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CLINICAL REPORT Guidance for the Clinician in Rendering
Pediatric Care
Physical Activity Assessment andCounseling in Pediatric Clinical
SettingsFelipe Lobelo, MD, PhD,a Natalie D. Muth, MD, MPH, FAAP,
FACSM,b Sara Hanson, PhD,c Blaise A. Nemeth, MD, FAAP,d COUNCIL
ONSPORTS MEDICINE AND FITNESS, SECTION ON OBESITY
abstractPhysical activity plays an important role in children’s
cardiovascular health,musculoskeletal health, mental and behavioral
health, and physical, social,and cognitive development. Despite the
importance in children’s lives,pediatricians are unfamiliar with
assessment and guidance regardingphysical activity in children.
With the release of the 2018 Physical ActivityGuidelines by the US
Department of Health and Human Services, pediatriciansplay a
critical role in encouraging physical activity in children
throughassessing physical activity and physical literacy; providing
guidance towardmeeting recommendations by children and their
families; advocating foropportunities for physical activity for all
children in schools, communities, andhospitals; setting an example
and remaining physically active personally;advocating for the use
of assessment tools and insurance coverage of physicalactivity and
physical literacy screening; and incorporating physical
activityassessment and prescription in medical school
curricula.
INTRODUCTION AND RATIONALE FOR PHYSICAL ACTIVITY ASSESSMENT
ANDCOUNSELING
The 2017 Youth Risk Behavior Survey (YRBS) revealed that only
26.1% ofAmerican adolescents reported levels of activity consistent
with currentguidelines, and 15.4% of students reported not being
physically active forat least 1 hour on a single day in the
previous week.1 With the exception ofincreased sports participation
among high school female students, overallyouth physical activity
levels have decreased.2 The lowest rates of physicalactivity occur
among adolescent girls, children and youth with specialhealth care
needs (CYSHCN), and youth of minority status; rates ofinactivity
increased with age.1,3 Although only approximately one-fourthof
children report meeting physical activity guidelines,
objectivemeasurement of activity by accelerometer reveals that less
than half ofchildren and 8% of adolescents were meeting the 2008
Physical ActivityGuidelines from the US Department of Health and
Human Services of60 minutes daily of moderate-to-vigorous physical
activity (MVPA) as
aHubert Department of Global Health and cNutrition and
HealthSciences Program, Laney Graduate School and Exercise is
MedicineGlobal Research and Collaboration Center, Rollins School of
PublicHealth, Emory University, Atlanta, Georgia; bChildren’s
Primary CareMedical Group, Carlsbad, California; and dAmerican
Family Children’sHospital and School of Medicine and Public Health,
University ofWisconsin–Madison, Madison, Wisconsin
Drs Lobelo, Muth, Hanson, and Nemeth served as coauthors of
themanuscript, providing substantial input into content and
revision; andall authors approved the final manuscript as
submitted.
Clinical reports from the American Academy of Pediatrics benefit
fromexpertise and resources of liaisons and internal (AAP) and
externalreviewers. However, clinical reports from the American
Academy ofPediatrics may not reflect the views of the liaisons or
theorganizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive
course oftreatment or serve as a standard of medical care.
Variations, takinginto account individual circumstances, may be
appropriate.
All clinical reports from the American Academy of
Pediatricsautomatically expire 5 years after publication unless
reaffirmed,revised, or retired at or before that time.
This document is copyrighted and is property of the
AmericanAcademy of Pediatrics and its Board of Directors. All
authors have filedconflict of interest statements with the American
Academy ofPediatrics. Any conflicts have been resolved through a
processapproved by the Board of Directors. The American Academy
ofPediatrics has neither solicited nor accepted any
commercialinvolvement in the development of the content of this
publication.
DOI: https://doi.org/10.1542/peds.2019-3992
Address correspondence to Blaise A. Nemeth, MD, FAAP.
E-mail:[email protected]
To cite: Lobelo F, Muth ND, Hanson S, et al. AAP COUNCILON
SPORTS MEDICINE AND FITNESS, AAP SECTION ONOBESITY. Physical
Activity Assessment and Counseling inPediatric Clinical Settings.
Pediatrics. 2020;145(3):e20193992
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recently as 2016.1,4,5 With rates ofobesity rising over the last
decades,annual relative increases of 4.8% inthe incidence of type 2
diabetesmellitus,6 and declines in estimatedlife expectancy at time
of birth since1993, the role of physical activity onchild, and
later adult, health remainsan important component ofpreventive care
and diseasetreatment.7,8
In 2006, the American Academy ofPediatrics (AAP) published the
policystatement “Active Healthy Living:Prevention of Childhood
Obesitythrough Increased Physical Activity.”9
That statement addressed not onlythe role of physical activity
in obesitybut also identification of individualsat risk for
decreased physical activity,age-appropriate
activityrecommendations, and the role ofschools in promoting
activity.9 Sincethat time, the AAP and otherorganizations have
publishedstatements on the assessment,prevention, and treatment
ofpediatric obesity that includerecommendations to promoteimproved
nutrition and sleep,decreased sedentary time, andincreased physical
activity, althoughdetails regarding how to achievephysical activity
recommendationsare limited.10–13 Unfortunately,5 years after the
2008 PhysicalActivity Guidelines were released,only 23% of family
physicians and33% of pediatricians were able tocorrectly identify
current physicalactivity guidelines for children 6 to18 years of
age.14,15 Physical activityis a “priority topic” in Bright
Futures:Guidelines for Health Supervision ofInfants, Children and
Adolescents,Fourth Edition, for every healthsupervision visit
starting at18 months of age, with inclusion ofrecommending meeting
the PhysicalActivity Guidelines beginning at5 years of age.16 The
2018 PhysicalActivity Guidelines outline therecommended physical
activity levelsfor children and adolescents, provide
guidelines for children younger than6 years, and support the
role ofphysical activity on not just physicalhealth but also in
development,mental health, and schoolperformance (Table 1).17 As
such, thisclinical report replaces the previousstatement on active
healthy living,augments existing statements,highlights the role of
physical activityin all children’s health, and providesguidance for
physicians to betterassist families in increasing
physicalactivity.
PHYSICAL ACTIVITY AND HEALTHOUTCOMES IN CHILDREN AND YOUTH
The relationships between physicalactivity, cardiovascular
health, andbody composition have been wellestablished. Morris et
al18
demonstrated decreased rates ofadult coronary heart disease in
activeversus sedentary employees of theLondon Transport Executive
in 1953.In the absence of longitudinal studiesassessing the impact
of childhoodphysical activity on adult mortality,studies have
confirmed the benefit ofphysical activity on
children’scardiorespiratory fitness, lipidprofiles, insulin
sensitivity, and serumglucose concentrations in individualswith
obesity as well as associationswith more optimal
cardiovascularprofiles in the most physically activechildren.19–24
Importantly, for thedeveloping child, aerobic activity andstrength
training result in increasedmuscle mass and decreased
fatmass.21,22,25 Physical activity also
increases bone density and improvesbalance, protecting against
falls andinjury both in childhood and later inlife.26–30 Overall,
strong evidencesupports that MVPA improvescardiovascular and
muscular fitness,bone health, weight status, andcardiometabolic
risk factor status inchildren and adolescents, as outlinedby the
2018 Physical ActivityGuidelines Advisory Committee.31
Less widely appreciated, physicalactivity benefits behavioral,
cognitive,and social aspects of child health.Increased physical
activity has alsobeen shown to be associated withdecreased rates of
smoking and fewersymptoms of depression, andincreased rates of
inactivity andsedentary activity can predict futurealcohol and drug
use inadolescents.32–34 Both randomizedcontrolled trials and
systematicreviews support the effect of physicalactivity on
academic performance,possibly even in a
dose-responserelationship.35–41 Children who areprovided
opportunities to bephysically active during school focusand behave
better, including childrenwith
attention-deficit/hyperactivitydisorder.42–44 Benefits may be
evengreater in children with autismspectrum disorder who
showdecreased perseverative behavior andeasier redirection after a
bout ofphysical activity.45,46 The 2018Physical Activity Guidelines
AdvisoryCommittee concluded that in childrenages 5 to 13 years,
acute bouts ofphysical activity and regular MVPA
TABLE 1 2018 Physical Activity Guidelines Applicable to
Children
Age Activity Amount Intensity
3–5 y 31 h/d Light, moderate, vigorous6–17 y $60 min/d Moderate
or vigorous aerobic activity daily
Vigorous at least 3 d/wkMuscle-strengthening activities at least
3 d/wkBone-strengthening activities at least 3 d per wk
Children notmeetingguidelines
Gradually increase activityin ways the child enjoys
Moderate-vigorous; increase time per d and No. daysper wk; use
multiple, smaller time increments inactivity that are additive
throughout the day
Adapted from US Department of Health and Human Services.
Physical Activity Guidelines for Americans. 2nd ed. Wash-ington,
DC: US Department of Health and Human Services; 2018. Available at:
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf.
Accessed December 10, 2018.
