Describing the food choices of Aboriginal children attending an afterschool cultural program from two different knowledge systems: The importance of Country, community, and kinship.

AIMS: This study describes a program co-created with Aboriginal communities to strengthen cultural ties with the children. Food data are reported from two knowledge systems (lenses): Western and Aboriginal relational, focused on Country, community, and kinship. METHODS: A cultural program was undertaken with primary school children of Aboriginal heritage, on Yuin nation, over 10 weeks including culturally appropriate practices (painting, bushtucker, and dance). We report mixed method food outcomes framed by Western (quantitative) 24-h recall and Aboriginal relational methods (qualitative) captured by cultural images, yarning and continuous consultation methods to expose lessons from community and Country, to extend kinship. RESULTS: In total, 111 children (79 providing food data) across three regional communities commenced the program. A storying approach to food data collection and interpretation was preferred. The number of serves of seafood products, such as fish increased, vegetable consumption improved, intakes of dairy improved in quality and energy intakes from discretionary foods decreased across the programs. Qualitative data exposed six themes: Eating with family, competing agendas, food as medicine, applying cultural practices, food choices driven by 'post-invasion tradition' and community events, which deepened our understanding of the food data. Teaching the importance of the ocean and water saw participants engage with family in practices such as fishing to improve overall awareness of culture through food. CONCLUSION: The kinship system in a cultural context supported positive shifts towards accessible food choices driven by messages from Country. While the changes cannot be isolated to the program, cultural immersion drove change and strength-based reporting.

Proportion and Correlates of Children in the US-Affiliated Pacific Region Meeting Sleep, Screen Time, and Physical Activity Guidelines.

INTRODUCTION: Limited data on 24-hour movement behaviors of children aged 5-8 years exist globally. We describe the prevalence and sociodemographic associations of meeting physical activity (PA), sedentary recreational screen time (ST), and sleep guidelines among children from 11 jurisdictions in the US-Affiliated Pacific region. METHODS: Cross-sectional representative data from 1192 children aged 5-8 years living in the US-Affiliated Pacific region were drawn from the baseline 2012-2014 Children's Healthy Living Program. Sleep and moderate- to vigorous-intensity PA were calculated from accelerometry. ST and sociodemographic data were collected from caregiver surveys. The percentage of children meeting the Asia-Pacific 24-hour movement guidelines for PA (≥60 min/d of moderate- to vigorous-intensity PA), sleep (≥9 and ≤ 11 h/d) and ST (≤2 h/d) were calculated. Generalized linear mixed models were used to examine associations with adiposity and sociodemographic variables. RESULTS: Twenty-seven percent (95% confidence interval, 24.6-30.0) of children met integrated guidelines; 98% (96.2-98.0) met PA, 78% (75.4-80.0) met sleep, and 35% (32.6-38.0) met ST guidelines. Females (adjusted odds ratio = 1.40 [95% confidence interval, 1.03-1.91]) and those living in lower-middle-income jurisdictions (2.29 [1.49-3.54]) were more likely to meet ST guidelines. Overweight children (0.62 [0.40-0.96]), those aged 8 years (0.39 [0.22-0.69]), and children with caregivers of an education level of high school or beyond (0.44 [0.29-0.68]) were less likely to achieve ST guidelines. Children from midrange annual household incomes were less likely to meet combined guidelines (0.60 [0.39-0.92]). CONCLUSIONS: Three-quarters of children are not meeting integrated Asia-Pacific 24-hour movement guidelines. Future strategies for reducing ST and increasing integrated guidelines compliance are needed.

Strong culture, healthy lifestyles: a mixed methods feasibility study for a co-created afterschool cultural programme for Australian Aboriginal children.

