Background
Methods
Overall guideline development process
Panel member | Affiliation | Role | Conflict of interest declaration |
---|---|---|---|
Research experts and credentials | |||
Kristi Adamo, PhD | Associate Professor, University of Ottawa (Canada) | PA and SB content expert, systematic review author | none |
Salome Aubert | doctoral student, University of Ottawa (Canada) | PA and SB content expert, systematic review author | none |
Valerie Carson, PhD | Associate Professor, University of Alberta (Canada) | compositional analyses leader, PA and SB content expert, Leadership Committee, Steering Committee, Surveillance Sub-Committee, systematic review author | none |
Jean-Philippe Chaput, PhD | Research Scientist, HALO, CHEO RI (Canada) | sleep, PA, and SB content expert, Leadership Committee, Steering Committee, Surveillance Sub-committee, systematic review author | none |
Guy Faulkner, PhD | Professor and CIHR-PHAC Chair in Applied Public Health, University of British Columbia (Canada) | PA and SB content expert, stakeholder consultation (focus groups author) | none |
Gary Goldfield, PhD | Senior Scientist, HALO, CHEO RI (Canada) | PA and SB content expert, systematic review author | none |
Reut Gruber, PhD | Professor, McGill University; Director, Attention Behaviour and Sleep Lab, Douglas Mental Health University Institute (Canada) | sleep content expert, systematic review author | Husband on ACSM Board of Directors 2010–2016 (ACSM produced clinical guidelines and position stands for sleep medicine field); received several grants as a Principal Investigator to investigate the interplay between sleep, nutrition and PA in children and developed an intervention program to target this interplay, expects to publish. |
Ian Janssen, PhD | Professor and Canada Research Chair in Physical Activity and Obesity, Queen’s University (Canada) | PA and SB content expert, Surveillance Sub-Committee, systematic review author | none |
Nicholas Kuzik | doctoral student, University of Alberta (Canada) | combined movement behaviour content expert, systematic review author, Leadership Committee | none |
Joanna MacLean, PhD, MD, FRCPC | paediatric respirologist and sleep medicine specialist; Associate Professor, University of Alberta (Canada) | sleep content expert, systematic review author | none |
John Spence, PhD | Professor and Vice-Dean of Physical Education and Recreation, University of Alberta (Canada) | PA and SB content expert, systematic review author | none |
Brian Timmons, PhD | Associate Professor and Canada Research Chair in Child Health and Exercise Medicine, McMaster University (Canada) | PA and SB content expert, systematic review author | none |
Mark Tremblay, PhD | Director, HALO, and Senior Scientist CHEO RI (Canada) | Chair, PA and SB content expert, Leadership Committee, Surveillance Sub-Committee, Steering Committee, systematic review author, dissemination and implementation, evaluation | none |
Stakeholder groups and knowledge users | |||
Louise Choquette | bilingual health promotion consultant, Health Nexus (Canada) | invited representative (Health Nexus), early years expert | none |
Mary Duggan, CAE | Manager, CSEP (Canada) | CSEP representative, Leadership Committee, Steering Committee, dissemination and implementation, evaluation | none |
Katherine Janson | Director of Communications and Public Affairs, ParticipACTION (Canada) | invited representative (ParticipACTION), creative development and marketing, Leadership Committee | none |
Claire LeBlanc, MD, FRCPC | paediatric rheumatologist and sport medicine physician, Montreal Children’s Hospital (Canada) | invited representative (Canadian Pediatric Society,) early years, PA, SB, and sleep content expert | none |
Mary-Ellen Rayner | Chief Partnerships and Communications Officer, The Sandbox Project | invited representative (The Sandbox Project), early years, PA, and SB content expert | none |
International collaborators | |||
Xanne Janssen, PhD | Postdoctoral Fellow, University of Strathclyde (Scotland) | PA and SB content expert, international representative, systematic review author | none |
Anthony Okely, PhD | Professorial Fellow and Director, Early Start Institute, University of Wollongong (Australia) | early years, SB, and PA content expert, international representative, systematic review author | Received funding as a consultant from Foxtel to advise on PA interstitial as part of their preschool television programs |
