Increasing sedentary leisure time, rising obesity rates and decreasing physical activity levels are a health concern globally including in young children (0–5 years) (1). A lack of adequate physical activity in children can lead to increased risk of high blood pressure, insulin resistance, musculo-skeletal problems, fatty liver disease and reflux (2) as well as obesity, teasing, bullying and being socially isolated. (3) Despite young children often being perceived as ‘active’, evidence shows less than 25% of young children meet 24-h movement (physical activity, sedentary behavior and sleep) guidelines (4, 5). The need to develop health-enhancing movement behaviors from an early age is important as they typically continue into adulthood (6, 7).

Guidelines on young children’s 24-h movement behaviors were recently released (8, 9). Led by Canada (9) and Australia (10) in 2017, the World Health Organization (WHO) (11), New Zealand, (12), South Africa (13), and the United Kingdom (14) also adopted evidence-based guidelines for the early years. Although similar, the small between country variation seen in the guidelines is due to the different ages at which children attend ECEC and start full-time school. The WHO 24-h movement guidelines recommend young children (0 < 5 years) accumulate: (1) at least 180 min of total physical activity per day including at least 60 min of moderate to vigorous physical activity for 3–4-year-olds, (2) no more than 60 min of sedentary screen time per day, and (3) 10–13 h of sleep per day (9–14). For infants, the recommendations are; (1) being physically active every day including at least 30 min of tummy time, (2) maximum of 60 min sedentary time and no screen time, and (3) 14–17 h of sleep per day (9–14).

Early childhood education and care (ECEC) services are well placed to influence young children’s movement behaviors (5, 8, 15). Young children can spend between 50% (0–2 years) to 90% (3–5 years) of their time in ECEC (16, 17) yet multiple studies have reported low levels of physical activity and high levels of sedentary time (18, 19). As children’s physical activity is generally accumulated between the hours of 9 am to 5 pm, (20) there is significant opportunity for movement behavior related interventions in the ECEC setting (8, 17, 20). Studies have shown that physical activity interventions in ECEC can increase young children’s physical activity levels via the development of staff knowledge and capacity, (2, 21) staff participation, role-modeling and promotion of physical activity (8, 22), time spent outdoors (8, 23), having large, open play spaces (22, 23), availability of portable play equipment (21, 23), and via the adoption of an ECEC-specific physical activity policy (8).

Early childhood education and care policies need to provide specific recommendations on the amount and type of physical activity children should do in care (7, 8). The 2001 US Institute of Medicine ECEC-specific physical activity guidelines provide an example recommending young children accumulate 15 min of physical activity per hour at ECEC and be sedentary for no more than 30 min at a time (24). This is in line with the WHO’s statement that physical activity guidelines and recommendations should measure duration, frequency, intensity and types of physical activity (25). Moreover the WHO’s recent Global action plan on physical activity 2018–2030: More active people for a healthier world (1) highlights the need for multi-level policies that target physical activity of sufficient duration and intensity to provide health benefits, reduce gender, social and geographic disparity and that allow tracking of progress (1). Even slight increases in physical activity can be beneficial (26) with measurement and monitoring of progress necessary to provide data about the implementation of policy actions (1). Therefore, movement policies that state specific types and amounts of movement behaviors instead of using subjective and inconsistent terms (e.g., large, small) is important for identifying progress toward 24-h movement guidelines and increasing physical activity in the ECEC setting (24).

It is currently unknown how well movement policies have been implemented into the ECEC sector (17). It is timely, therefore, to undertake an international scoping review of ECEC-specific movement behavior policies to identify where such policies exist, how they have been developed, the recommendations contained therein and the supports available to aid in their implementation.

This scoping review was undertaken using the framework developed by Arksey and O’Malley (27). The Comprehensive Analysis of Policy on Physical Activity (CAPPA) (2018) (28) framework was used to inform data collection and content analysis for the review.

