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Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): An Integration of Physical Activity,… Tremblay, Mark S; Chaput, Jean-Philippe; Adamo, Kristi B; Aubert, Salomé; Barnes, Joel D; Choquette, Louise; Duggan, Mary; Faulkner, Guy; Goldfield, Gary S; Gray, Casey E; Gruber, Reut; Janson, Katherine; Janssen, Ian; Janssen, Xanne; Jaramillo Garcia, Alejandra; Kuzik, Nicholas; LeBlanc, Claire; MacLean, Joanna; Okely, Anthony D; Poitras, Veronica J; Rayner, Mary-Ellen; Reilly, John J; Sampson, Margaret; Spence, John C; Timmons, Brian W; Carson, Valerie Nov 20, 2017

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RESEARCH Open AccessCanadian 24-Hour Movement Guidelinesfor the Early Years (0–4 years): AnIntegration of Physical Activity, SedentaryBehaviour, and SleepMark S. Tremblay1*, Jean-Philippe Chaput1, Kristi B. Adamo2, Salomé Aubert1, Joel D. Barnes1, Louise Choquette3,Mary Duggan4, Guy Faulkner5, Gary S. Goldfield1, Casey E. Gray1, Reut Gruber6, Katherine Janson7, Ian Janssen8,Xanne Janssen9, Alejandra Jaramillo Garcia10, Nicholas Kuzik11, Claire LeBlanc12, Joanna MacLean13,Anthony D. Okely14, Veronica J. Poitras1, Mary-Ellen Rayner15, John J. Reilly9, Margaret Sampson1,16,John C. Spence11, Brian W. Timmons17 and Valerie Carson11AbstractBackground: The Canadian Society for Exercise Physiology convened representatives of national organizations,research experts, methodologists, stakeholders, and end-users who followed rigorous and transparent guidelinedevelopment procedures to create the Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years): AnIntegration of Physical Activity, Sedentary Behaviour, and Sleep. These novel guidelines for children of the earlyyears 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) IIinstrument. Four systematic reviews (physical activity, sedentary behaviour, sleep, combined behaviours) examining therelationships within and among movement behaviours and several health indicators were completed and interpretedby a Guideline Development Panel. The systematic reviews that were conducted to inform the development of theguidelines, and the framework that was applied to develop the recommendations, followed the Grading ofRecommendations Assessment, Development, and Evaluation (GRADE) methodology. Complementary compositionalanalyses were performed using data from the Canadian Health Measures Survey to examine the relationships betweenmovement behaviours and indicators of adiposity. A review of the evidence on the cost effectiveness and resource useassociated 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 draftguidelines and their dissemination.Results: The guidelines provide evidence-informed recommendations as to the combinations of light-, moderate- andvigorous-intensity physical activity, sedentary behaviours, and sleep that infants (<1 year), toddlers (1–2 years) andpreschoolers (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.ca1Healthy Active Living and Obesity Research Group, Children’s Hospital ofEastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1,CanadaFull 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 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe 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):874DOI 10.1186/s12889-017-4859-6(Continued from previous page)Conclusions: These guidelines represent a sensible evolution of public health guidelines whereby optimal health isframed 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 integratedguidelines for other age groups should be developed.Keywords: Infants, Toddlers, Preschoolers, Adiposity, Motor development, Cognitive development, Public health,Recommendations, Guideline developmentBackgroundMovement behaviours across the whole day (24-hperiod) have recently garnered increased interest in pub-lic health research and practice. For example, Canada re-leased evidence-informed Canadian 24-Hour MovementGuidelines for Children and Youth: An Integration ofPhysical Activity, Sedentary Behaviour, and Sleep [1] inresponse 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 topicsshow desirable movement behaviours (e.g., longer sleep,less sedentary behaviour or screen time, more physicalactivity) to be beneficially associated with a variety ofholistic health indicators in children and youth [7–10].Subsequent analyses demonstrated consistent evidenceof additional health benefits associated with meeting anincreased number of movement behaviour guidelines[11–14], supporting their integration in public healthmessaging. Feedback from stakeholder and end-usergroups is supportive of this integrated approach [15, 16].Recent systematic reviews that focused on children ofthe 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] allsuggest health benefits associated with desirable move-ment behaviours. Current evidence indicates that 62–84% of Canadian preschoolers (aged 3–4 years) aremeeting 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 guidelinesbut only 15% meet screen time guidelines [28]. Con-cern over the low proportion of children of the earlyyears meeting screen time guidelines [27] is evidencedby recent published statements by the American Acad-emy of Pediatrics [29] and the Canadian Paediatric Society[30]. Several recent reviews have explored potentialmechanisms linking excessive screen time with healthindicators [20, 31, 32]. There are no previous system-atic review-informed Canadian sleep guidelines forthe 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 thiswork. Furthermore, evidence from focus group discus-sions and key informant interviews suggest that stake-holders (e.g., clinicians, practitioners, physical activityknowledge translation groups, researchers) and end-users’ (e.g., pediatricians, parents, early childhood educa-tors) are supportive of a similar approach for children ofthe early years [33]. Therefore, the purpose of thismanuscript is to outline the process and outcomes forthe development of the Canadian 24-Hour MovementGuidelines for the Early Years (0–4 years): An Integra-tion of Physical Activity, Sedentary Behaviour, and Sleepreleased by the Canadian Society for Exercise Physiologyand partners on November 20, 2017. There are no previ-ously developed Canadian evidence-based guidelines in-tegrating recommendations for all movement behavioursfor the early years. These new, integrated recommenda-tions are intended to provide parents, caregivers, healthprofessionals, and policy-makers with guidance on thequality 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 ≤1.5metabolic equivalents, while in a sitting, reclining orlying posture [34]), and sleep; thus, conceptualizingmovement on a continuum from sleep to high-intensity physical activity [35].MethodsOverall guideline development processThe process used to develop the Canadian 24-HourMovement Guidelines for the Early Years (0–4 years)followed the 15-stage framework described in detail byTremblay and Haskell [36]. The process included the ap-plication of the Appraisal of Guidelines for Research andEvaluation (AGREE) II instrument [37–40] from the out-set as well as the early engagement of guideline develop-ment methodologists, and benefitted from the significantThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 2 of 215experience and learning from earlier guideline develop-ment, dissemination, and implementation efforts. Fig. 1provides a summary of the timelines and sequence ofevents involved in the development of the guidelines.In November 2015, a Leadership Committee wasformed 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 OntarioResearch Institute; University of Alberta; and Partici-pACTION), methodologists, and support staff. In August2016, the Public Health Agency of Canada (PHAC) pro-vided support for the guideline development and alsojoined the Leadership Committee. The LeadershipCommittee met monthly to provide oversight, strategicdirection, fiscal accountability, and attentiveness toAGREE II criteria. Subsets of the Leadership Commit-tee met as required to ensure the project advancedefficiently. In January 2016, a Guideline DevelopmentPanel (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 providean overview of the guideline development process, re-sponsibilities, and timelines; introduce the methodologyconsultants and explain their responsibilities; hear frominternational delegates about other countries’ guidelineprocesses and the potential for harmonization andavoiding duplication of efforts; finalize the systematic re-view parameters; finalize the search strategies for thesystematic reviews; discuss and set timelines for the sys-tematic reviews; and initiate discussions regardingknowledge translation, dissemination, and evaluation. Inaccordance with the GRADE handbook [41], the groupalso identified and prioritized the health outcomes/indi-cators for each of the systematic reviews, with a focuson 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, sofor the purposes of this manuscript the term “healthindicator” will be used.Systematic reviewsThough the initial GDP meeting was funded by a CanadianInstitutes of Health Research (CIHR) grant to update theprevious early years sedentary behaviour guidelines [27],the Leadership Committee agreed that the effort mustadhere to the whole-day approach taken with the newCanadian 24-Hour Movement Guidelines for Childrenand Youth [1], and additional funding sources werediscussed 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 specialsupplement [18, 21–23]. Reviewers systematicallysearched online databases for articles on apparentlyhealthy children, including those with obesity, but ex-cluding papers specifically targeting children withknown disease, disability or impairments. The earlyyears were defined as ages 0–4 years and further sub-divided into infants (<1 year), toddlers (1–2 years),and preschoolers (3–4 years). The quality of evidencein each systematic review was assessed by indicator,study design, and age group (where possible), usingFig. 1 Timelines and sequence of events involved in the developmentof the Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years):An Integration of Physical Activity, Sedentary Behaviour, and SleepThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 3 of 215Table1GuidelineDevelopmentPanelPanelmemberAffiliationRoleConflictofinterestdeclarationResearchexpertsandcredentialsKristiAdamo,PhDAssociateProfessor,UniversityofOttawa(Canada)PAandSBcontentexpert,systematicreviewauthornoneSalomeAubertdoctoralstudent,UniversityofOttawa(Canada)PAandSBcontentexpert,systematicreviewauthornoneValerieCarson,PhDAssociateProfessor,UniversityofAlberta(Canada)compositionalanalysesleader,PAandSBcontentexpert,LeadershipCommittee,SteeringCommittee,SurveillanceSub-Committee,systematicreviewauthornoneJean-PhilippeChaput,PhDResearchScientist,HALO,CHEORI(Canada)sleep,PA,andSBcontentexpert,LeadershipCommittee,SteeringCommittee,SurveillanceSub-committee,systematicreviewauthornoneGuyFaulkner,PhDProfessorandCIHR-PHACChairinAppliedPublicHealth,UniversityofBritishColumbia(Canada)PAandSBcontentexpert,stakeholderconsultation(focusgroupsauthor)noneGaryGoldfield,PhDSeniorScientist,HALO,CHEORI(Canada)PAandSBcontentexpert,systematicreviewauthornoneReutGruber,PhDProfessor,McGillUniversity;Director,AttentionBehaviourandSleepLab,DouglasMentalHealthUniversityInstitute(Canada)sleepcontentexpert,systematicreviewauthorHusbandonACSMBoardofDirectors2010–2016(ACSMproducedclinicalguidelinesandpositionstandsforsleepmedicinefield);receivedseveralgrantsasaPrincipalInvestigatortoinvestigatetheinterplaybetweensleep,nutritionandPAinchildrenanddevelopedaninterventionprogramtotargetthisinterplay,expectstopublish.IanJanssen,PhDProfessorandCanadaResearchChairinPhysicalActivityandObesity,Queen’sUniversity(Canada)PAandSBcontentexpert,SurveillanceSub-Committee,systematicreviewauthornoneNicholasKuzikdoctoralstudent,UniversityofAlberta(Canada)combinedmovementbehaviourcontentexpert,systematicreviewauthor,LeadershipCommitteenoneJoannaMacLean,PhD,MD,FRCPCpaediatricrespirologistandsleepmedicinespecialist;AssociateProfessor,UniversityofAlberta(Canada)sleepcontentexpert,systematicreviewauthornoneJohnSpence,PhDProfessorandVice-DeanofPhysicalEducationandRecreation,UniversityofAlberta(Canada)PAandSBcontentexpert,systematicreviewauthornoneBrianTimmons,PhDAssociateProfessorandCanadaResearchChairinChildHealthandExerciseMedicine,McMasterUniversity(Canada)PAandSBcontentexpert,systematicreviewauthornoneMarkTremblay,PhDDirector,HALO,andSeniorScientistCHEORI(Canada)Chair,PAandSBcontentexpert,LeadershipCommittee,SurveillanceSub-Committee,SteeringCommittee,systematicreviewauthor,disseminationandimplementation,evaluationnoneThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 4 of 