John Reilly, PhD | Professor, University of Strathclyde (Scotland) | early years, PA and SB content expert, international representative, systematic review author | none |
Methodology consultants and project management | |||
Casey Gray, PhD | Project Manager, HALO, CHEO RI (Canada) | PA and SB content expert, Leadership Committee, Steering Committee, systematic review author, evaluation | none |
Alejandra Jaramillo Garcia | Global Health and Guidelines Division, PHAC (Canada) | AGREE II and GRADE methodological consultant, Steering Committee, systematic review author | none |
Veronica Poitras, PhD | Clinical Research Officer, Canadian Agency for Drugs and Technologies in Health (Canada)a
| PA and SB content expert, Leadership Committee, Steering Committee, Surveillance Sub-Committee, systematic review author | none |
Margaret Sampson, PhD | Manager, Library Services, Children’s Hospital of Eastern Ontario (Canada) | methodology expert, research librarian, systematic review author | none |
Systematic reviews
Compositional analyses
Additional considerations from GRADE
Guidelines recommendations and stakeholder consultations
Dissemination, implementation and evaluation plans
Research gaps and surveillance recommendations
Results
Overall guideline development process
Systematic reviews
Physical activity and health indicators
Sedentary behaviour and health indicators
Sleep and health indicators
Combined movement behaviours and health indicators
Compositional analyses
Guideline recommendations and stakeholder consultations
Stakeholder survey
Question | Strongly Agree n (%) | Somewhat Agree n (%) | Neither Agree Nor Disagree n (%) | Somewhat Disagree n (%) | Strongly Disagree n (%) | Total Responses n |
---|---|---|---|---|---|---|
The Title is clearly stated. | 339 (60.0%) | 193 (34.2%) | 19 (3.4%) | 13 (2.3%) | 1 (0.2%) | 565 |
Do you agree with the Title? | 303 (54.1%) | 196 (35.0%) | 36 (6.4%) | 22 (3.9%) | 3 (0.5%) | 560 |
The Preamble is clearly stated. | 322 (71.4%) | 113 (25.1%) | 9 (2.0%) | 7 (1.6%) | 0 (0.0%) | 451 |
Do you agree with the Preamble? | 339 (75.3%) | 94 (20.9%) | 10 (2.2%) | 7 (1.6%) | 0 (0.0%) | 450 |
The 24-Hour Guidelines are clearly stated. | 341 (78.0%) | 87 (20.0%) | 5 (1.1%) | 4 (1.0%) | 0 (0.0%) | 437 |
Do you agree with the 24-Hour Guidelines? | 327 (74.8%) | 93 (21.3%) | 12 (2.7%) | 5 (1.1%) | 0 (0.0%) | 437 |
Evidence to Decision Framework | ||||||
Yes | No | |||||
Are the 24-Hour Guidelines important to you? (priority) | 409 (95.8%) | 18 (4.2%) | ||||
Always | Frequently | Occasionally | Seldom | Never | ||
Would you use the Preamble? (acceptability) | 98 (21.4%) | 178 (38.8%) | 142 (30.9%) | 32 (7.0%) | 9 (2.0%) | |
Would you use the 24-Hour Guidelines? (acceptability) | 141 (32.9%) | 198 (46.2%) | 73 (17.0%) | 11 (2.6%) | 6 (1.4%) | |
Much More Useful | More Useful | Neutral | Less Useful | Much Less Useful | ||
In comparison to separate physical activity, sedentary behaviour and sleep guidelines, do you find these 24-Hour Guidelines... (acceptability) | 119 (27.8%) | 216 (50.5%) | 87 (20.3%) | 4 (0.9%) | 2 (0.5%) | |
Very Easy | Somewhat Easy | Neither Easy Nor Difficult | Somewhat Difficult | Very Difficult | ||
How easy or difficult would you find using the 24-Hour Guidelines? (feasibility) | 175 (41.0%) | 188 (44.0%) | 41 (9.6%) | 22 (5.2%) | 1 (0.2%) | |
Strongly Agree | Somewhat Agree | Neither Agree Nor Disagree | Somewhat Disagree | Strongly Disagree | I Don’t Know | |
The costs for you to use, or your organization to implement, the 24-Hour Guidelines are likely to be small or negligible compared to not using the Guidelines. (resource use) | 143 (35.0%) | 122 (29.8%) | 55 (13.4%) | 12 (2.9%) | 5 (1.2%) | 27 (6.6%) |
The benefits of using the 24-Hour Guidelines are likely to outweigh the costs. (perceived incremental cost-benefit ratio) | 211 (51.7%) | 120 (29.4%) | 47 (11.5%) | 3 (0.7%) | 1 (0.2%) | 26 (6.4%) |
Following the 24-Hour Guidelines is likely to benefit all population groups equally, irrespective of gender, race, ethnicity, or the socioeconomic status of the family. (equity) | 233 (57.1%) | 117 (28.7%) | 20 (4.9%) | 22 (5.4%) | 5 (1.2%) | 11 (2.7%) |
Focus groups and key informant interviews
Revisions to draft guidelines
GRADE evidence to decision framework: Summary
-
Being physically active several times in a variety of ways, particularly through interactive floor-based play; more is better. For those not yet mobile, this includes at least 30 min of tummy time spread throughout the day while awake. Moderate quality evidence, strong recommendation.
