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Physical Activity Guidelines for the Pediatric Population: A Review
Author: Thomas Munro, MD | Pediatric Resident
Column Editor: Angela Myers, MD, MPH | Director, Division of Infectious Diseases | Professor of Pediatrics, UMKC School of Medicine | Medical Editor, The Link Newsletter
In 2018, the Department of Health and Human Services (DHHS) updated its 2008 Physical Activity Guidelines.1 Two years later, in March of 2020, the American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness (COSMF) released its Clinical Report providing a pediatric lens focusing on these 2018 guidelines, affirming and expanding upon their recommendations.2 Coincidentally, the World Health Organization officially declared COVID-19 a global pandemic that same month. The United States began shutting down portions of the nation, clearly impacting people’s ability to stay active.3 As we continue to provide care through the era of COVID-19, it is important to reemphasize the 2018 Physical Activity Guidelines to best support the health of our pediatric population in the safest way possible.
With as many as two-thirds of pediatricians struggling to correctly identify physical activity guidelines, a brief refresher on what the physical activity guidelines recommend is warranted.4,5 The guidelines are first stratified based on age and make recommendations for the total duration and intensity of exercise based on these age ranges (Table 1). DHHS divides the pediatric population into two age ranges (3- to 5-year-olds and 6- to 17-year-olds), while the 2020 Clinical Report from COSMF further subdivides pediatric ages into smaller age cohorts with the same overall recommendation.1,2 For instance, 3- to 5-year-olds should achieve at least three total hours of physical activity per day. Due to developmental limitations, this activity will vary in intensity with the three total hours being the sum of short spurts of activity throughout the day. Children in the 6- to 17-year-old cohort should achieve at least one hour of physical activity per day that is moderate to vigorous in intensity. A simple way to screen for whether an activity is reaching the level of moderate to vigorous intensity is to ask the patient whether they are having difficulty speaking in full sentences or carrying a conversation while performing the exercise. If so, the activity is likely reaching an appropriate intensity, unless the difficulty is due to some form of pathology, such as asthma. Children in the 6- to 17-year-old cohort ought to reach a vigorous level of intensity at a minimum of three days each week. They should also incorporate exercise that focuses on muscle and bone strengthening three days each week, with the remainder of the exercise time primarily consisting of aerobic exercise (Table 2).
Physical activity is clearly a cornerstone in maintaining and increasing one’s health and wellbeing throughout life.1,2,6-10 Concerningly, health-promoting physical activity in the pediatric population has either stagnated or declined from 2009 to 2019.11 Specifically, the 2017 and 2019 Youth Risk Behavior Surveys indicate that, pre-COVID-19, only ~25% of high school students met the physical activity guidelines of ≥60 minutes/day on all seven days (26.1% and 23.2%).11,12 Even less met both the aerobic and muscle-strengthening physical activity guidelines (16.5%).11 Unfortunately, during the COVID-19 pandemic, physical activity levels have declined and sedentary behaviors have increased.3,13,14 A meta-analysis, which included 72 studies that specifically analyzed physical activity in the pediatric population, found that 79% of the studies (57) showed a decrease in physical activity ranging from a minimum decrease of 45 min/day to a maximum decrease of 91 min/day (four studies showed an increase, six no change, and eight with mixed results).15 In the field of pediatrics, physicians can set the foundation for physical literacy, where the need has been exacerbated by the COVID-19 pandemic.
