Utilizarea dispozitivelor electronice în prima copilărie (0-5 ani): beneficii educaționale, riscuri de neurodezvoltare și recomandări clinice bazate pe dovezi – o sinteză narativă

1. Introduction

The first five years of life represent a developmental window of unparalleled neurobiological plasticity, during which environmental input shapes the architecture of the cortex, the connectivity of major white matter tracts and the foundations of language, attention and socioemotional regulation. Within a single generation, the ecology of early childhood has been transformed by the ubiquitous availability of smartphones, tablets, smart televisions and dedicated children’s applications, with cumulative daily exposure that frequently exceeds the limits recommended by international authorities^(1,2).

Recent surveys carried out in high- and middle-income countries indicate that children younger than 2 years old are exposed to screens for approximately one hour per day on average, while children aged 2 to 4 exceed two and a half hours per day, predominantly through television, streaming videos and short-form video applications⁽³⁾. The trend has been reinforced by the COVID-19 pandemic, during which household screen time increased substantially and, in many cases, did not return to prepandemic levels⁽⁴⁾.

Such ubiquity has prompted concern within pediatric and developmental communities. Over the past decade, multiple longitudinal cohorts, neuroimaging investigations and meta-analyses have described associations between excessive early screen exposure and delays in language acquisition, attentional difficulties, reduced executive function and altered cortical and white matter development^(5-8). Conversely, well-designed educational content, viewed jointly with an attentive caregiver, may confer modest benefits for vocabulary and prosocial behavior, illustrating that the relationship between screens and child development is moderated by content, context and the manner of use rather than by exposure time alone⁽⁹⁾.

Against this backdrop, the present review aims to: (i) summarize current epidemiological data on electronic device use among children aged 0-5 years old; (ii) examine the neurobiological mechanisms through which excessive exposure may affect early brain development; (iii) review the principal cognitive, linguistic and behavioral outcomes documented in the recent literature; (iv) compare the most recent recommendations issued by international authorities; and (v) propose a pragmatic framework for pediatric counseling that integrates these elements into routine clinical practice.

2. Materials and method

This narrative review was conducted following the principles of evidence synthesis recommended for nonsystematic reviews in clinical pediatrics, with explicit attention to transparency in source selection and to minimization of citation bias.

Three electronic databases – PubMed/MEDLINE, Web of Science and Scopus – were interrogated for publications dated between January 2018 and April 2026. The search strategy combined controlled vocabulary (MeSH) and free-text terms structured around four conceptual axes: (i) exposure (screen time, digital media, electronic devices, smartphone, tablet, television); (ii) population (early childhood, preschool, toddler, infant, children aged 0-5); (iii) outcomes (neurodevelopment, cognitive development, language development, executive function, attention, behavior, white matter, cortical thickness); and (iv) study type (systematic review, meta-analysis, cohort, randomized controlled trial, guideline).

Reference lists of pivotal articles were screened manually to identify additional sources relevant to the review’s scope. Position statements and clinical practice guidelines published by the World Health Organization (WHO), the American Academy of Pediatrics, the Canadian Paediatric Society, and the Royal College of Paediatrics and Child Health were retrieved directly from the issuing institutions and considered separately as authoritative sources.

Inclusion was restricted to publications in English, articles addressing children aged 0-5 years old (or those reporting subgroup analyses for this age range) and studies focused on cognitive, linguistic, behavioral or neurobiological outcomes. Editorials, commentaries and articles not subjected to peer review were excluded, with the single exception of formal positional documents issued by the aforementioned authorities. Priority was given to systematic reviews and meta-analyses, large prospective cohorts and neuroimaging studies, in this order.

3. Epidemiology of screen exposure in early childhood

Quantifying screen exposure in young children is methodologically complex, given the diversity of devices, the prevalence of background media and the difficulty of obtaining accurate parental estimates. Nevertheless, large national and multinational surveys converge on several robust observations.