-
Not being restrained for more than 1 h at a time (e.g., in a stroller or high chair). Screen time is not recommended. When sedentary, engaging in pursuits such as reading and storytelling with a caregiver is encouraged. Moderate quality evidence, strong recommendation.
-
14–17 h (for those aged 0–3 months) or 12–16 h (for those aged 4–11 months) of good-quality sleep, including naps. High quality evidence, strong recommendation.
-
At least 180 min spent in a variety of physical activities at any intensity, including energetic play, spread throughout the day—more is better. Moderate quality evidence, strong recommendation.
-
Not being restrained for more than 1 h at a time (e.g., in a stroller or high chair) or sitting for extended periods. For those younger than 2 years, sedentary screen time is not recommended. For those aged 2 years, sedentary screen time should be no more than 1 h; less is better. When sedentary, engaging in pursuits such as reading and storytelling with a caregiver is encouraged. Moderate quality evidence, strong recommendation.
-
11–14 h of good-quality sleep, including naps, with consistent bedtimes and wake-up times. High quality evidence, strong recommendation.
-
At least 180 min spent in a variety of physical activities spread throughout the day, of which at least 60 min is energetic play—more is better. Moderate quality evidence, strong recommendation.
-
Not being restrained for more than 1 h at a time (e.g., in a stroller or car seat) or sitting for extended periods. Sedentary screen time should be no more than 1 h; less is better. When sedentary, engaging in pursuits such as reading and storytelling with a caregiver is encouraged. Moderate quality evidence, strong recommendation.
-
10–13 h of good-quality sleep, which may include a nap, with consistent bedtimes and wake-up times. High quality evidence, strong recommendation.
-
Replacing time restrained or sedentary screen time with additional energetic play, and trading indoor for outdoor time, while preserving sufficient sleep, can provide greater health benefits. Very low quality evidence, strong recommendation.