The literature search resulted in 539 citations for consideration. After duplicates were removed 136 citations remained for full text review. Following full text review, 43 (4 journal articles studies and 39 other documents) policy documents were included in this review. The review process is outlined in Figure 1.

Data was synthesized into tables describing: (1) ECEC policy recommendations of duration (minutes) and/or frequency of movement behaviors (Supplementary Tables S1, S2); and (2) an overview of ECEC movement behavior policies in terms of stakeholders, development, content and supports (Supplementary Table S3). The main characteristics of included studies and documents are provided in Table 2.

Most policy documents (74%) were published or updated in the last 5 years (12, 33, 35, 36, 39, 41, 44–46, 48, 51, 52, 57, 58, 60, 61, 65–70, 75–77) and were from high income countries. Three-quarters (75%) were published in the United States (24, 33–35, 37, 39, 40, 45, 47, 49–51, 53–56, 58–61, 64, 65, 70–72, 75), followed by Canada (12%), (36, 38, 42, 52, 62, 68, 69, 73, 74, 76) Australia (4%), (41, 48, 67) United Kingdom (4%), (44, 57, 63) and Finland, (43) South Africa, (66) Hong Kong (46), and New Zealand (12) (combined total 5%). Policy documents were located on websites (i.e., web pages listed under one domain name), in resources from websites (i.e., printable materials including advice and/or standards and/or policy template for physical activity) or online databases (i.e., online searchable structured dataset) (80%) (12, 33, 34, 36, 38, 39, 41–63, 68–70, 72–74, 76) with peer-reviewed journal articles (13%) (35, 64–67, 71, 75) and policy briefs/legislation (7%) (37, 40, 77) accounting for the remainder. While the focus was on ECEC-specific policy documents for children 0–5 years of age, over half of the policy documents (55%) included children up to the age of 6 years (12, 33–42, 44–49, 51, 52, 54–56, 58–63, 66–70, 74) with the remainder including children up to the ages of 8 or older (43, 50, 53, 57, 64, 73).

This scoping review identified the prevalence, content and development of ECEC movement behavior policies, regulations and standards internationally highlighting evidence gaps, limitations and future research priorities. We summarized 43 policy documents guided by the CAPPA framework (81).

There was considerable variation in the recommended amount (duration and/or frequency) of movement behaviors in ECEC policies. We also found that many policies contained recommendations for only one or two behaviors but not all three. These findings were not unexpected, given that many policies were published prior to the 2019 WHO Guidelines on physical activity, sedentary behavior and sleep for children under 5 years of age (11). It was a strength, however, that many policies included developmentally appropriate recommendations by age group for each movement behavior. Recommendations ranged between 60 and 180 min per day for TPA and MVPA ranged between 20 and 90 min per day. Infant tummy time recommendations were most commonly 3–5 min at a time (multiple times/day). Recommendations for the amount of structured and unstructured physical activity children should do at ECEC ranged between 30 and 60 min/day. ECEC sedentary and screen time recommendations varied with some policies including screen time as part of overall sedentary time recommendations and others specifying separate recommendations. For children over 2 years old screen time recommendations ranged between 15 and 120 min/day. Similarly, there was wide variability for ECEC sleep time recommendations with recommendations ranging between 30 and 120 min/day depending on the length of time in care.

The variation in recommended amounts of movement behaviors at ECEC reflects the limited evidence base on which these policies have been developed and most do not comprehensively reflect the WHO Guidelines on physical activity, sedentary behavior and sleep for children under 5 years of age (11). Small sample sizes - and consequently power issues - plague the early years ECEC movement behavior policy evidence base (4, 17, 82). Movement behavior measurement at ECEC has typically involved parent-report and proxy measures (4, 17, 82, 83). However, devices (e.g., accelerometers) capable of measuring the complete range and type of young children’s movement behaviors (including sleep) at ECEC have shown promise (84). Currently, there is debate over the use of cut points for processing accelerometer data with recent methodological studies proving machine learning algorithms to be more accurate (4, 83). In addition, few studies have outlined the processes for ECEC-specific movement behavior policy development. Given the limited amount of published literature on movement behavior policies in the ECEC setting the potential for methodological issues to influence movement behavior recommendations cannot be ignored. Therefore, more research is necessary to develop, test and implement ECEC-specific measures that expand the evidence base for movement behaviors in the ECEC setting. Attending to these issues is an important step in legitimizing the evidence base and ensuring that movement behavior recommendations are pragmatic, valid and consistent.