BACKGROUND: Having a strong connection to culture and Country is fundamental to the health and wellbeing of Australian Aboriginal children. The aim of the research was to evaluate the feasibility of study methods and programme implementation of a co-created afterschool cultural programme, and identify areas for improvement. METHODS: Aboriginal Relational Research Methodology and mixed methods were applied to evaluate the feasibility of the implementation of the programme and study methods using a non-randomised single-group study design. Australian Aboriginal children and their siblings aged 5-13 years were recruited within regional New South Wales, Australia. The primary outcomes for feasibility included recruitment rates of children and Aboriginal programme mentors, compliance rates of outcome data collection and of the planned programme activities, programme attendance, retention rates and mean enjoyment scores. Follow-up yarning circles were conducted with the children, their parents/caregivers, programme mentors and teachers to explore aspects of feasibility, and areas for improvement. RESULTS: A total of 90 caregivers consented to their children (n = 111) being part of the research. Sixteen Aboriginal mentors were recruited to deliver the programmes across the communities. Overall, 74.4% of all health outcome measures were completed across baseline (86.5%) and follow-up (55.9%). Only 61.0% of the programme activities were delivered as originally planned. The average programme attendance rate was 70.0% with a 92.0% retention rate. Eighty-nine percent of children reported a high level of enjoyment with the programmes. Follow-up yarning identified the importance of relational methodologies and flexibility within the programme design and implementation to ensure programmes were adapted to the local community, conditions and differing age groups. Considerations for future programmes included the timing of the programme and identifying health outcome assessment tools and methods that acknowledge cultural protocols and experiences. CONCLUSIONS: Engaging the communities in the development, implementation and evaluation of the programmes were key to community support of the programme and conducting the feasibility study. Future programmes and evaluations need to be built on strong partnerships and embrace flexible and culturally embedded methodologies in order to be adaptive and responsive to research approaches, communities and to Country. TRIAL REGISTRATION: ACTRN12619001224112. Retrospectively registered on 05 September 2019.

Children's physical activity and sedentary behaviour in before school care: An observational study.

OBJECTIVE: In Australia, less than one quarter of children aged 5-12 years meet national physical activity (PA) guidelines. Before school care operates as part of Out of School Hours Care (OSHC) services and provide opportunities for children to meet their daily PA recommendations. The aim of this study was to explore factors associated with children meeting 15 min of moderate-to-vigorous-intensity physical activity (MVPA) while attending before school care. METHODS: A cross-sectional study was conducted in 25 services in New South Wales, Australia. Each service was visited twice between March and June 2021. Staff behaviours and PA type and context were captured using staff interviews and the validated System for Observing Staff Promotion of Physical Activity and Nutrition (SOSPAN) time sampling tool. Child PA data were collected using Actigraph accelerometers and associations between program practices and child MVPA analysed. RESULTS: PA data were analysed for 654 children who spent an average of 39.2% (±17.6) of their time sedentary; 45.4% (±11.4) in light PA; and 14.9% (±11.7) in MVPA. Only 17% of children (n = 112) reached ≥15 min MVPA, with boys more likely to achieve this. Children were more likely to meet this recommendation in services where staff promoted and engaged in PA; PA equipment was available; children were observed in child-led free play; and a written PA policy existed. CONCLUSIONS: Before school care should be supported to improve physical activity promotion practices by offering staff professional development and guidance on PA policy development and implementation practices.

Parent wellbeing, family screen time and socioeconomic status during early childhood predict physical activity of Aboriginal and Torres Strait Islander children at ages 8-13.

OBJECTIVES: Physical activity is holistically linked to culture and wellbeing among Aboriginal and Torres Strait Islander peoples, the First Nation Peoples of Australia. Socioecological correlates of high physical activity among Indigenous children include living in a remote area and low screen time but little is known about early life determinants of physical activity. This paper examines sociodemographic, family, community, cultural, parent social and emotional wellbeing determinants of physical activity among Aboriginal and Torres Strait Islander children. DESIGN: Longitudinal cohort study. METHODS: The Longitudinal Study of Indigenous Children, the largest First Nations child cohort study in the world, primarily collects data through parental report. Multiple logistic regression analyses examined Wave 1 (age 0-5 years) predictors of achieving ≥1 h/day of physical activity at Wave 9 (aged 8-13 years). RESULTS: Of the 1181 children, 596 (50.5 %) achieved ≥1 h of physical activity every day. Achieving ≥1 h/day of physical activity at Wave 9 was associated with the following Wave 1 determinants: high parent social and emotional wellbeing (resilience; adjusted odds ratio 1.87 (95 % confidence interval: 1.32-2.65)), living in remote (odds ratio 3.66 (2.42-5.54)), regional (odds ratio 2.98 (2.13-4.18)) or low socioeconomic areas (odds ratio 1.85 (1.08-3.17)), main source of family income not wages/salaries (odds ratio 0.66 (0.46-0.97)), and if families played electronic games (odds ratio 0.72 (0.55-0.94)). CONCLUSIONS: To achieve high physical activity levels among Aboriginal and Torres Strait Islander children, high parental culture specific social and emotional wellbeing and low family screen time in early life may compensate for apparently low socio-economic circumstances, including living in remote areas.

