21 January 2022, Singapore – The Singapore Integrated 24-Hour Activity Guidelines for Early Childhood was launched today at the Asia Pacific Maternal and Child Metabolic Health Conference (APMCMHC) and Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women and Children (IPRAMHO) International Meeting 2022 at KK Women’s and Children’s Hospital (KKH), by Dr Koh Poh Koon, Senior Minister of State, Ministry of Health and Ministry of Manpower.

Towards a healthier nation with an early start in healthy lifestyle

This is Singapore’s first set of integrated activity guidelines for early childhood. It is developed by KKH-led IPRAMHO, one of the main programmes by SingHealth Duke-NUS Maternal and Child Health Research Institute (MCHRI). It aims to set a strong foundation for healthy lifestyle behaviours and good long-term health outcomes in young children under seven years of age, and improve national health.

The set of guidelines standardises advice in four main areas - physical activity, sedentary behaviour, sleep, as well as diet and eating habits - for young children, within a 24-hour period, to improve health and promote the adoption of healthy lifestyle behaviours.

“Over the past five years, there has been emerging evidence that shows that physical activity, sedentary behaviour and sleep for young children are closely related. Linked to this are eating behaviours and calorie intake. Together, these have a significant impact on a child’s health outcome,^1-5” said Professor Tan Kok Hian, Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, KKH, and Lead Principal Investigator of IPRAMHO.

“The activity guidelines is integral to what KKH and MCHRI hope to achieve – to prevent and reduce the risks of metabolic diseases in our children and women, by optimising the continuum of care from pregnancy to childbirth, infancy to childhood, and adolescent to adult. We are laying the foundation for transformation of our nation’s health for generations to come.”

Some of the new guidelines include:

For infants (under one year):

• Have at least 30 mins of tummy time (an exercise which involves laying the baby on his/her tummy) in a day.
• No screen viewing time, including background screen time.
• Avoid restraining and leaving infants unattended for more than one hour at a time.
• Have a total of 14 to 17 hours of sleep daily (up to three months) and 12 to 15 hours of sleep daily (four to 11 months), including naps.
• Meals to be spaced two to three hours apart to avoid overfeeding.

For toddlers (one to under three years):

• Accumulate at least 180 minutes of a variety of physical activities in a day, with outdoor active play highly encouraged.
• No screen time for those under 18 months of age and less than one hour for those 18 months and above.
• Avoid restraining toddlers in a seat for more than an hour at a time.
• Have a total of 11 to 14 hours of sleep daily, and regular sleep and wake times.
• Introduce healthy family meals, and offer whole milk and water while establishing a structured routine for meal and snack times.

For preschoolers (three to under seven years):

• Accumulate at least 180 minutes of a variety of physical activities in a day, including a minimum of 60 minutes of activities of moderate to vigorous intensity. More is better.
• Recreational screen viewing time to be limited to less than one hour.
• Have a total of 10 to 13 hours of sleep daily (three to five years) or nine to 11 hours of sleep daily (six years).
• Encourage healthy eating habits as a family, with caregivers as role models; Limit amount and frequency of sweetened beverage consumption.

These recommendations are based on locally and globally established studies and best practices, and a recent KKH-led survey. Developed with the Singapore population in mind, the guidelines include strategies to reduce Singapore’s childhood myopia rate which is among the highest in the world, as well as to promote family unit practices as most Asian parents are time-poor. The guidelines are also aligned with the national goals of the Health Promotion Board and Sport Singapore to promote healthier lifestyles (See Annex A for more details on the guidelines).

The Singapore Integrated 24-Hour Activity Guidelines for Early Childhood is part of a series of guidelines designed by IPRAMHO, to improve metabolic health in women and children, and transform national health in Singapore.

The Integrated Activity Guidelines for Children and Adolescents (seven to 18 years) was launched in 2021, Guidelines for Pregnant Women focusing on the management of gestational diabetes, and physical activity, were launched in 2020 and 2018 respectively, and Guidelines for Perinatal Nutrition, in 2019.

