DIGITAL FATIGUE IN CHILDREN: A LITERATURE REVIEW ON THE IMPACT OF INCREASING DIGITAL LOAD (LITERATURE REVIEW)

SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 60 DIGITAL FATIGUE IN CHILDREN: A LITERATURE REVIEW ON THE IMPACT OF INCREASING DIGITAL LOAD (LITERATURE REVIEW) D.R. Abdullaeva Tashkent State Medical University https://doi.org/10.5281/zenodo.18041907 Abstract. In the context of the rapid increase in digital load on children, especially after the transition to distance learning during the COVID-19 pandemic, the prevalence of digital asthenopic syndrome (digital eye strain, DES) has increased significantly. The aim of this review article is to systematize recent scientific data (2022–2024) on the prevalence, etiopathogenesis, clinical manifestations, risk factors, and prevention of DES in children. The analysis is based on six relevant review publications selected from the PubMed and PMC databases, including systematic and narrative reviews. According to research findings, the prevalence of DES in children ranges from 20% to 60%, with key symptoms including eye dryness, burning, headaches, visual fatigue, and blurred vision. The main pathophysiological mechanisms include accommodative strain, reduced blinking frequency, and tear film instability. Risk factors include prolonged use of digital devices (more than 3 hours per day), poor posture, improper lighting, lack of breaks, sleep disturbances, and reduced time spent outdoors. DES may also be associated with other visual impairments myopia, accommodative dysfunctions, and dry eye syndrome. Prevention should include adherence to visual hygiene, implementation of the 20-20-20 rule, optimization of screen-use conditions, regular ophthalmological examinations, and educational initiatives for parents and educators. The findings highlight the importance of a comprehensive approach to reducing the burden of digital visual fatigue in children and the need for further research using objective assessment methods. Keywords: digital asthenopic syndrome; children; visual fatigue; screen exposure; prevention. Introduction In recent years, there has been a sharp increase in the use of digital devices among children and adolescents, which intensified further against the background of the transition to remote learning during the COVID-19 pandemic. According to various international studies, the daily screen time of children has significantly exceeded recommended limits and has reached 4–7 hours or more, including both educational and entertainment activities. Such a load is accompanied by an increase in complaints of eye fatigue, burning sensations, dryness, decreased concentration, headaches, and other symptoms combined under the concept of digital asthenopic syndrome (Digital Eye Strain -DES), a condition that arises as a result of prolonged and uncomfortable visual stress during screen use. Unlike adults, these symptoms in children may be less consciously perceived and more often ignored, increasing the risk of chronic visual discomfort and subsequent functional vision disorders. Despite the growing prevalence of DES among the younger population, modern scientific literature shows significant fragmentation of data on this topic, especially within the pediatric population. The absence of unified diagnostic criteria, the predominance of subjective assessment SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 61 methods (questionnaires, self-reported screen time), and the limited number of high-quality systematic reviews and meta-analyses make it difficult to formulate clear clinical and preventive recommendations. This review aims to provide a comprehensive analysis of modern review and systematic publications (2022–2024) on DES in children, with the goal of identifying key epidemiological, clinical, and etiological aspects of the problem, evaluating the quality of the existing evidence base, and summarizing current prevention strategies and interventions. Literature Review Methodology For preparing this review, a targeted selection of scientific publications on digital asthenopic syndrome in children was conducted, with a focus on the most recent and integrative sources. Inclusion criteria were limited to review and systematic articles published between 2022 and 2024, with emphasis on works in which the pediatric population was either the main subject or one of the designated subgroups. The search strategy was restricted to two authoritative databases - PubMed and PubMed Central using keywords and combinations such as digital eye strain, computer vision syndrome, children, pediatrics, systematic review, screen time, and others. As a result of preliminary selection, six review publications meeting the specified criteria were identified: among them, two are systematic reviews, one is a systematic review with elements of a meta-analysis, and the remaining three are narrative reviews reflecting the current state of knowledge on the topic. All included works were evaluated based on the completeness of methodological descriptions, transparency of selection criteria, clarity of result presentation, and identification of potential sources of methodological bias. Epidemiology of Digital Asthenopic Syndrome in Children Analysis of the included review publications [2,4,7] shows that the prevalence of digital asthenopic syndrome symptoms among children varies widely ranging from 20–25% to 50–60%, depending on age, the nature of digital exposure, and study methodology. The highest rates were reported in studies conducted during or immediately after