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improve cognition, includingmemory, processing speed,attention,
and academicperformance.31
Even more concerning than the ratesof inactivity among children
overall isthe low rate of physical activityamong CYSHCN.3 CYSHCN
representa wide range of children with chronicphysical,
developmental, behavioral,or emotional conditions.47 Thebenefits of
physical activity forCYSHCN are substantial. Physicalactivity plays
a vital role in strength,endurance, and bone health for allchildren
and especially for childrenwith neuromotor disorders such asspina
bifida, muscular dystrophy andother myopathies,
Prader-Willisyndrome, and cerebral palsy.48–54
Beyond musculoskeletal benefits,activity may play a role in
speech andfine motor development, possiblythrough opportunities for
socialinteraction, postural control andpositioning, and use of
orofacialmuscles required for breathingduring physical
activity.55–60 Despiteits pronounced benefits, rates ofphysical
activity in CYSHCN are muchlower than in health-normativepeers.3,61
Any successful effort toincrease physical activity
requiresapproaches tailored to an individual’sunique needs.62
Physical activity may also createunexpected benefits in children
withother chronic health conditions.Children with a history of
cancerexperience increased rates ofcardiovascular events, and
physicalactivity has been shown to improvecardiovascular risk
factors in thispopulation.63–65 Physical activity alsoimproves
immune function, whichmay decrease pulmonary infection,and improves
weight gain in childrenwith cystic fibrosis.66–69 Physicalactivity
benefits cardiorespiratoryfunction in, and may be engaged insafely
by, children with congenitalheart disease under properly advisedand
supervised programs.70–72
CURRENT PHYSICAL ACTIVITYGUIDELINES IN YOUTH
The 2018 Physical Activity GuidelinesAdvisory Committee
reaffirmed the2008 Physical Activity Guidelines,which recommend
children andadolescents (6–17 years of age)engage in at least 60
minutes ofphysical activity every day, includingvigorous-intensity
as well as muscle-and bone-strengthening activities, atleast 3 days
per week (Table 1).31 TheAAP has advised that physical
activityshould also include a muscle-strengthening program that
targetsall major muscle groups, starts withno load and
incrementally may addload once exercise technique ismastered,
involves 2 to 3 sets of 8 to15 repetitions, and is performed 2 to3
days per week for at least 8weeks.73
The 2018 Physical Activity GuidelinesAdvisory Committee
concluded thereis strong evidence that a greatervolume of physical
activity amongchildren ages 3 to 5 years of age isassociated with a
decreased risk ofexcessive weight gain and improvedbone health.31
The committeeconcluded these children should aimto achieve at least
the median level ofphysical activity of children this age,which is
3 hours or more of physicalactivity per day.31 This is
consistentwith other guidelines that suggestthat adults should
provideopportunities for free play andunstructured physical
activity forchildren 3 to 5 years of age,15,74
including at least 180 minutes ofphysical activity throughout
the day(approximately 15 minutes everyhour while awake) that helps
todevelop movement skills in a varietyof activities and in a
variety ofenvironments. The higher volume ofactivity recommendation
for children3 to 5 years of age is based on thenature of their
activity beingintermittent and typically of lowerintensity than
older children.75
Infants should be physically activeseveral times per day, mostly
through
interactive floor-based play.75 TheAAP clinical report “The
Power ofPlay: A Pediatric Role in EnhancingDevelopment in Young
Children”offers guidance on appropriateapproaches for young
children.76
Caring for Our Children: NationalHealth and Safety
PerformanceStandards; Guidelines for Early Careand Education
Programs is anotherAAP publication providing guidancefor child care
settings.77
For all children and adolescents, it isimportant that activities
areappropriate to a child’s age,enjoyable, and varied.75 Examples
ofchild and youth physical activities aswell as recommendations
based onthe principles of frequency, intensity,time, and type of
activity are includedin Tables 2 and 3.
THE IMPORTANCE OF PHYSICALLITERACY IN SHAPING PHYSICALACTIVITY
PARTICIPATION
Attention to physical literacy, definedby the Aspen Institute as
“the ability,confidence, and desire to bephysically active for
life” may providean opportunity to increase andsustain physical
activity acrosschildhood and adolescence.85 Abilityincludes
competence in fundamentalmovement skills including
throwing,catching, jumping, striking, running,kicking, agility,
balance, andcoordination. Fundamentalmovement skills emerge
starting withgross motor skill development ininfancy and early
childhood, progressthroughout early and midchildhood,and are honed
in preadolescence andadolescence (see Table 4).85
Competency in fundamentalmovement skills is a strong predictorof
both current and future physicalactivity levels, cardiovascular
fitness,BMI, and risk of overweight andobesity.86–88 Confidence, or
self-efficacy in one’s ability to play sportsor enjoy physical
activity, developsfrom early positive experiences withphysical play
and a variety of sportsthat are inclusive and welcoming of
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all children, regardless of theirabilities.85 Desire encompasses
theinterest and enjoyment in physicalactivity and movement.85
Teenagers report the strongestfacilitators of physical activity
includea favorable attitude toward physicalactivity; motivation;
perception ofcompetence and body image; fun;influence of friends,
family, andphysical education teachers; andenvironmental physical
activityopportunities.91 Higher physicalliteracy is associated with
higherphysical activity levels andcardiorespiratory fitness in
childrenand adolescents.92,93 On the otherhand, children who do not
developfundamental movement skills areunlikely to develop the
confidenceand desire to be active and are atincreased risk for
sedentary lifestyleand its associated risks, asdemonstrated by
children withdevelopmental coordination disorder
who experience increased rates ofobesity.94,95
Children who do not engage inregular physical activity miss out
onimportant benefits such as improvedself-esteem, leadership and
teambuilding skills, decreased stress andanxiety, decreased
depression, andfun, as well as improved physical andbrain health.74
Because physicalactivity is essential to normalpediatric
development and health, theterm “exercise deficit disorder” hasbeen
proposed to identify childrenwho, for a variety of reasons, do
notengage in sufficient physical activityto promote overall
health.96
Many groups experience barriers tobeing physically active
anddeveloping fundamental movementskills, such as girls, children
ofminority status, children from low-income households (rural and
urban),and CYSHCN.85 If these skills do notdevelop, the likelihood
of being
physically inactive later in lifeincreases, creating an integral
role forthe pediatrician in screening forphysical literacy,
physical activityopportunities, and exercise deficitdisorder97 and
referring to a youthfitness specialist, physical educationteacher,
or physical and/oroccupational therapist becausestructured
programming improvesfitness, strength, and functionalmovement
skills.98,99 Nationalstandards outline physical literacy asthe
primary purpose of physicaleducation classes in schools.100
The role of early physical activity andliteracy on later adult
health may playa role in fracture risk beyond effectsof impact
activities on bone densityand geometry.101 Multidirectional
ballsports earlier in life appear to protectagainst stress
fractures in adolescentrunners.102 Physical function or,rather,
dysfunction has been found tobe a contributor to adult
“fragility”
TABLE 2 Examples of Types of Physical Activity
MET Physical Symptoms Examples of Activities
Rest 1 — —Light ,3 Easily able to converse Household chores
WalkingNo sweating or
shortness of breathPlaying catch
FishingModerate 3–6 Some difficulty talking Yardwork
Feeling warm Jogging or fast walkingLight sweating TagSlight
shortness of
breathMovement portion of
ball sportsVigorous .6 Unable to talk Manual labor
Short of breath RunFace red Skipping ropeSweating Skiing,
skating
Wheelchair use or use of assistivedevices (crutches or
ankle-footorthoses)
Comparable METs expended for comparable examples noted above(eg,
wheeling on a smooth surface = light; wheeling fast or up anincline
or as part of ball sports = moderate; wheelchair racing
orsit-skiing = vigorous) (use of crutches or ankle-foot
orthosesinvolves higher METs but usually not enough to increase the
levelof PA, eg, from light to moderate)
— —
Muscle strengthening — Pushing and/or pullingone’s body or
anobject
ClimbingPushups, curl-ups, or
resistance trainingWheeling a wheelchair
Bone strengthening — Increased impact Jumping
ropeTumblingRunning
Data are from references 78–82. MET, metabolic equivalent of
task; PA, physical activity; —, not applicable.
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fracture risk.103 Because osteopeniaonly explains part of
fracture risk, therole of sarcopenia, the loss of muscle,especially
with aging, has beenproposed as an important risk factorto the
extent that, similar to exercisedeficit disorder, the term
“dysmobilitysyndrome” has been coined foradults, both resulting
from dynapenia,the loss of muscle.104,105
INACTIVITY AND SEDENTARY TIME
The typical preschooler spends morethan 6 hours per day in
sedentaryactivity and just under 15 minutesper day in MVPA.106 More
than 20%of children watch 3 or more hours oftelevision per day on
school days,1
and the average 8- to 18-year-oldspends more than 7 hours per
day infront of a screen.107
The health effects of a sedentarylifestyle are an area of
intenseresearch and emerging concern. Foradults, physical
inactivity isassociated with increased all-causemortality,
cardiovascular diseaseincidence and mortality, cancerincidence and
mortality, and diabetesincidence,108 among other harmfulhealth
consequences. The 2018Physical Activity Guidelines
AdvisoryCommittee concluded that there islimited available
scientific evidencelinking sedentary behavior to healthoutcomes;
however, given the highprevalence of physical inactivity inyouth,
especially CYSHCN, replacingsome sedentary time with MVPAcould
improve health, given thestrong association.31,109 Moreresearch is
needed to betterunderstand the effects of time spentsitting and in
light-intensity physicalactivity among children
andadolescents.110
Although the advent of exergaming,or active video games, pose
anattractive option to promote physicalactivity in children drawn
toelectronic media and video gamesand averse to traditional
physicalactivity, exergaming primarilyTA
BLE3Age-AppropriateRecommendations
forIncreasedPhysical
Activity
Infant
(0–1y)
Toddler(1–3y)
Preschool(3–5y)
Elem
entary
(5–10
y)MiddleSchool
(11–14
y)Adolescence(15–18
y)
Frequency
Daily
Daily
Daily
Daily
Daily
Daily
Intensity
Any
Any
Any,includingsomemoderate
tovigorous
Moderateto
vigorous
Moderateto
vigorous
Moderateto
vigorous
Time
Severaltimes
perday
Atleast180min/d
Atleast180min/d,ofwhich
atleast60
min
aremoderate-
to-vigorousintensity
Atleast60
min/d
Atleast60
min/d
Atleast60
min/d
Type
Interactivefloor-
basedplay
andat
least30
min
oftummytim
espread
throughout
thedaywhile
awake
Activities
that
developgrossmotor
skills;exam
ples
includewalking
intheneighborhood,
unorganizedfree
play
outdoors,
walking
throughapark
orzoo,
orplayingon
aplayground
for
toddlers
Activities
that
developgross
motor
skills;unorganized
free
play
inasafe
environm
ent;activities
includewalking,running,
swimming,tumbling,
throwing,andcatching
Aerobicdaily;vigorousactivity,
muscle,andbone-strengthening
atleast3d/wk;includefree
play
with
opportunities
for
fundam
entalmovem
entskill
developm
entthroughwalk,
dance,jumprope.Introduce
organizedsports
with
flexible
rulesandshortinstructiontim
ewith
afocuson
enjoym
entrather
than
competition
Aerobicdaily;vigorousactivity,
muscle,andbone-
strengtheningat
least3d/wk;
incorporateactivities
that
are
enjoyableandencourage
socialization;avoidsports
specialization
Aerobicdaily;vigorousactivity,
muscle,andbone-
strengtheningat
least3d/wk;
incorporateactivities
that
are
enjoyableandencourage
socializationandcompetition,
whenappropriate
Data
arefrom
references
9,15,73,75,83,and84.