Strength of recommendations
Subgroup considerations
Dissemination, implementation and evaluation plans
Research gaps
Research needs arising from systematic reviews |
• Overall, there is a need for high-quality studies with strong designs (e.g., randomized controlled trials or longitudinal studies, larger sample sizes, objective measures). • To enable comparison across studies, objective measures of sedentary behaviour, physical activity, and sleep (e.g., accelerometry, inclinometry) are needed. Additionally, there is a need to standardize measurement procedures. • To establish the true effect of sedentary behaviour, physical activity, and sleep, possible confounders (e.g., diet) need to be controlled for in studies. • To understand possible dose-response relationships between health outcomes and movement behaviours, examination of the effect of different doses (i.e., duration, frequency) of physical activity, sedentary behaviour, and sleep on health outcomes is needed (e.g., the effect of participating in physical activity for 15 min/day versus 30 min/day versus 60 min/day) and baseline physical activity should be controlled in intervention studies. • Studies in infants and toddlers are required to establish developmentally-appropriate doses of sedentary behaviour and physical activity for these age groups. • Examination of the associations between physical activity and psychosocial health, fitness, bone and skeletal health, cardiometabolic health, and risk/harms are needed. • Examination of the associations between sedentary behaviour and bone and skeletal health, cardiometabolic health, fitness, and risks/harms are needed. • Exploration of the associations between total sedentary time and health outcomes as well as patterns of sedentary behaviour (e.g., combination of timing, length, order of sedentary behaviours relative to physical activity and sleep, and breaks in sedentary behaviours) and health outcomes are needed; • Studies examining the impact of new screen-based devices (e.g., mobile phones, tablets) and other common sedentary behaviours (e.g., reading, puzzles) on health outcomes are needed. • Examination of the associations between sleep and motor development, growth, cardiometabolic health, and risk/harms are needed. • Given the notable differences in development during the early years, studies focusing on sleep should report results based on narrow age ranges (i.e., newborns, infants, toddlers, and preschoolers). • There is a need to determine the distribution of daily movement behaviours for optimal health throughout the early years, more specifically a need for studies that use more balanced approaches to intervene on various movement behaviours in the early years. • Examination of the relationships between combinations of movement behaviours and health indicators is needed. |
Research needs arising from Guideline Development Panel meetings and discussions |
• Physical Activity |
◦ Whether the environment in which physical activity takes place (e.g., indoor vs. outdoor) influences the relationships with health indicators is unclear; using accurate measures to capture physical activity dose together with context is recommended (e.g., combining objective measures of physical activity with time-use diaries). ◦ Explore the differences between types and context (e.g., outdoors, organized, social) of physical activity and their association with health. ◦ The effects of light-intensity physical activity on health indicators in the early years remain unclear. There is need to examine whether activities at the higher end of light physical activity are more beneficial for health than those at the lower end of light physical activity. |
• Sedentary Behaviour |
◦ Some time spent sedentary may be required to enhance growth and development. The need for a minimum amount of sedentary time to improve growth and development remains to be determined. ◦ There is a need for the use of valid and reliable measures of sedentary behaviour in the early years (e.g., inclinometers). In addition, valid and reliable tools to measure sedentary behaviour in non-ambulatory infants need to be developed. ◦ Establish whether the effect of screens on several health outcomes is due to the use of screens or the lack of movement. ◦ Explore the effects of different types of sedentary behaviour content (e.g., educational vs recreational screen time) on different health indicators. |
• Sleep |
◦ Research studies focusing on sleep quality are needed (e.g., sleep efficiency, sleep consolidation, sleep architecture). ◦ Identify optimal ranges of sleep duration for the different age groups. Studies examining the effect of different sleep durations on health outcomes are required. ◦ Examine the effect of sleep routines (e.g., consistent bed/wake times, screen time before bed) on sleep quantity and quality. |
• Integrated movement behaviours |
◦ No cause-effect evidence exists with regard to 24-h movement patterns. Longitudinal and experimental studies are needed. ◦ Exploration of different health indicators (e.g., school readiness) that may be uniquely important during the early years. ◦ Identify additional methods for analyzing 24-h movement data. |
Stakeholder, intermediary, and end-user consultation and engagement research needs |
• There is a need to understand more completely the language and delivery mediums and methods that minimize end-user feelings of guilt and disengagement and maximize motivation and empowerment to implement and achieve the integrated guidelines. • There is a need to understand the nuances of guideline messaging to effectively and efficiently implement and activate the new guidelines in different end-user groups (e.g., parents, grandparents, child care providers, health care providers, early childhood educators). |