215Table1GuidelineDevelopmentPanel(Continued)PanelmemberAffiliationRoleConflictofinterestdeclarationStakeholdergroupsandknowledgeusersLouiseChoquettebilingualhealthpromotionconsultant,HealthNexus(Canada)invitedrepresentative(HealthNexus),earlyyearsexpertnoneMaryDuggan,CAEManager,CSEP(Canada)CSEPrepresentative,LeadershipCommittee,SteeringCommittee,disseminationandimplementation,evaluationnoneKatherineJansonDirectorofCommunicationsandPublicAffairs,ParticipACTION(Canada)invitedrepresentative(ParticipACTION),creativedevelopmentandmarketing,LeadershipCommitteenoneClaireLeBlanc,MD,FRCPCpaediatricrheumatologistandsportmedicinephysician,MontrealChildren’sHospital(Canada)invitedrepresentative(CanadianPediatricSociety,)earlyyears,PA,SB,andsleepcontentexpertnoneMary-EllenRaynerChiefPartnershipsandCommunicationsOfficer,TheSandboxProjectinvitedrepresentative(TheSandboxProject),earlyyears,PA,andSBcontentexpertnoneInternationalcollaboratorsXanneJanssen,PhDPostdoctoralFellow,UniversityofStrathclyde(Scotland)PAandSBcontentexpert,internationalrepresentative,systematicreviewauthornoneAnthonyOkely,PhDProfessorialFellowandDirector,EarlyStartInstitute,UniversityofWollongong(Australia)earlyyears,SB,andPAcontentexpert,internationalrepresentative,systematicreviewauthorReceivedfundingasaconsultantfromFoxteltoadviseonPAinterstitialaspartoftheirpreschooltelevisionprogramsJohnReilly,PhDProfessor,UniversityofStrathclyde(Scotland)earlyyears,PAandSBcontentexpert,internationalrepresentative,systematicreviewauthornoneMethodologyconsultantsandprojectmanagementCaseyGray,PhDProjectManager,HALO,CHEORI(Canada)PAandSBcontentexpert,LeadershipCommittee,SteeringCommittee,systematicreviewauthor,evaluationnoneAlejandraJaramilloGarciaGlobalHealthandGuidelinesDivision,PHAC(Canada)AGREEIIandGRADEmethodologicalconsultant,SteeringCommittee,systematicreviewauthornoneVeronicaPoitras,PhDClinicalResearchOfficer,CanadianAgencyforDrugsandTechnologiesinHealth(Canada)aPAandSBcontentexpert,LeadershipCommittee,SteeringCommittee,SurveillanceSub-Committee,systematicreviewauthornoneMargaretSampson,PhDManager,LibraryServices,Children’sHospitalofEasternOntario(Canada)methodologyexpert,researchlibrarian,systematicreviewauthornoneACSMAmericanCollegeofSportsMedicine,AGREEAppraisalofGuidelinesforResearchandEvaluation;CAECertifiedAssociationExecutive,CHEORIChildren’sHospitalofEasternOntarioResearchInstitute;CIHRCanadianInstitutesofHealthResearch,CSEPCanadianSocietyforExercisePhysiology,FRCPCFellowoftheRoyalCollegeofPhysiciansofCanada,GRADEGradingofRecommendationsAssessment,Development,andEvaluation,HALOHealthyActiveLivingandObesityResearchGroup,PAphysicalactivity,PHACPublicHealthAgencyofCanada,SB,sedentarybehavioura VeronicaPoitraswasaResearchManager(HALO,CHEORI)duringtheconductofthesystematicreviewsandpreparationoftheinitialdraftoftheguidelinesThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 5 of 215the Grading of Recommendations Assessment, Develop-ment, and Evaluation (GRADE) framework [42, 43].The first systematic review examined the relationshipsbetween objectively and subjectively measured physicalactivity and health indicators in the early years [18], up-dating and building on an earlier systematic review usedto inform Canadian Physical Activity Guidelines for theEarly Years [26, 44]. As detailed in the internationalProspective 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 bothcritical (adiposity, motor development, psychosocialhealth, cognitive development, fitness) and important(bone and skeletal health, cardiometabolic health, andrisks/harm) health indicators [18]. Note that accordingto GRADE, outcomes rated as “critical” are those thatare considered essential for decision-making; these areweighted most heavily in the process of moving from theevidence to the guideline recommendations (see GRADEevidence to decision framework: summary below).“Important” health indicators were also identified by theGDP but given lower weighting through the evidence todecision process.Updating and extending the earlier systematic reviewthat LeBlanc et al. [46] conducted for the CanadianSedentary Behaviour Guidelines for the Early Years [27],the second systematic review examined relationships be-tween sedentary behaviour and health indicators in theearly 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].The objective of the third systematic review was toexamine the associations between sleep duration andhealth indicators in children of the early years(PROSPERO Registration no. CRD42016040096) [22].The review included apparently healthy childrenaged 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, physicalactivity, quality of life/well-being, risks/injuries) healthindicators [22].The fourth systematic review examined combinationsof 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 physicalactivity; sedentary behaviour and physical activity; andsleep, sedentary behaviour, and physical activity]); com-parator (various levels and combinations of movementbehaviours); and indicators (critical: adiposity, motor de-velopment, psychosocial health/emotional regulation,cognitive development, fitness, and growth; important:bone and skeletal health, cardiometabolic health, andrisks) [23].Compositional analysesResearch on movement-related behaviours and theresultant public health guidelines have typically taken asegregated rather than integrated approach. Not surpris-ingly, the evidence base is similarly constructed. Whilethree of the systematic reviews outlined above provide acomprehensive assessment of the relationships betweenindividual movement behaviours (i.e., sleep, sedentarybehaviour, physical activity) and indicators of health,only the review by Kuzik et al. [23] examined evidencein relation to combinations of two or more movementbehaviours. Examining the combinations of movementbehaviours that constitute the complete 24-h period isnot common and presents inherent analytical challenges[47, 48]. Because the constituent parts (sleep, sedentarybehaviour, physical activity) saturate the entire 24-hperiod, a change in any behaviour must be done at theexpense of one of the other behaviours, making the vari-ables time-dependent and constitutionally collinear. Toaddress this reality, assess the legitimacy of the whole-day approach to health promotion in the early years, andhelp inform the new integrated guidelines, complemen-tary compositional data analyses [47, 49] were conductedusing data from the Canadian Health Measures Survey(CHMS) [50].The specific objectives of the compositional analyseswere twofold: (1) to explore the combined associationsof the composition of sleep duration, sedentary time,light-intensity physical activity (LPA), and moderate- tovigorous-intensity physical activity (MVPA) with adipos-ity indicators, and (2) to explore the association of thetime spent in sleep, sedentary behaviour, LPA, andMVPA with adiposity indicators relative to the timespent in the other behaviours in a representative sample(n = 552) of Canadian preschool-aged children from theCHMS [51]. Sedentary time, LPA, and MVPA were mea-sured with Actical accelerometers (Philips Respironics,The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 6 of 215Bend, Oregon, USA); sleep duration was measured byparental report. Height and body mass (to determinebody mass index [BMI] z-scores based on World HealthOrganization growth standards) and waist circumfer-ences (WC) were directly measured following standardprocedures [52–54]. Compositional data analyses wereused to examine the cross-sectional associations. Forcomplete details on the sample, measurement proce-dures and compositional analyses see Carson et al. [51].These compositional analytic procedures can be used asa blueprint for future research to examine the associa-tions of multiple movement behaviours and other healthindicators beyond adiposity.Additional considerations from GRADEThe GRADE process uses several sources of informationin a systematic and transparent fashion to inform guide-line recommendations. These factors include quality ofthe evidence (i.e., risk of bias, inconsistency, indirect-ness, imprecision, publication bias), balance of benefitsand harms, end-user preferences and values, resourceimplications, 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., strongor conditional/weak) of the recommendation.The quality of the evidence was assessed and reportedin the systematic reviews [18, 21–23]. The balance ofbenefits and harms was also informed by the systematicreviews as well as by detailed discussions and eventualconsensus by the GDP. End-user preferences and values,resource implications, feasibility, acceptability, and equityissues were assessed through the stakeholder survey, keyinformant interviews, and focus groups (described inGuidelines recommendations and stakeholder consulta-tions section). To further explore resource requirements(costs), a review of the evidence on cost and resourceuse related to 24-h movement behaviours was con-ducted. However, no evidence was found that met theinclusion criteria.Guidelines recommendations and stakeholder consultationsThe second meeting of the GDP was held in January2017. The objectives of this three-day meeting were toreview, discuss, debate, and interpret findings fromsystematic reviews and compositional analyses; reviewresults of cost-effectiveness/resource use analysis; craftindividual components of the movement behaviourguidelines; create 24-h integrated movement behaviourguidelines; identify research gaps; and plan the launch,dissemination, promotion, and evaluation activities.Draft guideline recommendations were created by theGDP based on the overall balance between the possiblebenefits and harms of various levels of physical activity,sedentary behavior, and sleep; stakeholder and end-userpreferences and values related to these movement be-haviours; and considerations related to feasibility, acces-sibility, resource use, and equity. The draft guidelineswere translated into French and back-translated for veri-fication. All GDP members approved the draft guidelinesfor the stakeholder consultations.A cross-sectional survey (see Additional file 1 forcomplete survey in English and French) was developedto gather stakeholder and end-user feedback on (1) thecontent and format of the draft guidelines, (2) elementsof importance to the GRADE Evidence to DecisionFramework (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 ofimplementing the guidelines) [55], and (3) suggestionsregarding key intermediaries to implement and activatethe guidelines. Following approval from the Children’sHospital of Eastern Ontario Research Institute’s Re-search Ethics Board, the survey was created online usingREDCap (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- andopen-ended responses. Descriptive statistics were calcu-lated to summarize participant characteristics andclosed-ended feedback. Open-ended feedback was syn-thesized qualitatively, using thematic analyses wherebyresearch staff read through the full transcripts of partici-pant responses and independently identified commonthemes 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 seriesof focus groups and key informant interviews were com-pleted to examine stakeholders’ (experts in pediatric andfamily 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 obtainedfrom the Research Ethics Boards of the University ofBritish Columbia and the Children’s Hospital of EasternOntario Research Institute. Stakeholders (n = 10) engagedin telephone interviews and end-users (n = 92) partici-pated in focus groups (n = 14) to discuss perceived clarityand need for the guidelines, potential barriers to imple-mentation, identification of credible messengers, andmethods for dissemination of the guidelines. Audio-recordings from the focus groups and interviews weretranscribed verbatim and thematic analysis was conductedconsistent with that reported by Faulkner et al. [16]. Fulldetails on the methodology are available elsewhere [33].The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 7 of 215A sub-committee of the GDP reviewed summaries ofthe stakeholder survey, focus group and interview re-sults, and revised the guidelines based on the feedback,ensuring changes remained true to the available evidencebase. The revised guidelines were circulated to the entireGDP for comment and final revisions. Consensus wasachieved on the final guidelines. Revisions were trans-lated to finalize the French version.Dissemination, implementation and evaluation plansThe release of the Canadian 24-Hour Movement Guidelinesfor Children and Youth [1] marked the initiation of a para-digm shift away from consideration of isolated behaviourstowards a “whole-day matters” approach. This shift createdopportunity 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 madeto 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.buildyourbestday.com). Members of the GDP, with additionalmembers from CSEP and ParticipACTION (Canadian not-for-profit organization promoting physical activity inCanada), formed a sub-committee (Guideline Implementa-tion and Activation Committee) to facilitate strategic andproactive dissemination, promotion, and implementation ofthe 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 identitywas used in the preparation of materials, tools and re-sources, both digital and print, for the release of theCanadian 24-Hour Movement Guidelines for the EarlyYears. The Guideline Implementation and ActivationCommittee also developed an integrated marketing andcommunications plan for sustained dissemination and im-plementation following the guideline launch. Finally, thework of the sub-committee responsible for evaluation of thechild 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 thebackground work done in Canada, and guided by theGRADE “adolopment” procedures [58], the Australian24-Hour Movement Guidelines for the Early Yearswere prepared [59] and concurrent launch plans werecoordinated.Research gaps and surveillance recommendationsResearch gaps were identified and recorded throughoutthe guideline development process (e.g., systematicreviews, 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 thecombination or composition of the behaviours.To make recommendations in this regard a SurveillanceSub-committee of the GDP, with additional members withextensive 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 anapproach similar to what was done for the child and youthguidelines [1].Four independent reviewers were contracted to con-duct an AGREE II assessment on the entire guidelinedevelopment process using the guideline materials andsystematic reviews [37–40]. All of the materials pre-sented in this special issue of BMC Public Health wereprovided to