Foods and beverages provided in out of school hours care services: an observational study.

INTRODUCTION: Out of school hours care (OSHC) is a fast-growing childcare setting in Australia, however the types of foods and beverages offered are relatively unknown. This study describes the food and beverages offered and investigates sector-level and setting-level factors which may impact OSHC in meeting the Australian Dietary Guidelines (ADG). METHODS: This cross-sectional, observational study was conducted in 89 OSHC services (between 2018 and 2019). Food and beverages offered, kitchen facilities and menus were captured via direct observation. Foods were categorised into five food groups or discretionary foods, based on the ADG, and frequencies determined. Short interviews with OSHC directors ascertained healthy eating policies, staff training, food quality assessment methods and food budgets. Fisher's exact test explored the influence of sector-level and setting-level factors on food provision behaviours. RESULTS: Discretionary foods (1.5 ± 0.68) were offered more frequently than vegetables (0.82 ± 0.80) (p < .001), dairy (0.97 ± 0.81) (p = .013) and lean meats (0.22 ± 0.54) (p < .001). OSHC associated with long day care and reported using valid food quality assessment methods offered more lean meats (p= .002, and p= .004). Larger organisations offered more vegetables (p = .015) and discretionary foods (p= .007). Menus with clearly worded instructions to provide fruits and vegetables daily offered more fruit (p= .009), vegetables (p < .001) and whole grains (p= .003). No other sector or setting-level factors were associated with services aligning with the ADG. CONCLUSION: Future interventions could benefit from trialling menu planning training and tools to assist OSHC services in NSW meet the ADG requirements.

A collaborative approach to adopting/adapting guidelines. The Australian 24-hour movement guidelines for children (5-12 years) and young people (13-17 years): An integration of physical activity, sedentary behaviour, and sleep.

BACKGROUND: In 2018, the Australian Government updated the Australian Physical Activity and Sedentary Behaviour Guidelines for Children and Young People. A requirement of this update was the incorporation of a 24-hour approach to movement, recognising the importance of adequate sleep. The purpose of this paper was to describe how the updated Australian 24-Hour Movement Guidelines for Children and Young People (5 to 17 years): an integration of physical activity, sedentary behaviour and sleep were developed and the outcomes from this process. METHODS: The GRADE-ADOLOPMENT approach was used to develop the guidelines. A Leadership Group was formed, who identified existing credible guidelines. The Canadian 24-Hour Movement Guidelines for Children and Youth best met the criteria established by the Leadership Group. These guidelines were evaluated based on the evidence in the GRADE tables, summaries of findings tables and recommendations from the Canadian Guidelines. We conducted updates to each of the Canadian systematic reviews. A Guideline Development Group reviewed, separately and in combination, the evidence for each behaviour. A choice was then made to adopt or adapt the Canadian recommendations for each behaviour or create de novo recommendations. We then conducted an online survey (n=237) along with three focus groups (n=11 in total) and 13 key informant interviews. Stakeholders used these to provide feedback on the draft guidelines. RESULTS: Based on the evidence from the Canadian systematic reviews and the updated systematic reviews in Australia, the Guideline Development Group agreed to adopt the Canadian recommendations and, apart from some minor changes to the wording of good practice statements, maintain the wording of the guidelines, preamble, and title of the Canadian Guidelines. The Australian Guidelines provide evidence-informed recommendations for a healthy day (24-hours), integrating physical activity, sedentary behaviour (including limits to screen time), and sleep for children (5-12 years) and young people (13-17 years). CONCLUSIONS: To our knowledge, this is only the second time the GRADE-ADOLOPMENT approach has been used to develop movement behaviour guidelines. The judgments of the Australian Guideline Development Group did not differ sufficiently to change the directions and strength of the recommendations and as such, the Canadian Guidelines were adopted with only very minor alterations. This allowed the Australian Guidelines to be developed in a shorter time frame and at a lower cost. We recommend the GRADE-ADOLOPMENT approach, especially if a credible set of guidelines that was developed using the GRADE approach is available with all supporting materials. Other countries may consider this approach when developing and/or revising national movement guidelines.

Physical activity in out of school hours care: an observational study.

