child reaches the toddler stage, things can get a little tricky when it comes to limiting screen time access. If you haven’t noticed yet, you’re about to learn that your digital device is one of a toddler’s favorite toys, if not her absolute favorite. As always, it’s important to stay in control as a parent. At this point, you can now start to pick and choose ways to introduce a toddler to the different functions of your digital device, but it’s best not to give her free reign.

The Problem With ‘Sharenting’
Fears about troubling videos and excessive screen time are legitimate. But the real threat is adults’ disregard for their children’s rights and best interests. The hard (for many adults to hear) truth is that many of technology’s effects on kids have less to do with screen time per se than they do with the decisions grown-ups are making—many of which place children’s privacy at great risk.

Computer Vision Syndrome
Computer Vision Syndrome, also referred to as Digital Eye Strain, describes a group of eye and vision-related problems that result from prolonged computer, tablet, e-reader and cell phone use. Many individuals experience eye discomfort and vision problems when viewing digital screens for extended periods. The level of discomfort appears to increase with the amount of digital screen use.


World Health Oganization Recommendations at a Glance
​
Infants (less than 1 year) should:
  • Be physically active several times a day in a variety of ways, particularly through interactive floor-based play; more is better. For those not yet mobile, this includes at least 30 minutes in a prone position (tummy time) spread throughout the day while awake.
  • Not be restrained for more than 1 hour at a time (e.g., prams/strollers, highchairs, or strapped on a caregiver’s back). Screen time is not recommended. When sedentary, engaging in reading and storytelling with a caregiver is encouraged.
  • Have 14–17 hours (0–3 months of age) or 12–16 hours (4–11 months of age) of good quality sleep, including naps.
Children 1-2 years of age should:
  • Spend at least 180 minutes in a variety of types of physical activities at any intensity, including moderate-to-vigorous-intensity physical activity, spread throughout the day; more is better.
  • Not be restrained for more than 1 hour at a time (e.g., prams/strollers, highchairs, or strapped on a caregiver’s back) or sit for extended periods of time. For 1-year-olds, sedentary screen time (such as watching TV or videos, playing computer games) is not recommended. For those aged 2 years, sedentary screen time should be no more than 1 hour; less is better. When sedentary, engaging in reading and storytelling with a caregiver is encouraged.
  • Have 11-14 hours of good quality sleep, including naps, with regular sleep and wake-up times.
Children 3-4 years of age should:
  • Spend at least 180 minutes in a variety of types of physical activities at any intensity, of which at least 60 minutes is moderate to vigorous intensity physical activity, spread throughout the day; more is better.
  • Not be restrained for more than 1 hour at a time (e.g., prams/strollers) or sit for extended periods of time. Sedentary screen time should be no more than 1 hour; less is better. When sedentary, engaging in reading and storytelling with a caregiver is encouraged.
  • Have 10–13 hours of good quality sleep, which may include a nap, with regular sleep and wake-up times.