Overall, the vast majority of movement behavior policies were ‘downstream’, i.e., focused on the ECEC end-user, and most contained some type of support for implementing the policy. The most common policy implementation supports were resource/practice guides, professional development, templates or websites. To ensure the successful implementation of movement behavior policies in ECEC, supports need to address implementation barriers for ECEC services, be contextually specific and supported by theoretical underpinnings. It is imperative, however, that the most useful implementation supports are chosen. While the evidence shows a general insufficiency of implementation supports to influence young children’s movement behavior change (78, 85, 86) it should be acknowledged that implementation best practice in the ECEC setting is still emerging (17, 87). Further, to address barriers identified by ECEC services, implementation supports should be ongoing to ensure transfer of knowledge to new ECEC staff in a traditionally high turnover work setting (82). Specifically, supports should be tailored to overcome barriers in the ECEC setting (88) that can influence the implementation success of an ECEC-specific movement behavior policy.

The large variation in the structure of ECEC-specific movement behavior policies made it challenging to assess policy processes, content and implementation. We also noted that there was little mention of the political, social, economic or cultural contexts in which the stakeholders operated and ECEC-specific movement behavior policies were developed. Framing and development of policy is dependent on the overarching agendas of who is proposing them (89). The inherent risk is that the resulting movement behavior policy may not be sufficiently pragmatic or reflect the complexity of the ECEC setting. Furthermore, future ECEC-specific movement behavior policy development should include experts and researchers who have comprehensive knowledge of the ECEC movement behavior field to ensure the policy, its recommendations and implementation supports are backed by current evidence.

The majority of movement behavior policies originated in high-income countries. This finding was not unexpected and while ECEC-specific movement behavior policies have become more widespread internationally in recent years, they remain the purview of wealthy countries (17). With an estimated 80% of deaths attributed to non-communicable diseases occurring in low to middle income countries (90, 91). healthy physical activity habits can improve short- and long-term health outcomes and reduce the economic cost of disease (11). More research, therefore, should be conducted to understand and address the specific barriers to the development and implementation of ECEC-specific movement behavior policies in low-middle income countries.

Most movement behavior policies reviewed were subnational and from the health, education and sport/recreation policy sectors. While most collaborations for policy agenda setting and development occurred at the local level, (92) there was little intersectoral collaboration in the development and implementation of ECEC-specific movement behavior policies. Government was the main stakeholder in the development of ECEC-specific movement behavior policies, with other stakeholder groups (community, end users, academia) also well represented. This is important as stakeholders, particularly end users (ECEC providers and related peak bodies), play key roles because of their interest, overarching values and potential influence over decision making and implementation of policies in the ECEC sector (89). While acknowledging it is complex and resource intensive, (93) intersectoral collaboration supports the development of strong stakeholder relationships and ‘win-win’ strategies (92, 93) to better support the development and implementation of ECEC-specific movement behavior policies. Notably, a recent umbrella review highlighted the importance of stakeholders and political will for legitimacy in the successful implementation of physical activity policies in various populations including young children (94). This position is reflected in the WHO’s Global Action Plan on Physical Activity 2018–2030 (1) whereby multisectoral collaboration underpins the strengthening of development, implementation and monitoring of physical activity targets. Going forward, policymakers should aim to develop broad, multi-sectoral collaborations to assist with effective ECEC-specific movement behavior policy development, implementation and outcomes.