BACKGROUND: Opportunities for physical activity within out of school hours care (OSHC) are not well documented in Australia. This study explored factors associated with children (5-12 years) meeting 30 min of moderate to vigorous physical activity (MVPA) while attending OSHC in the afternoon period. METHODS: A cross-sectional study, conducted in 89 OSHC services in New South Wales, Australia, serving 4,408 children. Each service was visited twice between 2018-2019. Physical activity promotion practices were captured via short interviews and System for Observing Staff Promotion of Physical Activity and Nutrition (SOSPAN). Physical activity spaces was measured (m2) and physical activity of 3,614 child days (42% girls), were collected using Acti-Graph accelerometers. Association between program practices and children accumulation of MVPA was tested using mixed effects logistic regression, adjusted by OSHC service and child. RESULTS: Twenty-six percent of children (n = 925) accumulated 30 min or more of MVPA. Factors associated with children reaching MVPA recommendations included: services scheduling greater amounts of child-led free play, both 30-59 min (OR 2.6, 95%CI 1.70, 3.98) and ≥ 60 min (OR 6.4, 95%CI 3.90, 10.49); opportunities for staff-led organised play of ≥ 30 min (OR 2.3, 95%CI 1.47, 3.83); and active games that engaged the majority of children (OR 1.7, 95%CI 1.11, 2.61). Children were less likely to meet MVPA recommendations if services played games with elimination components (OR 0.56, 95%CI 0.37, 0.86). CONCLUSION: Improvements to service-level physical activity promotion practices, specifically the type of physical activity scheduled and the structure of games, may be an effective strategy to increase MVPA of children attending OSHC afterschool in NSW, Australia.

Systematic observation of healthy eating environments in after-school services: a cross-sectional study.

OBJECTIVES: Few studies have examined the healthy eating environments within the Australian out of school hours care (OSHC) setting. This study aims to describe healthy eating environments, consisting of: (a) the alignment of provided food and beverages to Australian Dietary Guidelines; (b) healthy eating promotion practices; (c) nutrition education through cooking experiences; (d) staff role modelling healthy eating and (e) regular water availability. DESIGN: A cross-sectional study was conducted using direct observations and the validated System for Observing Staff Promotion of Activity and Nutrition (SOSPAN) tool. SETTING: OSHC located in urban and semi-rural regions of NSW, Australia. PARTICIPANTS: Staff (151) and children (1549) attending twelve OSHC services operating in the hours after school. RESULTS: Fifty per cent (50 %) of services offered fruits and 100 % offered water as a part of the afternoon snack on all four observation days. Discretionary foods were offered on more days compared to vegetables (+1·9/d, P = 0·009), lean meats (+2·7/d, P =·0 004) and wholegrains (+2·8/d, P = 0 002). Staff promoted healthy eating on 15 % of days, sat and ate with children 52 %, consumed high sugar drinks 15 % and ate discretionary foods in front of children 8 % of days, respectively. No opportunities for cooking or nutrition education were observed. CONCLUSION: Afternoon snacks regularly contained fruits and water. Opportunities exist to improve the frequency by which vegetables, wholegrains and lean meats are offered in addition to staff healthy eating promotion behaviours. Future research is warranted to further explore healthy eating behaviours, practices and policies within the after-school sector.

Validity of GENEActiv Accelerometer Wear and Nonwear Time for Use in Infants.

BACKGROUND: Tummy time is recommended by the World Health Organization as part of its global movement guidelines for infant physical activity. To enable objective measurement of tummy time, accelerometer wear and nonwear time requires validation. The purpose of this study was to validate GENEActiv wear and nonwear time for use in infants. METHODS: The analysis was conducted on accelerometer data from 32 healthy infants (4-25 wk) wearing a GENEActiv (right hip) while completing a positioning protocol (3 min each position). Direct observation (video) was compared with the accelerometer data. The accelerometer data were analyzed by receiver operating characteristic curves to identify optimal cut points for second-by-second wear and nonwear time. Cut points (accelerometer data) were tested against direct observation to determine performance. Statistical analysis was conducted using leave-one-out validation and Bland-Altman plots. RESULTS: Mean temperature (0.941) and z-axis (0.889) had the greatest area under the receiver operating characteristic curve. Cut points were 25.6°C (temperature) and -0.812g (z-axis) and had high sensitivity (0.84, 95% confidence interval, 0.838-0.842) and specificity (0.948, 95% confidence interval, 0.944-0.948). CONCLUSIONS: Analyzing GENEActiv data using temperature (>25.6°C) and z-axis (greater than -0.812g) cut points can be used to determine wear time among infants for the purpose of measuring tummy time.

Weekly group tummy time classes are feasible and acceptable to mothers with infants: a pilot cluster randomized controlled trial.