International and inter-jurisdictional research needs and opportunities |
• The dissemination, activation, implementation, impact, and uptake of the new integrated guidelines in different jurisdictions should be examined and compared. • Intra- and inter-jurisdictional acceptance of the new integrated guidelines approach should be assessed and compared. |
Other research needs |
• There is a need for cost-effectiveness analyses of interventions aiming to improve movement behaviours during the early years. • There is a need to increase the evidence on movement behaviours and health outcomes in young children with physical or mental diseases or disabilities. |
Surveillance recommendations
Movement Behaviour | Specific guideline recommendation for a healthy day | Specific surveillance recommendation | Rationale for specific surveillance recommendation | Recommendation for minimum inclusion in overall guideline surveillancea
|
---|---|---|---|---|
Age category | ||||
Physical activity | ||||
Infants (aged <1 year) | Being physically active several times in a variety of ways, particularly through interactive floor-based play; more is better | None | Currently there are no available benchmarks, further research is required. | ✓ b
|
For those not yet mobile, this includes at least 30 min of tummy time spread throughout the day while awake | Average total tummy time per day is ≥30 min while awakec
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical tummy time per day in their analyses. An average allows for some normal day-to-day variability. | ✓ | |
Toddlers (aged 1–2 years) | At least 180 min spent in a variety of physical activities at any intensity, including energetic play, spread throughout the day; more is better | Average total physical activity per day is ≥180 min with at least some energetic play (MVPA)c
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical physical activity per day in their analyses. An average allows for some normal day-to-day variability. There are currently no benchmarks for the recommended duration of energetic play in this age group. | ✓ |
Preschoolers (aged 3–4 years) | At least 180 min spent in a variety of physical activities spread throughout the day | Average total physical activity per day is ≥180 minutesc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical physical activity per day in their analyses. | ✓ |
of which at least 60 min is energetic play; more is better | Average MVPA per day is ≥60 minutesc
| An average allows for some normal day-to-day variability. | ✓ | |
Sedentary behaviour | ||||
Infants | Screen time is not recommended | A typical day includes no screen timed
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical screen time per day in their analyses. | ✓ |
Not being restrained for more than 1 h at a time (e.g., in a stroller or high chair) | Time spent restrained is ≤1 h at a timee
| Empirical evidence substantiating this threshold is lacking though this threshold is aligned with earlier guidelines and has met with stakeholder and end-user acceptance (Tremblay et al., 2012)f. | ||
When sedentary, engaging in pursuits like reading and storytelling with a caregiver is encouraged | None | Currently there are no available benchmarks, further research is required. | ||
Toddlers | For those younger than 2 years, sedentary screen time is not recommended | A typical day includes no sedentary screen timed
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sedentary screen time per day in their analyses. | ✓ |
For those aged 2 years, sedentary screen time should be no more than 1 h; less is better | Average sedentary screen time per day is ≤1 hourc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sedentary screen time per day in their analyses. An average allows for some day-to-day variability in sedentary screen time. | ✓ | |
Not being restrained for more than 1 h at a time (e.g., in a stroller or high chair) or sitting for extended periods | Time spent restrained is ≤1 h at a timee
| Empirical evidence substantiating this threshold is lacking though this threshold is aligned with earlier guidelines and has met with stakeholder and end-user acceptance (Tremblay et al., 2012)f. Currently there are no available benchmarks to be more specific for “sitting for extended periods”, further research is required. | ||
When sedentary, engaging in pursuits like reading and storytelling with a caregiver is encouraged | None | Currently there are no available benchmarks, further research is required. | ||
Preschoolers | Sedentary screen time should be no more than 1 h; less is better | Average sedentary screen time per day is ≤1 hourc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sedentary screen time per day in their analyses. An average allows for some day-to-day variability in sedentary screen time. | ✓ |
Not being restrained for more than 1 hour at a time (e.g., in a stroller or car seat) or sitting for extended periods | Time spent restrained is ≤1 hour at a timee
| Empirical evidence substantiating this threshold is lacking though this threshold is aligned with earlier guidelines and has met with stakeholder and end-user acceptance (Tremblay et al., 2012)f. Currently there are no available benchmarks to be more specific for “sitting for extended periods”, further research is required. | ||