In the United States of America, recent data indicate that children under 2 years old spend, on average, approximately 49 minutes per day in front of a screen, predominantly watching television or videos, while children aged 2 to 4 reach a daily mean of approximately two and a half hours, with a similar predominance of audiovisual content⁽³⁾. Comparable figures have been reported across Europe, Australia and parts of East Asia, with consistent evidence that exposure begins remarkably early in life: a substantial proportion of infants are exposed to screens during the first six months⁽¹⁰⁾.

Three trends warrant particular attention. Firstly, the proportion of mobile-device exposure (tablet and smartphone) has increased steadily, displacing the traditional dominance of television and introducing new patterns of solitary, hand-held use that are less amenable to caregiver mediation⁽¹¹⁾. Secondly, background media – television or other devices left running while the child is engaged in other activities – remain pervasive and have been independently associated with reduced parent-child verbal interaction, even when the child is not actively attending to the screen⁽¹²⁾. Thirdly, exposure tends to scale inversely with parental educational attainment and household socioeconomic status, raising concerns regarding the consolidation of inequalities in early development⁽³⁾.

The COVID-19 pandemic produced a marked, sustained increase in screen exposure across all pediatric age groups. Several prospective cohorts have demonstrated that the increment recorded during lockdown periods has only partly receded and that pandemic era preschool screen time was prospectively associated with lower achievement of developmental milestones^(4,14). These findings frame the current state of pediatric screen use as a public health concern of generational scope rather than an isolated parenting issue.

4. The neurobiological basis of vulnerability in early childhood

To understand why the first years of life constitute a particularly sensitive period for the impact of screen exposure, it is useful to revisit several elementary facts of cortical maturation. By the age of 3, the human brain attains approximately 80% of its adult volume; by the age of 5, the main long-association tracts – including the arcuate, inferior longitudinal and uncinate fasciculi – undergo intensive myelination, while the cortex of the prefrontal and temporoparietal regions exhibits maximal synaptic density and experience-dependent plasticity⁽¹⁵⁾. Cognitive and linguistic functions established during this window are markedly more difficult to acquire later, a principle that is the foundation of the broad consensus on the importance of early intervention in any neurodevelopmental disorder.

4.1. White matter and cortical effects: neuroimaging evidence

The seminal work of Hutton and colleagues, published in JAMA Pediatrics in 2020, was the first to use diffusion tensor imaging (DTI) to demonstrate, in a cohort of preschool children aged 3 to 5 years old, that scores indicative of higher screen use (assessed through the ScreenQ instrument, calibrated against AAP recommendations) were associated with significantly lower fractional anisotropy and with higher radial diffusivity in white matter tracts subserving language and emergent literacy⁽⁵⁾. Translated into developmental terms, these findings suggest a less efficient microstructural organization and a probable delay in the myelination of pathways essential for the acquisition of expressive language, the integration of audiovisual information and reading readiness.

A subsequent study by the same group, published in Scientific Reports in 2022, extended these observations to grey matter, showing associations between higher screen use and reduced cortical thickness in regions involved in social cognition, reasoning and empathy – areas that ought, at this developmental stage, to undergo physiological thickening rather than thinning⁽¹⁶⁾. Although these are correlational findings that do not establish causality, they have been interpreted, both by the authors and by independent commentators, as a biologically plausible signal of suboptimal stimulation during a window of intense plasticity.

Recent functional MRI studies have complemented this picture, indicating that during the consumption of animated audiovisual content, network connectivity supporting attention, language and visual imagery is less coherent than during exposure to illustrated narratives or shared reading⁽¹⁷⁾. These findings provide a neurobiological substrate for the recurrent recommendation regarding the importance of shared reading as the optimal alternative to screens in the preschool period.

4.2. Mechanisms of functional vulnerability

Three mechanisms have been advanced to explain how excessive screen exposure may interfere with early development.

