Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep

Abstract

Abstract Background The Canadian Society for Exercise Physiology convened representatives of national organizations, research experts, methodologists, stakeholders, and end-users who followed rigorous and transparent guideline development procedures to create the Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep. These novel guidelines for children of the early years embrace the natural and intuitive integration of movement behaviours across the whole day (24-h period). Methods The development process was guided by the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Four systematic reviews (physical activity, sedentary behaviour, sleep, combined behaviours) examining the relationships within and among movement behaviours and several health indicators were completed and interpreted by a Guideline Development Panel. The systematic reviews that were conducted to inform the development of the guidelines, and the framework that was applied to develop the recommendations, followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Complementary compositional analyses were performed using data from the Canadian Health Measures Survey to examine the relationships between movement behaviours and indicators of adiposity. A review of the evidence on the cost effectiveness and resource use associated with the implementation of the proposed guidelines was also undertaken. A stakeholder survey (n = 546), 10 key informant interviews, and 14 focus groups (n = 92 participants) were completed to gather feedback on draft guidelines and their dissemination. Results The guidelines provide evidence-informed recommendations as to the combinations of light-, moderate- and vigorous-intensity physical activity, sedentary behaviours, and sleep that infants (

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R E S E A R C H Open Access
Canadian 24-Hour Movement Guidelines
for the Early Years (0–4 years): An
Integration of Physical Activity, Sedentary
Behaviour, and Sleep
Mark S. Tremblay
1*
, Jean-Philippe Chaput
1
, Kristi B. Adamo
2
, Salomé Aubert
1
, Joel D. Barnes
1
, Louise Choquette
3
,
Mary Duggan
4
, Guy Faulkner
5
, Gary S. Goldfield
1
, Casey E. Gray
1
, Reut Gruber
6
, Katherine Janson
7
, Ian Janssen
8
,
Xanne Janssen
9
, Alejandra Jaramillo Garcia
10
, Nicholas Kuzik
11
, Claire LeBlanc
12
, Joanna MacLean
13
,
Anthony D. Okely
14
, Veronica J. Poitras
1
, Mary-Ellen Rayner
15
, John J. Reilly
9
, Margaret Sampson
1,16
,
John C. Spence
11
, Brian W. Timmons
17
and Valerie Carson
11
Abstract
Background: The Canadian Society for Exercise Physiology convened representatives of national organizations,
research experts, methodologists, stakeholders, and end-users who followed rigorous and transparent guideline
development procedures to create the Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An
Integration of Physical Activity, Sedentary Behaviour, and Sleep. These novel guidelines for children of the early
years embrace the natural and intuitive integration of movement behaviours across the whole day (24-h period).
Methods: The development process was guided by the Appraisal of Guidelines for Research and Evaluation (AGREE) II
instrument. Four systematic reviews (physical activity, sedentary behaviour, sleep, combined behaviours) examining the
relationships within and among movement behaviours and several health indicators were completed and interpreted
by a Guideline Development Panel. The systematic reviews that were conducted to inform the development of the
guidelines, and the framework that was applied to develop the recommendations, followed the Grading of
Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Complementary compositional
analyses were performed using data from the Canadian Health Measures Survey to examine the relationships between
movement behaviours and indicators of adiposity. A review of the evidence on the cost effectiveness and resource use
associated with the implementation of the proposed guidelines was also undertaken. A stakeholder survey (n=546),
10 key informant interviews, and 14 focus groups (n= 92 participants) were completed to gather feedback on draft
guidelines and their dissemination.
Results: The guidelines provide evidence-informed recommendations as to the combinations of light-, moderate- and
vigorous-intensity physical activity, sedentary behaviours, and sleep that infants (<1 year), toddlers (1–2years)and
preschoolers (3–4 years) should achieve for a healthy day (24 h). Proactive dissemination, promotion, implementation,
and evaluation plans were prepared to optimize uptake and activation of the new guidelines.
(Continued on next page)
* Correspondence: mtremblay@cheo.on.ca
1
Healthy Active Living and Obesity Research Group, Children’s Hospital of
Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1,
Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The Author(s) BMC Public Health 2017, 17(Suppl 5):874
DOI 10.1186/s12889-017-4859-6
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(Continued from previous page)
Conclusions: These guidelines represent a sensible evolution of public health guidelines whereby optimal health is
framed within the balance of movement behaviours across the whole day, while respecting preferences of end-users.
Future research should consider the integrated relationships among movement behaviours, and similar integrated
guidelines for other age groups should be developed.
Keywords: Infants, Toddlers, Preschoolers, Adiposity, Motor development, Cognitive development, Public health,
Recommendations, Guideline development
Background
Movement behaviours across the whole day (24-h
period) have recently garnered increased interest in pub-
lic health research and practice. For example, Canada re-
leased evidence-informed Canadian 24-Hour Movement
Guidelines for Children and Youth: An Integration of
Physical Activity, Sedentary Behaviour, and Sleep [1] in
response to undesirable trends in childhood physical ac-
tivity [2–4], sedentary behaviour [2–4], and sleep [4–6].
Systematic reviews of studies involving these three topics
show desirable movement behaviours (e.g., longer sleep,
less sedentary behaviour or screen time, more physical
activity) to be beneficially associated with a variety of
holistic health indicators in children and youth [7–10].
Subsequent analyses demonstrated consistent evidence
of additional health benefits associated with meeting an
increased number of movement behaviour guidelines
[11–14], supporting their integration in public health
messaging. Feedback from stakeholder and end-user
groups is supportive of this integrated approach [15, 16].
Recent systematic reviews that focused on children of
the early years (0–4 years) and examined the relation-
ships between health indicators and physical activity
[17–19], sedentary behaviours [20, 21], sleep duration
[22], and movement behaviour combinations [23] all
suggest health benefits associated with desirable move-
ment behaviours. Current evidence indicates that 62–
84% of Canadian preschoolers (aged 3–4 years) are
meeting physical activity guidelines [24–26]; however,
only 18–24% meet current screen time recommendations
[24–27]. Evidence on toddlers (aged 1–2 years) indi-
cates virtually all meet the physical activity guidelines
but only 15% meet screen time guidelines [28]. Con-
cern over the low proportion of children of the early
years meeting screen time guidelines [27] is evidenced
by recent published statements by the American Acad-
emy of Pediatrics [29] and the Canadian Paediatric Society
[30]. Several recent reviews have explored potential
mechanisms linking excessive screen time with health
indicators [20, 31, 32]. There are no previous system-
atic review-informed Canadian sleep guidelines for
the early years [22]. Collectively these findings pro-
vide evidence of the importance of all movement be-
haviours in the early years.
Following the rationale to develop the Canadian 24-
Hour Movement Guidelines for Children and Youth [1],
extending this whole-day approach to movement behav-
iours to the early years is a natural evolution of this
work. Furthermore, evidence from focus group discus-
sions and key informant interviews suggest that stake-
holders (e.g., clinicians, practitioners, physical activity
knowledge translation groups, researchers) and end-
users’(e.g., pediatricians, parents, early childhood educa-
tors) are supportive of a similar approach for children of
the early years [33]. Therefore, the purpose of this
manuscript is to outline the process and outcomes for
the development of the Canadian 24-Hour Movement
Guidelines for the Early Years (0–4 years): An Integra-
tion of Physical Activity, Sedentary Behaviour, and Sleep
released by the Canadian Society for Exercise Physiology
and partners on November 20, 2017. There are no previ-
ously developed Canadian evidence-based guidelines in-
tegrating recommendations for all movement behaviours
for the early years. These new, integrated recommenda-
tions are intended to provide parents, caregivers, health
professionals, and policy-makers with guidance on the
quality and quantity of physical activity, sedentary be-
haviour, and sleep in a 24-h period to achieve the great-
est health benefits in children 0 –4 years of age.
Throughout this paper the term “movement behaviours”
is used to encompass physical activities of all intensities,
sedentary behaviours (defined as any waking behav-
iour characterized by an energy expenditure ≤1.5
metabolic equivalents, while in a sitting, reclining or
lying posture [34]), and sleep; thus, conceptualizing
movement on a continuum from sleep to high-
intensity physical activity [35].
Methods
Overall guideline development process
The process used to develop the Canadian 24-Hour
Movement Guidelines for the Early Years (0–4years)
followed the 15-stage framework described in detail by
Tremblay and Haskell [36]. The process included the ap-
plication of the Appraisal of Guidelines for Research and
Evaluation (AGREE) II instrument [37–40] from the out-
set as well as the early engagement of guideline develop-
ment methodologists, and benefitted from the significant
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experience and learning from earlier guideline develop-
ment, dissemination, and implementation efforts. Fig. 1
provides a summary of the timelines and sequence of
events involved in the development of the guidelines.
In November 2015, a Leadership Committee was
formed that included the project principal investigators,
representatives from each of the funding partners
(Canadian Society for Exercise Physiology [CSEP];
Healthy Active Living and Obesity Research Group
[HALO] at the Children’s Hospital of Eastern Ontario
Research Institute; University of Alberta; and Partici-
pACTION), methodologists, and support staff. In August
2016, the Public Health Agency of Canada (PHAC) pro-
vided support for the guideline development and also
joined the Leadership Committee. The Leadership
Committee met monthly to provide oversight, strategic
direction, fiscal accountability, and attentiveness to
AGREE II criteria. Subsets of the Leadership Commit-
tee met as required to ensure the project advanced
efficiently. In January 2016, a Guideline Development
Panel (GDP) was formed with members including re-
search experts, stakeholder groups, knowledge users,
international collaborators, methodology consultants,
parents, and project managers (Table 1).
The GDP met in February 2016, for a two-day meet-
ing. The objectives of this initial meeting were to provide
an overview of the guideline development process, re-
sponsibilities, and timelines; introduce the methodology
consultants and explain their responsibilities; hear from
international delegates about other countries’guideline
processes and the potential for harmonization and
avoiding duplication of efforts; finalize the systematic re-
view parameters; finalize the search strategies for the
systematic reviews; discuss and set timelines for the sys-
tematic reviews; and initiate discussions regarding
knowledge translation, dissemination, and evaluation. In
accordance with the GRADE handbook [41], the group
also identified and prioritized the health outcomes/indi-
cators for each of the systematic reviews, with a focus
on health outcomes/indicators valued by the individ-
uals who will be applying these guidelines (e.g., par-
ents, early childhood educators, health professionals).
In the context of paediatrics, health outcomes (e.g.,
disease manifestations, mortality) are uncommon, so
for the purposes of this manuscript the term “health
indicator”will be used.
Systematic reviews
Though the initial GDP meeting was funded by a Canadian
Institutes of Health Research (CIHR) grant to update the
previous early years sedentary behaviour guidelines [27],
the Leadership Committee agreed that the effort must
adhere to the whole-day approach taken with the new
Canadian 24-Hour Movement Guidelines for Children
and Youth [1], and additional funding sources were
discussed to support this approach. Consequently,
four systematic reviews were required. A brief over-
view of each systematic review is provided below,
with full details available elsewhere in this special
supplement [18, 21–23]. Reviewers systematically
searched online databases for articles on apparently
healthy children, including those with obesity, but ex-
cluding papers specifically targeting children with
known disease, disability or impairments. The early
years were defined as ages 0–4 years and further sub-
divided into infants (<1 year), toddlers (1–2years),
and preschoolers (3–4 years). The quality of evidence
in each systematic review was assessed by indicator,
study design, and age group (where possible), using
Fig. 1 Timelines and sequence of events involved in the development
of the Canadian 24-Hour Movement Guidelines for the Early Years (0–4years):
An Integration of Physical Activity, Sedentary Behaviour, and Sleep
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Table 1 Guideline Development Panel
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
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Table 1 Guideline Development Panel (Continued)
Panel member Affiliation Role Conflict of interest declaration
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
ACSM American College of Sports Medicine, AGREE Appraisal of Guidelines for Research and Evaluation; CAE Certified Association Executive, CHEO RI Children’s Hospital of Eastern Ontario Research Institute; CIHR
Canadian Institutes of Health Research, CSEP Canadian Society for Exercise Physiology, FRCPC Fellow of the Royal College of Physicians of Canada, GRADE Grading of Recommendations Assessment, Development, and
Evaluation, HALO Healthy Active Living and Obesity Research Group, PA physical activity, PHAC Public Health Agency of Canada, SB, sedentary behaviour
a
Veronica Poitras was a Research Manager (HALO, CHEO RI) during the conduct of the systematic reviews and preparation of the initial draft of the guidelines
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the Grading of Recommendations Assessment, Develop-
ment, and Evaluation (GRADE) framework [42, 43].
