What the WHO?
GUIDELINES ON PHYSICAL ACTIVITY, SEDENTARY BEHAVIOUR AND SLEEP FOR CHILDREN UNDER 5 YEARS OF AGE by WHO
When I read headlines or recommendations or guidelines, I like to know where and how they came into being. What evidence or research or theory was guiding this?
The new document from the World Health Organisation was no different. When I intitally read the press release, which has been take up by the BBC and reported sensationally. I immediately thought oh where has that come from so I decided to delve a bit deeper into the why and how?
The document states:
"Physical inactivity has been identified as a leading risk factor for global mortality and a contributor to the rise in overweight and obesity. Early childhood is a period of rapid physical and cognitive development and a time during which a child’s habits are formed and family lifestyle habits are open to changes and adaptations. To meet daily physical activity time recommendations, particularly in children, the pattern of overall activity across a 24-hour period needs to be considered, since the day is made up of sleep time, sedentary time and light, moderate- or vigorous-intensity physical activity."
“The overall goals of these guidelines are to provide recommendations on the amount of time in a 24-hour day that young children, under 5 years of age, should spend being physically active or sleeping for their health and wellbeing, and the maximum recommended time these children should spend on screen-based sedentary activities or time restrained”.
Definition of restrained
“Time when an infant or child is strapped or harnessed in a pram, stroller, high chair, or on an adult’s body (front or back) and unable to move freely”
They don’t define “sling” in the glossary
I believe this is a really useful guide in many ways. We know many children are not active enough for their own health needs and benefits in later life. There is an overuse of containers for young children, and screens are a part of daily life for us all including young children. I do not feel slings are used in the same way as other containers, this is certainly not my experience of babywearing in the UK, over the last 10 years..
In reality they are promoting connection, communication, reading, playing, engaging and interacting with young children. All of which is key for their development. All of which promotes a secure attachment, which promotes brain development, which promotes health,
They give age specific recommendations for activity in a 24hr period
Infants (less than 1 year) should:
-Be physically active several times a day in a variety of ways, particularly through interactive floor-based play; more is better. For those not yet mobile, this includes at least 30 minutes in prone position (tummy time) spread throughout the day while awake.
-Not be restrained for more than 1 hour at a time (e.g., prams/strollers, high chairs, or strapped on a caregiver’s back). -Screen time is not recommended.
-When sedentary, engaging in reading and storytelling with a caregiver is encouraged.
-Have 14–17h (0–3 months of age) or 12–16h (4–11 months of age) of good quality sleep, including naps.
The recommendation for "not to be restrained" is the same regardless of age, for no more than an hour, they do not include the phrase "strapped on caregivers back" for the age 3-4 yrs, implying perhaps older children aren't carried for long periods of time when they are alert as they tend to want to walk which is my experience carrying older children, it doesn't mean don't carry older children!!!
The changes through the ages apply to the amount physical activity and screen time in particular.
We know from the science that babies sleep well when they are in contact with their caregivers as their brain perceives this as safe for them. The period they are describing as being "restrained" doesn't apply when asleep. They even state that "Sleep time is also know to influence health outcomes and short sleep duration is associated with overweight and obesity in childhood (7)". Chen X, Beydoun MA, Wang Y. Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring, Md). 2008;16(2):265-74.
"Physical activity in children under 5 years of age is favourably associated with health indicators such as adiposity, bone and skeletal health, cardiometabolic health, cognitive and motor skills development (11)." Timmons BW, Leblanc AG, Carson V, Connor Gorber S, Dillman C, Janssen I, et al. Systematic review of physical activity and health in the early years (aged 0–4 years). Applied physiology, nutrition, and metabolism = Physiologie appliquée, nutrition et métabolisme. 2012;37(4):773-92
The research on Adverse Childhood Experiences shows us just how important attachment is for life long mental and physical health. Things which promote attachment include being repsonsive to your child's needs and carrying can form part of this approach. (As I discuss in my Juno article published earlier this year).
To me it feels like a big missed opportunity around discussing the importance of attachment which the WHO do in their nurturing care document
And how this can lead to a brain that is able to control impluses and not wired for addiction. (in very simplistic terms!)
This guidance is not in alignment with the evidence cited in the latter document, although this new one is specific in addressing obesity.
The Commission on Ending Childhood Obesity called for clear guidance on physical activity, sedentary behaviour and sleep in young children in their recommendation. Which is then how this guidance came about.
The document states
"These guidelines are intended to assist officials as they develop national plans to increase physical activity, reduce sedentary time and improve sleep patterns in young children through guidance documents. The recommendations of these guidelines should be included in pre-service training for health care and early childhood education and care and child development professionals".
It therefore needs to be very carefully worded so it is not mis-interpreted that baby should not be in a sling for more than an hour a day, which from my reading is not what they are saying at all. This is how it was taken by the BBC who then stated "Should not be restrained (ie strapped into a recliner, seat or sling) for more than an hour at a time" without any context around sleep.
(I have contacted them about this and will update as actually the WHO do not mention slings as such but strapped on a caregiver's back).
On a review of evidence "The benefits of less time spent restrained (car seats, prams/strollers, high chairs, or strapped on a caregiver’s back) include reduced adiposity and improved motor development."
Adiposity = Excessive fat accumulation in the body (overweight, obesity), as measured by BMI, BMI-for-age, BMI z-score, skinfold thickness, body fat mass.
The particular research that was used in relation to "strapped on a caregivers back" was E. Pretorius & H. Naudé (2002) Results from an Empirical Study: The impact of carrying a child on the back on the development of visual integration pathways, Early Child Development and Care, 172:6, 585-594, DOI: 10.1080/03004430215106
"In a previous study, Pretorius and coworkers postulated that cultural behavior such as Pepa (carrying the baby on the mother’s back) could have a negative impact on the development of visual integration pathways, as it prevents the child to crawl adequately or enough during the sensorimotor stage. To prove the hypothesis presented previously, we present results from an empirical study conducted in a black township in South Africa."
"Although these infants are able to crawl, they are placed on the mother’s back for convenient traveling and to prevent them from crawling around in the workplace of the mother for as much as 6 to 8 hours per working day"
This is pretty specific situation they are exploring.
The study actually doesn't discuss obesity as such but that
. "Because of the lack of crawling experience, the elevated sitting position, and obstructed view, these infants may experience visual perceptual and spatial deficiencies, as well as obstruction of the peripheral visual field. This may lead to impaired visual scanning and visual integration deficiencies that might influence school readiness.".
There are also many other issues with this study, such as the measures of school readiness and they did not measure how much carrying was done in childhood at all but made cultural assumptions. Dr Rosie Knowles discusses some of this here
In western cultures, when babywearing we do not typically carry for long periods of time young babies on our backs. And whilst I agree with the overarching message this shows us that we should always question recommendations and look further.