Firstly, the displacement effect. Time spent in front of a screen replaces, in a quasi-mechanical fashion, activities essential to normal development – caregiver-child verbal interaction, manipulative play, gross-motor activity, social interaction with peers and exposure to language-rich environments. Studies using objective in-home audio recordings have shown that, for each additional minute of screen exposure, infants are exposed to fewer adult words, produce fewer vocalizations themselves, and engage in fewer conversational turns with their caregivers⁽¹⁸⁾.

Secondly, the video deficit effect. This phenomenon, well documented in infants and toddlers younger than 2 years old, refers to the markedly diminished capacity of these children to transfer information acquired from a two-dimensional screen into a three-dimensional context. Children under 2 years old learn an action, a word or a routine substantially less efficiently from a video than from a live demonstration, even when the audiovisual content is identical⁽¹⁹⁾. The neurobiological basis of this deficit lies in the immaturity of pathways supporting symbolic representation and abstraction.

Thirdly, dysregulation of attention. The rapid editing pace, the abundance of intense audiovisual stimuli and the structure designed to maximize engagement that characterize contemporary children’s content (particularly short-form video applications) contrast sharply with the temporal rhythm of natural environmental stimuli. Repeated exposure to such content during the period in which attentional networks are organized may favor a pattern of fragmented attention and difficulty sustaining concentration on slower, less stimulating tasks – including, crucially, those tasks essential for school readiness⁽²⁰⁾.

5. Cognitive and linguistic outcomes

5.1. Language development

Language development is the most extensively documented domain of vulnerability. A recent systematic review by Massaroni and colleagues, published in 2024, concluded that prolonged screen exposure during the first two years of life is consistently associated with negative effects on language development, both in the receptive component (vocabulary, comprehension) and in the expressive component (production, communicative gestures), with effects extending into the preschool age range⁽²¹⁾.

The mechanism is largely indirect, and it is mediated by reduced quantity and quality of verbal interaction with caregivers. Studies using Language Environment Analysis (LENA) recorders have shown that, for every additional hour of screen exposure, infants hear fewer adult words, produce fewer vocalizations, and participate in fewer conversational exchanges – in essence, the child is exposed to a poorer linguistic environment, with direct consequences for vocabulary growth and grammatical complexity⁽¹⁸⁾.

It is important, however, to qualify this picture. The longitudinal cohort study by Madigan and colleagues, conducted within the All Our Families cohort in Calgary and published in JAMA Pediatrics in 2019, used a cross-lagged panel model and demonstrated a directional, prospective association between screen time at 24 months and developmental performance at 36 months, and between screen time at 36 months and performance at 60 months – whereas the reverse pathway (poor developmental performance leading to greater subsequent screen exposure) was not observed, lending support to the hypothesis that screen exposure precedes developmental delay rather than merely accompanying it⁽⁶⁾. A 2024 cohort study by Binet and colleagues confirmed the persistence of this association even when measured during pandemic conditions⁽¹⁴⁾.

By contrast, certain forms of screen use can support language. Co-viewing with an attentive caregiver who comments, asks questions and integrates content into the child’s everyday life – sometimes referred to as “dialogic media use” – can recreate the educational dynamic of shared book reading, provided the content is age-appropriate and the duration is limited. The most recent meta-analysis by Mallawaarachchi and colleagues, published in JAMA Pediatrics in 2024, found small but significant positive associations between co-viewing of educational programming and certain cognitive outcomes, while the solitary use of entertainment content remained negatively associated with the same outcomes⁽⁹⁾.

5.2. Executive function and attention

Executive function – encompassing working memory, inhibitory control and cognitive flexibility – represents one of the most robust predictors of long-term academic outcomes, and it is one of the cognitive domains most sensitive to early environmental input. Recent data from large prospective cohorts have shown that excessive screen exposure during the preschool years is associated with attentional difficulties, hyperactivity and reduced inhibitory control during the school years, with effects partially mediated by reduced exposure to language-rich activities and by sleep disturbance⁽²³⁾. These findings are convergent with the meta-analysis by Eirich and colleagues, published in JAMA Psychiatry in 2022, which documented small but consistent associations between screen time and internalizing and externalizing behavioral problems in children younger than 12 years old⁽²⁴⁾.