BACKGROUND: The World Health Organization recommends 30 min of tummy time daily for improved motor development and reduced likelihood of plagiocephaly. As only 30% of infants meet this recommendation, parents require strategies and support to increase this proportion. METHODS: The aim of this study was to determine the feasibility, acceptability, and potential efficacy of a group intervention to promote tummy time. The design is a cluster randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Five groups of healthy infants (N = 35, baseline mean (SD) age 5.9 (2.8) weeks) and their mothers attending local mother's groups (Australia) were randomly allocated to the intervention or control group. The intervention group received group tummy time classes in addition to usual care. The control group received usual care with their child and family health nurse. Primary outcomes were intervention feasibility and acceptability. Secondary outcomes were tummy time duration (accelerometry), adherence to physical activity guidelines, head shape, and motor development. Measures were taken at baseline, post-intervention, and when infants were 6 months of age. Analyses were by linear mixed models and Cohen's d statistic. RESULTS: Recruitment, retention, and collection of objective data met feasibility targets. Acceptability was also met with intervention mothers reporting the information, goal planning, and handouts significantly more useful and relevant than control group mothers (p < 0.01). Moderate effect sizes were also found at post-intervention for tummy time duration, adherence to physical activity guidelines and infant ability in prone and supine favoring the intervention group (intervention infants had a mean of 30 min and 30% adherence to guidelines (95% CI 0 to 60.6 min) compared to the control infants who had a mean of 16.6 min and 13% adherence to the guidelines (95% CI 0 to 42.1 min, Cohen's d = 0.5). Limitations were the small sample size, 4-week intervention, limited accelerometer use, and a homogenous sample of participants. CONCLUSION: Group tummy time classes delivered in a mother's group setting were shown to be feasible and acceptable. A larger randomized controlled trial is warranted. TRIAL REGISTRATION: ANZCTR, ACTRN12617001298303p. Registered 11 September 2017.

Healthy eating and physical activity environments in out-of-school hours care: an observational study protocol.

INTRODUCTION: Childcare settings have been widely identified as important venues for promoting healthy lifestyles to children. Out-of-school hours care (OSHC) is a rapidly growing childcare service, yet there has been limited research reported on healthy eating and physical activity (HEPA) environments within the Australian OSHC setting. This research aims to describe the HEPA environments related to foods and beverages served, staff behaviours and child physical activity levels across two local health districts within New South Wales, Australia. This study will provide evidence to support future interventions and policies in Australian OSHC settings. METHODS AND ANALYSIS: A cross-sectional study design will be used to describe the food and beverages provided and child activity levels, and report on environmental correlates. OSHC programmes will be visited on non-consecutive weekdays between 2018 and 2020. The frequency of foods and beverages offered will be observed and categorised into food groups aligned to the Australian Dietary Guidelines. Children's physical activity will be measured using ActiGraph wGT3X-BT accelerometers. Staff behaviour will be captured via direct observation and the System for Observing Staff Promotion of Activity and Nutrition. Short interviews with programme directors will gather contextual information about OSHC practices and policies. ETHICS AND DISSEMINATION: Findings will be disseminated through peer-reviewed scientific journals, conference presentations and individualised feedback to each participating service. Ethical approval was granted by the University of Wollongong Human Research Ethics Committee (HE17/490).

Promoting Physical Activity and Executive Functions Among Children: A Cluster Randomized Controlled Trial of an After-School Program in Australia.

BACKGROUND: The aim of this study was to examine the efficacy of an embedded after-school intervention, on promoting physical activity and academic achievement in primary-school-aged children. METHODS: This 6-month, 2-arm cluster randomized controlled trial involved 4 after-school centers. Two centers were randomly assigned to the intervention, which involved training the center staff on and implementing structured physical activity (team sports and physical activity sessions for 75 min) and academic enrichment activities (45 min). The activities were implemented 3 afternoons per week for 2.5 hours. The control centers continued their usual after-school care practice. After-school physical activity (accelerometry) and executive functions (working memory, inhibition, and cognitive flexibility) were assessed pre- and postintervention. RESULTS: A total of 60 children were assessed (7.7 [1.8] y; 50% girls) preintervention and postintervention (77% retention rate). Children in the intervention centers spent significantly more time in moderate to vigorous physical activity (adjusted difference = 2.4%; 95% confidence interval, 0.6 to 4.2; P = .026) and scored higher on cognitive flexibility (adjusted difference = 1.9 units; 95% confidence interval, 0.9 to 3.0; P = .009). About 92% of the intervention sessions were implemented. The participation rates varied between 51% and 94%. CONCLUSION: This after-school intervention was successful at increasing moderate to vigorous physical activity and enhancing cognitive flexibility in children. As the intervention was implemented by the center staff and local university students, further testing for effectiveness and scalability in a larger trial is required.