the independent assessors.ResultsOverall guideline development processThe guideline development process successfully adheredto the framework outlined by Tremblay and Haskell[36]. Throughout the process, methodologists on theGDP familiar with AGREE II [37–40] and GRADE[42, 43, 55] provided advice and kept detailed records ofdiscussions 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 than50 times in the course of the guideline developmentprocess. Full GDP meetings were held in Ottawa, Canadain February 2016 and January 2017, with additional cor-respondence done through email.Systematic reviewsA brief summary of the findings of each systematic re-view is provided below, with detailed results availableelsewhere in this special issue of BMC Public Health[18, 21–23]. Because of significant heterogeneity in avariety of variables, meta-analyses could not be performedfor most indicators in the systematic reviews, so narrativesyntheses were predominantly employed. Collectively,34,566 titles and abstracts were screened and 271 paperswere included in the systematic reviews.Physical activity and health indicatorsNinety-six studies (71,291 unique participants from 36countries) were included in the review on physical activ-ity and health indicators in the early years [18]. Studydesigns 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 additionalThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 8 of 215cross-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. Physicalactivity was consistently associated with improved motorand cognitive development as well as psychosocial andcardiometabolic health in randomized and non-randomized intervention studies, and with favourablemotor development, fitness, and bone and skeletal healthin observational studies. Light- and moderate-intensityphysical activity were not consistently associated withany health indicators, whereas moderate- to vigorous-intensity, vigorous-intensity, and total physical activitywere consistently favourably associated with multiplehealth indicators. Across study designs, consistentfavourable associations with health indicators were ob-served for different types of physical activity, includingactive 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 forhealth. For infants, ≥30 min/day of the prone position,or “tummy time”, was most favourably associated withhealth indicators. The quality of the evidence rangedfrom “very low” to “high” and the majority of evidencewas in preschool-aged children (3–4 years).Sedentary behaviour and health indicatorsA total of 96 studies (195,430 participants from 33 coun-tries) were included in the sedentary behaviour system-atic review [21]. Study designs included randomizedcontrolled 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 betweenscreen 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 developmentwere favourable or null. Associations between time spentseated (e.g., in car seats or strollers) or in the supineposition, and indicators of adiposity and motor develop-ment, were primarily unfavourable or null. The qualityof evidence ranged from “very low” to “moderate” acrossstudy designs and health indicators.Sleep and health indicatorsThe systematic review on sleep duration and health indi-cators in the early years [22] included 69 studies (62unique samples; 148,524 unique participants from 23countries). 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 assessedby parental report in 70% of studies (n = 48) and wasmeasured objectively (or both objectively and subject-ively) in 30% of studies (n = 21). In general, shorter sleepduration was associated with higher adiposity, pooreremotional regulation, impaired growth, more screentime, and higher risk of injuries. The evidence related toindicators of cognitive development, motor develop-ment, physical activity, and quality of life/well-being wasless clear, with no consistent associations. The quality ofevidence ranged from “very low” to “high” across studydesigns and health indicators.Combined movement behaviours and health indicatorsThe systematic review that examined associations amongcombinations of movement behaviours and health indi-cators in children of the early years [23] included 10studies (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 studydesigns the most ideal combinations of sedentarybehaviour and physical activity (i.e., combinations ofmovement behaviours hypothesized to be beneficial forhealth, 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 amongtoddlers and preschool-aged children; and not associatedwith growth among toddlers and preschool-aged chil-dren. The most ideal combinations of sleep and seden-tary behaviour were favourably associated with adiposityamong infants and toddlers. The quality of evidenceranged 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 inthe early years.Overall, the reviews showed that a need exists forbetter quality studies with stronger research designs, es-pecially those that can provide information on dose-response relationships, if they exist. Furthermore, theyidentified a need for future research to determine theideal distribution and pattern of daily movement behav-iours (physical activity, sedentary behaviour, sleep) foroptimal health throughout the early years.Compositional analysesComplete data for cross-sectional compositional analyseswere available on 552 participants aged 3–4 years fromThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 9 of 215cycles 2 and 3 (2009–2013) of the CHMS [51]. The aver-age age of the sample was 3.5 years and was balancedbetween 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. Thetwo variables with the highest co-dependence were sed-entary time and sleep duration and the two variableswith the lowest co-dependence were sedentary time andMVPA. The composition of movement behaviours wassignificantly associated with BMI z-scores but not withWC. The time spent in sleep, sedentary behaviour, LPA,or MVPA relative to the other behaviours was not sig-nificantly associated with the adiposity indicators. Thisstudy was the first to use compositional analyses toexamine associations of all movement behaviours withadiposity indicators in preschool-aged children. Theoverall composition of movement behaviours, ratherthan any single movement behaviour in isolation, ap-pears important for healthy BMI z-scores in preschool-aged children. However, future research, especiallyexperimental research, is needed to determine the opti-mal movement behaviour composition that should bepromoted in this age group and for younger childrenaged 0–2 years.Guideline recommendations and stakeholder consultationsThe draft guidelines are available in Additional file 1 aspart of the stakeholder survey.Stakeholder surveyDemographics: Data from 695 stakeholders and end-users were collected by the online survey; missing dataranged from 130 to 287 per closed-ended item. Therewere participants from all provinces and territories ex-cept the Northwest Territories and Nunavut; the greatestproportion were employed in Ontario (51.7%), followedby 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 and4.5% worked outside of Canada. By sector, participantswere 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 completesummary of the stakeholder survey results is provided inTable 2. Participants agreed with the content and formatof the draft title of the guidelines, the preamble, and theguidelines (combined “Strongly Agree” and “SomewhatAgree”: 89.1, 96.2 and 96.1%, respectively), and agreedthat the title, preamble, and guidelines were clearlystated (combined “Strongly Agree” and “SomewhatAgree”: 94.2, 96.5, and 98.9%, respectively). A minorityof participants suggested additions or changes. Amongthe feedback received on the title, the most frequentcomments suggested the title was too long, the targetaudience was unclear (i.e., practitioners versus generalpopulation), and the early years age range needed to bemade 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 providedon the guidelines themselves, and there was no consist-ent pattern among comments received.GRADE Evidence to Decision Framework: There washigh 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 thatimplementing 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 implementingthe guidelines; most (81.1%) indicated that the benefitsof 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 assessingacceptability, 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?” respondedfavourably. Thirty participants provided favourable orneutral feedback and also suggested an addition orchange to some element of the guidelines, mostcommonly requesting examples or added descriptions.Fourteen respondents provided negative feedback and11 indicated the guidelines were not relevant in theirwork or their personal life. Fifty-five participants elabo-rated on their responses to the resource use item. Ofthose, 10 indicated the cost of using the guidelineswould be small to negligible, 4 indicated the cost wouldbe difficult to manage, and 13 described the costs butdid not indicate if it would be easy or difficult to absorbinto their operating budget. Other responses suggestedrespondents did not understand the question. Forty par-ticipants provided written feedback on the perceivedincremental cost-benefit ratio item. Among them, 19provided favourable responses, one responded that therewould be no benefit and only cost, and 19 participantsdid not provide clear feedback. Fifty-seven participantsexpanded on their responses to the equity item. Elevenindicated that following the guidelines would benefit allgroups equally while two disagreed, expressing a beliefthat socioeconomic status would moderate the relation-ship between guideline adherence and any expectedhealth indicators. Thirty-three participants describedbarriers or facilitators to implementation and 11 did notanswer the question.The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 10 of 215Implementation and activation of the guidelines:Stakeholders (227 total responses; some named multipleintermediaries) indicated childcare providers (176), par-ents (173), and health care providers (107) were themost important intermediaries to target for implementa-tion and activation of the guidelines. The most endorsedmodalities for supporting intermediaries to implementand activate the guidelines (125 total responses) includedtraining opportunities such as prenatal workshops aswell as pre-service and in-service training (n = 55), andproducts such as “toolboxes” or posters, with explanationsand examples of how to adopt ad activate the guide-lines (n = 43).Focus groups and key informant interviewsThe focus groups and key informant interviews rein-forced the findings from the stakeholder survey, that theproposed guidelines were very well received by bothstakeholders and end-users [33]. A clear need for suchintegrated guidelines was identified and most believedthe guidelines were achievable. Several potential barriersto uptake were identified including low awareness ofTable 2 Summary results of stakeholder surveyQuestion StronglyAgreen (%)SomewhatAgreen (%)Neither Agree NorDisagree n (%)SomewhatDisagreen (%)StronglyDisagreen (%)TotalResponses nThe Title is clearly stated. 339 (60.0%) 193 (34.2%) 19 (3.4%) 13 (2.3%) 1 (0.2%) 565Do you agree with the Title? 303 (54.1%) 196 (35.0%) 36 (6.4%) 22 (3.9%) 3 (0.5%) 560The Preamble is clearly stated. 322 (71.4%) 113 (25.1%) 9 (2.0%) 7 (1.6%) 0 (0.0%) 451Do you agree with the Preamble? 339 (75.3%) 94 (20.9%) 10 (2.2%) 7 (1.6%) 0 (0.0%) 450The 24-Hour Guidelines are clearly stated. 341 (78.0%) 87 (20.0%) 5 (1.1%) 4 (1.0%) 0 (0.0%) 437Do you agree with the 24-Hour Guidelines? 327 (74.8%) 93 (21.3%) 12 (2.7%) 5 (1.1%) 0 (0.0%) 437Evidence to Decision FrameworkYes NoAre the 24-Hour Guidelines important toyou? (priority)409 (95.8%) 18 (4.2%)Always Frequently Occasionally Seldom NeverWould 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 MoreUsefulMore Useful Neutral Less Useful Much LessUsefulIn 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 SomewhatEasyNeither EasyNor DifficultSomewhatDifficultVery DifficultHow easy or difficult would you find usingthe 24-Hour Guidelines? (feasibility)175 (41.0%) 188 (44.0%) 41 (9.6%) 22 (5.2%) 1 (0.2%)StronglyAgreeSomewhatAgreeNeither AgreeNor DisagreeSomewhatDisagreeStronglyDisagreeI Don’t KnowThe costs for you to use, or your organizationto implement, the 24-Hour Guidelines are likelyto be small or negligible compared to not usingthe 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 Guidelinesare 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 tobenefit all population groups equally, irrespectiveof gender, race, ethnicity, or the socioeconomicstatus of the family.