Less than one-third of movement behavior policies provided tools, e.g., checklists, periodic surveys, action plans for individual- or service-level self-evaluation, to assess implementation progress or compliance. Yet, national regulatory authorities in many countries (e.g., Australia, United States, United Kingdom, Japan Norway, Poland) assess compliance with national ECEC movement behavior-related policies and standards (95). Overall, we found that USA movement behavior policies were legislated and often linked to service funding. In other countries, such as Australia and New Zealand, policies were not legislated but linked to ECEC quality/standards. For example, in Australia, ECEC is heavily regulated by the Australian Children’s Education & Care Quality Authority and for movement behaviors states ‘Each child’s health and physical activity is supported and promoted’ (96). Conversely, USA young children’s ECEC movement behaviors policies contain specific requirements [e.g., 60–90 min/day TPA; no screen time <2 years, 60 min/day for >2 years (33)] that are legislated. Legislated policies, such as those seen in the USA, have the potential to influence how well an ECEC-specific movement behavior policy is implemented and subsequently practiced. Further, legislation that proportionally reflects current evidence, i.e., 24-Hour Movement Guidelines for the Early Years (9–11, 13) may provide an impetus to meet policy recommendations. In conjunction with improving young children’s health and development, ECEC-specific movement behavior legislation facilitates increased policy compliance, drives educator and service capacity building, embeds policy, normalizes practice (81, 88, 97, 98) and can be leveraged off existing national quality monitoring processes. Importantly, the presence of ECEC-specific movement behavior legislation aligns with other already-legislated ECEC service standards around nutrition, sun protection and space requirements.

This international scoping review identified the prevalence, content and development of ECEC-specific movement behavior policies and provided insight into the limitations, gaps and future research priorities in this area. Movement behavior policies in the ECEC setting are often vaguely worded, lacking a comprehensive evidence base, siloed in development and often not tailored for the ‘real world’. Moreover, no ECEC-specific recommendations for movement behaviors currently exist. Our findings highlighted that there are wide variations in the duration and frequency of recommendations in ECEC movement behavior policies. More research is needed to strengthen the evidence informing the amount of movement behaviors children should do at ECEC as well as the application of this evidence base in the development of ECEC-specific movement behavior policy. In particular, ECEC-specific movement behavior policies need to be proportionally aligned with national/international 24-h Movement Behavior Guidelines for the Early Years. Additionally, further work is required to develop effective and wide intersectoral collaborations of government and non-government organizations, increase stakeholder engagement and advocacy for legislated movement behavior policies. While implementation supports are provided, it is imperative they are backed by evidence and responsive to the needs of the ECEC services they were designed for. Overall, our findings indicate that evidence informed ECEC-specific movement behavior policies for the Early Years are needed to ensure young children attending ECEC have sufficient opportunity to be active.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

EW: conceptualization, methodology, data search, extraction and analysis, writing – original draft, review and editing. RV: methodology, data extraction, writing – review and editing. NP: conceptualization, writing – review and editing. CB: methodology, writing – review and editing. HC: conceptualization, methodology, supervision, writing – review and editing. All authors contributed to the article and approved the submitted version.

This work is supported by the National Health and Medical Research Council (NHMRC) partnership project grant (#APP1152086) and partially through the Australian Research Council’s Centre of Excellence for Children and Families over the Life Course (#CE200100025). EW is supported by an Australian Government Research Training Program (RTP) Stipend and RTP Fee-Offset Scholarship through The University of Western Australia and a Minderoo Foundation Top-up Scholarship through the Telethon Kids Institute. NP is supported by the Australian Government through the Australian Research Council’s Centre of Excellence for Children and Families over the Life Course (CE200100025). HC is supported by a National Heart Foundation Future Leader Fellowship (#102549). None of the funding bodies had a role in study design, data collection, analysis, report writing or publication of this article.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1077977/full#supplementary-material