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promotes only light physical activity,with few games
demonstratingeffectiveness in increasing activity tomoderate or
vigorous levels.111
Although MVPA occurs with specificgames in structured
settings,applicability to home settings and theability to achieve
sustained, orcumulative, durations necessary tomeet physical
activity guidelines hasnot been demonstrated.112,113
The AAP advises that parents developa family media use plan to
helpchildren limit screen time activities toensure they do not
replace adequatesleep, physical activity, and otherbehaviors
essential to health.114
Likewise, Bright Futures: Guidelinesfor Health Supervision of
Infants,Children and Adolescents, FourthEdition, recommends
physical activityand play as alternatives to screentime, as well as
a way to promotefamily routine and social interaction,in addition
to benefitting normalgrowth and development.16
EVIDENCE IN SUPPORT OF PHYSICALACTIVITY PROMOTION IN
PEDIATRICCARE SETTINGS
Among adults, substantialinternational evidence supports theuse
of multiprong physical activitycounseling and referral
strategies,particularly those linking health careand
community-based resources, toimprove physical activity
levels.115,116
Meta-analyses and systematicreviews have shown that
physiciancounseling (odds ratio, 1.42; 95%confidence interval,
1.17–1.73) andexercise referral systems (relativerisk, 1.20; 95%
confidence interval,1.06–1.35) promote improvements inadult
patients’ physical activity for upto 12 months,117–120 with
evidencesupporting the notion that physicalactivity counseling can
besuccessfully implemented in routineclinical practice121,122 and
thatprotocols are acceptable amonghealth care providers.123
Integrationof physical activity counseling andreferral strategies
into adult primary
TABLE 4 Supporting Physical Literacy
Infancy: supporting rudimentary motor skill developmentGrasping
(3–4 mo)Offer toys to support hand-eye coordination
Roll over (4–6 mo)Tummy time to build core strength
Sitting (6 mo)Tummy time to increase strength and
coordination
Crawling (7–10 mo)Place toys to help build strength and
balance
Cruising (9 mo)Offer a safe environment to explore which
increases strength and balance
Walking (12 mo)Create a safe environment to explore which
improves balance and coordination
Toddler or preschool age: support development of fundamental
skillsEncourage fun and socialization, incorporating activities
preferred by the child, family walks, and
chores (picking up, retrieving items, helping clean)Running (by
2 y)Play chase, visit parks, and offer a safe environment to
practice
Throwing (2 y)Play catch with easy-to-grasp foam or fabric
balls
Catching (21 y)Create a “basket” with arms to catch
Kicking (2 y)Play soccer with light, foam balls
Swimming (1–4 y)Enroll in swimming lessons
Skating (4 y)Elementary school age: improve fundamental skills
and develop self-efficacyEncourage fun and socialization,
incorporating fitness preferences (such as dance, yoga,
running,
hiking, sports), active transportation (walking, cycling to
school and activities), and chores(walking the dog)
RunningBuild fitness and skills with tag, introduce sports like
soccer by age 6
Throwing and catchingFalling and tumblingHelps decrease injury
by learning to tuck head, knees, and arms
Hopping and jumpingHopscotch and jump ropeCyclingTeach a child
to ride a bike
Striking sportsPractice at home with a plastic ball and bat,
hockey stick, etc; introduce sports programs
Dribbling sportsFine motor skills develop through practice and
repetition
GymnasticsOne of the best activities for agility, balance,
coordination, strength, and flexibility
SkiingLow center of gravity makes it easier; it helps with
balance
Preadolescence and adolescence: honing physical
literacyEncourage fun and socialization, incorporating fitness
preferences (such as dance, yoga, running,
hiking, sports), active transportation (walking, cycling to
school and activities), and chores(walking the dog)
Identify gaps in fundamental movement skills development,
confidence, or desire to be active anddevise a plan to remedy (eg,
motivational interviewing, physical therapy, community program)
Introduce skill development and strategy through coaching and
campsIntroduce more complex sports that incorporate
multidirectional movement and attention (eg,
sports with equipment and strategy and/or plays)Introduce
resistance training with supervision and instruction on proper
techniqueAvoid sports specialization until mid-to-late teenaged
years
Data are from references 16, 76, 83–85, 89, and 90.
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care settings has also been found tobe cost-effective,124–128
provide earlyreturn on investment because oflower health care use
and costs,129,130
and have been successfully scaled tonational levels with
adequatesustainability.128
Although the experience from adultmedicine shows that
multicomponentintervention approaches can beeffectively implemented
withinestablished primary care practicesmaking use of existing
resources andpersonnel, evidence on theeffectiveness of physical
activitypromotion in pediatric settings ismore limited.131 To date,
mostinterventions have been centered onmultiple health behaviors
includingsedentary time and healthy diet in thecontext of weight
management. Forexample, the Patient-CenteredAssessment and
Counseling forExercise Plus Nutrition (PACE1)intervention showed
that computer-assisted, individually tailoredcounseling for
physical activity inchildren 11 to 15 years of age can beeffective
in reducing sedentary timeand improving compliance withphysical
activity guidelines at 12months, particular among boys.132
The Physical Activity Guidelines forAmericans Midcourse
Reportassessed evidence-basedrecommendations to increase
youthphysical activity across multiplesectors.31 In this report,
the authorsfound insufficient evidence to supportspecific
strategies for physical activitypromotion in the clinical
setting.31
The 2018 Physical Activity GuidelinesAdvisory Committee remarked
thatthis could be improved with morerobust and standardized
strategiesincorporating additional teammembers and tools such
asmotivational interviewing anda specific exercise prescription.31
Thecommittee also noted thatindividually focused
interventionsdelivered in a variety of settings cansuccessfully
increase youth physicalactivity, especially when families and
schools are incorporated into theinterventions.31
The Healthcare Effectiveness Dataand Information Set measure
onWeight Assessment and Counselingfor Nutrition and Physical
Activity forChildren/Adolescents assesses thepercentage of patients
2 to 17 yearsof age who had an outpatient visitwith a primary care
provider and whohad evidence of BMI percentiledocumentation,
counseling fornutrition, and counseling for physicalactivity during
the measurementyear.133 Depending on insurance type,60% or fewer
pediatric visitscontained documentation ofcounseling for physical
activity orreferral for physical activity on thebasis of
administrative data ormedical record review that includeda note
indicating the date and at leastone of the following activities:
(1)discussion of current physical activitybehaviors (eg, exercise
routine,participation in sports activities,examination for sports
participation);(2) checklist indicating physicalactivity was
addressed; (3)counseling or referral for physicalactivity; (4)
member receivededucational materials on physicalactivity; or (5)
anticipatory guidancefor physical activity. Examples ofnotations
that do not count towardthis requirement include “notation
of‘cleared for gym class’ alone withoutany documentation of a
discussion”or “notation of ‘health education’ or‘anticipatory
guidance’ without anyspecific mention of physicalactivity.”133
The US Preventive Services TaskForce recommends that
cliniciansscreen children 6 years and older forobesity and offer
them or refer themto comprehensive, intensivebehavioral
intervention that includesphysical activity and
nutritionalcounseling to promote improvementin weight status. Rated
as a “B”recommendation, this strategy mustbe included in health
plans under theAffordable Care Act’s Prevention and
Health Promotion activities.134
Similarly, the AAP clinical report onobesity prevention also
underscoresthe importance of physical activitypromotion by
pediatricians and otherhealth care providers.10 Given thecritical
importance of play inchildhood, of which physical play isone type,
the AAP recommends thatclinicians write a “prescription forplay” at
well-child visits in the first2 years of life.76 Bright
Futures:Guidelines for Health Supervision ofInfants, Children and
Adolescents,Fourth Edition, encourages play asa way to decrease
screen timestarting at 18 months of age,promoting behavioral
managementand social development starting at2 years of age, and
advancing topromotion of physical activityguidelines at 5 years of
age forgrowth and development.16 As such,physical activity is a
component of theBright Futures health supervisionpriorities of
social and emotionalwell-being, school readiness andperformance,
and risk-behaviorreduction.16
ROLE OF PARENTS IN PHYSICALACTIVITY FOR CHILDREN
Early in life, opportunities for thedevelopment of physical
literacyoccur at home. Parents are integral,not only in
role-modeling movement,but also in playing with their childrento
allow for acquisition of necessaryskills.76 The role of parents is
evenmore important in CYHSCN given thecomplexity of needs and
barriers toparticipation that children withdisabilities face.135
Free-play is theprimary exposure of necessity.76
Playing catch, climbing structures andnatural elements, such as
bouldersand trees, and tag address skills intravel, hand-eye
coordination, andbalance and strength through naturalexploration
and fun play. Organizedsports are unnecessary at early agesbut are
beneficial for more specificskill development once a child isready
on the basis of physical,
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cognitive, and behavioralreadiness.136 Children who engage ina
variety of different activities andsports, especially those that
helpbuild fundamental movement skillssuch as gymnastics, swimming,
andtrack will be more likely to developphysical literacy as well as
enjoymentof physical activity and attainrecommended levels of
MVPA.85
Sport specialization, as outlined in theAAP statement “Sports
Specializationand Intensive Training in YoungAthletes,” is
discouraged beforepuberty because there is no evidencethat young
children will benefit fromearly sport specialization in themajority
of sports, and some datasuggest that early specialization leadsto
higher rates of overuse injury andburnout from
concentratedactivity.83,137,138 Exposure to naturehas also been
shown to have its ownbenefits on health; thus,opportunities for
play and movementoutdoors, even in the smallest ofgreen spaces, are
important andcreate an increased appreciation ofmovement and
nature.139,140
ROLE OF SCHOOLS IN PROMOTINGPHYSICAL ACTIVITY IN YOUTH
In many areas, school provides theprimary opportunity for
physicalactivity and acquisition of physicalliteracy. In fact, the
2018 PhysicalActivity Guidelines AdvisoryCommittee found strong
evidencethat interventions that affect multiplecomponents of
schools are effectivefor increasing youth physical
activity,particularly among those at highestrisk of physical
inactivity, such asadolescent girls and children withlimited access
to safe and affordableactivity opportunities outside ofschool.31
The American HeartAssociation calls for schools tobecome the
central element ina community system that ensuresthat students
participate in enoughphysical activity to develop
healthylifestyles.141 Developing physicaleducation curricula that
promotes
enjoyment of movement and skilldevelopment is important,
especiallyincluding CYSHCN, as is providingopportunities for
movement before,during, and after school.142 Nationalstandards
outline the role of physicaleducation classes in
physicalliteracy.100 It is important torecognize that in physical
educationclasses at school, a number of factorshave been shown to
result in childrenspending less than 50% of class timeengaged in
MVPA.143,144
Opportunities for additionalmovement throughout the daythrough
active classrooms benefit notonly the child through
increasedphysical activity but also the learningenvironment as a
result of improvedbehavior.36,42,145 Opportunities forrecess and
physical education duringschool that maximize movement andminimize
sedentary and/or standingtime and encourage social interactionare
critical.146,147 Schools alsoprovide a safe place for
physicalactivity before and after school thatmany children do not
have at home,especially outside, increasing the timespent in
MVPA.148–150 SHAPEAmerica, the Society of Health andPhysical
Educators, discourages theuse and withholding of physicalactivity
as punishment in schools.100
TOOLS FOR ASSESSING PHYSICALACTIVITY IN PEDIATRIC
CLINICALSETTINGS
In a nationally representative sample(N = 811) of US primary
carephysicians caring for children andadolescents (pediatrics and
familymedicine), most physicians reportedassessing physical
activity in youthusing general questions about theamount of
physical activity (98%).14
However, a lower proportion (66%)asked specific questions
aboutduration, intensity, and type ofphysical activity, and only a
minorityreported using a standardizedquestionnaire (7%) or other
writtenphysical activity assessments (6%).14
In comparison, 98% of physicians
reported regularly measuring weightobjectively on a scale in the
officesetting.14 That the majority ofpediatric primary care
physiciansreport somehow assessing physicalactivity levels in their
clinical practiceis encouraging, but the study byHuang et al14 that
revealed fewerthan one-third of pediatricians couldcorrectly
identify guidelines calls intoquestion the degree to whichproviders
are correctly screening forinsufficient physical activity
oradequately counseling adolescentsand their families on
therecommended “dose” of physicalactivity for health.