Tummy Time and Infant Health Outcomes: A Systematic Review.

CONTEXT: The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of poor uptake of these recommendations, the association of tummy time with other health outcomes requires further investigation. OBJECTIVE: To review existing evidence regarding the association of tummy time with a broad and specific range of infant health outcomes. DATA SOURCES: Electronic databases were searched between June 2018 and April 2019. STUDY SELECTION: Peer-reviewed English-language articles were included if they investigated a population of healthy infants (0 to 12 months), using an observational or experimental study design containing an objective or subjective measure of tummy time which examined the association with a health outcome (adiposity, motor development, psychosocial health, cognitive development, fitness, cardiometabolic health, or risks/harms). DATA EXTRACTION: Two reviewers independently extracted data and assessed their quality. RESULTS: Sixteen articles representing 4237 participants from 8 countries were included. Tummy time was positively associated with gross motor and total development, a reduction in the BMI-z score, prevention of brachycephaly, and the ability to move while prone, supine, crawling, and rolling. An indeterminate association was found for social and cognitive domains, plagiocephaly, walking, standing, and sitting. No association was found for fine motor development and communication. LIMITATIONS: Most studies were observational in design and lacked the robustness of a randomized controlled trial. High selection and performance bias were also present. CONCLUSIONS: These findings guide the prioritization of interventions aimed at assisting parents meet the global and national physical activity guidelines.

'Jump start' childcare-based intervention to promote physical activity in pre-schoolers: six-month findings from a cluster randomised trial.

BACKGROUND: Participation in adequate levels of physical activity during the early years is important for health and development. We report the 6-month effects of an 18-month multicomponent intervention on physical activity in early childhood education and care (ECEC) settings in low-income communities. METHODS: A cluster randomised controlled trial was conducted in 43 ECEC settings in disadvantaged areas of New South Wales, Australia. Three-year-old children were recruited and assessed in the first half of 2015 with follow-up 6 months later. The intervention was guided by Social Cognitive Theory and included five components. The primary outcome was minutes per hour in total physical activity during ECEC hours measured using Actigraph accelerometers. Intention-to-treat analysis of the primary outcome was conducted using a generalized linear mixed model. RESULTS: A total of 658 children were assessed at baseline. Of these, 558 (85%) had valid accelerometer data (mean age 3.38y, 52% boys) and 508 (77%) had valid accelerometry data at 6-month follow-up. Implementation of the intervention components ranged from 38 to 72%. There were no significant intervention effects on mins/hr. spent in physical activity (adjusted difference = - 0.17 mins/hr., 95% CI (- 1.30 to 0.97), p = 0.78). A priori sub-group analyses showed a greater effect among overweight/obese children in the control group compared with the intervention group for mins/hr. of physical activity (2.35mins/hr., [0.28 to 4.43], p = 0.036). CONCLUSIONS: After six-months the Jump Start intervention had no effect on physical activity levels during ECEC. This was largely due to low levels of implementation. Increasing fidelity may result in higher levels of physical activity when outcomes are assessed at 18-months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000597695.

Objective measurement of tummy time in infants (0-6 months): A validation study.

The 2017 Australian and Canadian 24-hour movement guidelines recommend infants receive 30 minutes of tummy time daily. Currently, there are no validated objective measurement tools or devices to assess tummy time. The purpose of this study was to: 1) test the practicality of using devices on infants as an objective measure of tummy time, and 2) test the accuracy of developed algorithms and cut-points for predicting prone posture. Thirty-two healthy infants aged 4 to 25 weeks completed a protocol of 12 positions. Infants were placed in each position for 3 minutes while wearing a MonBaby (chest), GENEActiv (right hip) and two ActiGraphs (right hip and ankle). Direct observation was the criterion measure. The accuracy of the algorithms or cut-points to predict prone on floor, non-prone and prone supported positions were analyzed. Parents also completed a practicality questionnaire. Algorithms and cut-points to classify posture using devices from MonBaby, GENEActiv and ActiGraph (hip and ankle) were 79%, 95%, 90% and 88% accurate at defining tummy time and 100%, 98%, 100% and 96% accurate at defining non-prone positions, respectively. GENEActiv had the smallest mean difference and limits of agreement (-8.4s, limits of agreement [LoA]: -78.2 to 61.3s) for the prone on floor positions and ActiGraph Hip had the smallest mean difference and LoA for the non-prone positions (-0.2s, LoA: -1.2 to 0.9s). The majority of parents agreed all devices were practical and feasible to use with MonBaby being the preferred device. The evaluated algorithms and cut-points for GENEActiv and ActiGraph (hip) are of acceptable accuracy to objectively measure tummy time (time spent prone on floor). Accurate measurement of infant positioning practices will be important in the observation of 24-hour movement guidelines in the early years.