the COVID-19 pandemic, when the proportion of schoolchildren spending more than 4-6 hours per day on screens sharply increased. Reviews [11,18] emphasize that increased screen time is a key determinant of DES: children who used digital devices for more than 3 hours per day reported symptoms of digital eye strain 1.5–2.3 times more frequently compared with those with moderate digital activity. The most common symptoms mentioned in the reviewed publications are eye dryness, reading fatigue, a foreign-body (“sand”) sensation, blurred vision, and headaches. These findings are consistent with data from adult users but tend to appear more prominently in children during prolonged uninterrupted screen use. Clear geographic and age-related differences in DES prevalence are evident. In Asian countries, according to systematic reviews, DES rates among children and adolescents are consistently higher, which is attributed to greater academic load, earlier access to digital devices, and a high prevalence of myopia—an independent risk factor for visual strain. In European and North American studies, prevalence rates are somewhat lower but also show an upward trend after 2020. Age-related patterns indicate that younger school-age children more often report discomfort related to accommodation and eye dryness, while adolescents tend to experience mixed symptoms, including both visual and cognitive fatigue. In preand post-pandemic dynamics, all included reviews highlight a significant surge in DES incidence; some authors describe this as a “shadow pandemic” accompanying the widespread transition to online learning. In the post-pandemic period, children’s digital load remains elevated, sustaining the high prevalence of DES and making the problem persistent and ongoing [1,3,6]. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 62 Etiology and Pathophysiology of Digital Asthenopic Syndrome in Children The etiopathogenesis of digital asthenopic syndrome (DES) in children, according to the analyzed reviews, represents a complex interaction of visual, neurological, and behavioral factors, which is exacerbated by prolonged and continuous use of screen devices. The key biomechanical mechanism is accommodative strain sustained near-focus under intense visual load causes ciliary muscle spasm, which can lead to transient or even persistent accommodation dysfunction. Children of younger school age are particularly vulnerable, as their visual system is still in a stage of functional development. Reviews highlight that accommodative dysfunction is more frequent when using smartphones and tablets, where the distance to the eyes is minimal and the text is small, requiring constant refocusing [8,12,15]. Another significant mechanism, confirmed in both adult and pediatric studies, is reduced blinking frequency during screen use. Normally, children blink about 15–20 times per minute, but during visual fixation on a screen, this can drop to 5–7 blinks, leading to tear film instability, increased tear evaporation, and the development of dry eye symptoms. The combination of dryness and accommodative strain underlies most complaints in DES, especially in children prone to allergic or inflammatory changes of the ocular surface. Visual overload is further exacerbated by lack of regular breaks, poor posture, and an improper viewing angle—all of which increase the load on periocular muscles and lead to headaches, a sensation of eye heaviness, and reduced visual endurance [9,13,19]. In addition to physiological factors, the included reviews emphasize the role of psychoemotional components in the manifestation of digital eye strain symptoms. Children experiencing high academic pressure, social isolation, sleep disturbances, or anxiety disorders more frequently report subjective DES complaints. In such cases, visual fatigue may result not only from biomechanical dysfunction but also as an expression of overall psycho-emotional stress. This consideration is important for differential diagnosis, especially in adolescents, where complaints of visual discomfort may be linked to a broader spectrum of psychosomatic conditions [10,11,17]. The reviews also pay particular attention to the role of screen light and brightness. Modern devices, especially smartphones, have high brightness and emit blue light, which, according to studies, can negatively affect circadian rhythms, sleep quality, and eye susceptibility to fatigue. LED backlighting of screens contributes to visual stress, particularly in dark environments or under excessive contrast. Children using screens under poor ambient lighting are at higher risk for DES, as dilated pupils allow more light to reach the retina, intensifying eye irritation. Improperly adjusted screen brightness and prolonged exposure to blue light can also reduce focusing ability and exacerbate visual fatigue [10,21,23]. Clinical Manifestations of Digital Asthenopic Syndrome in Children The symptomatology of digital asthenopic syndrome (DES) in children is diverse and largely depends on the duration and type of digital device use (see Table 1). Studies and reviews most consistently report the following types of symptoms in children with DES. Table 1. Burning sensation in the eyes Eye fatigue Questionnaire data Accommodative spasm Feeling of “sand” or a foreign body Difficulty reading Survey methodology Reduced amplitude of accommodation SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 63 Dryness Reduced concentration Questionnaire data Convergence instability Tearing Binocular vision disorders Redness Conjunctival