As pandemic restrictions have decreased, schools, parks and organized sports have begun to function again. Knowledge of the updated physical activity recommendations is important, but so too is keeping updated on new recommendations that will impact how physicians successfully promote appropriate physical activity for their patients during the continuation of the COVID-19 era. Physicians can prepare themselves with many reputable sources, such as the AAP COVID-19 Interim Guidance, which addresses many questions providers may face involving COVID-19 and physical activity (Table 3).16,17 After a long duration of decreased activity, our patients are often being presented with the opportunity to return to sports and activities at their pre-COVID-19 level of intensity. Due to a lack of physical preparedness, many of our patients are at an increased risk of injury due to detraining. A well-considered, gradual return should be advised.16 Questions related to COVID-19 should be highlighted during the pre-participation exam (PPE), with recommendations on clearance and return to play varying depending on severity of illness.18 The PPE also presents another pivotal point at which the pediatric community has an opportunity to discuss primary and booster COVID-19 vaccination. Physicians, too, can increase their own physical literacy to better coach their patients by accessing educational material, such as the free exercise modules developed and released by the American Medical Society for Sports Medicine (https://canvas.instructure.com/enroll/CY9TPG).10 Staying current on the latest physical activity guidelines and how to best support appropriate physical activity in our pediatric patients during the COVID-19 era is imperative and attainable.
Table 1: Physical activity guidelines.1
|Age||Duration of active time||Intensity level|
|3-5 yrs||3+ hrs/day every day of the week||Any level of activity|
|6-17 yrs||1+ hr/day every day of the week||Moderate-vigorous*|
|18+ yrs||Minimum of 150 min per week split over at least 3 days (goal is more around 300 min/week)||Moderate-vigorous**|
*6- to 17-year-olds should reach the intensity of vigorous activity at least 3x per week and incorporate muscle and bone strengthening exercises 3x per week.
** To convert time duration recommendations based upon level of intensity, use a 1:2 ratio of moderate:vigorous intensity. This means that if the level of intensity is vigorous, then the total weekly duration goal is a minimum of 75 minutes with a goal of 150 minutes.
Table 2: Definitions of aerobic, muscle strengthening and bone strengthening with different examples of each.1,2
|Aerobic||Muscle strengthening||Bone strengthening|
|Definition||Rhythmic muscle activation for a sustained period of time.||Load placed on muscles which exceeds everyday activity levels resulting in increased strength, endurance or power.||Movements that place force on the bones of the body. Often secondary to ground impact.|
|Younger age examples||Sustained floor play, tag, playground play, swimming, biking, dancing.||Tummy time, tug of war, climbing on playground equipment, throwing or kicking a ball.*||Hopping, skipping, jumping, running, jump rope.*|
|Older age examples||Similar to younger age with gradual increase in organized sport involvement.||Exercises using resistance bands,
body weight or external weights.
|Activities that include rapid change in direction and running.|
*Further in-depth examples/recommendations of age-appropriate exercise for younger kids can be found at https://activeforlife.com/activities19
Table 3: AAP COVID-19 interim guidance: return to sport questions examples.16
|What are the benefits of returning to sports and physical activity for children and adolescents?|
|What if children’s sports are disrupted or canceled? How can parents support their athletes’ physical and mental wellbeing?|
|Should parents and other spectators attend their children’s sports practices and games?|
|What about the sports pre-participation examination and preparing for the season?|
|What are the risks of transmission for youth in sports and physical activity?|
|How do families balance the risk versus benefit of returning to sports for children and adolescents?|
|Should children have a COVID-19 test before attending sports?|
|What modifications/strategies should be considered to reduce risk of transmission during youth sports?|
|When and should face masks be worn in physical activity?|
|Should my athlete/my family travel for sports competitions?|
|What if a child/adolescent is identified as a close contact of a person with COVID-19?|
|What if a child/adolescent tests positive for COVID-19?|
|What should I do if a child or adolescent who is active in sports and/or physical activity tests positive for COVID-19?|
|After testing positive for SARS-CoV-2, how should children and adolescents return to physical activity and/or sports?|
- 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. U.S. Dept of Health and Human Services; 2018.