The first systematic review examined the relationships
between objectively and subjectively measured physical
activity and health indicators in the early years [18], up-
dating and building on an earlier systematic review used
to inform Canadian Physical Activity Guidelines for the
Early Years [26, 44]. As detailed in the international
Prospective Register of Systematic Reviews (PROSPERO;
Registration no. CRD42016035937), the Population,
Intervention, Comparator, and Outcome (PICO) param-
eters [45] included apparently healthy children aged 1 to
<60 months; objectively and subjectively measured phys-
ical activity; various volumes, durations, frequencies, pat-
terns, types, and intensities of physical activity; and both
critical (adiposity, motor development, psychosocial
health, cognitive development, fitness) and important
(bone and skeletal health, cardiometabolic health, and
risks/harm) health indicators [18]. Note that according
to GRADE, outcomes rated as “critical”are those that
are considered essential for decision-making; these are
weighted most heavily in the process of moving from the
evidence to the guideline recommendations (see GRADE
evidence to decision framework: summary below).
“Important”health indicators were also identified by the
GDP but given lower weighting through the evidence to
decision process.
Updating and extending the earlier systematic review
that LeBlanc et al. [46] conducted for the Canadian
Sedentary Behaviour Guidelines for the Early Years [27],
the second systematic review examined relationships be-
tween sedentary behaviour and health indicators in the
early years (PROSPERO Registration no. CRD42016035270)
[21]. PICO parameters included the population of ap-
parently healthy children aged 1 to <60 months; inter-
ventions and comparators were durations, patterns,
and types of sedentary behaviours (e.g., seated watch-
ing television, playing on the computer, reading, eat-
ing, travelling in a car); and both critical (adiposity,
motor development, psychosocial health, cognitive develop-
ment) and important (bone and skeletal health, cardiometa-
bolic health, fitness, and risks/harms) health indicators [21].
Theobjectiveofthethirdsystematicreviewwasto
examine the associations between sleep duration and
health indicators in children of the early years
(PROSPERO Registration no. CRD42016040096) [22].
The review included apparently healthy children
aged 1 to <60 months; interventions and compara-
tors of various sleep durations; and both critical
(adiposity, emotional regulation, cognitive develop-
ment, motor development, growth) and important
(cardiometabolic health, sedentary behaviour, physical
activity, quality of life/well-being, risks/injuries) health
indicators [22].
The fourth systematic review examined combinations
of two or more movement behaviours and the associa-
tions with health indicators in children of the early years
(PROSPERO Registration no. CRD42015015493) [23].
The PICO parameters included the population of appar-
ently healthy children aged 1 to <60 months; interven-
tion/exposure (combination of ≥2 movement behaviours
[i.e., sleep and sedentary behaviour; sleep and physical
activity; sedentary behaviour and physical activity; and
sleep, sedentary behaviour, and physical activity]); com-
parator (various levels and combinations of movement
behaviours); and indicators (critical: adiposity, motor de-
velopment, psychosocial health/emotional regulation,
cognitive development, fitness, and growth; important:
bone and skeletal health, cardiometabolic health, and
risks) [23].
Compositional analyses
Research on movement-related behaviours and the
resultant public health guidelines have typically taken a
segregated rather than integrated approach. Not surpris-
ingly, the evidence base is similarly constructed. While
three of the systematic reviews outlined above provide a
comprehensive assessment of the relationships between
individual movement behaviours (i.e., sleep, sedentary
behaviour, physical activity) and indicators of health,
only the review by Kuzik et al. [23] examined evidence
in relation to combinations of two or more movement
behaviours. Examining the combinations of movement
behaviours that constitute the complete 24-h period is
not common and presents inherent analytical challenges
[47, 48]. Because the constituent parts (sleep, sedentary
behaviour, physical activity) saturate the entire 24-h
period, a change in any behaviour must be done at the
expense of one of the other behaviours, making the vari-
ables time-dependent and constitutionally collinear. To
address this reality, assess the legitimacy of the whole-
day approach to health promotion in the early years, and
help inform the new integrated guidelines, complemen-
tary compositional data analyses [47, 49] were conducted
using data from the Canadian Health Measures Survey
(CHMS) [50].
The specific objectives of the compositional analyses
were twofold: (1) to explore the combined associations
of the composition of sleep duration, sedentary time,
light-intensity physical activity (LPA), and moderate- to
vigorous-intensity physical activity (MVPA) with adipos-
ity indicators, and (2) to explore the association of the
time spent in sleep, sedentary behaviour, LPA, and
MVPA with adiposity indicators relative to the time
spent in the other behaviours in a representative sample
(n= 552) of Canadian preschool-aged children from the
CHMS [51]. Sedentary time, LPA, and MVPA were mea-
sured with Actical accelerometers (Philips Respironics,
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Bend, Oregon, USA); sleep duration was measured by
parental report. Height and body mass (to determine
body mass index [BMI] z-scores based on World Health
Organization growth standards) and waist circumfer-
ences (WC) were directly measured following standard
procedures [52–54]. Compositional data analyses were
used to examine the cross-sectional associations. For
complete details on the sample, measurement proce-
dures and compositional analyses see Carson et al. [51].
These compositional analytic procedures can be used as
a blueprint for future research to examine the associa-
tions of multiple movement behaviours and other health
indicators beyond adiposity.
Additional considerations from GRADE
The GRADE process uses several sources of information
in a systematic and transparent fashion to inform guide-
line recommendations. These factors include quality of
the evidence (i.e., risk of bias, inconsistency, indirect-
ness, imprecision, publication bias), balance of benefits
and harms, end-user preferences and values, resource
implications, feasibility, acceptability, and equity issues.
This collection of information is used to inform the dir-
ection (i.e., for or against) and the strength (i.e., strong
or conditional/weak) of the recommendation.
The quality of the evidence was assessed and reported
in the systematic reviews [18, 21–23]. The balance of
benefits and harms was also informed by the systematic
reviews as well as by detailed discussions and eventual
consensus by the GDP. End-user preferences and values,
resource implications, feasibility, acceptability, and equity
issues were assessed through the stakeholder survey, key
informant interviews, and focus groups (described in
Guidelines recommendations and stakeholder consulta-
tions section). To further explore resource requirements
(costs), a review of the evidence on cost and resource
use related to 24-h movement behaviours was con-
ducted. However, no evidence was found that met the
inclusion criteria.
Guidelines recommendations and stakeholder consultations
The second meeting of the GDP was held in January
2017. The objectives of this three-day meeting were to
review, discuss, debate, and interpret findings from
systematic reviews and compositional analyses; review
results of cost-effectiveness/resource use analysis; craft
individual components of the movement behaviour
guidelines; create 24-h integrated movement behaviour
guidelines; identify research gaps; and plan the launch,
dissemination, promotion, and evaluation activities.
Draft guideline recommendations were created by the
GDP based on the overall balance between the possible
benefits and harms of various levels of physical activity,
sedentary behavior, and sleep; stakeholder and end-user
preferences and values related to these movement be-
haviours; and considerations related to feasibility, acces-
sibility, resource use, and equity. The draft guidelines
were translated into French and back-translated for veri-
fication. All GDP members approved the draft guidelines
for the stakeholder consultations.
A cross-sectional survey (see Additional file 1 for
complete survey in English and French) was developed
to gather stakeholder and end-user feedback on (1) the
content and format of the draft guidelines, (2) elements
of importance to the GRADE Evidence to Decision
Framework (i.e., how much end-users value the out-
comes, the magnitude of the resource use requirements/
perceived incremental costs associated with implement-
ing the guidelines, equity, acceptability, and feasibility of
implementing the guidelines) [55], and (3) suggestions
regarding key intermediaries to implement and activate
the guidelines. Following approval from the Children’s
Hospital of Eastern Ontario Research Institute’s Re-
search Ethics Board, the survey was created online using
REDCap (Research Electronic Data Capture) [56] soft-
ware and was open from March 24 to April 18, 2017.
Participants were recruited via a snowball sampling pro-
cedure, initiated through GDP distribution networks.
Data were imported into Excel (Microsoft Corporation,
Seattle, Washington, USA) for analysis of closed- and
open-ended responses. Descriptive statistics were calcu-
lated to summarize participant characteristics and
closed-ended feedback. Open-ended feedback was syn-
thesized qualitatively, using thematic analyses whereby
research staff read through the full transcripts of partici-
pant responses and independently identified common
themes that emerged from the data. Independent assess-
ments were discussed among the assessors until agree-
ment on a final set of themes was achieved.
In addition to the online stakeholder survey, a series
of focus groups and key informant interviews were com-
pleted to examine stakeholders’(experts in pediatric and
family medicine, physical activity knowledge translation,
and research) and end-users’(parents and early child-
hood educators) perceptions of the draft guidelines [33].
Ethics approval for these consultations was obtained
from the Research Ethics Boards of the University of
British Columbia and the Children’s Hospital of Eastern
Ontario Research Institute. Stakeholders (n= 10) engaged
in telephone interviews and end-users (n= 92) partici-
pated in focus groups (n= 14) to discuss perceived clarity
and need for the guidelines, potential barriers to imple-
mentation, identification of credible messengers, and
methods for dissemination of the guidelines. Audio-
recordings from the focus groups and interviews were
transcribed verbatim and thematic analysis was conducted
consistent with that reported by Faulkner et al. [16]. Full
details on the methodology are available elsewhere [33].
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A sub-committee of the GDP reviewed summaries of
the stakeholder survey, focus group and interview re-
sults, and revised the guidelines based on the feedback,
ensuring changes remained true to the available evidence
base. The revised guidelines were circulated to the entire
GDP for comment and final revisions. Consensus was
achieved on the final guidelines. Revisions were trans-
lated to finalize the French version.
Dissemination, implementation and evaluation plans
The release of the Canadian 24-Hour Movement Guidelines
for Children and Youth [1] marked the initiation of a para-
digm shift away from consideration of isolated behaviours
towards a “whole-day matters”approach. This shift created
opportunity for the redevelopment of guideline dissemin-
ation and implementation practices [57]. In addition to trad-
itional passive dissemination strategies (e.g., website posts,
distribution of print resources), additional efforts were made
to implement and activate the child and youth guidelines.
An iconic visual identity was created, a pseudo-set (sweat,
step, sleep, sit) was established and an interactive web ex-
perience was created called “build your best day”(www.buil
dyourbestday.com). Members of the GDP, with additional
members from CSEP and ParticipACTION (Canadian not-
for-profit organization promoting physical activity in
Canada), formed a sub-committee (Guideline Implementa-
tion and Activation Committee) to facilitate strategic and
proactive dissemination, promotion, and implementation of
the new early years guidelines, building off the work com-
pleted for the children and youth guidelines, and maintain-
ing the same “look and feel”. The harmonized visual identity
was used in the preparation of materials, tools and re-
sources, both digital and print, for the release of the
Canadian 24-Hour Movement Guidelines for the Early
Years. The Guideline Implementation and Activation
Committee also developed an integrated marketing and
communications plan for sustained dissemination and im-
plementation following the guideline launch. Finally, the
work of the sub-committee responsible for evaluation of the
child and youth guidelines was expanded to include assess-
ment of the impact of the dissemination and implementa-
tion efforts of the guidelines for the early years.
The guideline development process in Canada insti-
gated a similar process in Australia. Leveraging the
background work done in Canada, and guided by the
GRADE “adolopment”procedures [58], the Australian
24-Hour Movement Guidelines for the Early Years
were prepared [59] and concurrent launch plans were
coordinated.
Research gaps and surveillance recommendations
Research gaps were identified and recorded throughout
the guideline development process (e.g., systematic
reviews, guideline meetings, sub-group discussions).
The new paradigm of the 24-h movement guidelines re-
quires earlier surveillance measures to be reconsidered,
with a shift from an individual behaviour focus to the
combination or composition of the behaviours.
To make recommendations in this regard a Surveillance
Sub-committee of the GDP, with additional members with
extensive movement behaviour surveillance experience,
convened via teleconferences to discuss and develop pre-
liminary recommendations for the monitoring and sur-
veillance of the new 24-h guidelines, following an
approach similar to what was done for the child and youth
guidelines [1].
Four independent reviewers were contracted to con-
duct an AGREE II assessment on the entire guideline
development process using the guideline materials and
systematic reviews [37–40]. All of the materials pre-
sented in this special issue of BMC Public Health were
provided to the independent assessors.