(equity)233 (57.1%) 117 (28.7%) 20 (4.9%) 22 (5.4%) 5 (1.2%) 11 (2.7%)The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 11 of 215current 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 disseminationwere recommended by focus group participants and keyinformants. Health care and child care settings were themost frequently cited locations for dissemination andphysicians and early childhood educators were the mostcommon suggestions for messengers. Results suggestthat going forward it will be important to dedicateappropriate support and funding toward disseminationefforts in order to reach end-users, particularly parents,health care providers, and early childhood educators.Revisions to draft guidelinesFollowing the Guideline Revision Meeting, three changeswere made that altered the content of the preamble: 1) inthe description of the groups for whom the guidelines arerelevant, the GDP decided that replacing “race and ethni-city” with “cultural background” (adopted in the Australianguidelines) would better indicate the diversity of popula-tions to whom the guidelines apply; 2) in the description ofthe context of children’s activities it was decided that alladults have a role in helping children of the early years tomeet 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” wasreplaced with “harm” for accuracy.Three changes that altered the content of the guidelineswere made: 1) “while awake” was added to the infanttummy time recommendation to avoid potential harm inhaving the recommendation misinterpreted as contradic-ting safe sleep recommendations; 2) based on feedbackfrom the focus groups and from discussions at theAustralian guideline development meetings, “energeticplay” (i.e., MVPA) was added to the toddler physical activityrecommendation; and 3) the term “sedentary” was added tothe screen time recommendation based on the AustralianGuideline development process and to better reflect theevidence, which did not include data on non-sedentaryscreen-based activities. Other changes were minor resultsof the copy-editing process. The final guidelines, with pre-amble, in English and French are provided in Figs. 2, 3, 4and 5. The final quality of evidence and strength of recom-mendation ratings are provided below in the GRADEEvidence to decision framework: summary section, includinga summary of the rationale for these decisions, with moreextensive explanations provided in Additional file 2.GRADE evidence to decision framework: SummaryThe specific guideline recommendations in theCanadian 24-Hour Movement Guidelines for theEarly Years are provided below with correspondingstatements indicating the quality of the evidenceinforming the recommendation and the strength ofthe recommendations.For infants (less than 1 year), a healthy 24 h includes: Being physically active several times in a variety ofways, particularly through interactive floor-basedplay; more is better. For those not yet mobile, thisincludes at least 30 min of tummy time spreadthroughout the day while awake. Moderate qualityevidence, strong recommendation. Not being restrained for more than 1 h at a time(e.g., in a stroller or high chair). Screen time is notrecommended.When sedentary, engaging in pursuitssuch as reading and storytelling with a caregiver isencouraged. Moderate quality evidence, strongrecommendation. 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, strongrecommendation.For toddlers (1–2 years), a healthy 24 h includes: At least 180 min spent in a variety of physicalactivities at any intensity, including energetic play,spread throughout the day—more is better. Moderatequality 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 extendedperiods. For those younger than 2 years, sedentaryscreen time is not recommended. For those aged2 years, sedentary screen time should be no morethan 1 h; less is better. When sedentary, engaging inpursuits such as reading and storytelling with acaregiver is encouraged. Moderate quality evidence,strong recommendation. 11–14 h of good-quality sleep, including naps, withconsistent bedtimes and wake-up times. High qualityevidence, strong recommendation.For preschoolers (3–4 years), a healthy 24 h includes: At least 180 min spent in a variety of physical activitiesspread throughout the day, of which at least 60 min isenergetic play—more is better. Moderate qualityevidence, strong recommendation. Not being restrained for more than 1 h at a time(e.g., in a stroller or car seat) or sitting for extendedperiods. Sedentary screen time should be no morethan 1 h; less is better. When sedentary, engaging inpursuits such as reading and storytelling with acaregiver is encouraged. Moderate quality evidence,strong recommendation.The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 12 of 215 10–13 h of good-quality sleep, which may include anap, with consistent bedtimes and wake-up times.High quality evidence, strong recommendation.For all age groups: Replacing time restrained or sedentary screen timewith additional energetic play, and trading indoor foroutdoor time, while preserving sufficient sleep, canprovide greater health benefits. Very low qualityevidence, strong recommendation.Strength of recommendationsThe GDP followed the GRADE system to make determi-nations about the strength of each recommendation byconsidering; 1) the quality of the supporting evidence, 2)the values and preferences of stakeholders and end-users, 3) whether the recommendations would beFig. 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 reservedThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 13 of 215considered a wise use of resources, 4) equity, acceptabil-ity, and feasibility, and 5) whether the potential benefitsoutweigh the potential harms [41].1) Overall quality of the evidence supporting therecommendations.The quality of the evidence from the four systematicreviews informing the recommendations wasconsidered in the process of assessing the overallquality of the evidence supporting each recommendation[42, 43]. After considering the quality of theevidence associated with the five “critical” healthFig. 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 reservedThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 14 of 215indicators examined in the physical activity systematicreview, the GDP did not change the previous physicalactivity recommendation [26] despite the “low” qualityevidence on adiposity and motor development, andthe “very low” quality evidence on fitness [18]. Theoverall certainty of the evidence supporting therecommendation is “moderate”. The panel reachedthis conclusion based on the fact the “moderate”quality evidence indicating that physical activityimproves psychosocial health and cognitive developmentwas considered sufficient to support a recommendationin favour of increasing physical activity [18]. The qualityFig. 4 Directives canadiennes en matière de mouvement sur 24 heures pour les enfants de 0 à 4 ans: une approche intégrée regroupant l’activité physique,le comportement sédentaire et le sommeil - French Preamble. © Société canadienne de physiologie de l'exercice, 2017. Tous les droits sont réservésThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 15 of 215Fig. 5 Directives canadiennes en matière de mouvement sur 24 heures pour les enfants de 0 à 4 ans: une approche intégrée regroupant l’activité physique,le comportement sédentaire et le sommeil - French Guidelines. © Société canadienne de physiologie de l'exercice, 2017. Tous les droits sont réservésThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 16 of 215assessment of “moderate” reflects moderate confidencethat the true effect is likely to be close to the estimate ofthe effect presented in the systematic review, but there isa possibility that it is substantially different.After considering the quality of the evidence associatedwith the four “critical” health indicators in thesedentary behaviour review, the GDP did notchange the sedentary behaviour recommendation[27]. Despite the “moderate” quality evidence thatsedentary behaviour may not affect adiposity andthe “very low” quality evidence showing inconclusivefindings for a relationship between sedentarybehaviour and motor development or cognitivedevelopment, there was “moderate” quality evidencethat low sedentary behaviour is favourably associatedwith psychosocial health [21]. This was consideredsufficient to support a recommendation in favour ofreducing sedentary behaviour. Therefore, theoverall certainty of the evidence supporting therecommendation was “moderate”, which reflectsmoderate confidence that the true effect is likelyto be close to the estimate of the effect presentedin the systematic review, but there is a possibilitythat it is substantially different.After considering the quality of the evidence associatedwith the five “critical” health indicators associated withthe sleep review, the GDP concluded that despite the“low” quality evidence that sleep duration is not relatedto adiposity, and the “very low” quality evidence thatsleep duration is not related to motor development orgrowth, “high” quality evidence indicating that longersleep durations are associated with improvedcognitive development and emotional regulation [22]was sufficient to support a recommendation in favourof longer sleep durations. As such, the GDP concludedthat the overall certainty of the evidence supporting therecommendation was “high”, which reflects high levelof confidence on the part of the GDP that the trueeffect lies close to the estimate of effect presented inthe systematic review.After considering the quality of the evidence associatedwith the six critical health indicators considered in theintegrated movement behaviours systematic review[23], the GDP concluded that the overall certainty ofthe evidence supporting the recommendation was “verylow”. The systematic review [23] found “moderate”quality evidence that the most ideal combinations ofmovement behaviours are not related to growth,“low” quality evidence indicating that the mostideal combinations of integrated behaviours werefavourably associated with motor development,and favourably or unrelated to adiposity, and“very low” quality evidence indicating idealcombinations were favourably related to fitness[23]. Furthermore, despite “very low” qualityevidence that outdoor time was only related to 1out of 10 motor skills, “low” quality evidenceshowed that higher outdoor time was associatedwith lower sedentary time, and “very low” qualityevidence showed that higher outdoor time wasassociated with lower blood pressure [60]. All sixcritical health indicators were taken into accountin the development of the integrated movementrecommendation, including two that were rated as“very low” quality evidence. The assessment of“very low” overall quality of the evidence indicatesthat the guideline panel has very little confidencein the effect estimate. The true effect is likely tobe substantially different from the estimate of effect.2) Values and preferences of stakeholders and end-users.While selecting “important” and “critical” healthindicators, the GDP considered the importance (i.e.,values and preferences) of each indicator to parents,stakeholders and end-users in terms of the developmentand health of children of the early years. A study wasnot conducted to have these groups identify importanthealth indicators, per se. However, almost all GDPmembers were parents, including parents of children ofthe early years, and several stakeholder and end-userrepresentatives were on the GDP. In addition, manyexternal reviewers of the guidelines were also parents,stakeholders or end-users and provided inputduring the stakeholder survey; almost all (95.8%)external reviewers indicated the recommendationswere important to them. Considering the indirectassessments of target group values and preferencestogether with the broad range of indicators includedin the systematic reviews that informed theserecommendations, the GDP concluded that therewould likely be no important variability in valuesand preferences of health indicators if target groupshad rated the indicators directly.3) Resource requirements (costs).A literature search was conducted using systematicreview searching techniques to inform the GDP’sunderstanding of the expected short-term costs(resource use) required to implement the guidelinesas a population-health strategy and to gain insightinto the cost-effectiveness of applying theserecommendations 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 fromexternal reviewers (via the stakeholder survey) on theiropinions about cost and resource use. Moststakeholders (64.8%) agreed that the costs associatedwith applying the recommendations would be smallor negligible. In terms of the perceived incrementalcost relative to the perceived net benefit, most (81.1%)The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 17 of 215agreed that over the course of a lifetime, the healthbenefits of applying the recommendations would likelyoutweigh the costs, which in the judgment of theGDP is likely to generate large savings from a healthcare systems perspective. In the judgment of theGDP considering the available information, thecost-effectiveness of the recommendations issupported.4) Equity, acceptability, and feasibility.A systematic review of the evidence examiningequity, acceptability, and feasibility amongststakeholders was not conducted. Thus, theseelements of the recommendations were informedby external reviewer input and by judgmentsmade by the GDP. Most external reviewers (85.5%)agreed that following these recommendations wouldbenefit all groups of the population equally. In thejudgment of the GDP, implementing theserecommendations would probably increase healthequity (i.e., decrease health inequity). Similarly, mostexternal reviewers (78%) indicated that they would“always” or “frequently” use the recommendations.Thus, in the judgment of the GDP, theserecommendations are acceptable. Finally, mostexternal reviewers (85%) indicated that in theirview the recommendations were “somewhat” to“very easy” to use. Based on this information, inthe judgment of the GDP, the recommendationsare feasible to implement.5) Benefits vs harms (justification)Physical Activity: Based on the systematic review byCarson et al. [18], higher physical activity amongchildren of the early years was favourably related toadiposity, motor development, psychosocial health,cognitive development, and fitness. Although noevidence pointed specifically to harm resulting fromincreasing physical activity, there was no clear effectobserved on bone and skeletal health, cardio-metabolichealth, and injuries to rule out the possibility of harm.Nevertheless, in the judgment of the GDP, the benefitsof