Several methods have been used toassess physical activity in
childrenand adolescents includingquestionnaires, activity
logs,pedometers, and research-grade andconsumer-oriented
accelerometers.Practicality, validity, and reliabilityare important
considerations whendeciding appropriate methods toassess physical
activity levels inclinical settings.120 Although physicalactivity
is important, assessment ofphysical literacy (Table 4) is
firstnecessary to quantify current activity,create appropriate
goals forimprovement, and allow for dose-response relationships to
changes inother health parameters (andsubsequent studies to
demonstratebenefit or lack thereof) (Table 5). Inthe absence of
opportunities todirectly assess movement,quantification of physical
activity mayserve as a surrogate measure foryounger children in
representingopportunities for development ofphysical literacy.
Simply askingchildren about their enjoyment ofmovement may provide
insight intotheir physical literacy.105
In the adult population, systematicassessment of physical
activity levelsin clinical settings has beenestablished through the
integration ofa self-reported physical activity vitalsign (PAVS)
into electronic healthrecords (EHRs).151 The PAVS has
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been promoted through the Exerciseis Medicine initiative of the
AmericanCollege of Sports Medicine.115,152–154
The PAVS consists of 2 questions(Fig 1), adapted from the
BehavioralRisk Factor Surveillance System andvalidated to screen
for inactivity inclinical settings.155–157 Integration ofthe PAVS
into the EHR of large healthcare systems resulted in
greaterphysical activity–related counseling,weight change in adult
patients withobesity, and hemoglobin A1c changesin those with
diabetes.158,159 TheInstitute of Medicine (now NationalAcademy of
Medicine) has supportedthe inclusion of the PAVS and/orobjective
assessment of physicalactivity in EHRs.160
Assessment of physical activity levelsin youth via self-report
is a morecomplex undertaking because youthare less likely to make
accurate self-report assessments than adultsbecause of
developmental differences,especially in the ability to
performdetailed recall and understandconcepts regarding physical
activityduration and intensity.161,162 Inaddition, youth have an
activitypattern that is more variable andintermittent compared with
adults.163
Furthermore, sports practices involveMVPA for only a fraction of
the time,and the amount of time varies greatlyby sport.164 A
thorough review ofphysical activity assessment tools isincluded in
the SupplementalInformation.
STRATEGIES TO OVERCOME BARRIERSTO PHYSICAL ACTIVITY
ASSESSMENT,COUNSELING, AND REFERRAL INCLINICAL PRACTICE
Physicians face many barriers toimplementing physical
activityassessment, counseling, and referralin the clinical
setting.151 Clinical visittimes are short, and the list
ofpreventive guidance to incorporateinto well-child checks is
long.151
Solutions will likely requireinterprofessional approaches
andengagement with communityorganizations in development of toolsto
provide interventions and trackphysical activity, integration
ofmeasurements of activity into theEHR, and identification
ofassociations with health outcomes.151
Regardless, physical activityassessment, counseling,
andpromotion follows the same approachas used in other areas of
lifestylechange for chronic disease, yet it isapplicable to all
patients (Table 5).165
Pediatricians will need efficientworkflows to incorporate
physicalactivity assessment, counseling, andreferral into the
clinical visit. Thiscould be accomplished througha PAVS in the
medical record, previsitquestionnaires, or screeningperformed by
support staff.151 EHRcompanies and health careinstitutions are
encouraged to includetools to measure, document, report,and
investigate physical activitymeasures and association with
other
health outcomes, including assessingfor physical literacy. For
example, theIntermountain Healthcare systemdeveloped and integrated
into theirEHR system a pediatric PAVS for useat preventive care
visits for childrenages 6 to 18 years.151 This toolcombines the
PACE1 validated itemwith the addition of questions toassess
activity participation onspecific settings and domains(physical
education, recreation,sports, transportation, home, afterschool,
sedentary or screen time) inan effort to facilitate
complianceassessment and guide goal-settingand domain-specific
counseling.151
Since 2011, the Kaiser PermanenteHealth System integrated into
its EHRsystem and clinical workflows thepediatric exercise vital
sign, modeledafter the YRBS questions, for youth 5to 18 years (Fig
1).166 Although notyet formally validated in children,implementing
the PAVS as a part ofthe health visit and within the EHRrepresents
a starting point ininitiating the conversation aroundphysical
activity in primary care andassessing the potential to
predictfuture disease risk158 as well asdetermining the validity of
the PAVSin pediatric practice.167 Brief tools forassessing physical
activity areincluded in Table 6 (see theSupplemental Information
for a fulldiscussion regarding the tools andmethodology used to
identifyadvantages and disadvantages ofeach).
Similar to adult-based approaches,once the current physical
activitylevel of the child is understood,providers can offer more
specific,developmentally tailored physicalactivity advice or set an
appropriateincremental goal for increase inactivity and can include
furtherguidance and referral resources in theafter-visit
summary.120 For childrenidentified as needing furtherintervention,
a brief follow-up visitcould be scheduled, or the patientcould be
referred to a community
TABLE 5 Steps Toward Integrating Physical Activity Assessment
and Counseling Into Clinical Practice
1. Ask about current physical activity frequency and duration
and enjoyment of movement.2. If it is an acute or subspecialty
visit, connect benefit of physical activity to current health
conditionand advise on restrictions in physical activity (if
applicable).
3. If it is a health supervision visit, assess physical literacy
and any gap between current andrecommended activity level. Assess
the patient and family interest in discussing promotion ofphysical
activity.a. If not interested, provide information on the benefit
of physical activity to current health, if the
patient has any chronic issues, and/or future health (including
athletic performance).b. If interested, discuss the reason for
interest and potential area of change and establish a specific,
attainable incremental goal to progress toward physical activity
guidelines. Connect patient and/or family to resources to support
achievement of goal, such as a physical education teacher,exercise
specialist, physical or occupational therapist, or coach.
4. Recommend scheduling an appointment to discuss achievement
toward goal; identify obstacles tochange and establish new
goals.
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resource (such as a teacher orcommunity center).120 In
addition,support staff could receiveappropriate training to
elaborate ona provider’s physical activityprescription and connect
patientswith community and technologyresources to fill the
prescription.120
Special emphasis on addressingbarriers for CYSHCN may be
neededto assist patients and families withunderlying mobility
issues.168,169
Further guidance for CYSHCN may befound in the AAP clinical
report“Promoting the Participation ofChildren With Disabilities in
Sports,
Recreation, and PhysicalActivities.”128
Institutional support of pediatricphysical therapists,
occupationaltherapists, athletic trainers, exercisespecialists,
social workers, and otherprofessionals is necessary to assist
inaddressing the needs of the childrenmost at risk for inactivity,
such asCYSHCN; children of minority, rural,and urban status who
experienceinsufficient access or resources tophysical activity; and
adolescentgirls.116,170 Ideal partnerships resultin access to
programs that are safe,
close to home, financially feasible,fun, and culturally
appropriate andoffer adaptive experiences andintellectually
appropriateprogramming (eg, SpecialOlympics) so that children
facingbarriers receive the sameopportunities as their peers(Table
6).168
Insurance companies can play a roleby providing coverage for
necessaryservices and reducing reasons forpayment denials
becauseimproved physical literacy andphysical activity, even
fornonambulatory individuals,result in later health benefit
andsavings in health careexpenditures.171
ROLE OF PHYSICIANS IN PROMOTINGPEDIATRIC PHYSICAL
ACTIVITYOUTSIDE OF DIRECT PATIENT CARE
Many patients, families, andcommunity organizations look
topediatricians to provide physicalactivity recommendations for
sportsparticipation, modifications forchildren with special needs
or anacute or chronic injury, andincreasingly for management of
manyphysical and behavioral conditionssuch as prediabetes and
attention-deficit/hyperactivity disorder.172 Yetmany pediatricians
may feel they donot have the experience or trainingneeded to guide
their patients towardmeeting physical activityrecommendations. In
medical school,they likely received little to notraining in
exercise prescription.173
Most did not fare any better inresidency, with only 26%
ofpediatric residency programsreported having a curriculum
inphysical activity counseling, withthe greatest barrier being the
lack offaculty with training in physicalactivity counseling,
limiting providerknowledge and self-efficacy.174–176
Encouragingly, training pediatricresidents in physical
activitycounseling has been shown toimprove the physical activity
of
FIGURE 1Brief office-based assessments of physical activity.
