Health promotion strategies to encourage physical activity in infants, toddlers, and preschoolers

Article Outline

• Background
• Why prevention?
• Contributing factors
• Guidelines and anticipatory guidance
• Parent guidelines: Birth—12 months (Box 2)
• Parent guidelines for toddlers: 12 months—36 months (Box 3)
• Parent guidelines for preschoolers: 3 years—5 years (Box 4)
• Conclusion
• Acknowledgment
• References
• Copyright

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Background 

Over the last two to three decades, the number of overweight children and adolescents in the United States has reached epidemic proportions, creating a significant public health problem. These children are at risk for developing immediate physical and psychological health problems, as well as the chronic comorbid conditions that affect obese adults (Eissa & Gunner 2004, Williams 2003). Research also has shown that children are unlikely to outgrow their overweight status through linear growth as previously thought (O'Loughlin, Gray-Donald, Paradis, & Meshefedjian, 2000). Of particular concern is the strong evidence that childhood overweight, especially in the adolescent, is a predictor of adult obesity (Williams, 2003). Thus, overweight adolescents enter adulthood either at risk for or with conditions that potentially lead to morbidity and mortality.

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Why prevention? 

The primary response by health care professionals to the obesity epidemic has been to treat the overweight child in an effort to reduce the child's risk of developing complications. This approach, like weight management programs for adults, has had limited success (Klish & Goodrick, 2003). Thus, the focus now has shifted from the management of overweight children to prevention of overweight (Klish & Goodrick 2003, Williams 2003). The goal is to develop health promotion strategies that emphasize healthy family lifestyle choices, reducing the risk of children becoming overweight.

Appropriate nutrition and physical activity are the key components of these strategies. This article addresses physical activity strategies that are aimed at preventing overweight in infants, toddlers, and preschool-age children. These strategies are based upon several factors: 1) identifying environmental risk factors for development of an overweight child, 2) overcoming barriers to physical activity, 3) promoting behaviors for healthy weight, and 4) establishing guidelines for appropriate physical activity in these age groups.

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Contributing factors 

Environmental risk factors associated with limited physical activity include: restricting children to infant seats, strollers, and small play spaces for long periods of time; television or video viewing for more than two hours per day; and lack of at least one hour of moderate physical activity per day (Dennison & Boyer 2004, National Association for Sport and Physical Education 2002). Barriers to physical activity include: 1) parental concern for safety in neighborhoods, 2) parental work demands that limit time for leisure activities, 3) design of suburban neighborhoods that discourages walking, 4) development and marketing of television and computer programs geared for young children that foster sedentary behavior, and 5) perceived costs of weight management activities (Neumark-Sztainer, 2003). In contrast, behaviors that promote healthy weight include: family participation in physical activities, parents role-modeling an active lifestyle, and children experiencing activities that are varied, short in duration (5- to 15-minute bursts), and perceived as fun (NASPE, 2002).

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Guidelines and anticipatory guidance 

Parents perceive the cost of weight management programs, equipment, and activities to be a significant barrier to increased family activity. However, the authors suggest the use of the guidelines developed by the National Association for Sport and Physical Education (BOX 1, BOX 2, BOX 3, BOX 4) as the framework to develop the following practical, inexpensive physical activity strategies (Figure). These strategies create an environment that fosters a parent's ability to support a growing child's natural abilities and encourages parents to seek ways of adopting and modeling an active lifestyle. It is easy to incorporate these suggestions into a health care provider's sick visits and routine well child examinations.

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• FIGURE. 

  Infants and young children at play

Educating parents how to build fun and engaging activity into their family's lifestyle should be part of anticipatory guidance at every well child visit. Discussion between providers and parents focuses attention on the importance of healthy, active lifestyles for children. A brief review of current family activity routines affords health care providers the opportunity to educate parents on the physical basis for encouraging playtime from infancy through preschool years. Offering recommendations and ideas on free or low-cost activities to increase daily activity provides this information to parents within the context of a child's development. In addition, highlighting the pivotal role the family plays in influencing the life skills and general health of their family may help parents appreciate how such simple, inexpensive changes in their family's lifestyle can have a big impact on the health of their child.

