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From the American Academy of PediatricsClinical Report

Physical Activity Assessment and Counseling in Pediatric Clinical Settings

Felipe Lobelo, Natalie D. Muth, Sara Hanson, Blaise A. Nemeth, COUNCIL ON SPORTS MEDICINE AND FITNESS and SECTION ON OBESITY
Pediatrics March 2020, 145 (3) e20193992; DOI: https://doi.org/10.1542/peds.2019-3992
Felipe Lobelo
aHubert Department of Global Health and
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Natalie D. Muth
bChildren’s Primary Care Medical Group, Carlsbad, California; and
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Sara Hanson
cNutrition and Health Sciences Program, Laney Graduate School and Exercise is Medicine Global Research and Collaboration Center, Rollins School of Public Health, Emory University, Atlanta, Georgia;
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Blaise A. Nemeth
dAmerican Family Children’s Hospital and School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
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    FIGURE 1

    Brief office-based assessments of physical activity. Adapted from Joy EA, Lobelo F. Promoting the athlete 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. Available at: 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 Prevention. 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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    TABLE 1

    2018 Physical Activity Guidelines Applicable to Children

    AgeActivity AmountIntensity
    3–5 y3+ h/dLight, moderate, vigorous
    6–17 y≥60 min/dModerate or vigorous aerobic activity daily
    Vigorous at least 3 d/wk
    Muscle-strengthening activities at least 3 d/wk
    Bone-strengthening activities at least 3 d per wk
    Children not meeting guidelinesGradually increase activity in ways the child enjoysModerate-vigorous; increase time per d and No. days per wk; use multiple, smaller time increments in activity that are additive throughout the day
    • Adapted from US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, 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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    TABLE 2

    Examples of Types of Physical Activity

    METPhysical SymptomsExamples of Activities
    Rest1——
    Light<3Easily able to converseHousehold chores
    Walking
    No sweating or shortness of breathPlaying catch
    Fishing
    Moderate3–6Some difficulty talkingYardwork
    Feeling warmJogging or fast walking
    Light sweatingTag
    Slight shortness of breathMovement portion of ball sports
    Vigorous>6Unable to talkManual labor
    Short of breathRun
    Face redSkipping rope
    SweatingSkiing, skating
    Wheelchair use or use of assistive devices (crutches or ankle-foot orthoses)Comparable METs expended for comparable examples noted above (eg, wheeling on a smooth surface = light; wheeling fast or up an incline or as part of ball sports = moderate; wheelchair racing or sit-skiing = vigorous) (use of crutches or ankle-foot orthoses involves higher METs but usually not enough to increase the level of PA, eg, from light to moderate)——
    Muscle strengthening—Pushing and/or pulling one’s body or an objectClimbing
    Pushups, curl-ups, or resistance training
    Wheeling a wheelchair
    Bone strengthening—Increased impactJumping rope
    Tumbling
    Running
    • Data are from references 78–82. MET, metabolic equivalent of task; PA, physical activity; —, not applicable.

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    TABLE 3

    Age-Appropriate Recommendations for Increased Physical Activity

    Infant (0–1 y)Toddler (1–3 y)Preschool (3–5 y)Elementary (5–10 y)Middle School (11–14 y)Adolescence (15–18 y)
    FrequencyDailyDailyDailyDailyDailyDaily
    IntensityAnyAnyAny, including some moderate to vigorousModerate to vigorousModerate to vigorousModerate to vigorous
    TimeSeveral times per dayAt least 180 min/dAt least 180 min/d, of which at least 60 min are moderate-to-vigorous intensityAt least 60 min/dAt least 60 min/dAt least 60 min/d
    TypeInteractive floor-based play and at least 30 min of tummy time spread throughout the day while awakeActivities that develop gross motor skills; examples include walking in the neighborhood, unorganized free play outdoors, walking through a park or zoo, or playing on a playground for toddlersActivities that develop gross motor skills; unorganized free play in a safe environment; activities include walking, running, swimming, tumbling, throwing, and catchingAerobic daily; vigorous activity, muscle, and bone- strengthening at least 3 d/wk; include free play with opportunities for fundamental movement skill development through walk, dance, jump rope. Introduce organized sports with flexible rules and short instruction time with a focus on enjoyment rather than competitionAerobic daily; vigorous activity, muscle, and bone- strengthening at least 3 d/wk; incorporate activities that are enjoyable and encourage socialization; avoid sports specializationAerobic daily; vigorous activity, muscle, and bone- strengthening at least 3 d/wk; incorporate activities that are enjoyable and encourage socialization and competition, when appropriate
    • Data are from references 9, 15, 73, 75, 83, and 84.

