More Exercise, Less Screen Time for Under Fives, Says WHO

Liam Davenport

April 26, 2019

GLASGOW, Scotland — Children under 5 years need to be physically active and get good quality sleep, as well as spend as little time as possible restrained in prams or seats, and sat in front of screens, if they are to grow up healthy, say guidelines by the World Health Organization (WHO).

The new guidance, which was published on April 24, will also be presented here this weekend at the European Conference on Obesity (ECO) 2019. The advice has drawn criticism, however, from experts who question the quality of the evidence used to make the recommendations, as well as the feasibility and benefits of limiting screen time.

The WHO convened a panel to review the available literature on the impact of inadequate sleep, screen time, and sedentary behaviors on children, as well as the benefit of increased activity.

They then developed a series of separate recommendations for infants, children aged 1-2 years, and those aged 3-4 years that emphasize physical activity and good quality sleep.

Moreover, they underline the importance of children not spending more than an hour a day restrained in prams or strollers, and recommend that children spend as little time as possible in front of a screen.

WHO Director-General Tedros Adhanom Ghebreyesus, PhD, said in a press release that "achieving health for all means doing what is best for health right from the beginning of people's lives."

Fiona Bull, PhD, program manager for surveillance and population-based prevention of noncommunicable diseases at WHO, added that increasing activity, reducing sedentary time, and ensuring good quality sleep will improve physical and mental health, and wellbeing.

Furthermore, such changes will "help prevent childhood obesity and associated diseases later in life."

Bring Back Playtime...Although It's Not Always Practical

And for Juana Willumsen, PhD, Department for Prevention of Noncommunicable Diseases, WHO, Geneva, Switzerland, the guidelines underline the need to "bring back play for children."

"This is about making the shift from sedentary time to playtime while protecting sleep," she urged.

Speaking to Medscape Medical News, Simon Williams, PhD, chair, Association for the Study of Obesity, said that although evidence for some of the recommendations is weak or lacking, "I applaud [WHO] for making an effort to use the evidence we have to come up with these recommendations."

He added that the recommendations can be used as objective goals, against which interventions can be evaluated, for parents and their children.

Williams continued: "One of the good things about these recommendations is the way in which they've clearly linked physical activity, sedentary screen time, and sleep in a way that makes us focus on each three of these behaviors across a 24-hour period and to think about how they can integrate with one another."

He added: "I suspect for some parents, being able to focus on reducing sedentary time might be more effective than asking them to focus on increasing physical activity, and what I suppose we might see is that if children reduce their sedentary time, especially the sedentary screen time, then that might well be replaced by physical activity."

However, Max Davie, MD, officer for health improvement, UK Royal College of Paediatrics and Child Health, warned in a statement that, although he welcomes the guidelines, they could have "unintended consequences."

"While it is important for children to be as active as possible, the barriers are more frequently to do with housing, work patterns, family stress, and lack of access to play spaces rather than actively choosing to be sedentary," he said.

"Likewise, the restricted screen time limits suggested by WHO do not seem proportionate to the potential harm."

Davie noted: "Our research has shown that currently there is not strong enough evidence to support the setting of screen time limits and that screen use should be considered alongside a range of activities to assess its impact."

He also questions whether households with children of mixed ages can successfully shield a baby from screen exposure, as recommended.

Latest Evidence Incorporated: No Screen Time for Babies

Development of the guidelines began in 2017, when technical experts and stakeholders from all six WHO regions met to determine the critical questions and outcomes that should be assessed.

Prior systematic literature reviews were updated and the search criteria expanded to include data published in 2017-2018, with the evidence reviewed in April 2018.

In addition, the guideline development group looked at the risks and benefits of implementing the recommendations, as well as their feasibility, acceptability, and resource implications.

The guidelines specify that infants younger than 1 year should be physically active several times a day in a variety of ways, including 30 minutes in prone position, or tummy time, throughout the day while the child is awake.

Infants should not be restrained in a pram, stroller, or high chair, for more than 1 hour at a time, and screen time is not recommended in this age group.

Infants should also have 14-17 hours a day of good quality sleep, including naps, when aged 0-3 months, and 12-16 hours when aged 4-11 months.

Children aged 1-2 years should be active for at least 180 minutes spread throughout the day, which includes moderate to vigorous intensity physical activity.

Again, they should not be restrained for more than 1 hour at a time or sit for extended periods.

Children aged 1-2 years should spend no more than 1 hour per day in front of a screen and also have 11-14 hours of good quality sleep per day, including naps, the guidelines state, with regular sleep and wake-up times.

Children aged 3-4 years should have 180 minutes of physical activity per day, at least 60 minutes of which should be moderate to vigorous intensity physical activity.

Again, they should not be restrained for more than an hour or sit for extended periods, and they should spend no more than 1 hour in front of a screen.

The recommended sleep time for children aged 3-4 years is 10-13 hours per day, potentially including a nap, with regular sleep and wake-up times.

The authors stress that the recommendations apply to all healthy children younger than 5 years, regardless of gender, cultural background, or family socioeconomic status.

Nonscreen Sedentary Activities Important: Reading and Doing Puzzles

The guidelines also emphasize that children should meet all the recommendations for physical activity, sedentary behavior, and sleep in a 24-hour period.

Moreover, quality sedentary time with a caregiver engaging in nonscreen-based activities such as reading, storytelling, singing, and puzzles is highlighted as being important for child development and recommended for all ages.

Andrew Przybylski, PhD, associate professor and director of research at the Oxford Internet Institute, University of Oxford, UK, commented in a press release that the advice in the guidelines "is based on correlational evidence which is very low quality."

He adds: "The authors are overly optimistic when they conclude screen time and physical activity can be swapped on a one-to-one basis.

"This suggestion, and many others in the report, are based on extremely small correlations and no evidence from intervention studies."

For Przybylski, there is too much focus on the quantity of screen time in the recommendations, which fail to consider "the content and context of use," as "not all screen time is created equal."

He says: "The context is key as screen time might have positive effects on the family system as a whole, for example, freeing up parents to do necessary household tasks and provide young people benefits such as relaxation, low energy play, or communication with family."

In a similar vein, Jenny Radesky, MD, assistant professor of pediatrics, University of Michigan, Ann Arbor, was quoted in the Washington Post as saying that screen time recommendations for children can induce "real conflict."

"The more guidelines we give, it just seems like there's going to be more of a mismatch between what experts say...and what it feels like to be a parent in the real world every day," she commented.

However, Jean M. Twenge, PhD, professor of psychology at San Diego State University, California, emphasized that the "absolute priority for very young children has to be on face-to-face interactions, physical exercise, and sleep.

"I think the temptation to hand young children a phone or a tablet any time they fuss is misguided," Twenge said.

"Children need to learn how to self-soothe and manage their emotions. And if they're frequently handed these devices, they don't learn these things."

No funding or conflicts of interest were declared.

WHO guidelines.

ECO 2019. Presented April 28, 2019. Abstract IS2.02.

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