5.3. Cognitive development and school readiness

Cognitive development in the broad sense – including nonverbal intelligence, problem-solving capacity and acquisition of pre-academic concepts – has been the subject of recent systematic reviews. The meta-analysis published by Madigan and colleagues in JAMA Pediatrics (2020) examined the association between screen use and child language skills, demonstrating that the quantity of screen time was negatively associated with vocabulary and language outcomes, while educational programming and co-viewing were positively associated⁽²⁵⁾.

These findings are consistent with the more recent scoping review by Sticca and colleagues, published in Frontiers in Developmental Psychology in 2024, which argues for a contextualized interpretation: in early childhood, screens are neither uniformly harmful nor uniformly beneficial, and child-, context- and content-related characteristics moderate the relationship between exposure and developmental outcomes⁽²⁶⁾. This conclusion has important practical implications: a pediatric public health policy formulated solely in terms of duration risks oversimplifying a complex phenomenon.

6. Indirect effects: sleep, physical activity and caregiver-child interaction

The effects of screen exposure on early development are not exhausted by direct cognitive consequences. Three indirect mechanisms – sleep, physical activity and caregiver-child interaction – modulate substantially the magnitude and clinical significance of observed associations.

Sleep is one of the most consistently documented me­dia­tors. Exposure to screens – particularly in the hour pre­ce­ding bedtime – has been associated with delayed sleep onset, reduced total sleep duration and with lower sleep quality in toddlers and preschool children⁽²⁷⁾. Plau­si­ble mechanisms include suppression of melatonin se­cre­tion by short-wavelength light, cognitive activation pro­duced by stimulating content and the displacement of bedtime routines that would otherwise prepare the child for sleep. Considering that sleep is essential for me­mory consolidation, synaptic pruning and emotional regulation, the cumulative effect of sleep deprivation may be one of the most underestimated routes through which screen exposure affects neurodevelopment.

Physical activity represents the second indirect mech­anism. The 2019 World Health Organization guidelines for children younger than 5 years old recommend at least 180 minutes of physical activity per day, with at least 60 minutes of moderate-to-vigorous activity in children aged 3 and 4, and explicitly identify sedentary screen time as a behavior to be limited⁽¹⁾. The recent systematic review by Bakht and colleagues, published in 2025, demonstrated that 17 of 24 included studies reported significant negative correlations between screen time and motor development in children aged 0-7 years old⁽²⁸⁾. Inactivity in early childhood is, moreover, an independent risk factor for pediatric obesity, with bidirectional consequences for cardiometabolic and cognitive trajectories.

The third mechanism – and possibly the most rele­vant from a pediatric perspective – is the caregiver-child interaction. Brushe and colleagues (2024) demonstrated, using objective in-home recordings, that increased screen time was associated with fewer adult words heard by the child, fewer child vocalizations and fewer conversational turns⁽¹⁸⁾. This phenomenon, conceptualized as “technoference”, highlights that screen exposure does not affect only the child’s direct attention; it interferes with the entire ecology of early communication, including parental availability for the verbal and nonverbal interactions that fuel language development.

7. International recommendations: comparative synthesis

Over the past decade, the main international authorities have developed positional documents that are largely convergent on the central message – caution and limitation of exposure during early childhood – but differ in nuance and in the specific thresholds proposed.

The American Academy of Pediatrics, in the policy statement issued in 2016 and reconfirmed in subsequent updates, recommends complete avoidance of screens before 18 months, with the exception of supervised video chat; introduction of high-quality, co-viewed media between 18 and 24 months only; and a maximum of one hour per day of high-quality programming, viewed jointly with the caregiver, for children aged 2 to 5 years old⁽²⁾. Recent updates of the Canadian Paediatric Society guidance retain the principles of restriction in early childhood but emphasize a shift toward content quality, viewing context and the development of healthy digital habits within the family, recognizing that arbitrary time limits are difficult to enforce in environments saturated with technology⁽²⁹⁾.