increasing physical activity in children of the earlyyears are likely to outweigh the potential harms, whichare likely to be limited to injuries and are unlikely to beserious.In balancing the benefits against the harms, in thejudgment of the GDP, the desirable indicators(moderate benefits) are likely to outweigh theundesirable indicators (very minor harms); therefore,a recommendation in favour of increasing physicalactivity is warranted. The GDP placed more value on“moderate” quality evidence showing improvementson adiposity and psychosocial health and on “high”quality evidence showing a benefit in motordevelopment, and less value on “very low” qualityevidence showing contradicting findings related tothe effect of physical activity on cardio-metabolichealth, and on “very low” quality evidence showingthat physical activity resulted in an increase in thenumber of injuries. The GDP also placed more valueon evidence showing that total physical activity (TPA),moderate-intensity (MPA), and MVPA resulted inimproved fitness.A strong recommendation in favour of increasingphysical activity is supported by the assessment ofoverall “moderate” quality evidence supporting therecommendation, the moderate magnitude of theeffect, the low variability in how parents andstakeholders value the recommendation, theanticipated small or negligible costs associatedwith implementing the recommendation, the largesavings to the healthcare system expected overthe course of a lifetime, and the stakeholder inputsuggesting that these recommendations would befeasible and acceptable to stakeholders.Sedentary behaviour: According to Poitras et al. [21],limiting sedentary screen-based behaviours wasassociated with benefits (i.e., psychosocial health andfitness), as was engaging in interactive non screen-based sedentary behaviour with an adult (i.e.,storytelling and reading was favourably associatedwith cognitive development). In terms of evidenceof potential harms, there was limited inconclusive“low” and “very low” quality evidence regardingthe effects of sedentary behaviour on motordevelopment and injuries. Therefore, the impactof sedentary behaviours on these indicators is uncertain.Nevertheless, in the judgment of the GDP it is highlyunlikely that decreasing sedentary time or screen-basedbehaviours would have an adverse or harmful effect onmotor development. The potential harms resulting fromlimiting sedentary behaviour in children are likelyto be minor.In considering the balance of the benefits versus theharms, it is the judgment of the GDP that themoderate benefits of limiting/avoiding restrainedtime, sedentary time, and screen based behavioursoutweigh the potential for very minor harms,warranting a recommendation in favour of thesedentary behaviour recommendations. The GDPplaced relatively more value on “moderate” qualityevidence showing that reducing sedentary timeimproved adiposity (critical) and psychosocial health(critical), and relatively less value on limited “verylow” quality evidence on the impact of sedentarybehaviour on motor development (critical) and thelack of evidence about injuries (important).The overall quality of evidence supporting therecommendation was deemed to be of “moderate”The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 18 of 215quality, and the magnitude of the effect is expectedto be moderate. Taken together with conclusionsdrawn from the parent and stakeholder survey, focusgroups and interviews (i.e, low variability in howparents and stakeholders value the recommendation,the costs associated with implementing therecommendation are expected to be small ornegligible, recommendations would be feasible andacceptable) and the large savings to the healthcaresystem expected over the course of a lifetime, astrong recommendation is warranted.Although the body of evidence indicated that limitingsedentary behaviour is likely to improve healthindicators in children in this age group, there was alack of evidence in relation to the optimal sedentarytime in a 24-h day. To address this uncertainty,experts recommended supporting the currentCanadian Sedentary Behaviour Guidelines for theEarly Years (aged 0 to 4 years) [27] from 2012with slight modifications to introduce guidingprinciples as to how sedentary behaviours can fitin the context of a healthy day. The recommendedsedentary time in the 2012 recommendations alignwith the new evidence identified by Poitras et al. [21]and, therefore, were adopted by the GDP.Sleep: The systematic review conducted by Chaputet al. [22] showed that longer sleep durations (totalsleep in 24 h) was associated with benefits related toemotional regulation, growth, and cognitivedevelopment, and reduced sedentary behaviour.With regard to potential harms, there was limitedand inconclusive evidence about the impact ofsleep on adiposity, motor development, physicalactivity, injuries and quality of life, and no evidence oncardio-metabolic health. Therefore, the GDP couldnot be certain of the impact of longer sleep durationson these indicators. However, in the judgment of theGDP, the potential harms resulting from longer sleepdurations are likely to be very minor.In considering the balance of the benefits versus theharms, it is the judgment of the GDP that themoderate benefits of longer sleep durations are likelyto outweigh any potential minor harms, warranting arecommendation in favour of longer sleep durationsincluding napping. The GDP placed more value on“high” quality evidence showing that longer sleepdurations improved emotional regulation (critical) andcognitive function (critical), and less value on limited“low” quality and “very low” quality evidence showingthat increasing the duration of sleep may impactadiposity or physical activity, and on the lack ofevidence examining metabolic health.The overall quality of evidence supporting therecommendation was deemed to be of “high” qualityand the magnitude of the effect is expected to bemoderate; the GDP is very confident that the trueeffect lies close to the estimate of the effect. Takentogether with the conclusions drawn from the parentand stakeholder survey, focus groups and interviews(low variability in how parents and stakeholders valuethe recommendation, recommendations would befeasible and acceptable, and the anticipated costsassociated with implementing the recommendationare expected to be small or negligible), and the largesavings to the healthcare system expected over thecourse of a lifetime, a strong recommendation infavour of longer sleep durations, including napping iswarranted.Although the body of evidence indicated that longersleep durations, when compared to shorter sleepdurations, were generally favourably associated withhealth indicators regardless of age, no conclusionscould be drawn in terms of optimal durations forinfants, toddlers, or preschoolers. Content expertsfrom the GDP pointed to the USA National SleepFoundation [61] and American Academy of SleepMedicine [62] guidelines, which recommend that ina 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 (3–5 years)sleep 10–13 h. This was consistent with the systematicreview findings [22], which did not uncover anyevidence to warrant deviating from these guidelines.Therefore, the newborn, infant, toddler, andpreschooler recommendations were adopted bythe GDP.Combined movement behaviours: The systematicreview conducted by Kuzik et al. indicated that themost ideal combinations of sedentary behaviour andphysical activity were favorably associated with motordevelopment and fitness; both favorably and notassociated with adiposity; and not associated withgrowth [23]. Replacing sedentary time with vigorousphysical activity was found to be beneficial for fitness.The most ideal combinations of sleep and sedentarybehaviour were favorably associated with adiposity.There was no evidence on harms/injuries. Therefore,it is unclear if there would be an impact of combinedmovement behaviours on this indicator. However, inthe judgement of the GDP, the potential harmsresulting from increasing physical activity, decreasingsedentary behaviours, and increasing sleep durationare likely to be very minor.In considering the balance of the benefits versus theharms shown in the four systematic reviews, it is thejudgement of the GDP that the potential benefitsassociated with the most ideal combinations ofmovement behaviours are likely to outweigh anyThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 19 of 215potential minor harms, warranting a strongrecommendation in favour of engaging in higherphysical activity, less time restrained and lesssedentary screen time, and longer sleep durations[18, 21–23]. The GDP also considered previouslypublished evidence that indicated improved healthbenefits, higher physical activity, and lowersedentary time when children of the early years areoutdoors [60, 63]. The GDP placed relatively morevalue on “very low” quality evidence showing thatthe most ideal combinations of movementbehaviours were associated with adiposity (critical)and fitness (critical), and “very low” quality evidenceon motor development (critical), and relatively lessvalue on the limited “very low” quality evidence ongrowth (critical) and the lack of evidence onpsychosocial health/emotional regulation (critical),cognitive development (critical), bone and skeletalhealth (important), cardiometabolic health (important),and injuries/harms (important).The overall quality of evidence supporting therecommendation was deemed to be of “very low”quality and the magnitude of the effect is expectedto be very low. Taken together with the conclusionsdrawn from the parent and stakeholder survey, focusgroups and interviews (i.e., low variability in howparents and stakeholders value the recommendation,recommendations would be feasible and acceptable,and the anticipated costs associated with implementingthe recommendation are expected to be small ornegligible), and the large savings to the healthcaresystem expected over the course of a lifetime, a strongrecommendation is warranted.The body of evidence showed that replacing sedentarytime or light physical activity with energetic play(MVPA) is likely to improve health indicators inchildren of the early years. However, there was noinformation available about combinations of all threemovement behaviours included in the systematicreview that would inform a specific recommendationfor the amounts of sedentary time to be tradedfor light, moderate, and vigorous physical activity,and sleep.Subgroup considerationsMost stakeholders agreed that if implemented in allCanadian children of early years age, the recommenda-tions would benefit all groups of the Canadian popula-tion equally. A few raised concerns about the difficultythat families from low socio-economic status may havein meeting these guidelines. In the judgment of the GDP,these are implementation issues, many of which couldbe addressed by developing knowledge translation toolstargeting 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 decisionframework” is provided in Additional file 2.Dissemination, implementation and evaluation plansThe Canadian 24-Hour Movement Guidelines for theEarly Years (0–4 years): An Integration of PhysicalActivity, Sedentary Behaviour, and Sleep were officiallyreleased on November 20, 2017 through a comprehen-sive media relations strategy to optimize exposure andcoverage. Dissemination, implementation, communica-tion, and evaluation plans for the new guidelines intendto 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, andadaptation 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 carepractitioners, and public health promoters, and indir-ectly with parents/caregivers. Proactive national mediarelations outreach, hard copy and e-distribution ofguideline-related materials have been orchestratedthrough Leadership Committee distribution networks. Across-Canada lecture tour in both French and English isalso planned to raise knowledge and awareness of theguidelines among important stakeholders and end-users,including researchers. Webinars targeted to differentend-user groups were developed, delivered, and pre-served on-line (www.csep.ca/guidelines). All promotionalmaterials, campaigns, and initiatives are available in bothEnglish and French.The visual identity created for the Canadian 24-HourMovement Guidelines for Children and Youth wasadapted for use with the Canadian 24-Hour MovementGuidelines for the Early Years (0–4 years) (see Figs. 3and 5) and used to create a digital marketing platformtargeted at practitioners who serve children and familiesof 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 portalthat provides the three key audiences identified throughstakeholder consultation (i.e., early childhood educators,healthcare providers, parents) with the information andresources they need to understand and implement thenew guidelines. This resource will be available atwww.buildyourbestday.com/earlyyears by March 31,2018. The site will provide simple, informational contentand resources related to this age group including an in-structional video that explains the guidelines, a suite ofThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 20 of 215digitized tools for download, a variety of public-facingand easy-to-read blog articles, infographic(s), poster(s),printable messaging materials (e.g., brochures, tipsheets), and promotional content pieces such as Twittercards, Facebook images, Instagram images, sample ads,and sample social media content.Metrics on the success of the guidelines launch will begathered including traditional media impressions, socialmedia activity, hard-copy and electronic distribution inthe first two weeks post-launch as well as the generaltone (positive/negative) of any media