Results
Overall guideline development process
The guideline development process successfully adhered
to the framework outlined by Tremblay and Haskell
[36]. Throughout the process, methodologists on the
GDP familiar with AGREE II [37–40] and GRADE
[42, 43, 55] provided advice and kept detailed records of
discussions and decisions to help inform the guideline rec-
ommendations and the Evidence to Decision Framework
[55]. The Leadership Committee and its various sub-
committees met in person or by teleconference more than
50 times in the course of the guideline development
process. Full GDP meetings were held in Ottawa, Canada
in February 2016 and January 2017, with additional cor-
respondence done through email.
Systematic reviews
A brief summary of the findings of each systematic re-
view is provided below, with detailed results available
elsewhere in this special issue of BMC Public Health
[18, 21–23]. Because of significant heterogeneity in a
variety of variables, meta-analyses could not be performed
for most indicators in the systematic reviews, so narrative
syntheses were predominantly employed. Collectively,
34,566 titles and abstracts were screened and 271 papers
were included in the systematic reviews.
Physical activity and health indicators
Ninety-six studies (71,291 unique participants from 36
countries) were included in the review on physical activ-
ity and health indicators in the early years [18]. Study
designs included randomized controlled trials (n= 8),
clustered randomized controlled trials (n= 4), non-
randomized interventions (n= 9), cross-over trials
(n= 3), longitudinal (n= 7), longitudinal with additional
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cross-sectional analyses (n= 5), case-control (n= 4),
case cross-over (n= 1), and cross-sectional (n= 55).
One small meta-analysis (four studies, 1100 participants)
was conducted examining adiposity as a health indicator;
otherwise narrative syntheses were employed. Physical
activity was consistently associated with improved motor
and cognitive development as well as psychosocial and
cardiometabolic health in randomized and non-
randomized intervention studies, and with favourable
motor development, fitness, and bone and skeletal health
in observational studies. Light- and moderate-intensity
physical activity were not consistently associated with
any health indicators, whereas moderate- to vigorous-
intensity, vigorous-intensity, and total physical activity
were consistently favourably associated with multiple
health indicators. Across study designs, consistent
favourable associations with health indicators were ob-
served for different types of physical activity, including
active play, aerobic activity, dance, prone position
(infants; <1 year), and structured/organized activities.
For toddlers and preschoolers, the most favourable fre-
quency and duration of physical activity were unclear,
however, more physical activity appeared better for
health. For infants, ≥30 min/day of the prone position,
or “tummy time”, was most favourably associated with
health indicators. The quality of the evidence ranged
from “very low”to “high”and the majority of evidence
was in preschool-aged children (3–4 years).
Sedentary behaviour and health indicators
A total of 96 studies (195,430 participants from 33 coun-
tries) were included in the sedentary behaviour system-
atic review [21]. Study designs included randomized
controlled trials (n= 1), case-control (n= 3), longitu-
dinal (n= 25), longitudinal with additional cross-
sectional analyses (n= 5), and cross-sectional (n= 62).
Associations between objectively measured total seden-
tary time and indicators of adiposity and motor develop-
ment were predominantly null; associations between
screen time and indicators of adiposity, motor or cogni-
tive development, and psychosocial health were primar-
ily unfavourable or null. Associations between reading/
storytelling and indicators of cognitive development
were favourable or null. Associations between time spent
seated (e.g., in car seats or strollers) or in the supine
position, and indicators of adiposity and motor develop-
ment, were primarily unfavourable or null. The quality
of evidence ranged from “very low”to “moderate”across
study designs and health indicators.
Sleep and health indicators
The systematic review on sleep duration and health indi-
cators in the early years [22] included 69 studies (62
unique samples; 148,524 unique participants from 23
countries). The study designs included randomized trials
(n= 3), non-randomized interventions (n= 1), longitu-
dinal studies (n= 16), cross-sectional studies (n= 42),
and longitudinal studies that also reported cross-
sectional analyses (n= 7). Sleep duration was assessed
by parental report in 70% of studies (n= 48) and was
measured objectively (or both objectively and subject-
ively) in 30% of studies (n= 21). In general, shorter sleep
duration was associated with higher adiposity, poorer
emotional regulation, impaired growth, more screen
time, and higher risk of injuries. The evidence related to
indicators of cognitive development, motor develop-
ment, physical activity, and quality of life/well-being was
less clear, with no consistent associations. The quality of
evidence ranged from “very low”to “high”across study
designs and health indicators.
Combined movement behaviours and health indicators
The systematic review that examined associations among
combinations of movement behaviours and health indi-
cators in children of the early years [23] included 10
studies (7549 participants from 5 countries). Study de-
signs included cluster randomized controlled trials
(n= 3), non-randomized intervention (n= 1), cross-
sectional (n= 4), and longitudinal (n= 2). Across study
designs the most ideal combinations of sedentary
behaviour and physical activity (i.e., combinations of
movement behaviours hypothesized to be beneficial for
health, based on research conducted in populations aged
≥5 years; e.g., decreased sedentary behaviour, high phys-
ical activity) were favourably associated with motor de-
velopment and fitness among preschool-aged children;
both favourably and not associated with adiposity among
toddlers and preschool-aged children; and not associated
with growth among toddlers and preschool-aged chil-
dren. The most ideal combinations of sleep and seden-
tary behaviour were favourably associated with adiposity
among infants and toddlers. The quality of evidence
ranged from “very low”to “moderate”. These data indi-
cate that ideal combinations of physical activity, seden-
tary behaviour and sleep may be important for health in
the early years.
Overall, the reviews showed that a need exists for
better quality studies with stronger research designs, es-
pecially those that can provide information on dose-
response relationships, if they exist. Furthermore, they
identified a need for future research to determine the
ideal distribution and pattern of daily movement behav-
iours (physical activity, sedentary behaviour, sleep) for
optimal health throughout the early years.
Compositional analyses
Complete data for cross-sectional compositional analyses
were available on 552 participants aged 3–4 years from
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cycles 2 and 3 (2009–2013) of the CHMS [51]. The aver-
age age of the sample was 3.5 years and was balanced
between males and females (49.2% female). On average,
participants spent 30.9% of the 24-h period sedentary,
15.9% in LPA, 4.5% in MVPA, and 48.7% in sleep. The
two variables with the highest co-dependence were sed-
entary time and sleep duration and the two variables
with the lowest co-dependence were sedentary time and
MVPA. The composition of movement behaviours was
significantly associated with BMI z-scores but not with
WC. The time spent in sleep, sedentary behaviour, LPA,
or MVPA relative to the other behaviours was not sig-
nificantly associated with the adiposity indicators. This
study was the first to use compositional analyses to
examine associations of all movement behaviours with
adiposity indicators in preschool-aged children. The
overall composition of movement behaviours, rather
than any single movement behaviour in isolation, ap-
pears important for healthy BMI z-scores in preschool-
aged children. However, future research, especially
experimental research, is needed to determine the opti-
mal movement behaviour composition that should be
promoted in this age group and for younger children
aged 0–2 years.
Guideline recommendations and stakeholder consultations
The draft guidelines are available in Additional file 1 as
part of the stakeholder survey.
Stakeholder survey
Demographics: Data from 695 stakeholders and end-
users were collected by the online survey; missing data
ranged from 130 to 287 per closed-ended item. There
were participants from all provinces and territories ex-
cept the Northwest Territories and Nunavut; the greatest
proportion were employed in Ontario (51.7%), followed
by Western Canada (36.7%), the Maritimes (3.0%),
Quebec (2.7%), and Yukon Territory (0.2%). In addition,
1.2% indicated their work was national in scope and
4.5% worked outside of Canada. By sector, participants
were primarily associated with physical activity/fitness
(22.9%), public health (16.2%), healthcare (14.2%), educa-
tion (12.4%), and research (10.2%).
Content and format of the Guidelines: A complete
summary of the stakeholder survey results is provided in
Table 2. Participants agreed with the content and format
of the draft title of the guidelines, the preamble, and the
guidelines (combined “Strongly Agree”and “Somewhat
Agree”: 89.1, 96.2 and 96.1%, respectively), and agreed
that the title, preamble, and guidelines were clearly
stated (combined “Strongly Agree”and “Somewhat
Agree”: 94.2, 96.5, and 98.9%, respectively). A minority
of participants suggested additions or changes. Among
the feedback received on the title, the most frequent
comments suggested the title was too long, the target
audience was unclear (i.e., practitioners versus general
population), and the early years age range needed to be
made explicit. Feedback regarding the preamble sug-
gested it was too long, the target audience was unclear,
and the language level was too high if intended for gen-
eral populations. There was limited feedback provided
on the guidelines themselves, and there was no consist-
ent pattern among comments received.
GRADE Evidence to Decision Framework: There was
high agreement (>60% was considered high agreement)
among participants that the 24-h guidelines are a prior-
ity for them (95.8%). There was also high agreement that
implementing the guidelines would be feasible (85.0%),
acceptable (79.1%), useful (78.3%), cost-effective (64.8%),
and equitable across population groups (85.8%). An add-
itional item prompted participants to judge the incre-
mental cost relative to the net benefit of implementing
the guidelines; most (81.1%) indicated that the benefits
of using the guidelines would likely outweigh the costs.
Open-ended response options were available for par-
ticipants who wished to explain or elaborate on their re-
sponses to closed-ended items for items assessing
acceptability, resource use, perceived incremental cost-
benefit ratio, and equity. Fifty-seven of the 112 partici-
pants who provided feedback to the acceptability item,
“Would you use the 24-Hour Guidelines?”responded
favourably. Thirty participants provided favourable or
neutral feedback and also suggested an addition or
change to some element of the guidelines, most
commonly requesting examples or added descriptions.
Fourteen respondents provided negative feedback and
11 indicated the guidelines were not relevant in their
work or their personal life. Fifty-five participants elabo-
rated on their responses to the resource use item. Of
those, 10 indicated the cost of using the guidelines
would be small to negligible, 4 indicated the cost would
be difficult to manage, and 13 described the costs but
did not indicate if it would be easy or difficult to absorb
into their operating budget. Other responses suggested
respondents did not understand the question. Forty par-
ticipants provided written feedback on the perceived
incremental cost-benefit ratio item. Among them, 19
provided favourable responses, one responded that there
would be no benefit and only cost, and 19 participants
did not provide clear feedback. Fifty-seven participants
expanded on their responses to the equity item. Eleven
indicated that following the guidelines would benefit all
groups equally while two disagreed, expressing a belief
that socioeconomic status would moderate the relation-
ship between guideline adherence and any expected
health indicators. Thirty-three participants described
barriers or facilitators to implementation and 11 did not
answer the question.
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Implementation and activation of the guidelines:
Stakeholders (227 total responses; some named multiple
intermediaries) indicated childcare providers (176), par-
ents (173), and health care providers (107) were the
most important intermediaries to target for implementa-
tion and activation of the guidelines. The most endorsed
modalities for supporting intermediaries to implement
and activate the guidelines (125 total responses) included
training opportunities such as prenatal workshops as
well as pre-service and in-service training (n= 55), and
products such as “toolboxes”or posters, with explanations
and examples of how to adopt ad activate the guide-
lines (n= 43).
Focus groups and key informant interviews
The focus groups and key informant interviews rein-
forced the findings from the stakeholder survey, that the
proposed guidelines were very well received by both
stakeholders and end-users [33]. A clear need for such
integrated guidelines was identified and most believed
the guidelines were achievable. Several potential barriers
to uptake were identified including low awareness of
Table 2 Summary results of 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%)
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current guidelines and ‘daily challenges’(such as the al-
lure of screen time, lack of time, competing priorities,
and challenges in the context of shifting social norms).
A range of methods and messengers of dissemination
were recommended by focus group participants and key
informants. Health care and child care settings were the
most frequently cited locations for dissemination and
physicians and early childhood educators were the most
common suggestions for messengers. Results suggest
that going forward it will be important to dedicate
appropriate support and funding toward dissemination
efforts in order to reach end-users, particularly parents,
health care providers, and early childhood educators.
Revisions to draft guidelines
Following the Guideline Revision Meeting, three changes
were made that altered the content of the preamble: 1) in
the description of the groups for whom the guidelines are
relevant, the GDP decided that replacing “race and ethni-
city”with “cultural background”(adopted in the Australian
guidelines) would better indicate the diversity of popula-
tions to whom the guidelines apply; 2) in the description of
the context of children’s activities it was decided that all
adults have a role in helping children of the early years to
meet the guidelines and therefore, “parents and caregivers”
was replaced with “adults”; and 3) in describing the ex-
pected balance of benefits and unfavourable outcomes as-
sociated with following the guidelines, the term “risk”was
replaced with “harm”for accuracy.