KKH-led study reveals need for integrated health guidelines for young children

The survey involving 340 parents with children aged under seven years, showed that there was a general lack of awareness of existing health guidelines and positive parenting practices.

Time allocated for physical activity, sleep and recreational screen viewing time practices were suboptimal in Singapore’s young children, with more than half the parents either underestimating or overestimating the actual duration required for adequate physical activity and recreational screen viewing time.

Dr Benny Loo, Consultant, General Paediatrics Service and Sport and Exercise Medicine Service, KKH, and Chairperson of the Workgroup for the guidelines said, “Our survey reflects the lifestyle patterns of typical urbanites including Singaporeans. Time-poor parents are not putting sufficient emphasis on activities for children and relying heavily on electronic devices for the children’s activities and even child minding. COVID-19 has worsened the situation.

“Our young children are kept at home more, have fewer social interactions and physical activities, using electronic devices for longer periods of time, and sleeping less. There is an urgent need for this set of integrated guidelines, to enable families and caregivers to nurture positive lifestyle habits, to improve the health outcomes of our children, and in the long term, our national health.”

A few of the more significant findings affecting infants (less than one year), toddlers (less than three years) and preschoolers (less than seven years) are:

Physical activity

• 40 per cent of infants engaged in only half the amount of recommended tummy time, with an average of 15 mins per day, as compared to the recommendation of at least 30 minutes per day.
• 40 per cent of toddlers and preschoolers engaged in only half the amount of physical activity recommended, which is an average of 90 minutes per weekday as compared to the recommendation of at least 180 minutes every day.

Recreational screen viewing time

• 70 and 80 per cent of toddlers below the age of 18 months had an average recreational screen viewing time of half an hour per day on weekdays and weekends, respectively despite the recommendation for no screen time in this group.
• 75 per cent of preschoolers had an average recreational screen viewing time of one hour per day on weekdays, and 95 per cent had an average of two hours per day on weekends - exceeding the recommendation to keep screen time to below an hour for this group.

Parental awareness

• 60 per cent of parents were unaware of existing physical activity guidelines, while 25 per cent were unaware of existing recreational screen viewing time, or sleep guidelines. Interestingly, parents who perceived to be aware of existing guidelines, had inaccurate information.

Refer to Annex B for other findings from the survey.

The APMCMHC and IPRAMHO International Meeting on Asia-Pacific perspectives in the management of metabolic diseases such as diabetes and obesity in pregnant women and children, takes place on 21 - 22 January 2022. The annual event is attended by key opinion leaders from Australia, China, Fiji, Hawaii, Hong Kong, India, Indonesia, Japan, Malaysia, Mongolia, Myanmar, Philippines, New Zealand, Singapore, Sri Lanka, Vietnam and Thailand.

References

1.  World Health Organization. Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age. Geneva: World Health Organization; 2019.
2. Tremblay MS, Chaput JP, Adamo KB, Aubert S, Barnes JD, Choquette L, et al. Canadian 24-Hour Movement Guidelines for the Early Years (0-4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep. BMC Public Health. 2017;17(Suppl 5):874.
3. Okely AD, Ghersi D, Hesketh KD, Santos R, Loughran SP, Cliff DP, et al. 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. BMC Public Health. 2017;17(Suppl 5):869.
4. Draper CE, Tomaz SA, Biersteker L, Cook CJ, Couper J, de Milander M, et al. The South African 24-Hour Movement Guidelines for Birth to 5 Years: An Integration of Physical Activity, Sitting Behavior, Screen Time, and Sleep. J Phys Act Health. 2020;17(1):109-19.
5. Kuzik N, Poitras VJ, Tremblay MS, Lee EY, Hunter S, Carson V. Systematic review of the relationships between combinations of movement behaviours and health indicators in the early years (0-4 years). BMC Public Health. 2017;17(Suppl 5):849.

Annex A

Annex B