Adapted from Joy EA, Lobelo F. Promoting theathlete in every child:
physical activity assessment and promotion in healthcare. Br J
Sports Med.2017;51(3):143–145. Adapted from Exercise is Medicine.
Healthcare providers’ action guide. Availableat:
https://exerciseismedicine.org/assets/page_documents/Complete%20HCP%20Action%20Guide_2016_01_01.pdf.
Accessed September 5, 2018. Adapted from Centers for Disease
Control and Pre-vention. YRBS Questionnaire Content - 1991–2017.
Available at:
https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/YRBS_questionnaire_content_1991-2017.pdf.
Accessed September 5, 2018. ACSM,American College of Sports
Medicine.
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patients.177 Implementing curriculaand providing education is
aneffective first step (Table 7), whichcould be expanded to
continuingmedical education for practicingclinicians.
Clinicians have a responsibility tomodel physical activity for
theirpatients and families through theirown physical activity and
communityengagement. Several studies haveshown that physicians’
personalphysical activity behaviors are animportant correlate of
their attitudesand clinical practice regardingphysical
activity.178,179 Interestingly,the greatest predictor of asking
aboutphysical activity by pediatricians isbeing personally “fit and
healthy”themselves.180 In addition, physicalactivity is integral to
personal well-being for the health care professional,improving
quality of life and work-lifebalance and decreasingburnout.181–184
The AAP haspublished a clinical report on thesubject.185
RECOMMENDATIONS
Pediatricians are encouraged topromote physical literacy and
activityin children and progress towardrecommended physical
activityguidelines in one or more of thefollowing ways.
1. Assess and document gross motorskills and physical activity
asappropriate at health care visits(Table 5, Fig 1).
a. Assess gross motor skilldevelopment, physical literacy,and
physical activity levels atall health supervision visits,with early
referral to assess andtreat identified delays ordeficits (Table 4).
A PAVSmay be a useful screeningtool to guide specific
counseling(Fig 1).
b. For CYSHCN, discuss physicalactivity prescription and
anyphysical activity limitationswith subspecialists who aresharing
in a patient’s care.
Clearly document a patient’sindividual physical
activityprescription so that otherproviders, therapists,caretakers,
and parents canhelp a child implement theprescription.
c. For children who areinsufficiently active, identifybarriers
to activity and usebehavioral strategies such asmotivational
interviewing tohelp patients and familiesidentify doable strategies
toincrease activity.
2. Discuss the role and benefits ofphysical activity on physical
andsocial growth and developmentand management of other
healthconditions as well as in mentalhealth, school
performance,behavioral management, and risk-behavior reduction
specificallyrelated to thepatient.
3. Encourage parents to not only “doas I say” but also “do as I
do”because children who grow up infamilies with active parents
aremuch more likely to be activethemselves.
4. Provide specific tools andresources to help families
buildskills. Assist families inovercoming barriers to
physicalactivity by referring families tocommunity advocates
andcommunity-based activityprograms and other places to beactive,
such as sports clubs,recreation centers, parks, walkingand biking
trails, skate parks, andplaygrounds.
5. Advocate with health careorganizations, insuranceproviders,
schools, and communityorganizations to increaseopportunities for
physical activityfor all children.
a. Encourage healthy child carecenters and preschools toprovide
ample opportunitiesfor children to move in ways
TABLE 6 Resources for Pediatricians on Physical Activity
Assessment and Counseling
Institute for Healthy Childhood Weight:
http://ihcw.aap.orgExercise is Medicine:
www.exerciseismedicine.orgNational Physical Activity Plan:
http://www.physicalactivityplan.orgNational Association of Physical
Literacy: http://naplusa.orgSHAPE America: 2016 Shape of the
Nation:
https://www.shapeamerica.org/advocacy/son/default.aspxPrescription
for Activity: https://www.prescriptionforactivity.org/Lifestyle
Medicine Education Collaborative:
http://lifestylemedicineeducation.org/National Recreation and Park
Association: “Prescribing Parks for Better Health Success
Stories”:https://www.nrpa.org/contentassets/f768428a39aa4035ae55b2aaff372617/final-prescribing-parks-for-better-health-success-stories.pdf
National Association for the Education of Young Children:
https://www.naeyc.org/ (includingDevelopmentally Appropriate
Practice in Early Childhood Programs Serving Children from
Birththrough Age 8, Third Edition, as a resource for schools)
SHAPE, Society of Health and Physical Educators.
TABLE 7 Recommendations for Promoting Physical Activity
Assessment and Counseling in MedicalEducation
1. Demonstrate assessment and counseling in practice for
learners.a. Primary care pediatricians and health care providers:
general physical activity assessment and
screening, counseling and goal-setting, and activity or exercise
prescription and referral tocommunity partners and resources.
b. Subspecialists: guidance on physical activity benefits and
restrictions as related to relevantmedical condition to patient,
family, and other physicians involved in the patient’s care.
2. Advocate for the inclusion of education regarding physical
activity guidelines within medical schooland residency
training.
3. Advocate for the inclusion of education regarding physical
activity counseling and exerciseprescription as part of
longitudinal curricula within medical school and residency
training.
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that they were designed tomove, that is, in frequent,
shortbursts.
b. Support education policies thatengineer physical educationand
literacy back into theschool day and shared usepolicies that allow
for safe,accessible, affordable access torecreational space.
c. Support the development ofprograms that provideresources for
physical activityof children who arehospitalized (and their
siblings)and for children needingadditional resources to
bephysically active, such asCYSHCN and those whoexperience
socioeconomicbarriers.
6. Identify opportunities for physicalactivity assessment
andprescription for children facingbarriers to activity. Those most
atrisk for inactivity include childrenof minority, urban, and
ruralstatus, adolescent girls, andCYSHCN. In many cases,
school-based physical activityinterventions are the mostpromising
approach to increasephysical activity.186
7. Advocate for the inclusion of physicalactivity assessments
within EHRs anduse the assessments to providepatient-specific
physical activityrecommendations for pediatricpatients.
a. Advocate for payment frompublic and private payers for
administration of validatedphysical activity
assessmentinstruments.
b. Investigate the type and effectsof physical activity onhealth
outcomes of pediatricpatients.
8. Work with medical schools,residency programs, and healthcare
institutions to developcurricula in exercise prescriptionand
methods for physical activityassessment and prescription
thatinclude the recommendedfrequency, intensity, duration, andtype
of activity, taking intoconsideration the child’s currenthealth,
fitness, and preferences(Table 7).
LEAD AUTHORS
Felipe Lobelo, MD, PhDNatalie D. Muth, MD, MPH, FAAP, FACSMSara
Hanson, PhDBlaise A. Nemeth, MD, MS, FAAP
COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE
COMMITTEE,2017–2018
Cynthia R. LaBella, MD, FAAP, ChairpersonM. Alison Brooks, MD,
FAAPGreg Canty, MD, FAAPAlex B. Diamond, DO, MPH, FAAPWilliam
Hennrikus, MD, FAAPKelsey Logan, MD, MPH, FAAPKody Moffatt, MD,
FAAPBlaise A. Nemeth, MD, MS, FAAPK. Brooke Pengel, MD, FAAPAndrew
R. Peterson, MD, MSPH, FAAPPaul R. Stricker, MD, FAAP
LIAISONS
Donald W. Bagnall – National AthleticTrainers’ Association
STAFF
Anjie Emanuel, MPH
SECTION ON OBESITY EXECUTIVECOMMITTEE, 2017–2018
Christopher F. Bolling, MD, FAAP,ChairpersonSarah Armstrong, MD,
FAAPMatthew Allen Haemer, MD, MPH, FAAPNatalie D. Muth, MD, MPH,
FAAPJohn Rausch, MD, MPH, FAAPVictoria Rogers, MD, FAAPStephanie
Moore Walsh, MD, FAAP
LIAISON
Alyson B. Goodman, MD, MPH – Centers forDisease Control and
Prevention
STAFF
Mala Thapar, MPH
ABBREVIATIONS
AAP: American Academy ofPediatrics
CYSHCN: children and youth withspecial health care needs
EHR: electronic health recordMVPA: moderate-to-vigorous
physical activityPACE1: Patient-centered
Assessment and Counselingfor Exercise plus Nutrition
PAVS: physical activity vital signYRBS: Youth Risk Behavior
Survey
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Muth receives royalties from the
American Academy of Pediatrics and F.A. Davis and previously had a
consulting relationship with the
American Council on Exercise; Drs Hanson, Lobelo, and Nemeth
have indicated they have no financial relationships relevant to
this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Muth receives royalties from
the American Academy of Pediatrics and F.A. Davis and previously
had a consulting relationship
with the American Council on Exercise; Drs Hanson, Lobelo, and
Nemeth have indicated they have no potential conflicts of interest
to disclose.
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2021www.aappublications.org/newsDownloaded from
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REFERENCES
1. Kann L, McManus T, Harris WA, et al.Youth risk behavior
surveillance -United States, 2015. MMWR SurveillSumm.
2018;67(8):1–479
2. Bassett DR, John D, Conger SA,Fitzhugh EC, Coe DP. Trends in
physicalactivity and sedentary behaviors ofUnited States youth. J
Phys Act Health.2015;12(8):1102–1111
3. Woodmansee C, Hahne A, Imms C,Shields N. Comparing
participation inphysical recreation activities betweenchildren with
disability and childrenwith typical development: a
secondaryanalysis of matched data. Res DevDisabil.
2016;49–50:268–276
4. Troiano RP, Berrigan D, Dodd KW,Mâsse LC, Tilert T, McDowell
M.Physical activity in the United Statesmeasured by accelerometer.