Three changes that altered the content of the guidelines
were made: 1) “while awake”was added to the infant
tummy time recommendation to avoid potential harm in
having the recommendation misinterpreted as contradic-
ting safe sleep recommendations; 2) based on feedback
from the focus groups and from discussions at the
Australian guideline development meetings, “energetic
play”(i.e., MVPA) was added to the toddler physical activity
recommendation; and 3) the term “sedentary”was added to
thescreentimerecommendationbasedontheAustralian
Guideline development process and to better reflect the
evidence, which did not include data on non-sedentary
screen-based activities. Other changes were minor results
of the copy-editing process. The final guidelines, with pre-
amble, in English and French are provided in Figs. 2, 3, 4
and 5. The final quality of evidence and strength of recom-
mendation ratings are provided below in the GRADE
Evidence to decision framework: summary section, including
a summary of the rationale for these decisions, with more
extensive explanations provided in Additional file 2.
GRADE evidence to decision framework: Summary
The specific guideline recommendations in the
Canadian 24-Hour Movement Guidelines for the
Early Years are provided below with corresponding
statements indicating the quality of the evidence
informing the recommendation and the strength of
the recommendations.
For infants (less than 1 year), a healthy 24 h includes:
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.
For toddlers (1–2 years), a healthy 24 h includes:
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.
For preschoolers (3–4 years), a healthy 24 h includes:
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.
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10–13 h of good-quality sleep, which may include a
nap, with consistent bedtimes and wake-up times.
High quality evidence, strong recommendation.
For all age groups:
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
The GDP followed the GRADE system to make determi-
nations about the strength of each recommendation by
considering; 1) the quality of the supporting evidence, 2)
the values and preferences of stakeholders and end-
users, 3) whether the recommendations would be
Fig. 2 Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep –
English Preamble. © Canadian Society for Exercise Physiology, 2017. All rights reserved
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considered a wise use of resources, 4) equity, acceptabil-
ity, and feasibility, and 5) whether the potential benefits
outweigh the potential harms [41].
1) Overall quality of the evidence supporting the
recommendations.
The quality of the evidence from the four systematic
reviews informing the recommendations was
considered in the process of assessing the overall
quality of the evidence supporting each recommendation
[42,43]. After considering the quality of the
evidence associated with the five “critical”health
Fig. 3 Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep –
English Guidelines. © Canadian Society for Exercise Physiology, 2017. All rights reserved
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indicators examined in the physical activity systematic
review, the GDP did not change the previous physical
activity recommendation [26] despite the “low”quality
evidence on adiposity and motor development, and
the “very low”quality evidence on fitness [18]. The
overall certainty of the evidence supporting the
recommendation is “moderate”. The panel reached
this conclusion based on the fact the “moderate”
quality evidence indicating that physical activity
improves psychosocial health and cognitive development
was considered sufficient to support a recommendation
in favour of increasing physical activity [18]. The quality
Fig. 4 Directives canadiennes en matière de mouvement sur 24 heures pour les enfants de 0 à 4 ans: uneapprocheintégréeregroupantl’activité physique,
le comportement sédentaire et le sommeil - French Preamble. © Société canadienne de physiologie de l'exercice, 2017. Tous les droits sont réservés
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Fig. 5 Directives canadiennes en matière de mouvement sur 24 heures pour les enfants de 0 à 4 ans: uneapprocheintégréeregroupantl’activité physique,
le comportement sédentaire et le sommeil - French Guidelines. © Société canadienne de physiologie de l'exercice, 2017. Tous les droits sont réservés
The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 16 of 215
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assessment of “moderate”reflects moderate confidence
that the true effect is likely to be close to the estimate of
the effect presented in the systematic review, but there is
a possibility that it is substantially different.
After considering the quality of the evidence associated
with the four “critical”health indicators in the
sedentary behaviour review, the GDP did not
change the sedentary behaviour recommendation
[27]. Despite the “moderate”quality evidence that
sedentary behaviour may not affect adiposity and
the “very low”quality evidence showing inconclusive
findings for a relationship between sedentary
behaviour and motor development or cognitive
development, there was “moderate”quality evidence
that low sedentary behaviour is favourably associated
with psychosocial health [21]. This was considered
sufficient to support a recommendation in favour of
reducing sedentary behaviour. Therefore, the
overall certainty of the evidence supporting the
recommendation was “moderate”,whichreflects
moderate confidence that the true effect is likely
to be close to the estimate of the effect presented
in the systematic review, but there is a possibility
that it is substantially different.
After considering the quality of the evidence associated
with the five “critical”health indicators associated with
the sleep review, the GDP concluded that despite the
“low”quality evidence that sleep duration is not related
to adiposity, and the “very low”quality evidence that
sleep duration is not related to motor development or
growth, “high”quality evidence indicating that longer
sleep durations are associated with improved
cognitive development and emotional regulation [22]
was sufficient to support a recommendation in favour
of longer sleep durations. As such, the GDP concluded
that the overall certainty of the evidence supporting the
recommendation was “high”,whichreflectshighlevel
of confidence on the part of the GDP that the true
effect lies close to the estimate of effect presented in
the systematic review.
After considering the quality of the evidence associated
with the six critical health indicators considered in the
integrated movement behaviours systematic review
[23], the GDP concluded that the overall certainty of
theevidencesupportingtherecommendationwas“very
low”. The systematic review [23]found“moderate”
quality evidence that the most ideal combinations of
movement behaviours are not related to growth,
“low”quality evidence indicating that the most
ideal combinations of integrated behaviours were
favourably associated with motor development,
and favourably or unrelated to adiposity, and
“very low”quality evidence indicating ideal
combinations were favourably related to fitness
[23]. Furthermore, despite “very low”quality
evidence that outdoor time was only related to 1
out of 10 motor skills, “low”quality evidence
showed that higher outdoor time was associated
with lower sedentary time, and “very low”quality
evidence showed that higher outdoor time was
associated with lower blood pressure [60]. All six
critical health indicators were taken into account
in the development of the integrated movement
recommendation, including two that were rated as
“very low”quality evidence. The assessment of
“very low”overall quality of the evidence indicates
that the guideline panel has very little confidence
in the effect estimate. The true effect is likely to
be substantially different from the estimate of effect.
2) Values and preferences of stakeholders and end-users.
While selecting “important”and “critical”health
indicators, the GDP considered the importance (i.e.,
values and preferences) of each indicator to parents,
stakeholders and end-users in terms of the development
and health of children of the early years. A study was
not conducted to have these groups identify important
health indicators, per se. However, almost all GDP
members were parents, including parents of children of
the early years, and several stakeholder and end-user
representatives were on the GDP. In addition, many
external reviewers of the guidelines were also parents,
stakeholders or end-users and provided input
during the stakeholder survey; almost all (95.8%)
external reviewers indicated the recommendations
were important to them. Considering the indirect
assessments of target group values and preferences
together with the broad range of indicators included
in the systematic reviews that informed these
recommendations, the GDP concluded that there
would likely be no important variability in values
and preferences of health indicators if target groups
had rated the indicators directly.
3) Resource requirements (costs).
A literature search was conducted using systematic
review searching techniques to inform the GDP’s
understanding of the expected short-term costs
(resource use) required to implement the guidelines
as a population-health strategy and to gain insight
into the cost-effectiveness of applying these
recommendations to children of the in early years.
No evidence was found that related to these guidelines.
Given the lack of evidence, the GDP sought input from
external reviewers (via the stakeholder survey) on their
opinions about cost and resource use. Most
stakeholders (64.8%) agreed that the costs associated
with applying the recommendations would be small
or negligible. In terms of the perceived incremental
cost relative to the perceived net benefit, most (81.1%)
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agreed that over the course of a lifetime, the health
benefits of applying the recommendations would likely
outweigh the costs, which in the judgment of the
GDP is likely to generate large savings from a health
care systems perspective. In the judgment of the
GDP considering the available information, the
cost-effectiveness of the recommendations is
supported.
4) Equity, acceptability, and feasibility.
A systematic review of the evidence examining
equity, acceptability, and feasibility amongst
stakeholders was not conducted. Thus, these
elements of the recommendations were informed
by external reviewer input and by judgments
made by the GDP. Most external reviewers (85.5%)
agreed that following these recommendations would
benefit all groups of the population equally. In the
judgment of the GDP, implementing these
recommendations would probably increase health
equity (i.e., decrease health inequity). Similarly, most
external reviewers (78%) indicated that they would
“always”or “frequently”use the recommendations.
Thus, in the judgment of the GDP, these
recommendations are acceptable. Finally, most
external reviewers (85%) indicated that in their
view the recommendations were “somewhat”to
“very easy”to use. Based on this information, in
the judgment of the GDP, the recommendations
are feasible to implement.
5) Benefits vs harms (justification)
Physical Activity: Based on the systematic review by
Carson et al. [18], higher physical activity among
children of the early years was favourably related to
adiposity, motor development, psychosocial health,
cognitive development, and fitness. Although no
evidence pointed specifically to harm resulting from
increasing physical activity, there was no clear effect
observed on bone and skeletal health, cardio-metabolic
health, and injuries to rule out the possibility of harm.
Nevertheless, in the judgment of the GDP, the benefits
of increasing physical activity in children of the early
years are likely to outweigh the potential harms, which
are likely to be limited to injuries and are unlikely to be
serious.
In balancing the benefits against the harms, in the
judgment of the GDP, the desirable indicators
(moderate benefits) are likely to outweigh the
undesirable indicators (very minor harms); therefore,
a recommendation in favour of increasing physical
activity is warranted. The GDP placed more value on
“moderate”quality evidence showing improvements
on adiposity and psychosocial health and on “high”
quality evidence showing a benefit in motor
development, and less value on “very low”quality
evidence showing contradicting findings related to
the effect of physical activity on cardio-metabolic
health, and on “very low”quality evidence showing
that physical activity resulted in an increase in the
number of injuries. The GDP also placed more value
on evidence showing that total physical activity (TPA),
moderate-intensity (MPA), and MVPA resulted in
improved fitness.
A strong recommendation in favour of increasing
physical activity is supported by the assessment of
overall “moderate”quality evidence supporting the
recommendation, the moderate magnitude of the
effect, the low variability in how parents and
stakeholders value the recommendation, the
anticipated small or negligible costs associated
with implementing the recommendation, the large
savings to the healthcare system expected over
the course of a lifetime, and the stakeholder input
suggesting that these recommendations would be
feasible and acceptable to stakeholders.
Sedentary behaviour: According to Poitras et al. [21],
limiting sedentary screen-based behaviours was
associated with benefits (i.e., psychosocial health and
fitness), as was engaging in interactive non screen-
based sedentary behaviour with an adult (i.e.,
storytelling and reading was favourably associated
with cognitive development). In terms of evidence
of potential harms, there was limited inconclusive
“low”and “very low”quality evidence regarding
the effects of sedentary behaviour on motor
development and injuries. Therefore, the impact
of sedentary behaviours on these indicators is uncertain.
Nevertheless, in the judgment of the GDP it is highly
unlikely that decreasing sedentary time or screen-based
behaviours would have an adverse or harmful effect on
motor development. The potential harms resulting from
limiting sedentary behaviour in children are likely
to be minor.
In considering the balance of the benefits versus the
harms, it is the judgment of the GDP that the
moderate benefits of limiting/avoiding restrained
time, sedentary time, and screen based behaviours
outweigh the potential for very minor harms,
warranting a recommendation in favour of the
sedentary behaviour recommendations. The GDP
placed relatively more value on “moderate”quality
evidence showing that reducing sedentary time
improved adiposity (critical) and psychosocial health
(critical), and relatively less value on limited “very
low”quality evidence on the impact of sedentary
behaviour on motor development (critical) and the
lack of evidence about injuries (important).
The overall quality of evidence supporting the
recommendation was deemed to be of “moderate”
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quality, and the magnitude of the effect is expected
to be moderate. Taken together with conclusions
drawn from the parent and stakeholder survey, focus
groups and interviews (i.e, low variability in how
parents and stakeholders value the recommendation,
the costs associated with implementing the
recommendation are expected to be small or
negligible, recommendations would be feasible and
acceptable) and the large savings to the healthcare
system expected over the course of a lifetime, a
strong recommendation is warranted.
Although the body of evidence indicated that limiting
sedentary behaviour is likely to improve health
indicators in children in this age group, there was a
lack of evidence in relation to the optimal sedentary
time in a 24-h day. To address this uncertainty,
experts recommended supporting the current
Canadian Sedentary Behaviour Guidelines for the
Early Years (aged 0 to 4 years) [27]from2012
with slight modifications to introduce guiding
principles as to how sedentary behaviours can fit
in the context of a healthy day. The recommended
sedentary time in the 2012 recommendations align
with the new evidence identified by Poitras et al. [21]
and, therefore, were adopted by the GDP.
