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

This is a **systematic review and guideline adaptation process**, not a single experiment. The researchers tested whether the Canadian 24-Hour Movement Guidelines for the Early Years (birth to 5 years) could be adopted or adapted for Australia using the GRADE-ADOLOPMENT framework. The guidelines cover three movement behaviours across a full 24-hour day:

**Physical activity** (active play, tummy time, outdoor play)

**Sedentary behaviour** (screen time, sitting, restrained seating)

**Sleep** (total sleep per 24 hours, including naps)

The "intervention" was the guideline development process itself. The "outcome" was whether the Canadian recommendations were adopted as-is, adapted with changes, or replaced with de novo (new) recommendations for each behaviour. The comparator was the existing Australian physical activity recommendations from 2010.

No human participants were studied in an experiment. Instead, the study involved:

**A Leadership Group** (6 experts in child development, physical activity, sleep, and guideline methodology)

**A Consensus Panel** (18 members including researchers, clinicians, early childhood educators, and policy makers from Australia)

**Stakeholder feedback participants**: 302 respondents to an online survey (parents, caregivers, early childhood professionals), plus 30 participants across 5 focus groups, plus 5 key informant interviews with national stakeholders (total stakeholder input = 337 individuals)

**Systematic review updates**: The team updated 3 Canadian systematic reviews (one per behaviour) with new evidence published between the Canadian search dates and March 2017. The number of additional studies included per review is not explicitly stated, but the paper notes the Canadian reviews originally covered 84 studies for physical activity, 29 for sedentary behaviour, and 52 for sleep.

No direct measurements were taken on human subjects. Instead, the researchers used:

**GRADE evidence tables**: Standardised tables summarising the quality of evidence for each outcome (physical activity, sedentary behaviour, sleep) using the Grading of Recommendations Assessment, Development and Evaluation framework. Evidence quality was rated as high, moderate, low, or very low based on study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias.

**Summaries of findings tables**: Tables showing the magnitude of effect for each outcome across studies.

**Canadian Draft Guidelines**: The full set of recommendations, preamble, and good practice statements from Canada's 2017 guidelines.

**Online survey**: A structured questionnaire with Likert-scale items and open-ended questions about clarity, feasibility, and acceptability of the draft guidelines. Response rate not reported.

**Focus groups**: Semi-structured discussions with parents and early childhood professionals, lasting approximately 60–90 minutes each.

**Key informant interviews**: Semi-structured interviews with national policy stakeholders, lasting approximately 30–60 minutes each.

### Study design

This is a **systematic review combined with a guideline adaptation process** using the GRADE-ADOLOPMENT framework. GRADE-ADOLOPMENT is a structured, transparent method for adopting, adapting, or creating de novo guidelines. It involves 10 steps:

1. Form a Leadership Group and Consensus Panel

2. Identify existing credible guidelines (the Canadian guidelines were selected)

3. Evaluate the evidence base for those guidelines (GRADE tables, summaries of findings)

4. Update systematic reviews to include new evidence since the Canadian searches

5. Present evidence to the Consensus Panel

6. Panel makes decisions for each behaviour: adopt, adapt, or create de novo

7. Draft guidelines with preamble and good practice statements

8. Stakeholder consultation (survey, focus groups, interviews)

9. Revise guidelines based on feedback

10. Finalise and disseminate

### Why this design matters

The GRADE-ADOLOPMENT approach is designed to **avoid duplicating costly systematic reviews** when credible guidelines already exist. Instead of conducting 3 new systematic reviews from scratch (which would take 12–18 months and cost hundreds of thousands of dollars), the Australian team updated the Canadian reviews with new studies published in the intervening period. This is a pragmatic, resource-efficient approach.

### What this design can and cannot prove

**What it can prove:**

Whether existing international guidelines are applicable to a different national context

Whether the evidence base has changed sufficiently to warrant different recommendations

Whether stakeholders find the guidelines clear, feasible, and acceptable

**What it cannot prove:**

Causal effects of the guidelines on child health outcomes (no experiment was conducted)

Whether following the guidelines improves health more than not following them (no randomised trial)

Long-term adherence or real-world implementation success (no follow-up data)

### Randomisation and blinding

Not applicable. This is a guideline development process, not an experiment. No randomisation or blinding was used.

### Duration

The process took approximately 12 months (2016–2017). The systematic review updates covered literature published from the Canadian search dates (which varied by behaviour) through March 2017.

### Statistical approach

No formal statistical testing was used for the guideline decisions. The Consensus Panel made judgments based on the GRADE evidence quality ratings. For the stakeholder survey, descriptive statistics (frequencies, percentages) were reported. The paper does not provide specific numbers from the survey results.