coverage. Canadianparents’ baseline awareness of the guidelines immedi-ately post launch will be collected via a ParticipACTIONsurvey consistent with evaluation procedures beingemployed with the guidelines for children and youth.Beliefs among identified key stakeholders (primary careproviders, public health promoters, and early childhoodeducators) about the relative benefits of the 24-h move-ment guidelines (integrated physical activity, sedentarybehaviour, and sleep) versus separate guidelines for eachbehaviour are being assessed via an online, survey.An unplanned outcome of the development of thesenew Canadian guidelines was that they initiated the de-velopment of similar guidelines in Australia [59]. Indeed,the Australian guidelines “adoloped” [58] the Canadianguidelines and the concurrent release of both guidelineswas coordinated facilitating international collaboration,reducing duplication of effort and enhancing enthusiasmand excitement in both jurisdictions. This bilateral co-operation enticed the World Health Organization tocommence the development of Global 24-Hour MovementGuidelines for the Early Years (see www.who.int/end-childhood-obesity/news/public-consultation-2017/en forfurther details). This global momentum should facilitateawareness and uptake of the various jurisdictionalguidelines.Research gapsThe systematic reviews, GDP meetings, and stakeholderand end-user consultations highlighted several researchneeds that are listed in Table 3. Briefly, in all threemovement behaviour domains (i.e., physical activity, sed-entary behaviour, and sleep), more research is requiredfocusing on the dose-response relationships betweenthese behaviours and important health indicators. Fewstudies to date have used valid and reliable measures ofsedentary behaviour or sleep, focused on infants or tod-dlers, or controlled for important confounders (e.g.,diet). The range of health indicators with available datawas limited with a lack of evidence for the relationshipsbetween the three movement behaviours and fitness,bone and skeletal health, cardiometabolic health, andrisk/harms. The change to 24-h movement guidelineshas highlighted several additional research gaps.Currently, limited evidence is available on the combinedeffects of physical activity, sedentary behaviour, and sleepon health in the early years. Future research shouldfocus on examining the combined effect of these behav-iours while developing innovative ways to analyze these24-h data.Surveillance recommendationsThe Surveillance Sub-committee met several timesthrough teleconferences to discuss and agree upon thesurveillance recommendations for the Canadian 24-Hour Movement Guidelines for the Early Years, with dueconsideration to the existing surveillance structures inCanada (Table 4). It is recommended that in order for achild to be considered to have met these new guidelines,all specific recommendations with a check mark inTable 4 should be met. To meet a specific movementbehaviour guideline (e.g., physical activity) each rec-ommendation would need to be met (e.g., for pre-schoolers meeting the recommendations for bothaverage total physical activity per day of ≥180 minand average MVPA per day of ≥60 min is required).It is recommended that future surveillance work forsedentary 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 theduration of screen time that occurs while in a sitting orlying position. Furthermore, future surveillance effortsshould attempt to account for multitasking during seden-tary behaviours (e.g., eating while watching television andusing social media on a small screen device).AGREE II assessmentThe four independent assessors scored the proceduresused to develop the Canadian 24-Hour MovementGuidelines for the Early Years (0–4 years): An Integrationof Physical Activity, Sedentary Behaviour, and Sleepfollowing the rubric of the AGREE II [40]. A summaryof the combined scores for each AGREE II domain areprovided in Table 5. Overall, the guideline developmentprocess was scored very high (Domain average ratings89–100%) and all assessors indicated that they wouldrecommend the guidelines for use. Additional details onall aspects of the guideline development process areavailable in the Guideline Development Report atwww.csep.ca/guidelines.DiscussionGuideline development process and outcomesThis paper outlines the process and outcomes for thedevelopment of the Canadian 24-Hour MovementGuidelines for the Early Years (0–4 years): An IntegrationThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 21 of 215of Physical Activity, Sedentary Behaviour, and Sleep. Thedevelopment of these guidelines that integrate all move-ment behaviours follows the shift toward a whole-dayapproach to conceptualizing movement behaviours thatwas initiated by the Canadian 24-Hour MovementGuidelines for Children and Youth: An Integration ofPhysical 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 otherbehavioural research [64], and logic. As summarized brieflyin the results and in more detail in Additional file 2, it isTable 3 Research gaps identified through the guidelinedevelopment processResearch 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 samplesizes, objective measures).• To enable comparison across studies, objective measures of sedentarybehaviour, physical activity, and sleep (e.g., accelerometry, inclinometry)are needed. Additionally, there is a need to standardize measurementprocedures.• To establish the true effect of sedentary behaviour, physical activity, andsleep, possible confounders (e.g., diet) need to be controlled for instudies.• To understand possible dose-response relationships between healthoutcomes and movement behaviours, examination of the effect ofdifferent doses (i.e., duration, frequency) of physical activity, sedentarybehaviour, and sleep on health outcomes is needed (e.g., the effect ofparticipating in physical activity for 15 min/day versus 30 min/dayversus 60 min/day) and baseline physical activity should be controlledin intervention studies.• Studies in infants and toddlers are required to establish developmentally-appropriate doses of sedentary behaviour and physical activity for theseage groups.• Examination of the associations between physical activity and psychosocialhealth, fitness, bone and skeletal health, cardiometabolic health, and risk/harms are needed.• Examination of the associations between sedentary behaviour andbone and skeletal health, cardiometabolic health, fitness, and risks/harms are needed.• Exploration of the associations between total sedentary time andhealth outcomes as well as patterns of sedentary behaviour (e.g.,combination of timing, length, order of sedentary behaviours relativeto physical activity and sleep, and breaks in sedentary behaviours) andhealth outcomes are needed;• Studies examining the impact of new screen-based devices (e.g., mobilephones, 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 ageranges (i.e., newborns, infants, toddlers, and preschoolers).• There is a need to determine the distribution of daily movementbehaviours for optimal health throughout the early years, morespecifically a need for studies that use more balanced approaches tointervene on various movement behaviours in the early years.• Examination of the relationships between combinations of movementbehaviours and health indicators is needed.Research needs arising from Guideline Development Panel meetingsand discussions• Physical Activity◦ Whether the environment in which physical activity takes place (e.g.,indoor vs. outdoor) influences the relationships with health indicatorsis unclear; using accurate measures to capture physical activity dosetogether with context is recommended (e.g., combining objectivemeasures 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 inthe early years remain unclear. There is need to examine whetheractivities at the higher end of light physical activity are more beneficialfor health than those at the lower end of light physical activity.• Sedentary Behaviour◦ Some time spent sedentary may be required to enhance growthand development. The need for a minimum amount of sedentarytime to improve growth and development remains to be determined.Table 3 Research gaps identified through the guidelinedevelopment process (Continued)◦ There is a need for the use of valid and reliable measures of sedentarybehaviour in the early years (e.g., inclinometers). In addition, valid andreliable tools to measure sedentary behaviour in non-ambulatoryinfants need to be developed.◦ Establish whether the effect of screens on several health outcomesis 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 healthindicators.• Sleep◦ Research studies focusing on sleep quality are needed (e.g., sleepefficiency, sleep consolidation, sleep architecture).◦ Identify optimal ranges of sleep duration for the different agegroups. Studies examining the effect of different sleep durations onhealth outcomes are required.◦ Examine the effect of sleep routines (e.g., consistent bed/waketimes, 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) thatmay be uniquely important during the early years.◦ Identify additional methods for analyzing 24-h movement data.Stakeholder, intermediary, and end-user consultation and engagementresearch needs• There is a need to understand more completely the language anddelivery mediums and methods that minimize end-user feelings ofguilt and disengagement and maximize motivation and empowermentto implement and achieve the integrated guidelines.• There is a need to understand the nuances of guideline messaging toeffectively and efficiently implement and activate the new guidelinesin different end-user groups (e.g., parents, grandparents, child careproviders, health care providers, early childhood educators).International and inter-jurisdictional research needs and opportunities• The dissemination, activation, implementation, impact, and uptake ofthe new integrated guidelines in different jurisdictions should beexamined and compared.• Intra- and inter-jurisdictional acceptance of the new integrated guidelinesapproach should be assessed and compared.Other research needs• There is a need for cost-effectiveness analyses of interventions aimingto improve movement behaviours during the early years.• There is a need to increase the evidence on movement behavioursand health outcomes in young children with physical or mental diseasesor disabilities.The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 22 of 215Table4SurveillancerecommendationsfortheCanadian24-HourMovementGuidelinesfortheEarlyYearsMovementBehaviourSpecificguidelinerecommendationforahealthydaySpecificsurveillancerecommendationRationaleforspecificsurveillancerecommendationRecommendationforminimuminclusioninoverallguidelinesurveillanceaAgecategoryPhysicalactivityInfants(aged<1year)Beingphysicallyactiveseveraltimesinavarietyofways,particularlythroughinteractivefloor-basedplay;moreisbetterNoneCurrentlytherearenoavailablebenchmarks,furtherresearchisrequired.✓bForthosenotyetmobile,thisincludesatleast30minoftummytimespreadthroughoutthedaywhileawakeAveragetotaltummytimeperdayis≥30minwhileawakecTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicaltummytimeperdayintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.✓Toddlers(aged1–2years)Atleast180minspentinavarietyofphysicalactivitiesatanyintensity,includingenergeticplay,spreadthroughouttheday;moreisbetterAveragetotalphysicalactivityperdayis≥180minwithatleastsomeenergeticplay(MVPA)cTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalphysicalactivityperdayintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.Therearecurrentlynobenchmarksfortherecommendeddurationofenergeticplayinthisagegroup.✓Preschoolers(aged3–4years)Atleast180minspentinavarietyofphysicalactivitiesspreadthroughoutthedayAveragetotalphysicalactivityperdayis≥180minutescTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalphysicalactivityperdayintheiranalyses.✓ofwhichatleast60minisenergeticplay;moreisbetterAverageMVPAperdayis≥60minutescAnaverageallowsforsomenormalday-to-dayvariability.✓SedentarybehaviourInfantsScreentimeisnotrecommendedAtypicaldayincludesnoscreentimedTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalscreentimeperdayintheiranalyses.✓Notbeingrestrainedformorethan1hatatime(e.g.,inastrollerorhighchair)Timespentrestrainedis≤1hatatimeeEmpiricalevidencesubstantiatingthisthresholdislackingthoughthisthresholdisalignedwithearlierguidelinesandhasmetwithstakeholderandend-useracceptance(Tremblayetal.,2012)f .Whensedentary,engaginginpursuitslikereadingandstorytellingwithacaregiverisencouragedNoneCurrentlytherearenoavailablebenchmarks,furtherresearchisrequired.The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 23 of 215Table4SurveillancerecommendationsfortheCanadian24-HourMovementGuidelinesfortheEarlyYears(Continued)MovementBehaviourSpecificguidelinerecommendationforahealthydaySpecificsurveillancerecommendationRationaleforspecificsurveillancerecommendationRecommendationforminimuminclusioninoverallguidelinesurveillanceaToddlersForthoseyoungerthan2years,sedentaryscreentimeisnotrecommendedAtypicaldayincludesnosedentaryscreentimedTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsedentaryscreentimeperdayintheiranalyses.✓Forthoseaged2years,sedentaryscreentimeshouldbenomorethan1h;lessisbetterAveragesedentaryscreentimeperdayis≤1hourcTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsedentaryscreentimeperdayintheiranalyses.Anaverageallowsforsomeday-to-dayvariabilityinsedentaryscreentime.