Med SciSports Exerc. 2008;40(1):181–188
5. Li K, Haynie D, Lipsky L, Iannotti RJ,Pratt C, Simons-Morton
B. Changes inmoderate-to-vigorous physical activityamong older
adolescents. Pediatrics.2016;138(4):e20161372
6. Mayer-Davis EJ, Lawrence JM, DabeleaD, et al; SEARCH for
Diabetes in YouthStudy. Incidence trends of type 1 andtype 2
diabetes among youths, 2002-2012. N Engl J Med.
2017;376(15):1419–1429
7. Arias E, Heron M, Xu J. United StatesLife Tables, 2012. In:
Natl Vital Stat Rep,vol. 65. 2016:1–65
8. Xu J, Murphy SL, Kochanek KD, Arias E.Mortality in the United
States, 2015. In:NCHS Data Brief. 2016:1–8
9. Council on Sports Medicine andFitness; Council on School
Health.Active healthy living: prevention ofchildhood obesity
through increasedphysical activity. Pediatrics.
2006;117(5):1834–1842
10. Daniels SR, Hassink SG; Committee onNutrition. The role of
the pediatrician inprimary prevention of obesity.Pediatrics.
2015;136(1). Available
at:www.pediatrics.org/cgi/content/full/136/1/e275
11. Barlow SE; Expert Committee. ExpertCommittee
recommendationsregarding the prevention, assessment,and treatment
of child and adolescent
overweight and obesity: summaryreport. Pediatrics.
2007;120(suppl 4):S164–S192
12. Styne DM, Arslanian SA, Connor EL,et al. Pediatric
obesity-assessment,treatment, and prevention: anEndocrine Society
clinical practiceguideline. J Clin Endocrinol
Metab.2017;102(3):709–757
13. Spear BA, Barlow SE, Ervin C, et al.Recommendations for
treatment ofchild and adolescent overweight andobesity. Pediatrics.
2007;120(suppl 4):S254–S288
14. Huang TT, Borowski LA, Liu B, et al.Pediatricians’ and
family physicians’weight-related care of children in theU.S. Am J
Prev Med. 2011;41(1):24–32
15. US Department of Health and HumanServices. Physical activity
guidelines.2008. Available at: www.health.gov/PAGuidelines.
Accessed January 7, 2013
16. Hagan JF Jr, Shaw JS, Duncan PM, eds.Bright Futures:
Guidelines for HealthSupervision of Infants, Children,
andAdolescents. 4th ed. Elk Grove, IL:American Academy of
Pediatrics; 2017
17. US Department of Health and HumanServices. Physical Activity
Guidelines forAmericans. 2nd ed. Washington, DC: USDepartment of
Health and HumanServices; 2018. Available at:
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf.
Accessed December 10, 2018
18. Morris JN, Heady JA, Raffle PA, RobertsCG, Parks JW.
Coronary heart-diseaseand physical activity of work.
Lancet.1953;262(6796):1111–1120; concl
19. Herrmann SD, Angadi SS. Children’sphysical activity and
sedentary timeand cardiometabolic risk factors.Clinical J Sport
Med. 2013;23(5):408–409
20. Belcher BR, Berrigan D,Papachristopoulou A, et al. Effects
ofinterrupting children’s sedentarybehaviors with activity on
metabolicfunction: a randomized trial. J ClinEndocrinol Metab.
2015;100(10):3735–3743
21. van der Baan-Slootweg O, Benninga MA,Beelen A, et al.
Inpatient treatment ofchildren and adolescents with severe
obesity in the Netherlands:a randomized clinical trial.
JAMAPediatr. 2014;168(9):807–814
22. Davis CL, Pollock NK, Waller JL, et al.Exercise dose and
diabetes risk inoverweight and obese children:a randomized
controlled trial. JAMA.2012;308(11):1103–1112
23. Moore JB, Beets MW, Brazendale K,et al. Associations of
vigorous-intensityphysical activity with biomarkers inyouth. Med
Sci Sports Exerc. 2017;49(7):1366–1374
24. Tarp J, Child A, White T, et al;International Children’s
AccelerometryDatabase (ICAD) Collaborators. Physicalactivity
intensity, bout-duration, andcardiometabolic risk markers
inchildren and adolescents [publishedcorrection appears in Int J
Obes (Lond).2019;43(11):2346]. Int J Obes
(Lond).2018;42(9):1639–1650
25. Sigal RJ, Alberga AS, Goldfield GS, et al.Effects of aerobic
training, resistancetraining, or both on percentage bodyfat and
cardiometabolic risk markersin obese adolescents: the healthy
eatingaerobic and resistance training inyouth randomized clinical
trial. JAMAPediatr. 2014;168(11):1006–1014
26. Hind K, Burrows M. Weight-bearingexercise and bone mineral
accrual inchildren and adolescents: a review ofcontrolled trials.
Bone. 2007;40(1):14–27
27. Wu F, Callisaya M, Wills K, Laslett LL,Jones G, Winzenberg
T. Both baselineand change in lower limb musclestrength in younger
women areindependent predictors of balance inmiddle age: a 12-year
population-basedprospective study. J Bone Miner
Res.2017;32(6):1201–1208
28. Collard DC, Verhagen EA, Chinapaw MJ,Knol DL, van Mechelen
W. Effectivenessof a school-based physical activityinjury
prevention program: a clusterrandomized controlled trial.
ArchPediatr Adolesc Med. 2010;164(2):145–150
29. MacKelvie KJ, Khan KM, Petit MA,Janssen PA, McKay HA. A
school-basedexercise intervention elicits substantialbone health
benefits: a 2-yearrandomized controlled trial in girls.
PEDIATRICS Volume 145, number 3, March 2020 13 by guest on June
26, 2021www.aappublications.org/newsDownloaded from
http://www.pediatrics.org/cgi/content/FUll/136/1/e275http://www.pediatrics.org/cgi/content/FUll/136/1/e275http://www.health.gov/PAGuidelineshttp://www.health.gov/PAGuidelineshttps://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfhttps://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfhttps://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdfhttps://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
-
Pediatrics. 2003;112(6 pt 1). Availableat:
www.pediatrics.org/cgi/content/full/112/6/e447
30. Detter F, Rosengren BE, Dencker M,Lorentzon M, Nilsson J,
Karlsson MK. A6-year exercise program improvesskeletal traits
without affecting fracturerisk: a prospective controlled study
in2621 children. J Bone Miner Res. 2014;29(6):1325–1336
31. Physical Activity Guidelines ScientificAdvisory Committee.
Physical ActivityGuidelines Advisory Committee Report.Washington,
DC: US Department ofHealth and Human Services; 2018
32. Ali MM, Amialchuk A, Heller LR. Theinfluence of physical
activity oncigarette smoking among adolescents:evidence from Add
Health. Nicotine TobRes. 2015;17(5):539–545
33. Korhonen T, Kujala UM, Rose RJ, KaprioJ. Physical activity
in adolescence asa predictor of alcohol and illicit druguse in
early adulthood: a longitudinalpopulation-based twin study. Twin
ResHum Genet. 2009;12(3):261–268
34. Korczak DJ, Madigan S, Colasanto M.Children’s physical
activity anddepression: a meta-analysis.
Pediatrics.2017;139(4):e20162266
35. Van Dusen DP, Kelder SH, Kohl HW III,Ranjit N, Perry CL.
Associations ofphysical fitness and academicperformance among
schoolchildren.J Sch Health. 2011;81(12):733–740
36. Mullender-Wijnsma MJ, Hartman E, deGreeff JW, Doolaard S,
Bosker RJ,Visscher C. Physically active math andlanguage lessons
improve academicachievement: a cluster randomizedcontrolled trial.
Pediatrics. 2016;137(3):e20152743
37. Ardoy DN, Fernández-Rodríguez JM,Jiménez-Pavón D, Castillo
R, Ruiz JR,Ortega FB. A physical education trialimproves
adolescents’ cognitiveperformance and academicachievement: the
EDUFIT study. ScandJ Med Sci Sports. 2014;24(1):e52–e61
38. Martin A, Saunders DH, Shenkin SD,Sproule J. Lifestyle
intervention forimproving school achievement inoverweight or obese
children andadolescents. Cochrane Database SystRev.
2014;(3):CD009728
39. Bass RW, Brown DD, Laurson KR,Coleman MM. Physical fitness
andacademic performance in middleschool students. Acta Paediatr.
2013;102(8):832–837
40. Rauner RR, Walters RW, Avery M,Wanser TJ. Evidence that
aerobic fitnessis more salient than weight status inpredicting
standardized math andreading outcomes in fourth-
througheighth-grade students. J Pediatr. 2013;163(2):344–348
41. Lamming L, Pears S, Mason D, et al; VBIProgramme Team. What
do we knowabout brief interventions for physicalactivity that could
be delivered inprimary care consultations? Asystematic review of
reviews. Prev Med.2017;99:152–163
42. Mahar MT. Impact of short bouts ofphysical activity on
attention-to-task inelementary school children. Prev
Med.2011;52(suppl 1):S60–S64
43. Carlson JA, Engelberg JK, Cain KL, et al.Implementing
classroom physicalactivity breaks: associations withstudent
physical activity and classroombehavior. Prev Med.
2015;81:67–72
44. Silva AP, Prado SO, Scardovelli TA,Boschi SR, Campos LC,
Frère AF.Measurement of the effect of physicalexercise on the
concentration ofindividuals with ADHD. PLoS One.
2015;10(3):e0122119
45. Neely L, Rispoli M, Gerow S, Ninci J.Effects of antecedent
exercise onacademic engagement and stereotypyduring instruction.
Behav Modif. 2015;39(1):98–116
46. Oriel KN, George CL, Peckus R, Semon A.The effects of
aerobic exercise onacademic engagement in youngchildren with autism
spectrumdisorder. Pediatr Phys Ther. 2011;23(2):187–193
47. McPherson M, Arango P, Fox H, et al. Anew definition of
children with specialhealth care needs. Pediatrics. 1998;102(1 pt
1):137–140
48. Schoenmakers MA, de Groot JF, GorterJW, Hillaert JL, Helders
PJ, Takken T.Muscle strength, aerobic capacity andphysical activity
in independentambulating children with lumbosacralspina bifida.