Child care centre adherence to infant physical activity and screen time recommendations in Australia, Canada and the United States: An observational study.

OBJECTIVE: The aim of this study was to compare adherence to physical activity and sedentary behaviour recommendations within the 2011 Institute of Medicine Early Childhood Obesity Prevention Policies as well as screen time recommendations from the 2013 American Academy of Pediatrics for samples of infants in child care centres in Australia, Canada, and the United States (US). METHODS: This cross-sectional study used data from: the Australian 2013 Standing Preschools (N=9) and the 2014-2017 Early Start Baseline (N=22) studies; the 2011 Canadian Healthy Living Habits in Pre-School Children study (N=14); and the American 2008 (N=31) and 2013-2017 (N=31) Baby Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) trials. Data were compared on the above infant recommendations. Percentages were used to describe compliance to the recommendations and chi-square tests to determine whether compliance differed by country. RESULTS: Child care centres were most compliant (74%-95%) with recommendations to: provide daily indoor opportunities for infants to move freely under adult supervision, daily tummy time for infants less than 6 months of age, indoor and outdoor recreation areas that encourage infants to be physically active, and discourage screen time. Centres were least compliant (38%-41%) with adhering to recommendations to: limit the use of equipment that restricts an infant's movement and provide education about physical activity to families. Compared with Canadian and US centres, Australian centres were less compliant (46%) with the recommendation to engage with infants on the ground each day, to optimize adult-infant interactions and to limit the use of equipment that restricts the infant's movement. Canadian centres were less compliant (39%) with the recommendation to provide training to staff and education to parents about children's physical activity. US centres were less compliant (25%-41%) with the recommendations to provide daily opportunities for infants to explore their outdoor environment, limit the use of equipment that restricts the infant's movement and provide education to families about children's physical activity. CONCLUSIONS: Assisting child care centres on limiting the use of equipment that restricts an infant's movement, and providing education about children's physical activity to families may be important targets for future interventions.

A collaborative approach to adopting/adapting guidelines - The Australian 24-Hour Movement Guidelines for the early years (Birth to 5 years): an integration of physical activity, sedentary behavior, and sleep.

BACKGROUND: In 2017, the Australian Government funded the update of the National Physical Activity Recommendations for Children 0-5 years, with the intention that they be an integration of movement behaviours across the 24-h period. The benefit for Australia was that it could leverage research in Canada in the development of their 24-h guidelines for the early years. Concurrently, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group published a model to produce guidelines based on adoption, adaption and/or de novo development using the GRADE evidence-to-decision framework. Referred to as the GRADE-ADOLOPMENT approach, it allows guideline developers to follow a structured and transparent process in a more efficient manner, potentially avoiding the need to unnecessarily repeat costly tasks such as conducting systematic reviews. The purpose of this paper is to outline the process and outcomes for adapting the Canadian 24-Hour Movement Guidelines for the Early Years to develop the Australian 24-Hour Movement Guidelines for the Early Years guided by the GRADE-ADOLOPMENT framework. METHODS: The development process was guided by the GRADE-ADOLOPMENT approach. A Leadership Group and Consensus Panel were formed and existing credible guidelines identified. The draft Canadian 24-h integrated movement guidelines for the early years best met the criteria established by the Panel. These were evaluated based on the evidence in the GRADE tables, summaries of findings tables and draft recommendations from the Canadian Draft Guidelines. Updates to each of the Canadian systematic reviews were conducted and the Consensus Panel reviewed the evidence for each behaviour separately and made a decision to adopt or adapt the Canadian recommendations for each behaviour or create de novo recommendations. An online survey was then conducted (n = 302) along with five focus groups (n = 30) and five key informant interviews (n = 5) to obtain feedback from stakeholders on the draft guidelines. RESULTS: Based on the evidence from the Canadian systematic reviews and the updated systematic reviews in Australia, the Consensus Panel agreed to adopt the Canadian recommendations and, apart from some minor changes to the wording of good practice statements, keep the wording of the guidelines, preamble and title of the Canadian Guidelines. The Australian Guidelines provide evidence-informed recommendations for a healthy day (24-h), integrating physical activity, sedentary behaviour (including limits to screen time), and sleep for infants (<1 year), toddlers (1-2 years) and preschoolers (3-5 years). CONCLUSIONS: To our knowledge, this is only the second time the GRADE-ADOLOPMENT approach has been used. Following this approach, the judgments of the Australian Consensus Panel did not differ sufficiently to change the directions and strength of the recommendations and as such, the Canadian recommendations were adopted with very minor alterations. This allowed the Guidelines to be developed much faster and at lower cost. As such, we would recommend the GRADE-ADOLOPMENT approach, especially if a credible set of guidelines, with all supporting materials and developed using a transparent process, is available. Other countries may consider using this approach when developing and/or revising national movement guidelines.