Sleep: The systematic review conducted by Chaput
et al. [22] showed that longer sleep durations (total
sleep in 24 h) was associated with benefits related to
emotional regulation, growth, and cognitive
development, and reduced sedentary behaviour.
With regard to potential harms, there was limited
and inconclusive evidence about the impact of
sleep on adiposity, motor development, physical
activity, injuries and quality of life, and no evidence on
cardio-metabolic health. Therefore, the GDP could
not be certain of the impact of longer sleep durations
on these indicators. However, in the judgment of the
GDP, the potential harms resulting from longer sleep
durations are likely to be very minor.
In considering the balance of the benefits versus the
harms, it is the judgment of the GDP that the
moderate benefits of longer sleep durations are likely
to outweigh any potential minor harms, warranting a
recommendation in favour of longer sleep durations
including napping. The GDP placed more value on
“high”quality evidence showing that longer sleep
durations improved emotional regulation (critical) and
cognitive function (critical), and less value on limited
“low”quality and “very low”quality evidence showing
that increasing the duration of sleep may impact
adiposity or physical activity, and on the lack of
evidence examining metabolic health.
The overall quality of evidence supporting the
recommendation was deemed to be of “high”quality
and the magnitude of the effect is expected to be
moderate; the GDP is very confident that the true
effect lies close to the estimate of the effect. Taken
together with the conclusions drawn from the parent
and stakeholder survey, focus groups and interviews
(low variability in how parents and stakeholders value
the recommendation, recommendations would be
feasible and acceptable, and the anticipated costs
associated with implementing the recommendation
are expected to be small or negligible), and the large
savings to the healthcare system expected over the
course of a lifetime, a strong recommendation in
favour of longer sleep durations, including napping is
warranted.
Although the body of evidence indicated that longer
sleep durations, when compared to shorter sleep
durations, were generally favourably associated with
health indicators regardless of age, no conclusions
could be drawn in terms of optimal durations for
infants, toddlers, or preschoolers. Content experts
from the GDP pointed to the USA National Sleep
Foundation [61] and American Academy of Sleep
Medicine [62] guidelines, which recommend that in
a 24-h cycle, newborns (0–3 months) sleep 14–17 h,
infants (4–11 months) sleep 12–15/16 h, toddlers
(1–2 years) sleep 11–14 h, and preschoolers (3–5years)
sleep 10–13 h. This was consistent with the systematic
review findings [22], which did not uncover any
evidence to warrant deviating from these guidelines.
Therefore, the newborn, infant, toddler, and
preschooler recommendations were adopted by
the GDP.
Combined movement behaviours: The systematic
review conducted by Kuzik et al. indicated that the
most ideal combinations of sedentary behaviour and
physical activity were favorably associated with motor
development and fitness; both favorably and not
associated with adiposity; and not associated with
growth [23]. Replacing sedentary time with vigorous
physical activity was found to be beneficial for fitness.
The most ideal combinations of sleep and sedentary
behaviour were favorably associated with adiposity.
There was no evidence on harms/injuries. Therefore,
it is unclear if there would be an impact of combined
movement behaviours on this indicator. However, in
the judgement of the GDP, the potential harms
resulting from increasing physical activity, decreasing
sedentary behaviours, and increasing sleep duration
are likely to be very minor.
In considering the balance of the benefits versus the
harms shown in the four systematic reviews, it is the
judgement of the GDP that the potential benefits
associated with the most ideal combinations of
movement behaviours are likely to outweigh any
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potential minor harms, warranting a strong
recommendation in favour of engaging in higher
physical activity, less time restrained and less
sedentary screen time, and longer sleep durations
[18,21–23]. The GDP also considered previously
published evidence that indicated improved health
benefits, higher physical activity, and lower
sedentary time when children of the early years are
outdoors [60,63]. The GDP placed relatively more
value on “very low”quality evidence showing that
the most ideal combinations of movement
behaviours were associated with adiposity (critical)
and fitness (critical), and “very low”quality evidence
on motor development (critical), and relatively less
value on the limited “very low”quality evidence on
growth (critical) and the lack of evidence on
psychosocial health/emotional regulation (critical),
cognitive development (critical), bone and skeletal
health (important), cardiometabolic health (important),
and injuries/harms (important).
The overall quality of evidence supporting the
recommendation was deemed to be of “very low”
quality and the magnitude of the effect is expected
to be very low. Taken together with the conclusions
drawn from the parent and stakeholder survey, focus
groups and interviews (i.e., low variability in how
parents and stakeholders value the recommendation,
recommendations would be feasible and acceptable,
and the anticipated costs associated with implementing
the recommendation are expected to be small or
negligible), and the large savings to the healthcare
system expected over the course of a lifetime, a strong
recommendation is warranted.
The body of evidence showed that replacing sedentary
time or light physical activity with energetic play
(MVPA) is likely to improve health indicators in
children of the early years. However, there was no
information available about combinations of all three
movement behaviours included in the systematic
review that would inform a specific recommendation
for the amounts of sedentary time to be traded
for light, moderate, and vigorous physical activity,
and sleep.
Subgroup considerations
Most stakeholders agreed that if implemented in all
Canadian children of early years age, the recommenda-
tions would benefit all groups of the Canadian popula-
tion equally. A few raised concerns about the difficulty
that families from low socio-economic status may have
in meeting these guidelines. In the judgment of the GDP,
these are implementation issues, many of which could
be addressed by developing knowledge translation tools
targeting families with low socio-economic status.
Therefore, the GDP decided not to issue a separate rec-
ommendation for this subgroup of the population.
A more detailed version of the “evidence to decision
framework”is provided in Additional file 2.
Dissemination, implementation and evaluation plans
The Canadian 24-Hour Movement Guidelines for the
Early Years (0–4 years): An Integration of Physical
Activity, Sedentary Behaviour, and Sleep were officially
released on November 20, 2017 through a comprehen-
sive media relations strategy to optimize exposure and
coverage. Dissemination, implementation, communica-
tion, and evaluation plans for the new guidelines intend
to build on work that is ongoing with the Canadian 24-
Hour Movement Guidelines for Children and Youth [1],
including the development of a comprehensive market-
ing plan focused on a digital marketing platform, and
adaptation of the visual identity and creative concept
(“Build your best day”–www.buildyourbestday.com)
that will enable clear, consistent and targeted communi-
cation with early childhood educators, primary care
practitioners, and public health promoters, and indir-
ectly with parents/caregivers. Proactive national media
relations outreach, hard copy and e-distribution of
guideline-related materials have been orchestrated
through Leadership Committee distribution networks. A
cross-Canada lecture tour in both French and English is
also planned to raise knowledge and awareness of the
guidelines among important stakeholders and end-users,
including researchers. Webinars targeted to different
end-user groups were developed, delivered, and pre-
served on-line (www.csep.ca/guidelines). All promotional
materials, campaigns, and initiatives are available in both
English and French.
The visual identity created for the Canadian 24-Hour
Movement Guidelines for Children and Youth was
adapted for use with the Canadian 24-Hour Movement
Guidelines for the Early Years (0–4years)(see Figs. 3
and 5) and used to create a digital marketing platform
targeted at practitioners who serve children and families
of children in the early years. This visual identity pro-
vides a consistent, clear, and recognizable look, tone,
and feel for the early years guidelines, facilitating in-
creased awareness and recognition of the guidelines.
A digital platform was created as a knowledge portal
that provides the three key audiences identified through
stakeholder consultation (i.e., early childhood educators,
healthcare providers, parents) with the information and
resources they need to understand and implement the
new guidelines. This resource will be available at
www.buildyourbestday.com/earlyyears by March 31,
2018. The site will provide simple, informational content
and resources related to this age group including an in-
structional video that explains the guidelines, a suite of
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digitized tools for download, a variety of public-facing
and easy-to-read blog articles, infographic(s), poster(s),
printable messaging materials (e.g., brochures, tip
sheets), and promotional content pieces such as Twitter
cards, Facebook images, Instagram images, sample ads,
and sample social media content.
Metrics on the success of the guidelines launch will be
gathered including traditional media impressions, social
media activity, hard-copy and electronic distribution in
the first two weeks post-launch as well as the general
tone (positive/negative) of any media coverage. Canadian
parents’baseline awareness of the guidelines immedi-
ately post launch will be collected via a ParticipACTION
survey consistent with evaluation procedures being
employed with the guidelines for children and youth.
Beliefs among identified key stakeholders (primary care
providers, public health promoters, and early childhood
educators) about the relative benefits of the 24-h move-
ment guidelines (integrated physical activity, sedentary
behaviour, and sleep) versus separate guidelines for each
behaviour are being assessed via an online, survey.
An unplanned outcome of the development of these
new Canadian guidelines was that they initiated the de-
velopment of similar guidelines in Australia [59]. Indeed,
the Australian guidelines “adoloped”[58] the Canadian
guidelines and the concurrent release of both guidelines
was coordinated facilitating international collaboration,
reducing duplication of effort and enhancing enthusiasm
and excitement in both jurisdictions. This bilateral co-
operation enticed the World Health Organization to
commence the development of Global 24-Hour Movement
Guidelines for the Early Years (see www.who.int/end-
childhood-obesity/news/public-consultation-2017/en for
further details). This global momentum should facilitate
awareness and uptake of the various jurisdictional
guidelines.
Research gaps
The systematic reviews, GDP meetings, and stakeholder
and end-user consultations highlighted several research
needs that are listed in Table 3. Briefly, in all three
movement behaviour domains (i.e., physical activity, sed-
entary behaviour, and sleep), more research is required
focusing on the dose-response relationships between
these behaviours and important health indicators. Few
studies to date have used valid and reliable measures of
sedentary behaviour or sleep, focused on infants or tod-
dlers, or controlled for important confounders (e.g.,
diet). The range of health indicators with available data
was limited with a lack of evidence for the relationships
between the three movement behaviours and fitness,
bone and skeletal health, cardiometabolic health, and
risk/harms. The change to 24-h movement guidelines
has highlighted several additional research gaps.
Currently, limited evidence is available on the combined
effects of physical activity, sedentary behaviour, and sleep
on health in the early years. Future research should
focus on examining the combined effect of these behav-
iours while developing innovative ways to analyze these
24-h data.
Surveillance recommendations
The Surveillance Sub-committee met several times
through teleconferences to discuss and agree upon the
surveillance recommendations for the Canadian 24-
Hour Movement Guidelines for the Early Years, with due
consideration to the existing surveillance structures in
Canada (Table 4). It is recommended that in order for a
child to be considered to have met these new guidelines,
all specific recommendations with a check mark in
Table 4 should be met. To meet a specific movement
behaviour guideline (e.g., physical activity) each rec-
ommendation would need to be met (e.g., for pre-
schoolers meeting the recommendations for both
average total physical activity per day of ≥180 min
and average MVPA per day of ≥60 min is required).
It is recommended that future surveillance work for
sedentary behaviour concentrate on the following: 1)
distinguish between recreational screen time and non-
recreational screen time; 2) incorporate new technology
(e.g., tablets, smart phones); and 3) specifically capture the
duration of screen time that occurs while in a sitting or
lying position. Furthermore, future surveillance efforts
should attempt to account for multitasking during seden-
tary behaviours (e.g., eating while watching television and
using social media on a small screen device).
AGREE II assessment
The four independent assessors scored the procedures
used to develop the Canadian 24-Hour Movement
Guidelines for the Early Years (0–4 years): An Integration
of Physical Activity, Sedentary Behaviour, and Sleep
following the rubric of the AGREE II [40]. A summary
of the combined scores for each AGREE II domain are
provided in Table 5. Overall, the guideline development
process was scored very high (Domain average ratings
89–100%) and all assessors indicated that they would
recommend the guidelines for use. Additional details on
all aspects of the guideline development process are
available in the Guideline Development Report at
www.csep.ca/guidelines.
Discussion
Guideline development process and outcomes
This paper outlines the process and outcomes for the
development of the Canadian 24-Hour Movement
Guidelines for the Early Years (0–4 years): An Integration
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of Physical Activity, Sedentary Behaviour, and Sleep. The
development of these guidelines that integrate all move-
ment behaviours follows the shift toward a whole-day
approach to conceptualizing movement behaviours that
was initiated by the Canadian 24-Hour Movement
Guidelines for Children and Youth: An Integration of
Physical Activity, Sedentary Behaviour, and Sleep [1].