When sedentary, engaging in pursuits like reading and storytelling with a caregiver is encouraged | None | Currently there are no available benchmarks, further research is required. | ||
Sleep | ||||
Infants | 14 to 17 h (for those aged 0–3 months) of good quality sleep, including naps | Average total sleep duration per 24 h is 14 to 17 hoursc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sleep duration per 24 h in their analyses. An average allows for some normal day-to-day variability. | ✓ |
12 to 16 h (for those aged 4–11 months) of good quality sleep, including naps | Average total sleep duration per 24 h is 12 to 16 hoursc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sleep duration per 24 h in their analyses. An average allows for some normal day-to-day variability. | ✓ | |
Toddlers | 11 to 14 h of good quality sleep, including naps | Average total sleep duration per 24 h is 11 to 14 hoursc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sleep duration per 24 h in their analyses. An average allows for some normal day-to-day variability. | ✓ |
Consistent bed and wake-up times | Bedtime and wake-up time should not typically vary by more than ±30 min including on weekendsg
| Although the empirical support for a specific surveillance recommendation is weak (Allen et al., 2016)h, we propose that sleep schedules (bedtime and wake-up times) should not vary by more than ±30 min each. | ||
Preschoolers | 10 to 13 h of good quality sleep, which may include a nap | Average total sleep duration per 24 h is 10 to 13 hoursc
| The evidence upon which the guideline is based is predominantly comprised of studies that used average or typical sleep duration per 24 h in their analyses. An average allows for some normal day-to-day variability. | ✓ |
Consistent bed and wake-up times | Bedtime and wake-up time should not typically vary by more than ±30 min including on weekendsg
| Although the empirical support for a specific surveillance recommendation is weak (Allen et al., 2016)h, we propose that sleep schedules (bedtime and wake-up times) should not vary by more than ±30 min each. |
AGREE II assessment
AGREE II Item | Reporting Location | Domain Score (%)b
|
---|---|---|
Domain 1. Scope and Purpose | 100 | |
1. The overall objective(s) of the guideline is (are) specifically described. | • Guideline Development Report • This manuscript | |
2. The health question(s) covered by the guideline is (are) specifically described. | • Guideline Development Report • This manuscript | |
3. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. | • Guideline Development Report • This manuscript | |
Domain 2. Stakeholder Involvement | 99 | |
4. The guideline development group includes individuals from all the relevant professional groups. | • Guideline Development Report • This manuscript | |
5. The views and preferences of the target population (patients, public, etc.) have been sought. | • Guideline Development Report • This manuscript • Focus groups and key informant interviews [33] | |
6. The target users of the guideline are clearly defined. | • Guideline Development Report • This manuscript | |
Domain 3. Rigour of Development | 95 | |
7. Systematic methods were used to search for evidence. | • Guideline Development Report | |
8. The criteria for selecting the evidence are clearly described. | • Guideline Development Report | |
9. The strengths and limitations of the body of evidence are clearly described. | • Guideline Development Report • This manuscript | |
10. The methods for formulating the recommendations are clearly described. | • Guideline Development Report • This manuscript | |
11. The health benefits, side effects, and risks have been considered in formulating the recommendations. | • Guideline Development Report • This manuscript | |
12. There is an explicit link between the recommendations and the supporting evidence. | • Guideline Development Report | |
13. The guideline has been externally reviewed by experts prior to its publication. | • Guideline Development Report • This manuscript • Focus groups and key informant interviews [33] | |
14. A procedure for updating the guideline is provided. | • Guideline Development Report • This manuscript | |
Domain 4. Clarity of Presentation | 99 | |
15. The recommendations are specific and unambiguous. | • Guideline Development Report • This manuscript | |
16. The different options for management of the condition or health issue are clearly presented.a
| • Not applicable | |
17. Key recommendations are easily identifiable. | • Guideline Development Report • This manuscript | |
Domain 5. Applicability | 89 | |
18. The guideline describes facilitators and barriers to its application. | • Guideline Development Report • This manuscript • Focus groups and key informant interviews [33] | |
19. The guideline provides advice and/or tools on how the recommendations can be put into practice. | • Guideline Development Report • This manuscript • CSEP website (www.csep.ca/guidelines) | |
20. The potential resource implications of applying the recommendations have been considered. | • Guideline Development Report • This manuscript | |
21. The guideline presents monitoring and/or auditing criteria. | • Guideline Development Report • This manuscript | |
Domain 6. Editorial Independence | 89 | |
22. The views of the funding body have not influenced the content of the guideline. | • Guideline Development Report • This manuscript | |
23. Competing interests of guideline development group members have been recorded and addressed. | • This manuscript |