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Parent guidelines: Birth—12 months (Box 2) 

Infants and toddlers experiment with bodily sensations and motor movements with objects and people, a type of activity called sensorimotor play (Phillips, 1969). Infants need opportunities that will encourage large motor activity and increase mastery over body movements. Physical activity in a safe setting, particularly with encouragement from a parent or caretaker, allows time to acquire crucial skills for motor development and lays the foundation for critical neuronal connections (NASPE, 2002).

It is important for parents to know they are responsible for their baby's having ample opportunity for both structured and unstructured play and the rationale for attention to appropriate infant play experiences. Informed parents are more likely to be prepared to build frequent activity into their routine. Safe areas for play, games that stimulate interaction between themselves and baby, and avoidance of gross motor delays due to prolonged time in strollers, walkers, and the like are critical elements of infant anticipatory guidance (NASPE, 2002). Educating parents about anticipated developmental milestones, such as sitting, pulling up, and reaching, prepares the parent for encouraging activities that set the stage for accomplishment (Figure).

The importance of safety cannot be under-emphasized. Toys should be lightweight, large enough not to be swallowed, and without sharp points or edges. Remind parents that before placing babies on the floor, a general “eye level” visual sweep for potential hazards should be made.

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Parent guidelines for toddlers: 12 months—36 months (Box 3) 

Building on sensorimotor play, toddlers begin to understand the world in more symbolic terms (Phillips, 1969). They begin to perceive the function of objects and enjoy mimicking family activities. For instance, at this age they understand that they may use a baby bottle to feed a doll. Young children continue to expand their world and refine motor skills and movement (Dowshen & Walter, 2001). Toddlers often play side-by-side with peers in parallel play; however, solitary play is equally important. It is important for parents to learn that a child's environment shapes their learning experiences (Dowshen & Walter, 2001). Creative and imaginary play fosters the joy of seeking out activities that are fun. Activities such as hopping, scribbling, and imitating household activities are natural to 2- or 3-year-olds. However, without necessary materials or modeling, children may not learn these tasks early on and may be described as slow or delayed in accomplishing these milestones.

Some parents express concern that their children are overly active, when the children are expressing age-appropriate enthusiasm and activity. It is important to stress the value of opportunities to engage in activities such as running, hopping, dancing, and throwing to help the child build physical skills necessary for later in life. Children who learn to throw, catch, or kick a ball will gain important eye-hand coordination. Parents who take their child to a park to climb a toddler-sized slide build self-confidence, balance, and the ability to climb stairs. Providing children safe places to experience their physical world daily creates flexibility, balance, and strength, as well as promotes cardiovascular health.

Health care professionals help to assure these activities are thoughtfully age-appropriate by providing recommendations for both structured and unstructured play. Unstructured physical activity provides a child the opportunity to experiment and discover the world around them in play either alone or with other children. Each well child visit offers the health care professional the opportunity to identify the activities the family shares and enjoys and to provide information about developmental milestones for their 1-, 2-, or 3-year-old. Educate parents that just as their child's imagination and world around them is expanding, so too are their opportunities to model the importance of physical activity and to influence how their child perceives the phys-ical world (Figure).

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Parent guidelines for preschoolers: 3 years—5 years (Box 4) 

Preschoolers are ready to engage in the world of symbolic play where they substitute one object for another (Phillips, 1969). A preschooler may use a paper towel tube as a musical instrument or an empty box as a drum. In this process, 4-year-old to 5-year-old children infuse play with their experiences with family members and their immediate world. Children often play “school” or “house” with peers or friends, share play with parents or find solitary activities for brief periods (Dowshen & Walter, 2001). A child's unique interests are starting to become more apparent. Expending energy in short bursts of activity for more than an hour daily will help reduce or prevent excessive weight gain (NASPE, 2002).