This reconceptualization is supported by existing litera-
ture [18, 21–23], compositional analyses from a nation-
ally representative dataset [51], evidence from other
behavioural research [64], and logic. As summarized briefly
in the results and in more detail in Additional file 2, it is
Table 3 Research gaps identified through the guideline
development process
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.
Table 3 Research gaps identified through the guideline
development process (Continued)
◦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.
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Table 4 Surveillance recommendations for the Canadian 24-Hour Movement Guidelines for the Early Years
Movement Behaviour Specific guideline recommendation
for a healthy day
Specific surveillance
recommendation
Rationale for specific surveillance recommendation Recommendation for minimum inclusion
in overall guideline surveillance
a
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 awake
c
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 minutes
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.
✓
of which at least 60 min is energetic
play; more is better
Average MVPA per day is ≥60
minutes
c
An average allows for some normal day-to-day
variability.
✓
Sedentary behaviour
Infants Screen time is not recommended A typical day includes no screen
time
d
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 ≤1h
at a time
e
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.
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Table 4 Surveillance recommendations for the Canadian 24-Hour Movement Guidelines for the Early Years (Continued)
Movement Behaviour Specific guideline recommendation
for a healthy day
Specific surveillance
recommendation
Rationale for specific surveillance recommendation Recommendation for minimum inclusion
in overall guideline surveillance
a
Toddlers For those younger than 2 years,
sedentary screen time is not
recommended
A typical day includes no sedentary
screen time
d
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 hour
c
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 ≤1h
at a time
e
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 hour
c
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 time
e
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 hours
c
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.
✓
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Table 4 Surveillance recommendations for the Canadian 24-Hour Movement Guidelines for the Early Years (Continued)
Movement Behaviour Specific guideline recommendation
for a healthy day
Specific surveillance
recommendation
Rationale for specific surveillance recommendation Recommendation for minimum inclusion
in overall guideline surveillance
a
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 hours
c
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 hours
c
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 weekends
g
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 hours
c
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 weekends
g
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.
MVPA moderate- to vigorous-intensity physical activity
a
The check marks indicate the current recommended minimum inclusion recommendations for surveillance of meeting the 24-h guidelines. Other specific guideline recommendations, which have not been identified
as recommended components for surveillance of meeting the 24-h guidelines, should still be measured for descriptive purposes and to determine if changes are occurring prospectively. As evidence grows and surveillance
measures evolve for these other recommendations, updates to the minimum surveillance criteria may be required
b
It is recognized that there is currently no benchmark for this recommendation; however, it remains a recommended component for surveillance of the 24-h guidelines for mobile infants. The implication is that at the
present time surveillance of mobile (e.g., crawling or walking) infants meeting the 24-h guidelines is not possible; however, non-mobile infants meeting the tummy time recommendation can be considered to have
met the physical activity recommendation and surveillance of meeting the 24-h guidelines for this sub-group is therefore possible
c
If weekend and weekday measures are available, it is recommended that the average time engaged in each behaviour be weighted 2/7 for weekend days and 5/7 for weekdays to most accurately reflect average
weekly measures
d
It is understood that under special circumstances exposure to screen time may happen but this should be rare or unusual
e
It is understood that under special circumstances being restrained in excess of 1 h at a time may occur but this should be rare or unusual
f
Tremblay et al. Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0–4 years). Appl Physiol Nutr Metab 37:370–380, 2012
g
To accurately assess consistency of bedtime and wake-up time data should be collected on both weekday and weekend days. If data from weekday and weekend days are available, it is recommended that the average
variation in bedtime and wake-up time be weighted 2/7 for weekend days and 5/7 for weekdays to most accurately reflect average weekly measures
h
Allen et al. ABCs of SLEEPING: A review of the evidence behind pediatric sleep practice recommendations. Sleep Med Rev. 29:1–14, 2016
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Table 5 Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting grid summary from four independent assessors
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
•Systematic reviews [18,21–23] and PROSPERO Registrations
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
•Systematic reviews [18,21–23,60]
8. The criteria for selecting the evidence are
clearly described.
•Guideline Development Report
•Systematic reviews [18,21–23,60]
9. The strengths and limitations of the body
of evidence are clearly described.
•Guideline Development Report
•This manuscript
•Systematic reviews [18,21–23,60]
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
•Systematic reviews [18,21–23,47,49,60]
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)
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the opinion of the GDP that sufficient evidence exists
from all movement behaviour domains to strongly
support the final guideline recommendations pre-
sented in this paper. The paucity of high quality stud-
ies, especially those with experimental dose-response
designs, for all movement behaviours is acknowledged
and a call for more and better-quality research has
been issued.
The guideline development procedures used here
followed comprehensive, rigorous, and transparent pro-
cesses [36, 37, 43], incorporating systematic review find-
ings, consultation findings, and compositional analysis
findings, as well as expert, stakeholder, and end-user
input. The final guidelines (Figs. 2, 3, 4 and 5) adhere
to the structure used with previous Canadian guide-
lines [1, 26, 27, 65, 66], whereby context is provided for
the guidelines through a preamble followed by the guide-
lines themselves. The preamble and guidelines as pre-
sented in Figs. 2, 3, 4 and 5 are intended for practitioners,
professionals, stakeholders, and researchers. Additional
more user-friendly messaging materials targeted to par-
ents and the general public were developed as outlined in
the dissemination, implementation, and evaluation plans
section of the Results.
The individual behaviour components of the guide-
lines have not changed significantly from the earlier
Canadian Physical Activity Guidelines for the Early
Years [26] and Canadian Sedentary Behaviour Guide-
lines for the Early Years [27]. The major change is the
integration of all movement behaviours across the 24-h
period, with the most notable additions being 1) specific
recommendations for sleep duration for all age groups;
2) a recommendation for a duration of 30 min of tummy
time spread throughout the day while awake for infants
not yet mobile; 3) a recommendation for the inclusion
of energetic play in toddlers; 4) a recommendation that
preschoolers get at least 60 min of energetic play by age
5 years (changed from the previous recommendation of
progression toward at least 60 min of energetic play by
age 5 years); and 5) for all age groups, the encourage-
ment of quality sedentary behaviours like reading and
storytelling with a caregiver. In addition to providing
specific advice for physical activity, sedentary behavior,
and sleep, the guidelines also provide some general guid-
ance regarding trade-offs, with the final guideline recom-
mendation being “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”. It is also
worth highlighting that the GDP used neutral language
purposefully, not advocating for or against naps in pre-
schoolers (“which may include a nap”), as it was inter-
preted that the evidence for health benefits one way or
the other was equivocal.
It is possible that busy parents may initially view the 24-
h guidelines as just another challenge and potential source
of stress. Nevertheless, the overall conceptualization of the
integrated approach to all behaviours on the movement
continuum holds wide appeal with stakeholders and
end-users [1, 15, 16, 33, 67] and they are perceived to
be acceptable, affordable, feasible, and realistic.
Agreement existed amongst the GDP that proceeding
with the 24-h guidelines for the Early Years using the
best available evidence, expert consensus, and stake-
holder and end-user input, while being transparent
about the quantity and quality of the evidence base and
the strength of the guideline recommendations, was the
most responsible approach in providing public health
recommendations regarding movement behaviours for a
healthy day for children of the early years. The GDP be-
lieves that the evidence is supportive of all the recommen-
dations, and the potential for benefits still exists even
Table 5 Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting grid summary from four independent assessors
(Continued)
AGREE II Item Reporting Location Domain Score (%)
b
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
•Systematic reviews [18,21–23]
a
Item 16 was rated as “not applicable”by one reviewer and assessments from the other reviewers were included in the scaled Domain 4 score
b
Four independent reviewers applied the AGREE II assessment; the Domain Scores (%) were calculated by summing all the scores of the individual items in adomain
and by scaling the total as a percentage of the maximum possible score for that domain (as per the AGREE II Instrument, available at www.agreetrust.org).
The “Reporting Location”is not a comprehensive summary of all places where the information in each item can be found. The Guideline Development Report is
available at www.csep.ca/guidelines
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where the evidence is weakest, while the likelihood of
harm is very small. Challenges to these recommendations
are encouraged and will result in more refined and in-
formed guideline recommendations in the future.
Despite being presented as “24-h movement guide-
lines”, it is not possible to give precise recommendations
that add exactly to 24 h, because there are ranges pro-
vided for all behaviour components (e.g., 11–14 h of
sleep, at least 60 min of energetic play, no more than
1 h of recreational screen time). Obviously if one child
sleeps 11 h and another 14 h, the former has three add-
itional hours of time to be distributed among the wake-
time behaviours. Moreover, some degree of day-to-day
variability is normal, and provision of ranges allows for
this flexibility, accommodating to different schedules
and changes in schedules. Collectively, guidance for a
healthy 24-h period is provided.
A study examining the proportions of preschool-aged
Canadian children (3–4 years) meeting the new guide-
lines and different recommendations within the guide-
lines was completed using CHMS data [24]. Associations
of meeting the guidelines with adiposity indicators were
also explored. Approximately 13% of preschool-aged
children met the overall 24-h movement guidelines (as
defined by the surveillance recommendations in Table 4),
and 3% met none of the three recommendations. Most
preschool children met the sleep duration (84%) and phys-
ical activity (62%) recommendations, while only 24% met
the screen time recommendation. No associations were
found between meeting individual or combined recom-
mendations, and anthropometric measures of adiposity. It
may be that these anthropometric measures are not sensi-
tive enough to detect differences in adiposity that are ac-
tually present. It may be more appropriate to measure
other indicators of holistic health in this age group. This is
the first study to employ the new guidelines for surveil-
lance assessments in Canada [24]. The findings related to
screen time provide evidence for the importance of the
recommendations from the recent Canadian Paediatric
Society Position Statement that advocates for minimizing,
mitigating, mindfully using and modeling healthy use of
screens [30].
Release, dissemination, implementation, and activation
planning
A suite of materials to complement and message the
guideline recommendations to various subgroups was
developed and is publicly available at www.csep.ca/
guidelines. These materials present a relative advantage
over previous guidelines, in that they show how the
guidelines can be easily assimilated into current practice
by organizations (compatibility), and how they can most
clearly and succinctly be conveyed (simplicity). These
clear, supporting messages are essential to informing
stakeholders, parents, early childhood educators, public
health/health care professionals, and governments, of
the value and use of the 24-h movement guidelines. The
guidelines themselves provide evidence-informed targets
associated with health benefits for children of the early
years to follow (under the direction of caregivers).
The Leadership Committee partners (CSEP, HALO,
ParticipACTION, University of Alberta, PHAC) will take
the lead to disseminate the new guidelines to Canadians
both directly and through the partners’networks. Each
partner has a national mandate related to the promotion
of healthy active living to Canadians. In addition, the
knowledge user representatives on the GDP come from
diverse fields concerned with the movement behaviours
of children of the early years, and are committed to mo-
bilizing this work to various settings and populations.
CSEP will embed these new guidelines into their training
materials in order to ensure CSEP members as well as
public health professionals, health care practitioners,
teachers, and parents understand the importance of all
movement behaviours across the 24-h period. As with
previous guidelines, ParticipACTION will actively par-
ticipate in the dissemination, promotion, implementa-
tion, and activation of these new guidelines.
In order to motivate adoption, the new guidelines
should be followed up with messages that explain the
“why”and “how”to the various stakeholder groups, as
well as sustained implementation and activation strategies
[1, 57, 67]. The suite of prepared messaging and commu-
nication tools, adapted visual identity, and digital platform
are designed to serve as a foundation for a long-term,
multi-platform, multi-sector, multi-jurisdictional, and
multi-disciplinary marketing and communication efforts
to facilitate uptake and activation of the new guidelines.
The impact and success of the launch of the new
guidelines will be assessed through media hits and im-
pressions. Dissemination reach will be assessed with
metrics from online and hard-copy distribution. Funding
is in place to collect baseline data on parents’and other
stakeholders’awareness of the new guidelines, allowing
for future follow-up research.
Through these various implementation, activation, and
evaluation efforts, the long-term goal is that that these
guidelines will enhance the promotion of healthy active
lifestyles and improved sleep quality and hygiene among
infants, toddlers, and preschool children across Canada,
and inform healthy active living policy at the local, pro-
vincial, and national levels. It is further anticipated that
in the long-term this project will provide international
leadership and will advance a global healthy active living
agenda. Early evidence of success in the form of
international leadership can be found with these new
Canadian guidelines being the impetus for the devel-
opment of similar guidelines in Australia [59], New
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Zealand [68], and the initiation of similar global
guidelines by the World Health Organization.