changes Headaches in the frontal or temporal region Blink rate abnormalities Burning sensation in the eyes Accommodative spasm Blurred vision Myopia or astigmatism In some studies, the clinical presentation of DES in children differs from that in adults not only in the spectrum of symptoms but also in how they are perceived. Younger children often cannot accurately describe their sensations, which makes the diagnosis more dependent on indirect signs such as decreased interest in screen activities, rubbing of the eyes, frequent blinking, avoidance of visual tasks, and complaints of fatigue [1,4,7,22,24]. While adults more often report localized pain and can accurately assess symptom severity, children express their condition through behavioral changes, decreased academic performance, and irritability. Moreover, children may not realize that the symptoms they experience are related to screen use, which complicates timely identification of the syndrome [4,9,14]. It is important to note that in children, symptoms often appear more quickly than in adults, especially when using smartphones, due to the closer viewing distance, higher screen brightness, and constant focus. Children also tend to adhere less to visual hygiene: they take fewer breaks, often use devices while lying down, and frequently work in poor lighting or dark environments. All of these factors contribute to faster development of visual discomfort and may lead to chronic symptoms if no corrective or preventive measures are taken. Risk Factors for Digital Asthenopic Syndrome in Children According to the included review publications, the most significant risk factor for DES in children is the duration of daily digital device use. Almost all analyzed reviews emphasize that the risk of developing visual discomfort increases substantially when digital device use exceeds 2–3 hours per day, and with usage above 4-6 hours per day, symptom prevalence reaches 50–70%. Children engaged in prolonged remote learning, combining educational and recreational screen time, are particularly vulnerable. Lack of breaks, insufficient awareness of visual hygiene among parents and teachers, and the absence of clear regulations on device use in schools exacerbate this problem [10,15,20]. The type of device used also plays an important role. According to a systematic review by Mataftsi et al. (2023) [16], smartphones and tablets produce more pronounced symptoms than computers or laptops. This is because when using a smartphone, the child holds the device closer to the eyes, the screen is smaller requiring constant accommodation, and it has brighter LED backlighting. Tablets, though larger, are often used in awkward positions, which also affects visual and postural strain. Computers and stationary monitors are generally placed at a greater distance from the eyes, reducing accommodative load; however, prolonged use without breaks can still cause DES. The physical environment in which a child uses a digital device is also critical. Poor posture leaning forward, lying down, or sitting without back support increases strain on periocular and neck muscles. Lighting is another important factor: working in dim or high-contrast lighting increases visual stress, causes pupil dilation, and leads to discomfort. Insufficient ambient light SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 64 also increases the risk of myopia. Moreover, the absence of regular breaks significantly raises the risk of DES, especially during continuous sessions lasting more than 30–40 minutes [2,6,16]. Alongside visual and postural factors, reviews highlight behavioral and daily habits that exacerbate the severity of symptoms. Sleep disruption is a common consequence of evening gadget use, especially in the absence of “night mode” or blue light filters. The blue light emitted by screens suppresses melatonin production, impairs sleep onset, and reduces sleep quality, which in turn lowers overall resistance to visual and cognitive fatigue. In addition, reduced time spent outdoors, particularly for children in urban settings, is associated not only with increased risk of myopia but also with decreased overall visual tone. Studies show that children who spend less than 1 hour per day outdoors report more frequent visual complaints, including DES symptoms. These observations highlight the need for a comprehensive prevention approach, which includes not only limiting digital device use but also modifying the child’s daily routine [3,9,13]. Relationship of Digital Asthenopic Syndrome with Other Visual Disorders in Children. Analysis of contemporary review studies shows that DES in children is not only an independent clinical problem but can also be a predictor or comorbid factor in the development of other visual disorders, primarily myopia. Increased screen time, particularly with near-focus tasks and limited outdoor exposure, is associated with accelerated myopia progression. The review by Demirayak B. (2022) [11] emphasizes a statistically significant link between high digital load and the risk of myopia in children and adolescents. While DES and myopia are distinct conditions, both are aggravated by prolonged gadget use and may coexist, creating a “synergistic” effect on vision deterioration. Furthermore, the presence of DES symptoms in children with pre-existing myopia may indicate additional accommodative overload and the need to adjust visual activity schedules. There is also overlap between DES and functional vision disorders, such as accommodative spasm, convergence weakness, and