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    TABLE 4

    Supporting Physical Literacy

    Infancy: supporting rudimentary motor skill development
     Grasping (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 skills
     Encourage 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 (2+ 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-efficacy
     Encourage 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)
     Running
      Build fitness and skills with tag, introduce sports like soccer by age 6
     Throwing and catching
     Falling and tumbling
      Helps decrease injury by learning to tuck head, knees, and arms
     Hopping and jumping
     Hopscotch and jump rope
     Cycling
      Teach a child to ride a bike
     Striking sports
      Practice at home with a plastic ball and bat, hockey stick, etc; introduce sports programs
     Dribbling sports
      Fine motor skills develop through practice and repetition
     Gymnastics
      One of the best activities for agility, balance, coordination, strength, and flexibility
     Skiing
      Low center of gravity makes it easier; it helps with balance
    Preadolescence and adolescence: honing physical literacy
     Encourage 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 and devise a plan to remedy (eg, motivational interviewing, physical therapy, community program)
     Introduce skill development and strategy through coaching and camps
     Introduce 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 technique
     Avoid sports specialization until mid-to-late teenaged years
    • Data are from references 16, 76, 83–85, 89, and 90.

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    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 condition and advise on restrictions in physical activity (if applicable).
    3. If it is a health supervision visit, assess physical literacy and any gap between current and recommended activity level. Assess the patient and family interest in discussing promotion of physical 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 to change and establish new goals.
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    TABLE 6

    Resources for Pediatricians on Physical Activity Assessment and Counseling

    Institute for Healthy Childhood Weight: http://ihcw.aap.org
    Exercise is Medicine: www.exerciseismedicine.org
    National Physical Activity Plan: http://www.physicalactivityplan.org
    National Association of Physical Literacy: http://naplusa.org
    SHAPE America: 2016 Shape of the Nation: https://www.shapeamerica.org/advocacy/son/default.aspx
    Prescription 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/ (including Developmentally Appropriate Practice in Early Childhood Programs Serving Children from Birth through Age 8, Third Edition, as a resource for schools)
    • SHAPE, Society of Health and Physical Educators.

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    TABLE 7

    Recommendations for Promoting Physical Activity Assessment and Counseling in Medical Education

    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 to community partners and resources.
     b. Subspecialists: guidance on physical activity benefits and restrictions as related to relevant medical 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 school and residency training.
    3. Advocate for the inclusion of education regarding physical activity counseling and exercise prescription as part of longitudinal curricula within medical school and residency training.

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1 Mar 2020
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Physical Activity Assessment and Counseling in Pediatric Clinical Settings
Felipe Lobelo, Natalie D. Muth, Sara Hanson, Blaise A. Nemeth, COUNCIL ON SPORTS MEDICINE AND FITNESS, SECTION ON OBESITY
Pediatrics Mar 2020, 145 (3) e20193992; DOI: 10.1542/peds.2019-3992

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Physical Activity Assessment and Counseling in Pediatric Clinical Settings
Felipe Lobelo, Natalie D. Muth, Sara Hanson, Blaise A. Nemeth, COUNCIL ON SPORTS MEDICINE AND FITNESS, SECTION ON OBESITY
Pediatrics Mar 2020, 145 (3) e20193992; DOI: 10.1542/peds.2019-3992
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  • Article
    • Abstract
    • Introduction and Rationale for Physical Activity Assessment and Counseling
    • Physical Activity and Health Outcomes in Children and Youth
    • Current Physical Activity Guidelines in Youth
    • The Importance of Physical Literacy in Shaping Physical Activity Participation
    • Inactivity and Sedentary Time
    • Evidence in Support of Physical Activity Promotion in Pediatric Care Settings
    • Role of Parents in Physical Activity for Children
    • Role of Schools in Promoting Physical Activity in Youth
    • Tools for Assessing Physical Activity in Pediatric Clinical Settings
    • Strategies to Overcome Barriers to Physical Activity Assessment, Counseling, and Referral in Clinical Practice
    • Role of Physicians in Promoting Pediatric Physical Activity Outside of Direct Patient Care
    • Recommendations
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    • Council on Sports Medicine and Fitness Executive Committee, 2017–2018
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    • Section on Obesity Executive Committee, 2017–2018
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