Updating the guidelines
The final stage in the guideline development cycle is the
planning of updates and revisions [36]. It was recom-
mended by the GDP that these guidelines be revisited
every 10 years or whenever important new evidence is
identified that could inform or alter changes to the exist-
ing guideline recommendations. Ten years was recom-
mended as an appropriate period that allows for
complete sector penetration and normative utilization by
stakeholders, intermediaries, and end-users, while also
providing sufficient time for research gaps to be ad-
dressed, and is supported by the literature [69, 70].
Strengths and limitations
There were several strengths of the process used to de-
velop the Canadian 24-Hour Movement Guidelines for
the Early Years (0–4 years): An Integration of Physical
Activity, Sedentary Behaviour, and Sleep including ad-
hering to a rigorous, robust and transparent guideline
development process [36, 37, 43]; independent assess-
ment by AGREE II reviewers; involvement of and
consultation with a broad assortment of experts, inter-
national collaborators, stakeholders, and end-users; con-
sideration of a range of holistic health indicators; using
both systematic reviews and novel compositional data
analyses to provide a comprehensive evidence base; pro-
active planning for dissemination, promotion, imple-
mentation, and evaluation; and publishing all scholarly
work in an open-access, peer-reviewed journal.
Despite these strengths, the guideline development
process also had limitations. First, the evidence base for
the guidelines was generally incomplete and of low qual-
ity, though it does represent the best available evidence
collected through systematic reviews and original re-
search. Second, there was very little research available to
inform specific aspects of the guidelines (e.g., dose–re-
sponse studies on behaviour frequency, intensity, duration,
type, context). Third, very little research exists on inte-
grated movement behaviours and health indicators in this
age group. Because of this limitation, evidence is presently
insufficient to provide specific advice on behaviour substi-
tution options for a particular early years child, in a particu-
lar situation. Nevertheless, behaviour changes that ensure
adequate sleep, reduced screen time, and increased ener-
geticoroutdoorplayarelikelytoprovidehealthbenefitsto
most children of the early years. Fourth, it is possible that
the various consultation processes used resulted in biased
feedback and that voices of important subsets of the popu-
lation were missed. Fifth, evidence of the cost effectiveness
of the guideline recommendations was not available.
Future research
Specific research needs identified in the development of
these guidelines are listed in Table 3. As noted, more re-
search is needed to further inform, substantiate or chal-
lenge these new guidelines. Going forward, research
should consider the integrated relationships among
movement behaviours, and similar integrated 24-h
movement guidelines for other age groups (e.g., adults
and older adults) should be developed. Such work holds
promise in not only creating new opportunities and ap-
proaches for healthy lifestyle interventions but also for
the discovery of new and novel relationships among
movement behaviours, and the underlying physiology
and pathophysiology. A need exists for a standardized
measurement protocol to collect required information to
assess whether the new guidelines are being met. This
protocol should be arrived at following a thorough scan
of available methods, instruments, and procedures
assessed by an expert group, with final consensus rec-
ommendations posted and promoted for widespread use.
Conclusion
The new Canadian 24-Hour Movement Guidelines for the
Early Years (0–4 years): An Integration of Physical Activity,
Sedentary Behaviour, and Sleep are part of a paradigm
shift in thinking about daily movement behaviours. This
shift from focusing on movement behaviours in isolation
to a whole-day approach is supported by the available evi-
dence and stakeholder opinion. These guidelines represent
a sensible evolution of public health guidelines whereby
optimal health is framed within the balance of movement
behaviours across the whole day, while respecting prefer-
ences of end-users. The GDP rated these as strong recom-
mendations with the potential benefits of following these
guidelines far exceeding the potential risks. It is hoped
that these guidelines open new avenues for population
health promotion and instigate new research on the health
effects of integrated movement behaviours.
Additional files
Additional file 1: Stakeholder Survey (English followed by French version).
(DOC 202 kb)
Additional file 2: Detailed evidence to decision framework explanation
for the Canadian 24-Hour Movement Guidelines for the Early Years
(0–4 years): An Integration of Physical Activity, Sedentary Behaviour,
and Sleep. (DOC 90 kb)
Abbreviations
AGREE: Appraisal of Guidelines for Research and Evaluation; BMI: Body mass
index; CHEO RI: Children’s Hospital of Eastern Ontario Research Institute;
CHMS: Canadian Health Measures Survey; CIHR: Canadian Institutes of Health
Research; CSEP: Canadian Society for Exercise Physiology; FRCPC: Fellow of
the Royal College of Physicians of Canada; GDP: Guideline Development
Panel; GRADE: Grading of Recommendations, Assessment, Development and
Evaluation; HALO: Healthy Active Living and Obesity research group;
LPA: Light-intensity physical activity; MPA: Moderate-intensity physical
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activity; MVPA: Moderate- to vigorous-intensity physical activity; PA: Physical activity;
PHAC: Public Health Agency of Canada; PROSPERO: International Prospective
Register of Systematic Reviews; REDCap: Research Electronic Data Capture;
SB: Sedentary behaviour; TPA: Total physical activity; WC: Waist circumference
Acknowledgements
The authors wish to acknowledge the assistance of Rachel Colley (Statistics
Canada) and Karen Roberts (PHAC) in developing surveillance recommendations
for the new guidelines. The authors would like to thank Geneviève Leduc and
Kevin Belanger for their assistance on various aspects of the guideline
development project. Finally, we are grateful to the many students and
research assistants that assisted with the systematic reviews, focus groups, and
key informant interviews.
Funding
This study has been made possible through funding from CIHR (Grants KRS-
144044 and FRN 147990); CSEP; HALO Research Group at the Children’s
Hospital of Eastern Ontario Research Institute; Faculty of Physical Education
and Recreation, University of Alberta; and PHAC. Publication charges for this
article have been funded through a grant from PHAC. Valerie Carson and
Kristi Adamo are supported by CIHR New Investigator Salary Awards. Guy
Faulkner is supported by a Chair Award in Applied Public Health funded by
PHAC in partnership with CIHR. Anthony Okely is supported by a National
Heart Foundation of Australia Career Development Fellowship. Ian Janssen
and Brian Timmons are supported by Tier II Canada Research Chair positions.
The funding bodies had no role in the design of the study; in the collection,
analysis, and interpretation of data; or in the writing of the manuscript.
Availability of data and materials
Any raw data or materials used in the preparation of this manuscript are available
upon reasonable request to Dr. Mark Tremblay (mtremblay@cheo.on.ca).
About this supplement
This article has been published as part of BMC Public Health Volume 17
Supplement 5, 2017: 24-Hour Movement Guidelines for the Early Years: An
Integration of Physical Activity, Sedentary Behaviour, and Sleep. The full con-
tents of the supplement are available online at https://bmcpublichealth.
biomedcentral.com/articles/supplements/volume-17-supplement-5.
Authors’contributions
MST, VC, MD, JPC, CEG, and VJP were responsible for the initiation, conceptualization,
and leadership of the guideline development process. VC led the physical activity
systematic review. VJP led the sedentary behaviour systematic review. JPC led the
sleep systematic review. NK led the integrated systematic review. JDB, SA, CEG, and
MST were responsible for the stakeholder survey. GF, CEG, and MST were responsible
for focus groups and key informant interviews. VC led the compositional analyses. VJP,
CEG, and AJG were responsible for the GRADE analysis and interpretation of data.
CEGcoordinatedtheAGREEIIindependentassessments.KJ,MD,CEG,andMSTled
the dissemination, implementation, and activation planning. MST was the primary
author of the manuscript. All coauthors were part of the GDP and were responsible
for reviewing and revising the manuscript for important intellectual content.
All authors read and approved the final manuscript.
Ethics approval and consent to participate
Ethics approval was obtained for the stakeholder survey, key informant
interviews and focus groups as described in the manuscript.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Healthy Active Living and Obesity Research Group, Children’s Hospital of
Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1,
Canada.
2
School of Human Kinetics, Faculty of Health Sciences, University of
Ottawa, Ottawa, ON K1N 1A2, Canada.
3
Best Start Resource Centre, Health
Nexus, Toronto, ON M5G 1Z8, Canada.
4
Canadian Society for Exercise
Physiology, Ottawa, ON K1R 6Y6, Canada.
5
School of Kinesiology, University
of British Columbia, Vancouver, BC V6T 1Z3, Canada.
6
Department of
Psychiatry, Faculty of Medicine, McGill University, Montreal, QC H3A 1A1,
Canada.
7
ParticipACTION, Toronto, ON M5S 1M2, Canada.
8
School of
Kinesiology and Health Studies, and Department of Community Health and
Epidemiology, Queen’s University, Kingston, ON K7L 3N6, Canada.
9
University
of Strathclyde, School of Psychological Science and Health, Glasgow,
Scotland G1 1QE, UK.
10
Public Health Agency of Canada, Ottawa, ON K1A
0K9, Canada.
11
Faculty of Physical Education and Recreation, University of
Alberta, Edmonton, AB T6G 2H9, Canada.
12
Montreal Children’s Hospital,
Montreal, QC H3H 1P3, Canada.
13
Department of Pediatrics, Faculty of
Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada.
14
Early Start Research Institute, Faculty of Social Sciences, University of
Wollongong, Wollongong, NSW 2522, Australia.
15
The Sandbox Project,
Toronto, ON M5C 2C5, Canada.
16
Library Services, Children’s Hospital of
Eastern Ontario, Ottawa, ON K1H 8L1, Canada.
17
Child Health & Exercise
Medicine Program, Department of Pediatrics, McMaster University, Hamilton,
ON L8S 4K1, Canada.
Published: 20 November 2017
References
1. Tremblay MS, Carson V, Chaput J-P, Connor Gorber S, Dinh T, Duggan M,
et al. Canadian 24-Hour Movement Guidelines for Children and Youth: An
Integration of Physical Activity, Sedentary Behaviour, and Sleep. Appl Physiol
Nutr Metab. 2016;41(6 suppl.3):S311–27.
2. Colley RC, Garriguet D, Janssen I, Craig CL, Clarke J, Tremblay MS. Physical
activity of Canadian children and youth: accelerometer results from the 2007
to 2009 Canadian health measures survey. Health Rep. 2011;22(1):15–24.
3. ParticipACTION. The Biggest Risk is Keeping Kids Indoors. The 2015
ParticipACTION Report Card on Physical Activity for Children and Youth.
Toronto, ON: ParticipACTION; 2015.
4. ParticipACTION. Too Tired To Move? The 2016 ParticipACTION Report Card on
Physical Activity for Children and Youth. Toronto, ON: ParticipACTION; 2016.
5. Owens J. The adolescent sleep working group, committee on adolescence.
Insufficient sleep in adolescents and young adults: an update on causes
and consequences. Pediatrics. 2014;134:e921–32.
6. Matricciani L, Olds T, Petkov J. Search of lost sleep: secular trends in the
sleep time of school-aged children and adolescents. Sleep Med Rev. 2012;
16:203–11.
7. Carson V, Hunter S, Kuzik N, Gray CE, Poitras VJ, Chaput J-P, et al. Systematic
review of sedentary behaviour and health indicators in school-aged children
and youth: an update. Appl Physiol Nutr Metab. 2016;41(6 suppl.3):S240–65.
8. Chaput J-P, Gray CE, Poitras VJ, Carson V, Gruber R, Olds T, et al. Systematic
review of the relationships between sleep duration and health indicators in
school-aged children and youth. Appl Physiol Nutr Metab. 2016;41(6 suppl.3):
S266–82.
9. Poitras VJ, Gray CE, Borghese MM, Carson V, Chaput J-P, Janssen I, et al.
Systematic review of the relationships between objectively measured
physical activity and health indicators in school-aged children and youth.
Appl Physiol Nutr Metab. 2016;41(6 suppl.3):S197–239.
10. Saunders TJ, Gray CE, Poitras VJ, Chaput J-P, Janssen I, Katzmarzyk PT, et al.
Combinations of physical activity, sedentary behaviour and sleep: relationships
with health indicators in school-aged children and youth. Appl Physiol Nutr
Metab. 2016;41(6):S283–93.
11. Carson V, Chaput J-P, Janssen I, Tremblay MS. Health associations with
meeting new 24-hour movement guidelines for Canadian children and
youth. Prev Med. 2017;95:7–13.
12. Janssen I, Roberts KC, Thompson W. Is adherence to the Canadian 24-hour
movement behaviour guidelines for children and youth associated with
improved indicators of physical, mental, and social health? Appl Physiol
Nutr Metab. 2017;42:725–31.