latent forms of strabismus, which may become clinically significant under high visual load. Studies by Kaur K., Gurnani B., and Nayak S. (2022) describe that children with chronic DES often exhibit binocular interaction disorders and reduced accommodation amplitude. Such functional disturbances may go undiagnosed during routine school eye exams but manifest as fatigue, decreased concentration, or complaints about “jumping” text. Children aged 6–10 years are particularly sensitive, as this is a period of active development of binocular functions and visual coordination [14]. Digital visual fatigue also impacts overall ophthalmic health. Reduced blinking frequency and tear film instability, characteristic of DES, can provoke or exacerbate dry eye syndrome even in children, especially those with concomitant allergic or inflammatory eye conditions. Moreover, prolonged visual strain can lead to chronic extraocular muscle spasm and compensatory headaches, increasing overall somatic stress. Recurrent DES episodes can reduce visual endurance, limit learning efficiency, and negatively affect the child’s psycho-emotional well-being, particularly in environments with high academic demands [4,8,15]. Finally, it should be noted that the presence of pronounced DES can mask other ophthalmic disorders such as hypermetropia, astigmatism, or latent amblyopia especially if the child does not have previously established optical correction. In studies by Pucker A.D., Kerr A.M., Sanderson J., and Lievens (2024), it is noted that prolonged use of digital devices without adequate optical correction significantly increases the risk of developing DES. In this context, the syndrome can be considered a “marker” of hidden visual dysfunction, signaling the need for an ophthalmological examination. Thus, DES in children has not only independent clinical significance but is also SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 12 DECEMBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 65 closely associated with a number of other visual disorders, necessitating a systemic approach to diagnosis and prevention [20]. Prevention and Interventions for Digital Asthenopic Syndrome in Children The review articles [4,11] included in this analysis emphasize that DES prevention in children should be comprehensive and multi-level, as it involves not only modification of visual load but also the development of sustainable behavioral habits. The most universal and evidencebased recommendation is the “20-20-20 rule”: every 20 minutes of screen work, the child should take a 20-second break and look at an object at least 6 meters away. This helps reduce accommodative strain and gives the eyes a rest. It is also recommended to monitor blinking frequency reminding children to blink while working with screens, especially when signs of dryness or irritation appear. Proper screen settings are important: brightness should match ambient lighting, and contrast should be comfortable for reading. Using blue light filters, particularly in the evening, helps reduce negative effects on circadian rhythms and improves sleep quality. Visual hygiene practices for children are highlighted in current recommendations. Included reviews emphasize that regular breaks, alternating between screen and offline activities, maintaining proper posture, and keeping an appropriate distance from the screen at least 30–40 cm for tablets and 50–60 cm for monitors are basic measures to reduce DES risk. Adequate room lighting is essential: it should be diffuse, without glare or harsh contrasts. Whenever possible, natural lighting should be used, especially during study activities. Children should avoid using devices in dark rooms and refrain from using smartphones while lying down or with a tilted head, as this not only increases visual strain but may also lead to postural problems. An optimal routine includes short offline breaks with physical activity, which relieve both the visual and muscular systems [5,7,12]. Educational Programs and Awareness Educational programs aimed at parents, teachers, and children themselves play a significant role in prevention. Studies by Bhattacharya S., Heidler P., Saleem S.M., Marzo R.R. (2022) and Demirayak B., Yılmaz Tugan B., Toprak M., Çinik R. (2022) emphasize that many parents are unaware of the risks associated with excessive screen time, particularly during remote learning, often considering it a “necessary evil.” Raising awareness about DES and its manifestations facilitates early symptom recognition and the implementation of simple yet effective strategies to reduce visual load. It is important to include basic knowledge of visual hygiene in school curricula, conduct interactive lessons on healthy use of digital devices, and promote school initiatives encouraging outdoor activity, especially for younger children. Furthermore, dialogue with teachers is crucial to ensure that digital-based learning alternates with traditional methods [5,11]. Some review articles discuss the potential use of optical aids, such as anti-reflective glasses or blue-light filters; however, their effectiveness in the pediatric population has not been fully established and requires further research. Regardless, proper optical correction remains an important component of DES prevention [6,14]. Conclusion Effective prevention is impossible without regular ophthalmological monitoring. Reviews highlight the importance of preventive eye exams, particularly for children who frequently use digital devices. 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