Disabil Rehabil. 2009;31(4):259–266
49. Jansen M, van Alfen N, Geurts AC, deGroot IJ. Assisted
bicycle trainingdelays functional deterioration in boyswith
Duchenne muscular dystrophy: therandomized controlled trial “no use
isdisuse”. Neurorehabil Neural Repair.2013;27(9):816–827
50. Voet NB, van der Kooi EL, Riphagen II,Lindeman E, van
Engelen BG, Geurts AC.Strength training and aerobic
exercisetraining for muscle disease. CochraneDatabase Syst Rev.
2010;(1):CD003907
51. Reus L, Pillen S, Pelzer BJ, et al. Growthhormone therapy,
muscle thickness,and motor development in Prader-Willisyndrome: an
RCT. Pediatrics. 2014;134(6). Available at:
www.pediatrics.org/cgi/content/full/134/6/e1619
52. Chad KE, Bailey DA, McKay HA, Zello GA,Snyder RE. The effect
of a weight-bearing physical activity program onbone mineral
content and estimatedvolumetric density in children withspastic
cerebral palsy. J Pediatr. 1999;135(1):115–117
53. Henderson RC, Lark RK, Gurka MJ, et al.Bone density and
metabolism inchildren and adolescents withmoderate to severe
cerebral palsy.Pediatrics. 2002;110(1 pt 1). Availableat:
www.pediatrics.org/cgi/content/full/110/1/e5
54. Szalay EA, Cheema A. Children withspina bifida are at risk
for low bonedensity. Clin Orthop Relat Res.
2011;469(5):1253–1257
55. Coleman A, Weir KA, Ware RS, Boyd RN.Relationship between
communicationskills and gross motor function inpreschool-aged
children with cerebralpalsy. Arch Phys Med Rehabil.
2013;94(11):2210–2217
56. Visscher C, Houwen S, Scherder EJ,Moolenaar B, Hartman E.
Motor profileof children with developmental speechand language
disorders. Pediatrics.2007;120(1). Available at:
www.pediatrics.org/cgi/content/full/120/1/e158
57. Oudgenoeg-Paz O, Volman MC, LesemanPP. Attainment of sitting
and walkingpredicts development of productivevocabulary between
ages 16 and28 months. Infant Behav Dev. 2012;35(4):733–736
14 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 26,
2021www.aappublications.org/newsDownloaded from
http://www.pediatrics.org/cgi/content/FUll/112/6/e447http://www.pediatrics.org/cgi/content/FUll/112/6/e447http://www.pediatrics.org/cgi/content/FUll/134/6/e1619http://www.pediatrics.org/cgi/content/FUll/134/6/e1619http://www.pediatrics.org/cgi/content/FUll/110/1/e5http://www.pediatrics.org/cgi/content/FUll/110/1/e5http://www.pediatrics.org/cgi/content/FUll/120/1/e158http://www.pediatrics.org/cgi/content/FUll/120/1/e158http://www.pediatrics.org/cgi/content/FUll/120/1/e158
-
58. Oudgenoeg-Paz O, Volman MC, LesemanPP. First steps into
language? Examiningthe specific longitudinal relationsbetween
walking, exploration andlinguistic skills. Front Psychol.
2016;7:1458
59. Apkon SD, Grady R, Hart S, et al.Advances in the care of
children withspina bifida. Adv Pediatr. 2014;61(1):33–74
60. Casey AF, Emes C. The effects of swimtraining on respiratory
aspects ofspeech production in adolescents withdown syndrome. Adapt
Phys Activ Q.2011;28(4):326–341
61. Pan CY, Tsai CL, Chu CH, Sung MC, MaWY, Huang CY.
Objectively measuredphysical activity and health-relatedphysical
fitness in secondary school-aged male students with autismspectrum
disorders. Phys Ther. 2016;96(4):511–520
62. Murphy NA, Carbone PS; AmericanAcademy of Pediatrics Council
onChildren With Disabilities. Promotingthe participation of
children withdisabilities in sports, recreation, andphysical
activities. Pediatrics. 2008;121(5):1057–1061
63. Mulrooney DA, Yeazel MW, Kawashima T,et al. Cardiac outcomes
in a cohort ofadult survivors of childhood andadolescent cancer:
retrospectiveanalysis of the Childhood CancerSurvivor Study cohort.
BMJ. 2009;339:b4606
64. Järvelä LS, Kemppainen J, Niinikoski H,et al. Effects of a
home-based exerciseprogram on metabolic risk factors andfitness in
long-term survivors ofchildhood acute lymphoblasticleukemia.
Pediatr Blood Cancer. 2012;59(1):155–160
65. Järvelä LS, Niinikoski H, Heinonen OJ,Lähteenmäki PM, Arola
M, KemppainenJ. Endothelial function in long-termsurvivors of
childhood acutelymphoblastic leukemia: effects ofa home-based
exercise program.Pediatr Blood Cancer. 2013;60(9):1546–1551
66. Boas SR, Danduran MJ, McBride AL,McColley SA, O’Gorman
MR.Postexercise immune correlates inchildren with and without
cysticfibrosis. Med Sci Sports Exerc. 2000;32(12):1997–2004
67. van de Weert-van Leeuwen PB, SliekerMG, Hulzebos HJ,
Kruitwagen CL, vander Ent CK, Arets HG. Chronic infectionand
inflammation affect exercisecapacity in cystic fibrosis. Eur Respir
J.2012;39(4):893–898
68. van de Weert-van Leeuwen PB, HulzebosHJ, Werkman MS, et al.
Chronicinflammation and infection associatewith a lower exercise
training responsein cystic fibrosis adolescents. RespirMed.
2014;108(3):445–452
69. Selvadurai HC, Blimkie CJ, Meyers N,Mellis CM, Cooper PJ,
Van Asperen PP.Randomized controlled study of in-hospital exercise
training programs inchildren with cystic fibrosis. PediatrPulmonol.
2002;33(3):194–200
70. Duppen N, Etnel JR, Spaans L, et al.Does exercise training
improvecardiopulmonary fitness and dailyphysical activity in
children and youngadults with corrected tetralogy of Fallotor
Fontan circulation? A randomizedcontrolled trial. Am Heart J.
2015;170(3):606–614
71. Takken T, Giardini A, Reybrouck T, et al.Recommendations for
physical activity,recreation sport, and exercise trainingin
paediatric patients with congenitalheart disease: a report from
theExercise, Basic & TranslationalResearch Section of the
EuropeanAssociation of CardiovascularPrevention and Rehabilitation,
theEuropean Congenital Heart and LungExercise Group, and the
Association forEuropean Paediatric Cardiology. EurJ Prev Cardiol.
2012;19(5):1034–1065
72. Lantin-Hermoso MR, Berger S, Bhatt AB,et al; Section on
Cardiology; CardiacSurgery. The care of children withcongenital
heart disease in theirprimary medical home.
Pediatrics.2017;140(5):e20172607
73. McCambridge TM, Stricker PR;American Academy of
PediatricsCouncil on Sports Medicine and Fitness.Strength training
by children andadolescents. Pediatrics. 2008;121(4):835–840
74. US Department of Health and HumanServices. Physical Activity
Guidelines forAmericans Midcourse Report:strategies to increase
physical activityamong youth. 2012. Available at:
www.health.gov/paguidelines/midcourse/
pag-mid-course-report-final.pdf.Accessed September 27, 2016
75. Lipnowski S, Leblanc CM; CanadianPaediatric Society, Healthy
Active Livingand Sports Medicine Committee.Healthy active living:
physical activityguidelines for children andadolescents. Paediatr
Child Health.2012;17(4):209–212
76. Yogman M, Garner A, Hutchinson J,Hirsh-Pasek K, Golinkoff
RM; Committeeon Psychosocial Aspects of Child andFamily Health;
Council onCommunications and Media. The powerof play: a pediatric
role in enhancingdevelopment in young children.Pediatrics.
2018;142(3):e20182058
77. American Academy of Pediatrics;American Public Health
Association;National Resource Center for Healthand Safety in Child
Care and EarlyEducation. Preventing ChildhoodObesity in Early Care
and Education:Selected Standards From Caring forOur Children:
National Health andSafety Performance Standards, 4th ed.Itasca, IL:
American Academy ofPediatrics; 2019
78. Garber CE, Blissmer B, Deschenes MR,et al; American College
of SportsMedicine. American College of SportsMedicine position
stand. Quantity andquality of exercise for developing
andmaintaining cardiorespiratory,musculoskeletal, and
neuromotorfitness in apparently healthy adults:guidance for
prescribing exercise. MedSci Sports Exerc. 2011;43(7):1334–1359
79. Jetté M, Sidney K, Blümchen G.Metabolic equivalents (METS)
inexercise testing, exercise prescription,and evaluation of
functional capacity.Clin Cardiol. 1990;13(8):555–565
80. Conger SA, Bassett DR. A compendiumof energy costs of
physical activities forindividuals who use manualwheelchairs. Adapt
Phys Activ Q. 2011;28(4):310–325
81. Clanchy KM, Tweedy SM, Boyd RN, TrostSG. Validity of
accelerometry inambulatory children and adolescentswith cerebral
palsy. Eur J Appl Physiol.2011;111(12):2951–2959
82. Butte NF, Watson KB, Ridley K, et al. Ayouth compendium of
physicalactivities: activity codes and metabolic
PEDIATRICS Volume 145, number 3, March 2020 15 by guest on June
26, 2021www.aappublications.org/newsDownloaded from
http://www.health.gov/paguidelines/midcourse/pag-mid-course-report-final.pdfhttp://www.health.gov/paguidelines/midcourse/pag-mid-course-report-final.pdfhttp://www.health.gov/paguidelines/midcourse/pag-mid-course-report-final.pdf
-
intensities. Med Sci Sports Exerc. 2018;50(2):246–256
83. Brenner JS; Council on Sports Medicineand Fitness. Sports
specialization andintensive training in young athletes.Pediatrics.
2016;138(3):e20162148
84. Denny SA, Quan L, Gilchrist J, et al;Council on Injury,
Violence, and PoisonPrevention. Prevention of drowning.Pediatrics.