The World Health Organization, in the 2019 guidelines for physical activity, sedentary behavior and sleep in children younger than 5 years old, recommends no sedentary screen time for children younger than 1 year, no more than one hour for children aged 2 to 4 years old (less is preferable) and prioritization of physical activity and adequate sleep – at least 14-17 hours per day in the first months of life, gradually decreasing to 10-13 hours at the age of three to four years⁽¹⁾.

The Canadian Paediatric Society and the Royal College of Paediatrics and Child Health have published similar guidelines, with subtle differences regarding the specific threshold for the 2-5-year-old age range and with notable insistence on the four contextual dimensions: total exposure time, content, context (where, when, with whom) and communication (the conversation between parent and child about content)^(30,31).

Adherence to these recommendations remains, however, modest. The recent meta-analysis by McArthur and colleagues (2022), pooling data from 63 studies, demonstrated that only a minority of children younger than 5 years old globally meet screen time guidelines, with prevalence as low as 24.7% among children under 2 years old and 35.6% among those aged 2 to 5⁽²²⁾. National data from Canadian and other cohorts yield comparable estimates, and adherence is even lower in households where parents themselves use screens intensively⁽³²⁾. This finding emphasizes the importance of an integrated approach in which pediatric counseling addresses simultaneously the child’s behavior, the parents’ habits and the entire family’s media ecology.

8. Implications for pediatric clinical practice

The integration of evidence on screen exposure into routine pediatric practice requires a structured approach that goes beyond the simple communication of an arbitrary time limit. Several principles can guide effective intervention.

8.1. History taking and risk assessment

Counseling on digital media should become a routine component of well-child visits, particularly during developmental check-ups at 9, 18, 24 and 30 months and at the ages of 4 and 5 years old. Useful questions include: What kinds of screens are accessible to the child? How much time per day is spent in front of each? What is the predominant content? Is there a screen in the child’s bedroom? Is the screen used during meals or before bed? Does the child use the screen alone or with a caregiver? These questions can be incorporated into a brief interview structure or, alternatively, into a structured screening tool, such as the ScreenQ described by Hutton and colleagues⁽⁵⁾.

8.2. Anticipatory guidance

Anticipatory guidance, the provision of counsel before a problematic behavior develops, is widely advocated as more effective than reactive intervention in shaping early family habits. As soon as the third or fourth month of life, parents should receive clear information about the principles of avoidance during the first 18 months, the importance of direct caregiver-child interaction and the development of bedtime routines that exclude screens^(2,13). Pediatricians’ professional authority and parental confidence in the pediatrician’s recommendations make this counseling potentially more influential than any informational campaign.

8.3. The family media plan

The American Academy of Pediatrics has developed an instrument known as the Family Media Plan, which encourages families to define jointly the limits, screen-free zones (typically the bedroom and the dining table), screen-free times (typically meals and the hour before bed) and rules for the type of content permitted⁽²⁹⁾. The implementation of such a plan, although it requires only a brief discussion in clinic, can produce sustained behavioral changes and significantly improve adherence to international recommendations.

8.4. Differential diagnosis and referral

In children presenting with delayed language development, attentional difficulties or behavioral disturban­ces, history taking regarding screen exposure must be performed systematically. Although excessive exposure does not, in itself, constitute a sufficient diagnosis for these manifestations, it can act as a relevant risk factor or, in certain cases, as the main modifiable contributor. Where the clinical picture is suggestive of a primary neurodevelopmental disorder – autism spectrum disorder, attention-deficit/hyperactivity disorder, specific language disorder – referral to specialized assessment is essential, even if a substantial reduction in screen exposure has already produced symptomatic improvement.

9. Limitations of the evidence and future research directions

The body of evidence summarized in this review presents several methodological limitations that warrant explicit acknowledgement.

Firstly, most studies are observational, with cross-sectional or, at best, prospective designs that do not allow rigorous causal inference. The few existing randomized controlled trials are limited in size and duration, and have generally produced more nuanced results than observational studies⁽²⁶⁾.