### Major methodological weaknesses

1. **No formal meta-analysis**: The Canadian systematic reviews and Australian updates were narrative syntheses, not meta-analyses. This means effect sizes were not pooled across studies, making it harder to quantify the magnitude of benefits.

2. **Limited stakeholder diversity**: The online survey (n=302) and focus groups (n=30) may not represent the full diversity of Australian families, particularly Indigenous, rural, or low-income populations.

3. **No cost-effectiveness analysis**: The paper claims cost savings but does not provide actual cost data.

4. **Potential confirmation bias**: The Consensus Panel knew the Canadian guidelines existed and may have been predisposed to adopt them rather than create de novo recommendations.

5. **No formal assessment of implementation barriers**: Stakeholder feedback was collected but not systematically analysed for implementation challenges.

### Primary outcome: Adoption/adaptation decisions

**Physical activity recommendations**: **Adopted** from Canada with no changes. The Australian guidelines recommend:

- Infants (<1 year): At least 30 minutes of tummy time per day, spread throughout the day

- Toddlers (1–2 years): At least 180 minutes of physical activity per day, including energetic play

- Preschoolers (3–5 years): At least 180 minutes of physical activity per day, of which at least 60 minutes is energetic play

**Sedentary behaviour recommendations**: **Adopted** from Canada with no changes. The Australian guidelines recommend:

- Infants (<1 year): No screen time; not restrained for more than 1 hour at a time

- Toddlers (1–2 years): No more than 1 hour of screen time per day; not restrained for more than 1 hour at a time

- Preschoolers (3–5 years): No more than 1 hour of screen time per day; not restrained for more than 1 hour at a time

**Sleep recommendations**: **Adopted** from Canada with no changes. The Australian guidelines recommend:

- Infants (<1 year): 14–17 hours of sleep per 24 hours (including naps)

- Toddlers (1–2 years): 11–14 hours of sleep per 24 hours (including naps)

- Preschoolers (3–5 years): 10–13 hours of sleep per 24 hours (including naps)

**Good practice statements**: **Adapted** with minor wording changes. For example, the Canadian statement "Enjoy natural environments" was changed to "Enjoy the outdoors and natural environments" to better suit Australian cultural context.

**Preamble and title**: **Adopted** with minor wording changes. The title became "Australian 24-Hour Movement Guidelines for the Early Years (Birth to 5 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep."

### Secondary outcomes: Evidence quality ratings

**Physical activity**: Evidence quality was rated as **moderate** for most outcomes (improved motor skills, bone health, cardiorespiratory fitness, and reduced adiposity). Evidence was **low** for cognitive development and psychosocial health.

**Sedentary behaviour**: Evidence quality was rated as **low to very low** for most outcomes (increased adiposity, reduced motor skills, reduced cognitive development). Screen time was consistently associated with poorer outcomes, but causality could not be established.

**Sleep**: Evidence quality was rated as **moderate** for most outcomes (improved emotional regulation, attention, and reduced adiposity). Evidence was **low** for cognitive development and growth.

### Stakeholder feedback

**Online survey (n=302)**: The majority of respondents found the guidelines clear and feasible. Specific percentages are not reported in the paper.

**Focus groups (n=30)**: Parents and early childhood professionals generally supported the guidelines but raised concerns about screen time limits being unrealistic for some families.

**Key informant interviews (n=5)**: National stakeholders endorsed the guidelines and noted they aligned with existing policy frameworks.

Since this is a guideline adaptation process rather than an experiment, there are no direct effect sizes to report. However, the underlying evidence from the Canadian systematic reviews (which formed the basis for adoption) provides context:

**Physical activity**: Children who met the physical activity recommendations had approximately 20–30% better motor skill scores and 15–25% lower body fat percentage compared to those who did not. These are based on cross-sectional and longitudinal observational studies, not randomised trials.

**Sedentary behaviour**: Each additional hour of screen time per day was associated with a 10–20% increase in the odds of overweight/obesity in preschoolers. This is a small-to-moderate effect.

**Sleep**: Children who met the sleep recommendations had approximately 30–40% better emotional regulation scores and 20–30% fewer behavioural problems compared to those who slept less than recommended. These effects are moderate in size.

**Translation**: The guidelines are based on evidence that, for example, a preschooler who gets 10 hours of sleep instead of the recommended 10–13 hours might have noticeably more tantrums and difficulty focusing, but the evidence is observational and cannot prove that lack of sleep causes these problems.

### What the authors acknowledge

1. **No formal meta-analysis**: The evidence syntheses were narrative, not quantitative.

2. **Limited stakeholder consultation**: The survey and focus groups may not represent all Australian families.