2019;143(5):e20190850
85. The Aspen Institute. Physical literacy inthe United States:
A model, strategicplan, and call to action. Available
at:https://assets.aspeninstitute.org/content/uploads/files/content/docs/pubs/PhysicalLiteracy_AspenInstitute.pdf.Accessed
January 18, 2020
86. Lubans DR, Morgan PJ, Cliff DP, BarnettLM, Okely AD.
Fundamental movementskills in children and adolescents:review of
associated health benefits.Sports Med. 2010;40(12):1019–1035
87. O’ Brien W, Belton S, Issartel J. Therelationship between
adolescents’physical activity, fundamentalmovement skills and
weight status.J Sports Sci. 2016;34(12):1159–1167
88. Jaakkola T, Yli-Piipari S, Huotari P, WattA, Liukkonen J.
Fundamental movementskills and physical fitness as predictorsof
physical activity: a 6-year follow-upstudy. Scand J Med Sci Sports.
2016;26(1):74–81
89. Centers for Disease Control andPrevention. CDC’s
developmentalmilestones. Available at:
https://www.cdc.gov/ncbddd/actearly/milestones/index.html. Accessed
May 4, 2019
90. US Olympic and Paralympic Committee.American Development
Model. Availableat:
https://www.teamusa.org/About-the-USOC/Programs/Coaching-Education/American-Development-Model.
AccessedMay 4, 2019
91. Martins J, Marques A, Sarmento H,Carreiro da Costa F.
Adolescents’perspectives on the barriers andfacilitators of
physical activity:a systematic review of qualitativestudies. Health
Educ Res. 2015;30(5):742–755
92. Belanger K, Barnes JD, Longmuir PE,et al. The relationship
between physicalliteracy scores and adherence toCanadian physical
activity and
sedentary behaviour guidelines. BMCPublic Health. 2018;18(suppl
2):1042
93. Lang JJ, Chaput JP, Longmuir PE, et al.Cardiorespiratory
fitness is associatedwith physical literacy in a large sampleof
Canadian children aged 8 to12 years. BMC Public Health.
2018;18(suppl 2):1041
94. Hendrix CG, Prins MR, Dekkers H.Developmental coordination
disorderand overweight and obesity in children:a systematic review.
Obes Rev. 2014;15(5):408–423
95. Cairney J, Hay JA, Faught BE, Hawes R.Developmental
coordination disorderand overweight and obesity in childrenaged
9-14 y. Int J Obes (Lond). 2005;29(4):369–372
96. Myer GD, Faigenbaum AD, Stracciolini A,Hewett TE, Micheli
LJ, Best TM. Exercisedeficit disorder in youth: a paradigmshift
toward disease prevention andcomprehensive care. Curr Sports
MedRep. 2013;12(4):248–255
97. Kantomaa MT, Purtsi J, Taanila AM, et al.Suspected motor
problems and lowpreference for active play in childhoodare
associated with physical inactivityand low fitness in adolescence.
PLoSOne. 2011;6(1):e14554
98. Farhat F, Masmoudi K, Hsairi I, et al. Theeffects of 8 weeks
of motor skilltraining on cardiorespiratory fitnessand endurance
performance inchildren with developmentalcoordination disorder.
Appl Physiol NutrMetab. 2015;40(12):1269–1278
99. Faigenbaum AD, Rial Rebullido T,MacDonald JP. The unsolved
problem ofpaediatric physical inactivity: it’s timefor a new
perspective. Acta Paediatr.2018;107(11):1857–1859
100. Society of Health and PhysicalEducators; American Heart
Association.2016 Shape of the Nation report: statusof physical
education in the USA. 2016.Available at:
https://www.shapeamerica.org/advocacy/son/.Accessed May 4, 2019
101. Scerpella TA, Bernardoni B, Wang S,Rathouz PJ, Li Q,
Dowthwaite JN. Site-specific, adult bone benefits attributedto
loading during youth: a preliminarylongitudinal analysis. Bone.
2016;85:148–159
102. Tenforde AS, Sainani KL, Carter SayresL, Milgrom C,
Fredericson M.Participation in ball sports mayrepresent a
prehabilitation strategy toprevent future stress fractures
andpromote bone health in young athletes.PM R.
2015;7(2):222–225
103. Cawthon PM, Fullman RL, Marshall L,et al; Osteoporotic
Fractures in Men(MrOS) Research Group. Physicalperformance and risk
of hip fracturesin older men. J Bone Miner Res.
2008;23(7):1037–1044
104. Binkley N, Krueger D, Buehring B. What’sin a name
revisited: shouldosteoporosis and sarcopenia beconsidered
components of “dysmobilitysyndrome?”. Osteoporos Int.
2013;24(12):2955–2959
105. Faigenbaum AD, Rebullido TR,MacDonald JP. Pediatric
inactivity triad:a risky PIT. Curr Sports Med Rep.
2018;17(2):45–47
106. Dolinsky DH, Brouwer RJ, Evenson KR,Siega-Riz AM, Østbye T.
Correlates ofsedentary time and physical activityamong
preschool-aged children. PrevChronic Dis. 2011;8(6):A131
107. Kaiser Family Foundation. GenerationM2: media in the lives
of 8- to 18-year-olds. 2010. Available at:
http://kff.org/other/event/generation-m2-media-in-the-lives-of/.
Accessed September 29,2016
108. Biswas A, Oh PI, Faulkner GE, et al.Sedentary time and its
association withrisk for disease incidence, mortality,and
hospitalization in adults:a systematic review and
meta-analysis[published correction appears in AnnIntern Med.
2015;163(5):400]. Ann InternMed. 2015;162(2):123–132
109. Lobenius-Palmér K, Sjöqvist B, Hurtig-Wennlöf A, Lundqvist
LO. Accelerometer-assessed physical activity andsedentary time in
youth withdisabilities. Adapt Phys Activ Q. 2018;35(1):1–19
110. Cliff DP, Hesketh KD, Vella SA, et al.Objectively measured
sedentarybehaviour and health and developmentin children and
adolescents: systematicreview and meta-analysis. Obes
Rev.2016;17(4):330–344
111. Biddiss E, Irwin J. Active video games topromote physical
activity in children
16 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 26,
2021www.aappublications.org/newsDownloaded from
https://assets.aspeninstitute.org/content/uploads/files/content/docs/pubs/PhysicalLiteracy_AspenInstitute.pdfhttps://assets.aspeninstitute.org/content/uploads/files/content/docs/pubs/PhysicalLiteracy_AspenInstitute.pdfhttps://assets.aspeninstitute.org/content/uploads/files/content/docs/pubs/PhysicalLiteracy_AspenInstitute.pdfhttps://www.cdc.gov/ncbddd/actearly/milestones/index.htmlhttps://www.cdc.gov/ncbddd/actearly/milestones/index.htmlhttps://www.cdc.gov/ncbddd/actearly/milestones/index.htmlhttps://www.teamusa.org/About-the-USOC/Programs/Coaching-Education/American-Development-Modelhttps://www.teamusa.org/About-the-USOC/Programs/Coaching-Education/American-Development-Modelhttps://www.teamusa.org/About-the-USOC/Programs/Coaching-Education/American-Development-Modelhttps://www.shapeamerica.org/advocacy/son/https://www.shapeamerica.org/advocacy/son/http://kff.org/other/event/generation-m2-media-in-the-lives-of/http://kff.org/other/event/generation-m2-media-in-the-lives-of/http://kff.org/other/event/generation-m2-media-in-the-lives-of/
-
and youth: a systematic review. ArchPediatr Adolesc Med.
2010;164(7):664–672
112. Barnett A, Cerin E, Baranowski T. Activevideo games for
youth: a systematicreview. J Phys Act Health. 2011;8(5):724–737
113. Lamboglia CM, da Silva VT, deVasconcelos Filho JE, et al.
Exergamingas a strategic tool in the fight againstchildhood
obesity: a systematic review.J Obes. 2013;2013:438364
114. Council on Communications and Media.Media use in
school-aged children andadolescents. Pediatrics.
2016;138(5):e20162592
115. Lobelo F, Stoutenberg M, Hutber A. Theexercise is medicine
global healthinitiative: a 2014 update. Br J SportsMed.
2014;48(22):1627–1633
116. Vuori IM, Lavie CJ, Blair SN. Physicalactivity promotion in
the health caresystem. Mayo Clinic Proc. 2013;88(12):1446–1461
117. Orrow G, Kinmonth AL, Sanderson S,Sutton S. Effectiveness
of physicalactivity promotion based in primarycare: systematic
review and meta-analysis of randomised controlledtrials. BMJ.
2012;344:e1389
118. Williams NH, Hendry M, France B, LewisR, Wilkinson C.
Effectiveness of exercise-referral schemes to promote
physicalactivity in adults: systematic review. BrJ Gen Pract.
2007;57(545):979–986
119. Sanchez A, Bully P, Martinez C, GrandesG. Effectiveness of
physical activitypromotion interventions in primarycare: a review
of reviews. Prev Med.2015;76(suppl):S56–S67
120. Lobelo F, Rohm Young D, Sallis R, et al;American Heart
Association PhysicalActivity Committee of the Council onLifestyle
and Cardiometabolic Health;Council on Epidemiology andPrevention;
Council on ClinicalCardiology; Council on Genomic andPrecision
Medicine; Council onCardiovascular Surgery andAnesthesia; and
Stroke Council. Routineassessment and promotion of physicalactivity
in healthcare settings:a scientific statement from theAmerican
Heart Association.Circulation. 2018;137(18):e495–e522
121. Eakin EG, Brown WJ, Marshall AL,Mummery K, Larsen E.
Physical activitypromotion in primary care: bridgingthe gap between
research and practice.Am J Prev Med. 2004;27(4):297–303
122. Grandes G, Sanchez A, Sanchez-PinillaRO, et al; PEPAF
Group. Effectiveness ofphysical activity advice andprescription by
physicians in routineprimary care: a cluster randomizedtrial. Arch
Intern Med. 2009;169(7):694–701
123. Aittasalo M, Miilunpalo S, Kukkonen-Harjula K, Pasanen M. A
randomizedintervention of physical activitypromotion and patient
self-monitoringin primary health care. Prev Med.
2006;42(1):40–46
124. Garrett S, Elley CR, Rose SB, O’Dea D,Lawton BA, Dowell AC.
Are physicalactivity interventions in primary careand the community
cost-effective? Asystematic review of the evidence. BrJ Gen Pract.
2011;61(584):e125–e133
125. Murphy SM, Edwards RT, Williams N,et al. An evaluation of
the effectivenessand cost effectiveness of the NationalExercise
Referral Scheme in Wales, UK:a randomis