Secondly, exposure measurement is heterogeneous and frequently relies on parental reports – a method known to underestimate, by a factor of two to three, the values obtained through objective methods (sensors, electronic logs). This systematic bias may attenuate the observed associations and introduce uncertainty regarding the magnitude of true effects.

Thirdly, distinction between forms of screen use – passive television, mobile-device use, video games, video chat, educational programming – is often insufficient in epidemiological studies, although converging evidence indicates that effects vary substantially by content type, viewing context and the presence or absence of an attentive caregiver^(9,26).

Fourthly, the reciprocal-causality hypothesis – that children with developmental difficulties may be exposed to more screens because parents resort to media as a means of managing challenging behavior – cannot be entirely excluded, although recent longitudinal studies have provided arguments that favor a unidirectional pathway from screen exposure to developmental delay^(6,14).

Future research directions include the implementation of randomized intervention studies that test the effect of structured exposure reduction on developmental outcomes; the use of longitudinal neuroimaging in larger cohorts in order to characterize the long-term trajectories of structural and functional effects; the methodological refinement of exposure measurement, with the integration of objective methods; and exploration of the differential effects of contemporary platforms – particularly short-form video applications – on attention, emotional regulation and social development in early childhood.

10. Conclusions

Exposure to electronic devices during the first five years of life represents one of the most significant ecological transformations of contemporary childhood. The body of evidence accumulated over the past decade indicates that excessive or developmentally inappropriate exposure is consistently associated with delays in language acquisition, reduced executive function, attentional difficulties and with altered cortical and white matter development. These effects are largely mediated by indirect mechanisms – displacement of caregiver-child interaction, disruption of sleep and reduction of physical activity –, and are moderated by content, viewing context and parental presence.

Current evidence supports a precautionary approach that includes complete avoidance of screen exposure (other than supervised video chat) before 18 months, very limited use of high-quality, co-viewed content between 18 and 24 months, and a maximum of one hour per day of curated programming for children aged 2 to 5. International recommendations, although not unanimous in detail, are convergent on this main message and provide a coherent framework for pediatric counseling.

Pediatricians occupy a privileged position in mediating between scientific evidence and family practice. The integration of digital media counseling into routine well-child visits, the implementation of family media plans and active anticipatory guidance can substantially modify the population trajectory of early screen exposure, with potentially substantial long-term benefits for cognitive, linguistic and emotional development.

Although the evidence still presents methodological limitations and although future research directions remain open, the magnitude and consistency of available data justify a clinically active stance, prudent in tone but firm in principles. In the digital era, pediatric protection of early childhood requires explicit consideration of media ecology as a determinant of neurodevelopment with the same rigor with which we already consider nutrition, sleep and physical activity.

Acknowledgements. The authors thank the staff of the “Sf. Maria” Emergency Clinical Hospital for Children, Iași, and the Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania, for their continuous support during the preparation of this manuscript.

Conflict of interest statement. The authors declare no conflict of interest in relation to the subject of this review.

Funding. This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions: conceptualization – A.Mi., O.-R.T. and A.Mu.; methodology – A.Mi., O.-R.T. and I.K.I.; literature search and data curation – A.Mi., P.P. and A.N.G.; writing, original draft preparation – A.Mi.; writing, review and editing – O.-R.T., I.K.I., P.P., A.N.G. and A.Mu.; supervision – O.-R.T. and A.Mu.; project administration – A.Mi. All authors have read and agreed to the published version of the manuscript. O.-R.T. and A.Mu. share corresponding authorship.

Note on initials: A.Mi. = Adriana Mihai; A.Mu. = Alina Murgu; I.K.I. = Ileana Katerina Ioniuc; O.-R.T. = Oana-Raluca Temneanu; P.P. = Paula Popovici; A.N.G. = Alice Nicoleta Grudnicki.

Autor corespondent:  Alina Murgu E-mail: alina.murgu@umfiasi.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.