✓Notbeingrestrainedformorethan1hatatime(e.g.,inastrollerorhighchair)orsittingforextendedperiodsTimespentrestrainedis≤1hatatimeeEmpiricalevidencesubstantiatingthisthresholdislackingthoughthisthresholdisalignedwithearlierguidelinesandhasmetwithstakeholderandend-useracceptance(Tremblayetal.,2012)f .Currentlytherearenoavailablebenchmarkstobemorespecificfor“sittingforextendedperiods”,furtherresearchisrequired.Whensedentary,engaginginpursuitslikereadingandstorytellingwithacaregiverisencouragedNoneCurrentlytherearenoavailablebenchmarks,furtherresearchisrequired.PreschoolersSedentaryscreentimeshouldbenomorethan1h;lessisbetterAveragesedentaryscreentimeperdayis≤1hourcTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsedentaryscreentimeperdayintheiranalyses.Anaverageallowsforsomeday-to-dayvariabilityinsedentaryscreentime.✓Notbeingrestrainedformorethan1houratatime(e.g.,inastrollerorcarseat)orsittingforextendedperiodsTimespentrestrainedis≤1houratatimeeEmpiricalevidencesubstantiatingthisthresholdislackingthoughthisthresholdisalignedwithearlierguidelinesandhasmetwithstakeholderandend-useracceptance(Tremblayetal.,2012)f .Currentlytherearenoavailablebenchmarkstobemorespecificfor“sittingforextendedperiods”,furtherresearchisrequired.Whensedentary,engaginginpursuitslikereadingandstorytellingwithacaregiverisencouragedNoneCurrentlytherearenoavailablebenchmarks,furtherresearchisrequired.SleepInfants14to17h(forthoseaged0–3months)ofgoodqualitysleep,includingnapsAveragetotalsleepdurationper24his14to17hourscTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsleepdurationper24hintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.✓The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 24 of 215Table4SurveillancerecommendationsfortheCanadian24-HourMovementGuidelinesfortheEarlyYears(Continued)MovementBehaviourSpecificguidelinerecommendationforahealthydaySpecificsurveillancerecommendationRationaleforspecificsurveillancerecommendationRecommendationforminimuminclusioninoverallguidelinesurveillancea12to16h(forthoseaged4–11months)ofgoodqualitysleep,includingnapsAveragetotalsleepdurationper24his12to16hourscTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsleepdurationper24hintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.✓Toddlers11to14hofgoodqualitysleep,includingnapsAveragetotalsleepdurationper24his11to14hourscTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsleepdurationper24hintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.✓Consistentbedandwake-uptimesBedtimeandwake-uptimeshouldnottypicallyvarybymorethan±30minincludingonweekendsgAlthoughtheempiricalsupportforaspecificsurveillancerecommendationisweak(Allenetal.,2016)h,weproposethatsleepschedules(bedtimeandwake-uptimes)shouldnotvarybymorethan±30mineach.Preschoolers10to13hofgoodqualitysleep,whichmayincludeanapAveragetotalsleepdurationper24his10to13hourscTheevidenceuponwhichtheguidelineisbasedispredominantlycomprisedofstudiesthatusedaverageortypicalsleepdurationper24hintheiranalyses.Anaverageallowsforsomenormalday-to-dayvariability.✓Consistentbedandwake-uptimesBedtimeandwake-uptimeshouldnottypicallyvarybymorethan±30minincludingonweekendsgAlthoughtheempiricalsupportforaspecificsurveillancerecommendationisweak(Allenetal.,2016)h,weproposethatsleepschedules(bedtimeandwake-uptimes)shouldnotvarybymorethan±30mineach.MVPAmoderate-tovigorous-intensityphysicalactivitya Thecheckmarksindicatethecurrentrecommendedminimuminclusionrecommendationsforsurveillanceofmeetingthe24-hguidelines.Otherspecificguidelinerecommendations,whichhavenotbeenidentifiedasrecommendedcomponentsforsurveillanceofmeetingthe24-hguidelines,shouldstillbemeasuredfordescriptivepurposesandtodetermineifchangesareoccurringprospectively.Asevidencegrowsandsurveillancemeasuresevolvefortheseotherrecommendations,updatestotheminimumsurveillancecriteriamayberequiredbItisrecognizedthatthereiscurrentlynobenchmarkforthisrecommendation;however,itremainsarecommendedcomponentforsurveillanceofthe24-hguidelinesformobileinfants.Theimplicationisthatatthepresenttimesurveillanceofmobile(e.g.,crawlingorwalking)infantsmeetingthe24-hguidelinesisnotpossible;however,non-mobileinfantsmeetingthetummytimerecommendationcanbeconsideredtohavemetthephysicalactivityrecommendationandsurveillanceofmeetingthe24-hguidelinesforthissub-groupisthereforepossiblec Ifweekendandweekdaymeasuresareavailable,itisrecommendedthattheaveragetimeengagedineachbehaviourbeweighted2/7forweekenddaysand5/7forweekdaystomostaccuratelyreflectaverageweeklymeasuresdItisunderstoodthatunderspecialcircumstancesexposuretoscreentimemayhappenbutthisshouldberareorunusuale Itisunderstoodthatunderspecialcircumstancesbeingrestrainedinexcessof1hatatimemayoccurbutthisshouldberareorunusualf Tremblayetal.CanadianSedentaryBehaviourGuidelinesfortheEarlyYears(aged0–4years).ApplPhysiolNutrMetab37:370–380,2012gToaccuratelyassessconsistencyofbedtimeandwake-uptimedatashouldbecollectedonbothweekdayandweekenddays.Ifdatafromweekdayandweekenddaysareavailable,itisrecommendedthattheaveragevariationinbedtimeandwake-uptimebeweighted2/7forweekenddaysand5/7forweekdaystomostaccuratelyreflectaverageweeklymeasureshAllenetal.ABCsofSLEEPING:Areviewoftheevidencebehindpediatricsleeppracticerecommendations.SleepMedRev.29:1–14,2016The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 25 of 215Table 5 Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting grid summary from four independent assessorsAGREE II Item Reporting Location Domain Score (%)bDomain 1. Scope and Purpose 1001. The overall objective(s) of the guidelineis (are) specifically described.• Guideline Development Report• This manuscript2. The health question(s) covered by theguideline is (are) specifically described.• Guideline Development Report• This manuscript• Systematic reviews [18, 21–23] and PROSPERO Registrations3. The population (patients, public, etc.) towhom the guideline is meant to applyis specifically described.• Guideline Development Report• This manuscriptDomain 2. Stakeholder Involvement 994. The guideline development group includesindividuals from all the relevant professionalgroups.• Guideline Development Report• This manuscript5. The views and preferences of the targetpopulation (patients, public, etc.) havebeen sought.• Guideline Development Report• This manuscript• Focus groups and key informant interviews [33]6. The target users of the guideline are clearlydefined.• Guideline Development Report• This manuscriptDomain 3. Rigour of Development 957. Systematic methods were used to searchfor evidence.• Guideline Development Report• Systematic reviews [18, 21–23, 60]8. The criteria for selecting the evidence areclearly described.• Guideline Development Report• Systematic reviews [18, 21–23, 60]9. The strengths and limitations of the bodyof evidence are clearly described.• Guideline Development Report• This manuscript• Systematic reviews [18, 21–23, 60]10. The methods for formulating therecommendations are clearly described.• Guideline Development Report• This manuscript11. The health benefits, side effects, and riskshave been considered in formulating therecommendations.• Guideline Development Report• This manuscript• Systematic reviews [18, 21–23, 47, 49, 60]12. There is an explicit link between therecommendations and the supportingevidence.• Guideline Development Report13. The guideline has been externally reviewedby experts prior to its publication.• Guideline Development Report• This manuscript• Focus groups and key informant interviews [33]14. A procedure for updating the guideline isprovided.• Guideline Development Report• This manuscriptDomain 4. Clarity of Presentation 9915. The recommendations are specific andunambiguous.• Guideline Development Report• This manuscript16. The different options for management of thecondition or health issue are clearly presented.a• Not applicable17. Key recommendations are easily identifiable. • Guideline Development Report• This manuscriptDomain 5. Applicability 8918. The guideline describes facilitators and barriersto its application.• Guideline Development Report• This manuscript• Focus groups and key informant interviews [33]19. The guideline provides advice and/or toolson how the recommendations can beput into practice.• Guideline Development Report• This manuscript• CSEP website (www.csep.ca/guidelines)The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 26 of 215the opinion of the GDP that sufficient evidence existsfrom all movement behaviour domains to stronglysupport the final guideline recommendations pre-sented in this paper. The paucity of high quality stud-ies, especially those with experimental dose-responsedesigns, for all movement behaviours is acknowledgedand a call for more and better-quality research hasbeen issued.The guideline development procedures used herefollowed comprehensive, rigorous, and transparent pro-cesses [36, 37, 43], incorporating systematic review find-ings, consultation findings, and compositional analysisfindings, as well as expert, stakeholder, and end-userinput. The final guidelines (Figs. 2, 3, 4 and 5) adhereto the structure used with previous Canadian guide-lines [1, 26, 27, 65, 66], whereby context is provided forthe 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. Additionalmore user-friendly messaging materials targeted to par-ents and the general public were developed as outlined inthe dissemination, implementation, and evaluation planssection of the Results.The individual behaviour components of the guide-lines have not changed significantly from the earlierCanadian Physical Activity Guidelines for the EarlyYears [26] and Canadian Sedentary Behaviour Guide-lines for the Early Years [27]. The major change is theintegration of all movement behaviours across the 24-hperiod, with the most notable additions being 1) specificrecommendations for sleep duration for all age groups;2) a recommendation for a duration of 30 min of tummytime spread throughout the day while awake for infantsnot yet mobile; 3) a recommendation for the inclusionof energetic play in toddlers; 4) a recommendation thatpreschoolers get at least 60 min of energetic play by age5 years (changed from the previous recommendation ofprogression toward at least 60 min of energetic play byage 5 years); and 5) for all age groups, the encourage-ment of quality sedentary behaviours like reading andstorytelling with a caregiver. In addition to providingspecific 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 sedentaryscreen time with additional energetic play, and tradingindoor for outdoor time, while preserving sufficientsleep, can provide greater health benefits”. It is alsoworth highlighting that the GDP used neutral languagepurposefully, 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 orthe other was equivocal.It is possible that busy parents may initially view the 24-h guidelines as just another challenge and potential sourceof stress. Nevertheless, the overall conceptualization of theintegrated approach to all behaviours on the movementcontinuum holds wide appeal with stakeholders andend-users [1, 15, 16, 33, 67] and they are perceived tobe acceptable, affordable, feasible, and realistic.Agreement existed amongst the GDP that proceedingwith the 24-h guidelines for the Early Years using thebest available evidence, expert consensus, and stake-holder and end-user input, while being transparentabout the quantity and quality of the evidence base andthe strength of the guideline recommendations, was themost responsible approach in providing public healthrecommendations regarding movement behaviours for ahealthy 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 evenTable 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 (%)b20. The potential resource implications ofapplying the recommendations havebeen considered.• Guideline Development Report• This manuscript21. The guideline presents monitoring and/orauditing criteria.• Guideline Development Report• This manuscriptDomain 6. Editorial Independence 8922. The views of the funding body have notinfluenced the content of the guideline.• Guideline Development Report• This manuscript23. Competing interests of guideline developmentgroup members have been recorded andaddressed.