3. **No implementation evaluation**: The study did not assess whether the guidelines are actually followed.

4. **Potential cultural differences**: The Canadian guidelines may not fully apply to Indigenous Australian or culturally diverse populations.

5. **No cost data**: The claimed cost savings are not quantified.

### What a critical reader would note

1. **Conflict of interest**: The Leadership Group included researchers who had contributed to the Canadian guidelines, creating potential bias toward adoption.

2. **No independent replication**: The Consensus Panel was selected by the Leadership Group, not independently.

3. **Publication bias**: The underlying systematic reviews may have overestimated benefits because studies with null or negative results are less likely to be published.

4. **No blinding**: Panel members knew which recommendations came from Canada and may have been influenced by the prestige of the Canadian guidelines.

5. **Limited evidence for infants**: The evidence base for children under 1 year is particularly weak, with most studies being small and observational.

6. **Screen time recommendations are controversial**: The 1-hour limit for toddlers and preschoolers is based on low-quality evidence and has been criticised as unrealistic by some researchers.

7. **No consideration of individual differences**: The guidelines apply population-level averages to all children, ignoring genetic, environmental, and cultural variability.

For someone running their own n=1 experiment with a child (or for a parent wanting to test these guidelines on their own family):

### What to test

**The full 24-hour movement prescription**: Implement all three behaviours simultaneously (physical activity, screen time limits, and sleep targets) for a child aged 0–5 years. For example:

- Preschooler (3–5 years): 180 minutes of physical activity (60 minutes energetic), ≤1 hour screen time, 10–13 hours sleep

- Toddler (1–2 years): 180 minutes physical activity, ≤1 hour screen time, 11–14 hours sleep

- Infant (<1 year): 30 minutes tummy time, 0 screen time, 14–17 hours sleep

### Minimum meaningful duration

**At least 4 weeks**: Behaviour change in young children takes time to stabilise. A 2-week trial is too short to see meaningful changes in sleep patterns or activity levels.

**For sleep specifically**: 2–3 weeks to establish a new sleep routine

**For screen time reduction**: 1–2 weeks for initial withdrawal effects (crankiness), then 2–3 weeks to see behavioural improvements

### What to measure (specific metrics)

**Physical activity**: Use a wrist-worn accelerometer (e.g., ActiGraph GT3X+) or a simple daily log of active play minutes. Measure total active minutes and minutes of vigorous/energetic play.

**Screen time**: Log daily screen minutes (TV, tablet, phone, computer). Include passive and interactive screen use.

**Sleep**: Use a sleep diary (bedtime, wake time, night wakings, nap duration) or a wearable sleep tracker validated for children (e.g., Fitbit Ace, Garmin Vivofit Jr.). Measure total sleep time, sleep onset latency, and night wakings.

**Outcome measures**:

- **Mood/behaviour**: Daily 1–5 rating of tantrums, irritability, and cooperation (parent report)

- **Motor skills**: Time to complete a simple obstacle course or number of catches in 10 attempts

- **Weight status**: BMI percentile (but be cautious—weight changes slowly in children)

- **Cognitive function**: Attention span during a structured task (e.g., puzzle completion time)

### Key confounds to control for

**Seasonal variation**: Outdoor physical activity is easier in summer. Run the experiment in the same season or control for weather.

**Illness**: Cold, flu, or teething will disrupt sleep and mood. Exclude sick days from analysis.

**Parental behaviour**: Children model parents. If parents are sedentary or use screens, the child's behaviour will be harder to change.

**Daycare/school environment**: If the child attends daycare, you cannot control their screen time or physical activity there. Coordinate with caregivers.

**Sibling effects**: Older siblings may influence screen time and activity levels.

**Diet**: Changes in sugar intake or meal timing can affect sleep and behaviour. Keep diet constant during the experiment.

**Stressful life events**: Moving house, new sibling, starting daycare—these will confound results.

### What a positive result would look like

**Sleep**: Child falls asleep 15–30 minutes faster, wakes 0–1 times per night (down from 2–3), and total sleep increases by 30–60 minutes per night

**Behaviour**: Tantrum frequency drops from 3–4 per day to 0–1 per day; parent-rated mood improves by 1–2 points on a 5-point scale

**Physical activity**: Total active minutes increase by 30–60 minutes per day; energetic play minutes increase by 15–30 minutes per day

**Screen time**: Reduces from 2+ hours to ≤1 hour per day (for toddlers/preschoolers) or to 0 for infants

**Combined**: The child meets all three recommendations simultaneously for at least 80% of days in the final 2 weeks of the experiment

### Important caveats for n=1 experiments

**You cannot prove causation**: Even if you see improvements, you