Physical activity guidelines for under fives: what the numbers mean

The numbers, stated exactly

The UK reference document is the 2019 physical activity guidelines from the four UK Chief Medical Officers, summarised for families on the NHS website.

The World Health Organization's 2019 guidelines for children under 5 give broadly the same activity figures, and add explicit sedentary and screen limits: no sedentary screen time for children under one, no more than one hour of sedentary screen time for those aged two to four, and limits on continuous time in prams, high chairs and carriers.

What counts, which is almost everything

The most misunderstood part of the guidance is what qualifies. For under fives, activity at any intensity counts. Walking to the shop counts. Pushing a toy pram around a room counts. Getting in and out of a box repeatedly counts. Climbing on a sofa counts. Dancing badly in a kitchen counts.

Nothing in the guidance requires a class, a session, a coach or any equipment, and nothing requires the activity to happen in one block. The phrase "spread across the day" is in the guidance because young children's activity is naturally intermittent, in short bursts with recovery, and expecting a sustained period would be expecting something that does not match how they move.

Tummy time, and the reason for it

Tummy time means supervised time on the front while awake. It builds head, neck and shoulder strength, gives a different visual perspective, and supports the sequence of rolling, sitting and crawling.

It exists as an explicit recommendation because babies now sleep on their backs, which is correct and has been followed by a very large fall in sudden infant deaths, and which reduces the time spent on the front. Tummy time restores that awake, supervised, on the front. It is never a sleeping position.

Many babies dislike it at first. Short frequent periods work better than long ones, and starting with a baby lying on an adult's chest is usually accepted more readily than the floor. A few minutes several times a day, accumulating towards the total, is the realistic approach.

How firm are these numbers

This is where a publication should be careful, because guidance numbers acquire an authority their evidence base does not always support.

The physical activity evidence for adults is extensive. For under fives it is much thinner, consisting largely of observational studies with varied measurement methods, few long-term outcomes and very few trials. Guideline development groups have said so. The figures represent a consensus judgement informed by that evidence rather than a threshold derived from it.

Two consequences follow. First, the numbers should be read as direction rather than as a cliff edge: a child getting 150 minutes is not being harmed, and a child getting 240 is not banking a benefit. Second, "minimise sedentary time" is doing more work in the guidance than the specific figures, and is better supported.

The restraint point, which is easy to miss

The sedentary recommendation covers prams, car seats used outside the car, high chairs, bouncers and carriers. Long periods restrained restrict the movement that development runs on, and time accumulates quickly across a day without anyone noticing.

Two specific points recur in safety guidance. Car seats are for travel, and long periods in them outside the car, particularly for young infants, are discouraged because of the position they hold a baby's head and airway in. And sit-in baby walkers are discouraged, are associated with injury, and do not speed up independent walking.

What actually determines whether children meet this

Very little of it is family attitude. Access to safe outdoor space, whether there is a garden, traffic on the street, whether a nursery has outdoor provision in poor weather, the cost of waterproofs, adult working hours and distance to open space determine most of it, and they are not equally distributed.

That is worth stating in an article about guidelines, because guidance addressed to individuals can imply that falling short is a failure of effort. Population activity levels move when facilities, streets and settings change, and Sport England's Active Lives survey tracks the resulting inequalities year on year.