Correlates of tummy time in infants aged 0-12 months old: A systematic review.

BACKGROUND: Tummy time, defined as an infant being placed on their stomach whilst they are awake and supervised, has been shown to have a positive effect on infant development and head shape. Tummy time can be influenced by a number of factors. Using a social ecological model, categories of potential variables can be examined to determine their influence on behaviours such as tummy time. The purpose of this systematic review was to examine potential correlates of tummy time in infants from birth to 12 months old. METHODS: Electronic databases were originally searched between March to December 2016. Included studies needed to be peer-reviewed, written in English, and meet a priori study criteria. The population was apparently healthy infants aged from birth to 12 months old. The article needed to contain an objective or subjective measure of tummy time as a dependent variable and examine the association between a demographic, psychological, behavioral, and/or environmental variable and tummy time. For this study, tummy time could include the ability of the infant to move whilst being positioned on their stomach, for example, the infant's ability to roll from back to front, or lift their head when lying on their stomach (prone positioning ability), or the capacity, time spent, age started, or parent attitudes/behaviours regarding the infant being placed on their stomach. The outcomes were the relationships between potential correlates and tummy time. Risk of bias was assessed at the individual study level using the Cochrane risk of bias assessment for observational studies. RESULTS: 15 articles representing 2372 unique participants from 7 countries were included. Correlates that were positively correlated with tummy time were age, prone sleeping, spending greater than 15minutes whilst awake in tummy time when 2 months old, amount of time in the bath, order of achievement of prone extension and prone on elbow positions and parents/carers setting aside time for tummy time. Risk of bias of the included studies ranged from low to high. CONCLUSIONS: Specific demographic, environmental and behavioral variables were found to be positively and negatively associated with tummy time. This evidence could assist future research regarding interventions to promote tummy time, enhance motor development, increase infant physical activity and contribute to future tummy time recommendations for parents and health care providers.

Accelerometer wear-site detection: When one site does not suit all, all of the time.

OBJECTIVES: Choice of accelerometer wear-site may facilitate greater compliance in research studies. We aimed to test whether a simple method could automatically discriminate whether an accelerometer was worn on the hip or wrist from free-living data. DESIGN: Cross-sectional. METHODS: Twenty-two 10-12y old children wore a GENEActiv at the wrist and at the hip for 7-days. The angle between the forearm and the total acceleration vector for the wrist-worn monitor and between the pelvis and the total acceleration vector for the hip-worn monitor (i.e. the angle between the Y-axis component of the acceleration and the total acceleration vector) was calculated for each 5s epoch. The standard deviation of this angle (SDangle) was calculated over time for the wrist-worn and hip-worn monitor for windows of varying lengths. We hypothesised that the wrist angle would be more variable than the hip angle. RESULTS: Wear site could be discriminated based on SDangle; the shorter the time window the lower the optimal threshold and Area under the Receiver-Operating-Characteristic curve (AUROC) for discrimination of wear-site (AUROC=0.833 (1min) - 0.952 (12h)). Classification accuracy was good for windows of 8min (sensitivity=90%, specificity=87%, AUROC=0.92) and plateaued for windows of ≥60min (sensitivity and specificity >90%, AUROC=0.95-0.96). CONCLUSIONS: We have presented a robust, computationally simple method that detects whether an accelerometer is being worn on the hip or wrist from 8 to 60min of data. This facilitates the use of wear-site specific algorithms to analyse accelerometer data.