• This manuscript• Systematic reviews [18, 21–23]aItem 16 was rated as “not applicable” by one reviewer and assessments from the other reviewers were included in the scaled Domain 4 scorebFour independent reviewers applied the AGREE II assessment; the Domain Scores (%) were calculated by summing all the scores of the individual items in a domainand 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 isavailable at www.csep.ca/guidelinesThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 27 of 215where the evidence is weakest, while the likelihood ofharm is very small. Challenges to these recommendationsare 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 recommendationsthat add exactly to 24 h, because there are ranges pro-vided for all behaviour components (e.g., 11–14 h ofsleep, at least 60 min of energetic play, no more than1 h of recreational screen time). Obviously if one childsleeps 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-dayvariability is normal, and provision of ranges allows forthis flexibility, accommodating to different schedulesand changes in schedules. Collectively, guidance for ahealthy 24-h period is provided.A study examining the proportions of preschool-agedCanadian children (3–4 years) meeting the new guide-lines and different recommendations within the guide-lines was completed using CHMS data [24]. Associationsof meeting the guidelines with adiposity indicators werealso explored. Approximately 13% of preschool-agedchildren met the overall 24-h movement guidelines (asdefined by the surveillance recommendations in Table 4),and 3% met none of the three recommendations. Mostpreschool children met the sleep duration (84%) and phys-ical activity (62%) recommendations, while only 24% metthe screen time recommendation. No associations werefound between meeting individual or combined recom-mendations, and anthropometric measures of adiposity. Itmay 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 measureother indicators of holistic health in this age group. This isthe first study to employ the new guidelines for surveil-lance assessments in Canada [24]. The findings related toscreen time provide evidence for the importance of therecommendations from the recent Canadian PaediatricSociety Position Statement that advocates for minimizing,mitigating, mindfully using and modeling healthy use ofscreens [30].Release, dissemination, implementation, and activationplanningA suite of materials to complement and message theguideline recommendations to various subgroups wasdeveloped and is publicly available at www.csep.ca/guidelines. These materials present a relative advantageover previous guidelines, in that they show how theguidelines can be easily assimilated into current practiceby organizations (compatibility), and how they can mostclearly and succinctly be conveyed (simplicity). Theseclear, supporting messages are essential to informingstakeholders, parents, early childhood educators, publichealth/health care professionals, and governments, ofthe value and use of the 24-h movement guidelines. Theguidelines themselves provide evidence-informed targetsassociated with health benefits for children of the earlyyears to follow (under the direction of caregivers).The Leadership Committee partners (CSEP, HALO,ParticipACTION, University of Alberta, PHAC) will takethe lead to disseminate the new guidelines to Canadiansboth directly and through the partners’ networks. Eachpartner has a national mandate related to the promotionof healthy active living to Canadians. In addition, theknowledge user representatives on the GDP come fromdiverse fields concerned with the movement behavioursof 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 trainingmaterials in order to ensure CSEP members as well aspublic health professionals, health care practitioners,teachers, and parents understand the importance of allmovement behaviours across the 24-h period. As withprevious 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 guidelinesshould be followed up with messages that explain the“why” and “how” to the various stakeholder groups, aswell as sustained implementation and activation strategies[1, 57, 67]. The suite of prepared messaging and commu-nication tools, adapted visual identity, and digital platformare designed to serve as a foundation for a long-term,multi-platform, multi-sector, multi-jurisdictional, andmulti-disciplinary marketing and communication effortsto facilitate uptake and activation of the new guidelines.The impact and success of the launch of the newguidelines will be assessed through media hits and im-pressions. Dissemination reach will be assessed withmetrics from online and hard-copy distribution. Fundingis in place to collect baseline data on parents’ and otherstakeholders’ awareness of the new guidelines, allowingfor future follow-up research.Through these various implementation, activation, andevaluation efforts, the long-term goal is that that theseguidelines will enhance the promotion of healthy activelifestyles and improved sleep quality and hygiene amonginfants, toddlers, and preschool children across Canada,and inform healthy active living policy at the local, pro-vincial, and national levels. It is further anticipated thatin the long-term this project will provide internationalleadership and will advance a global healthy active livingagenda. Early evidence of success in the form ofinternational leadership can be found with these newCanadian guidelines being the impetus for the devel-opment of similar guidelines in Australia [59], NewThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 28 of 215Zealand [68], and the initiation of similar globalguidelines by the World Health Organization.Updating the guidelinesThe final stage in the guideline development cycle is theplanning of updates and revisions [36]. It was recom-mended by the GDP that these guidelines be revisitedevery 10 years or whenever important new evidence isidentified that could inform or alter changes to the exist-ing guideline recommendations. Ten years was recom-mended as an appropriate period that allows forcomplete sector penetration and normative utilization bystakeholders, intermediaries, and end-users, while alsoproviding sufficient time for research gaps to be ad-dressed, and is supported by the literature [69, 70].Strengths and limitationsThere were several strengths of the process used to de-velop the Canadian 24-Hour Movement Guidelines forthe Early Years (0–4 years): An Integration of PhysicalActivity, Sedentary Behaviour, and Sleep including ad-hering to a rigorous, robust and transparent guidelinedevelopment process [36, 37, 43]; independent assess-ment by AGREE II reviewers; involvement of andconsultation with a broad assortment of experts, inter-national collaborators, stakeholders, and end-users; con-sideration of a range of holistic health indicators; usingboth systematic reviews and novel compositional dataanalyses to provide a comprehensive evidence base; pro-active planning for dissemination, promotion, imple-mentation, and evaluation; and publishing all scholarlywork in an open-access, peer-reviewed journal.Despite these strengths, the guideline developmentprocess also had limitations. First, the evidence base forthe guidelines was generally incomplete and of low qual-ity, though it does represent the best available evidencecollected through systematic reviews and original re-search. Second, there was very little research available toinform 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 thisage group. Because of this limitation, evidence is presentlyinsufficient to provide specific advice on behaviour substi-tution options for a particular early years child, in a particu-lar situation. Nevertheless, behaviour changes that ensureadequate sleep, reduced screen time, and increased ener-getic or outdoor play are likely to provide health benefits tomost children of the early years. Fourth, it is possible thatthe various consultation processes used resulted in biasedfeedback and that voices of important subsets of the popu-lation were missed. Fifth, evidence of the cost effectivenessof the guideline recommendations was not available.Future researchSpecific research needs identified in the development ofthese 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, researchshould consider the integrated relationships amongmovement behaviours, and similar integrated 24-hmovement guidelines for other age groups (e.g., adultsand older adults) should be developed. Such work holdspromise in not only creating new opportunities and ap-proaches for healthy lifestyle interventions but also forthe discovery of new and novel relationships amongmovement behaviours, and the underlying physiologyand pathophysiology. A need exists for a standardizedmeasurement protocol to collect required information toassess whether the new guidelines are being met. Thisprotocol should be arrived at following a thorough scanof available methods, instruments, and proceduresassessed by an expert group, with final consensus rec-ommendations posted and promoted for widespread use.ConclusionThe new Canadian 24-Hour Movement Guidelines for theEarly Years (0–4 years): An Integration of Physical Activity,Sedentary Behaviour, and Sleep are part of a paradigmshift in thinking about daily movement behaviours. Thisshift from focusing on movement behaviours in isolationto a whole-day approach is supported by the available evi-dence and stakeholder opinion. These guidelines representa sensible evolution of public health guidelines wherebyoptimal health is framed within the balance of movementbehaviours 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 theseguidelines far exceeding the potential risks. It is hopedthat these guidelines open new avenues for populationhealth promotion and instigate new research on the healtheffects of integrated movement behaviours.Additional filesAdditional file 1: Stakeholder Survey (English followed by French version).(DOC 202 kb)Additional file 2: Detailed evidence to decision framework explanationfor 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)AbbreviationsAGREE: Appraisal of Guidelines for Research and Evaluation; BMI: Body massindex; CHEO RI: Children’s Hospital of Eastern Ontario Research Institute;CHMS: Canadian Health Measures Survey; CIHR: Canadian Institutes of HealthResearch; CSEP: Canadian Society for Exercise Physiology; FRCPC: Fellow ofthe Royal College of Physicians of Canada; GDP: Guideline DevelopmentPanel; GRADE: Grading of Recommendations, Assessment, Development andEvaluation; HALO: Healthy Active Living and Obesity research group;LPA: Light-intensity physical activity; MPA: Moderate-intensity physicalThe Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 29 of 215activity; MVPA: Moderate- to vigorous-intensity physical activity; PA: Physical activity;PHAC: Public Health Agency of Canada; PROSPERO: International ProspectiveRegister of Systematic Reviews; REDCap: Research Electronic Data Capture;SB: Sedentary behaviour; TPA: Total physical activity; WC: Waist circumferenceAcknowledgementsThe authors wish to acknowledge the assistance of Rachel Colley (StatisticsCanada) and Karen Roberts (PHAC) in developing surveillance recommendationsfor the new guidelines. The authors would like to thank Geneviève Leduc andKevin Belanger for their assistance on various aspects of the guidelinedevelopment project. Finally, we are grateful to the many students andresearch assistants that assisted with the systematic reviews, focus groups, andkey informant interviews.FundingThis study has been made possible through funding from CIHR (Grants KRS-144044 and FRN 147990); CSEP; HALO Research Group at the Children’sHospital of Eastern Ontario Research Institute; Faculty of Physical Educationand Recreation, University of Alberta; and PHAC. Publication charges for thisarticle have been funded through a grant from PHAC. Valerie Carson andKristi Adamo are supported by CIHR New Investigator Salary Awards. GuyFaulkner is supported by a Chair Award in Applied Public Health funded byPHAC in partnership with CIHR. Anthony Okely is supported by a NationalHeart Foundation of Australia Career Development Fellowship. Ian Janssenand 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 materialsAny raw data or materials used in the preparation of this manuscript are availableupon reasonable request to Dr. Mark Tremblay (mtremblay@cheo.on.ca).About this supplementThis article has been published as part of BMC Public Health Volume 17Supplement 5, 2017: 24-Hour Movement Guidelines for the Early Years: AnIntegration 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’ contributionsMST, VC, MD, JPC, CEG, and VJP were responsible for the initiation, conceptualization,and leadership of the guideline development process. VC led the physical activitysystematic review. VJP led the sedentary behaviour systematic review. JPC led thesleep systematic review. NK led the integrated systematic review. JDB, SA, CEG, andMST were responsible for the stakeholder survey. GF, CEG, and MST were responsiblefor 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.CEG coordinated the AGREE II independent assessments. KJ, MD, CEG, and MST ledthe dissemination, implementation, and activation planning. MST was the primaryauthor of the manuscript. All coauthors were part of the GDP and were responsiblefor reviewing and revising the manuscript for important intellectual content.All authors read and approved the final manuscript.Ethics approval and consent to participateEthics approval was obtained for the stakeholder survey, key informantinterviews and focus groups as described in the manuscript.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Healthy Active Living and Obesity Research Group, Children’s Hospital ofEastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1,Canada. 2School of Human Kinetics, Faculty of Health Sciences, University ofOttawa, Ottawa, ON K1N 1A2, Canada. 3Best Start Resource Centre, HealthNexus, Toronto, ON M5G 1Z8, Canada. 4Canadian Society for ExercisePhysiology, Ottawa, ON K1R 6Y6, Canada. 5School of Kinesiology, Universityof British Columbia, Vancouver, BC V6T 1Z3, Canada. 6Department ofPsychiatry, Faculty of Medicine, McGill University, Montreal, QC H3A 1A1,Canada. 7ParticipACTION, Toronto, ON M5S 1M2, Canada. 8School ofKinesiology and Health Studies, and Department of Community Health andEpidemiology, Queen’s University, Kingston, ON K7L 3N6, Canada. 9Universityof Strathclyde, School of Psychological Science and Health, Glasgow,Scotland G1 1QE, UK. 10Public Health Agency of Canada, Ottawa, ON K1A0K9, Canada. 11Faculty of Physical Education and Recreation, University ofAlberta, Edmonton, AB T6G 2H9, Canada. 12Montreal Children’s Hospital,Montreal, QC H3H 1P3, Canada. 13Department of Pediatrics, Faculty ofMedicine & Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada.14Early Start Research Institute, Faculty of Social Sciences, University ofWollongong, Wollongong, NSW 2522, Australia. 15The Sandbox Project,Toronto, ON M5C 2C5, Canada. 16Library Services, Children’s Hospital ofEastern Ontario, Ottawa, ON K1H 8L1, Canada. 17Child Health & ExerciseMedicine Program, Department of Pediatrics, McMaster University, Hamilton,ON L8S 4K1, Canada.Published: 20 November 2017References1. 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Fam Pract. 2008;25(S1):i20–4.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:The Author(s) BMC Public Health 2017, 17(Suppl 5):874 Page 32 of 215


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