It is important for parents to understand that prior to entering school, a child should have the skills to gain control of his body and actions. This is the stage of child's play called mastery, during which, for instance, a 4- or 5-year-old child playing on a swing has full control of his actions and of the swing. Moving from parallel play to group play becomes more appropriate for 3-, 4-, and 5-year-olds as interactions with peers become more sophisticated (Phillips 1969, Dowshen & Walter 2001).

Parents should understand that children in this age group need to develop skills in a wide variety of activities, not one particular activity (Dowshen & Walter, 2001). This is a period of combining and refining skills that have already been learned. Parents and other caregivers have a significant impact on how preschool children perceive themselves and should be reminded to offer encouragement and foster a positive attitude. A parent taking an interest and participating in physical activity models to their child that such activity is a normal part of their daily routine (Figure).

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Conclusion 

Lifestyle changes and modern conveniences insidiously have created a more sedentary population. These sedentary changes affect children, starting with the infant, and have been linked to the surge of overweight children, adolescents and adults (National Association for Sport and Physical Education 2002, Neumark-Sztainer 2003). Once overweight is established, attempts at weight reduction are most often modestly successful for only a short time (Reilly & McDowell, 2002). The focus has shifted now to prevention through promotion of a healthy, active lifestyle (Klish & Goodrick 2003, Williams 2003).

The health care professional is a key player in educating parents (Box 5) about their pivotal role in giving their child a healthy start. The anticipatory guidelines offered here are designed to assist the provider in giving the parents specific, concrete, fun, and low-cost activities to counteract a sedentary lifestyle. Current and ongoing research will no doubt provide more insight into interventions that will be successful in reducing the number of overweight children.

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Acknowledgment 

The authors would like to thank Robert J. Yetman, MD, for his assistance in the preparation of this article.

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References 

1. Corbin C , Pangrazi R , Beighle A , Le Masurier G , Morgan C . Guidelines for Appropriate Physical activity for Elementary School Children 2003 update. A position statement . Council for Physical Education for Children (COPEC) of the National Association for Sport and Physical Education, an Association of the American Alliance for Health Physical Education and Recreation . New York: AAHPERD Publications; 2003;
   • View In Article
2. Dennison B , Boyer P . Risk evaluation in pediatric practice aids in prevention of childhood overweight . Pediatric Annals . 2004;33:25–30
   • View In Article
   • MEDLINE
3. Dowshen S., Walter R. (2001). The power of play. Available online: http://www.kidshealth.org
   • View In Article
4. Eissa M , Gunner K . Evaluation and management of obesity in children and adolescents . Journal of Pediatric Health Care . 2004;18:35–38
   • View In Article
5. Klish W , Goodrick G . Strategic plan for the prevention of obesity in Texas . Austin, Texas: Texas Dep-artment of State Health Services; 2003; Available online: http://www.dshs.state.tx.us/phn/obesity.shtm
   • View In Article
6. National Association for Sport and Physical Education  . Active start: A statement of physical activity guidelines for children birth to five years . New York: AAHPERD Publications; 2002;
   • View In Article
7. Neumark-Sztainer D . Childhood and adolescent obesity: An ecological perspective . Basic Pediatrics . 2003;101:12–20
   • View In Article
8. O'Loughlin J , Gray-Donald K , Paradis G , Meshefadjian G . One- and two-year predictors of excess weight gain among elementary school children in multiethnic, low-income, inner-city neighborhoods . American Journal of Epidemology . 2002;152:739–746
   • View In Article
9. Phillips J . In: The origins of intellect: Piaget's theory . San Francisco, California: W.H. Freeman and Company; 1969;p. 15–41
   • View In Article
10. Reilly J , McDowell Z . Physical activity interventions in the prevention and treatment of paediatric obesity: systematic review and critical appraisal . Proceedings of the Nutrition Society . 2003;62:611–619
    • View In Article
11. Williams C . Childhood obesity new epidemic of an old disease . Pediatric Basics . 2003;101:2–8
    • View In Article