- Lobelo F, Muth ND, Hanson S, et al; Council on Sports Medicine and Fitness: Section on Obesity. Physical activity assessment and counseling in pediatric clinical settings. Pediatrics. 2020;145(3):e20193992. Accessed May 16, 2022. https://publications.aap.org/pediatrics/article/145/3/e20193992/36817/Physical-Activity-Assessment-and-Counseling-in
- Stockwell S, Trott M, Tully M, et al. Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: a systematic review. BMJ Open Sport Exerc Med. 2021;7(1):e000960. doi:10.1136/bmjsem-2020-000960
- Huang TTK, Borowski LA, Liu B, et al. Pediatricians’ and family physicians’ weight-related care of children in the U.S. Am J Prev Med. 2011;41(1):24-32. doi:10.1016/j.amepre.2011.03.016
- Gordia AP, de Quadros TMB, Silva LR, dos Santos GM. Knowledge of pediatricians regarding physical activity in childhood and adolescence. Rev Paul Pediatr. 2015;33(4):400-406. doi:10.1016/j.rpped.2015.02.001
- Sothern MS, Loftin M, Suskind RM, Udall JN, Blecker U. The health benefits of physical activity in children and adolescents: implications for chronic disease prevention. Eur J Pediatr. 1999;158(4):271-274. doi:10.1007/s004310051070
- Faienza MF, Lassandro G, Chiarito M, Valente F, Ciaccia L, Giordano P. How physical activity across the lifespan can reduce the impact of bone ageing: a literature review. Int J Environ Res Public Health. 2020;17(6):E1862. doi:10.3390/ijerph17061862
- Dimitri P, Joshi K, Jones N; Moving Medicine for Children Working Group. Moving more: physical activity and its positive effects on long term conditions in children and young people. Arch Dis Child. 2020;105(11):1035-1040. doi:10.1136/archdischild-2019-318017
- Stricker PR, Faigenbaum AD, McCambridge TM, et al. Resistance training for children and adolescents. Pediatrics. 2020;145(6):e20201011. doi:10.1542/peds.2020-1011
- Asif I, Thornton JS, Carek S, et al. Exercise medicine and physical activity promotion: core curricula for US medical schools, residencies and sports medicine fellowships: developed by the American Medical Society for Sports Medicine and endorsed by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med. 2022;56(7):369-375. doi:10.1136/bjsports-2021-104819
- Merlo CL, Jones SE, Michael SL, et al. Dietary and physical activity behaviors among high school students — Youth Risk Behavior Survey, United States, 2019. MMWR Suppl. 2020;69(1):64-76. doi:10.15585/mmwr.su6901a8
- Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance - United States, 2017. MMWR Surveill Summ. 2018;67(8):479.
- Puccinelli PJ, da Costa TS, Seffrin A, et al. Reduced level of physical activity during COVID-19 pandemic is associated with depression and anxiety levels: an internet-based survey. BMC Public Health. 2021;21(1):425. doi:10.1186/s12889-021-10470-z
- Planinšec J, Matejek Č, Pišot S, Pišot R, Šimunič B. Consequences of COVID-19 lockdown restrictions on children physical activity—a Slovenian study. Front Public Health. 2022;10. Accessed May 19, 2022. https://www.frontiersin.org/article/10.3389/fpubh.2022.843448
- Rossi L, Behme N, Breuer C. Physical activity of children and adolescents during the COVID-19 pandemic—a scoping review. Int J Environ Res Public Health. 2021;18(21):11440. doi:10.3390/ijerph182111440
- COVID-19 interim guidance: return to sports and physical activity. American Academy of Pediatrics. Accessed May 16, 2022. http://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/
- Physical activity and return to sports during COVID-19. American Academy of Pediatrics. Accessed May 17, 2022. http://www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/physical-activity-and-return-to-sport-during-covid-19/
- Baggish AL, Chang CJ, Drezner JA, et al. ACSM-AMSSM call to action: adapting preparticipation cardiovascular screening to the COVID-19 pandemic. Curr Sports Med Rep. 2022;21(5):159-162. doi:10.1249/JSR.0000000000000956
- Activities for kids. Active For Life. Accessed June 10, 2022. https://activeforlife.com/activities/