13. Roman-Viñas B, Chaput J-P, Katzmarzyk PT, Fogelholm M, Lambert EV,
Maher C, et al. Proportion of children meeting recommendations for 24-
hour movement guidelines and associations with adiposity in a 12-country
study. Int J Behavl Nutr Phys Act. 2016;13:123.
14. Sampasa-Kanyinga H, Standage M, Tremblay MS, Katzmarzyk PT, Hu G,
Kuriyan R, et al. Associations between meeting combinations of 24-hour
The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 30 of 215
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

movement guidelines and health-related quality of life in children from 12
countries. Public Health. 2017;153:16–24.
15. Carson V, LeBlanc C, Moreau E, Tremblay MS. Paediatricians’awareness of,
agreement with, and use of the new Canadian physical activity and sedentary
behaviour guidelines for ages 0-17 years. Paediatr Child Health. 2013;18:538–42.
16. Faulkner G, White L, Riazi N, Latimer-Cheung AE. Tremblay MS. Canadian
24-hour movement guidelines for children and youth: exploring the
perceptions of stakeholders regarding their acceptability, barriers to uptake,
and dissemination. Appl Physiol Nutr Metab. 2016;41(6 suppl.3):S303–10.
17. Carson V, Hunter S, Kuzik N, Wiebe SA, Spence JC, Friedman A, et al.
Systematic review of physical activity and cognitive development in early
childhood. J Sci Med Sport. 2016;19:573–8.
18. Carson V, Lee E-Y, Hewitt L, Jennings C, Hunter S, Kuzik N, et al. Systematic
review of the relationships between physical activity and health indicators
in the early years (0-4 years). BMC Public Health. 2017;17(5) [in press]
19. Hinkley T, Teychenne M, Downing KL, Ball K, Salmon J, Hesketh KD. Early
childhood physical activity, sedentary behaviors and psychosocial well-being:
a systematic review. Prev Med. 2014;62:182–92.
20. Carson V, Kuzik N, Hunter S, Wiebe SA, Spence JC, Friedman A, et al.
Systematic review of sedentary behavior and cognitive development in
early childhood. Prev Med. 2015;78:115–22.
21. Poitras VJ, Gray CE, Janssen X, Aubert S, Carson V, Faulkner G, et al. Systematic
review of the relationships between sedentary behaviour and health indicators
in the early years (0-4 years). BMC Public Health. 2017;17(5) [in press]
22. Chaput J-P, Gray CE, Poitras VJ, Carson V, Gruber R, Birken CS, et al. Systematic
review of the relationships between sleep duration and health indicators in
the early years (0-4 years). BMC Public Health. 2017;17(5) [in press]
23. KuzikN,PoitrasVJ,TremblayMS,LeeE-Y,HunterS,CarsonV.Systematicreview
of the relationships between combinations of movement behaviours and health
indicators in the early years (0-4 years). BMC Public Health. 2017;17(5) [in press]
24. Chaput J-P, Colley RC, Aubert S, Carson V, Janssen I, Roberts KC, et al.
Proportion of preschool-aged children meeting the Canadian 24-hour
movement guidelines and associations with ad iposity: results from the
Canadian health measures survey. BMC Public Health. 2017;17(5) [in press]
25. Colley RC, Garriguet D, Adamo KB, Carson V, Janssen I, Timmons BW, et al.
Physical activity and sedentary behavior during the early years in Canada: a
cross-sectional study. Int J Behav Nutr Phys Act. 2013;10(54):1–11.
26. Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C,
et al. Canadian Physical Activity Guidelines for the Early Years (aged 0-4 years).
Appl Physiol Nutr Metab. 201 2;37:345–56.
27. Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor GS, Dillman C, et al.
Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0-4 years).
Appl Physiol Nutr Metab. 201 2;37:370–91.
28. Lee E-Y, Hesketh KD, Hunter S, Kuzik N, Rhodes RE, Rinaldi CM, et al. Meeting
new Canadian 24-hour movement guidelines for the early years and
associations with adiposity among toddlers living in Edmonton, Canada. BMC
Public Health. 2017;17(5) [in press]
29. American Academy of Pediatrics, Council on Communications and Media.
Media and young minds. Pediatrics. 2016;138(5):e20162591.
30. Canadian Pediatric Society. Position Statement: Screen time and young
children: Promoting health and development in a digital world. www.cps.
ca/en/documents/position/screen-time-and-young-children. Accessed 28
Aug 2017.
31. Sigman A. Screen dependency disorders: a new challenge for child neurology.
J Int Child Neurol Ass. 2017;17:119.
32. Zimmerman FJ, Christakis DA, Meltzoff AN. Televisio n and DVD/video
viewing in children younger than 2 years. Arch Pediatr Adolesc Med.
2007;161:473–9.
33. Riazi N, Ramanathan S, O’Neill M, Tremblay MS, Faulkner G. Canadian 24-hour
movement guidelines for the early years (0-4 years): exploring the perceptions
of stakeholders and end users regarding their acceptability, barriers to uptake,
and dissemination. BMC Public Health. 2017;17(5) [in press]
34. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE,
et al. Sedentary Behavior Research Network (SBRN) - Terminology Consensus
Project process and outcome. Int J Behav Nutr Phys Act. 2017;14:75.
35. Tremblay MS, Colley R, Saunders TJ, Healy GN, Owen N. Physiological and
health implications of a sedentary lifestyle. Appl Physiol Nutr Metab. 2010;
35:725–40.
36. Tremblay MS, Haskell WL. From science to physical activity guidelines. In:
Bouchard C, Blair SN, Haskell WL, editors. Physical activity and health. 2nd
ed. Champaign: Human Kinetics Publishers; 2012. p. 359–78.
37. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.
For the AGREE next steps consortium. AGREE II: advancing guideline
development, reporting and evaluation in health care. CMAJ. 2010;182:
E839–42.
38. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.
For the AGREE next steps consortium. Development of the AGREE II, part 1:
performance, usefulness and areas for improvement. CMAJ. 2010;182:1045–52.
39. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.
For the AGREE next steps consortium. Development of the AGREE II, part 2:
assessment of validity of items and tools to support application. CMAJ.
2010;182:E472–8.
40. Brouwers MS, Kerkvliet K, Spithoff K, and the AGREE Next Steps Consortium.
The AGREE reporting checklist: a tool to improve reporting of clinical practice
guidelines. BMJ 2016;352:i1152.
41. Schünemann H, Brożek J, Guyatt G, Oxman A (Eds.). GRADE handbook for
grading quality of evidence and strength of recommendations. Updated
October 2013. The GRADE Working Group, 2013. Available from
www.guidelinedevelopment.org/handbook. Accessed 15 Sept 2017.
42. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, et al.
GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;
64(4):401–6.
43. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines:
1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin
Epidemiol. 2011;64(4):383–94.
44. Timmons BW, LeBlanc AG, Carson V, Connor GS, Dillman C, Janssen I, et al.
Systematic review of physical activity and health in the early years (aged 0-4
years). Appl Physiol Nutr Metab. 2012;37(4):773–92.
45. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO
framework to improve searching PubMed for clinical questions. BMC Med
Inform Decis Mak. 2007;7:16.
46. LeBlanc AG, Spence JC, Carson V, Connor GS, Dillman C, Janssen I, et al.
Systematic review of sedentary behaviour and health indicators in the early
years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37(4):753–72.
47. Chastin SFM, Palarea-Albaladejo J, Dontje ML, Skelton DA. Combined effects
of time spent in physical activity, sedentary behaviors and sleep on obesity
and cardio-metabolic health markers: a novel compositional data analysis
approach. PLoS One. 2015;10(10):e0139984.
48. Pedisic Z. Measurement issues and poor adjustments for physical activity
and sleep undermine sedentary behaviour research –the focus should shift
to the balance between sleep, sedentary behaviour, standing and activity.
Kinesiology. 2014;46(1):135–46.
49. Carson V, Tremblay MS, Chaput J-P, Chastin SFM. Associations between
sleep duration, sedentary time, physical activity and health indicators
among Canadian children and youth using compositional analyses. Appl
Physiol Nutr Metab. 2016;41(6 suppl.3):S294–302.
50. Tremblay MS, Wolfson M, Connor Gorber S. Canadian health measures survey:
background, rationale and overview. Health Rep. 2007;18(Suppl):7–20.
51. Carson V, Tremblay MS, Chastin SFM. Cross-sectional associations between
sleep duration, sedentary time, physical activity and adiposity indicators
among Canadian preschool-aged children using compositional analyses.
BMC Public Health. 2017;17(5) in press
52. Canadian Society for Exercise Physiology. Canadian Physical Activity, Fitness
and Lifestyle Approach (CPAFLA), 3rd edition. Ottawa. 2003.
53. National Institutes of Health. The practical guide to the identification,
evaluation and treatment of overweight and obesity in adults. Bethesda.
Maryland: National Institutes of Health; 2000.
54. World Health Organization Multicentre Growth Reference Study Group.
WHO child growth standards based on length/height, weight and age. Acta
Paediatr. 2006;450:76–85.
55. Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA,
Davoli M, et al. GRADE evidence to decision (EtD) frameworks: a systematic
and transparent approach to making well informed healthcare choices. 1:
introduction. BMJ. 2016;353:i2016.
56. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research
electronic data capture (REDCap) –a metadata-driven methodology and
workflow process for providing translational research informatics support.
J Biomed Inform. 2009;42(2):377–81.
57. Latimer-Cheung AE, Copeland JL, Fowles J, Zehr L, Duggan M, Tremblay MS.
The Canadian 24-hour movement guidelines for children and youth: implications
for practitioners, professionals, and organizations. Appl Physiol Nutr Metab. 2016;
41(6 suppl.3):S328–35.
The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 31 of 215
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

58. Schünemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA,
Manja V, et al. GRADE evidence to decision (EtD) frameworks for adoption,
adaptation, and de novo development of trustworthy recommendations:
GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101–10.
59. Okely AD, Ghersi D, Hesketh KD, Santos R, Loughran SP, Cliff DP, et al.
A collaborative approach to adopting/adapting guidelines - The Australian
24-Hour Movement Guidelines for the early years (Birth to 5 years): an
integration of physical activity, sedentary behavior, and sleep. BMC Public
Health 2017. 2017;17(5) [in press].
60. Gray C, Gibbons R, Larouche R, Sandseter EBH, Bienenstock A, Brussoni M,
et al. What is the relationship between outdoor time and physical activity,
sedentary behaviour, and physical fitness in children? A systematic review.
Int J Environ Res Public Health. 2015;12:6455–74.
61. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al.
National Sleep Foundation’s updated sleep duration recommendations: final
report. Sleep Health. 2015;1:233–43.
62. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, et al.
Recommended amount of sleep for pediatric populations: a consensus
statement of the American Academy of Sleep Medicine. J Clin Sleep Med.
2016;12:785–6.
63. Larouche R, Garriguet D, Tremblay MS. Outdoor time, physical activity and
sedentary behavior among young children: the 2012-2013 Canadian health
measures survey. Can J Public Health. 2016;107(6):e500–6.
64. Health Canada. Eating well with Canada’s Food Guide. Health Canada, Ottawa,
ON, Canada. HC Pub.: 4651, 2011.
65. Tremblay MS, Warburton DER, Janssen I, Paterson DH, Latimer AE, Rhodes RE,
et al. New Canadian Physical Activity Guidelines. Appl Physiol Nutr Metab.
2011;36(1):36–46.
66. Tremblay MS, LeBlanc AG, Janssen I, Kho ME, Hicks A, Murumets K,
et al. Canadian Sedentary Behaviour Guidelines for Children and Youth.
Appl Physiol Nutr Metab. 2011;36(1):59–64.
67. Carson V, Barnes J, LeBlanc CMA, Moreau E, Tremblay MS. Increasing Canadian
Paediatricians’awareness and use of the new Canadian physical activity and
sedentary behaviour guidelines for ages 0-17 years. Paediatr Child Health.
2017;22:17–22.
68. New Zealand Ministry of Health. Sit Less, Move More, Sleep Well: Active Play
Guidelines for under-fives. Wellington: New Zealand, Ministry of Health; 2017.
69. Balas EA, Boren SA. Managing clinical knowledge for health care improvement.
In: Bemmel J, AT MC, editors. Yearbook of medical informatics 2000: patient-
centered systems. Stuttgart: SchattauerVerlagsgesellschaftmbH;2000.p.65–70.
70. Green LW. Making research relevant: if it is an evidence-based practice,
where’s the practice-based evidence? Fam Pract. 2008;25(S1):i20–4.
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