Study sample

Caregivers participating in this study were enlisted as part of the Singaporean Lifestyle Questionnaire for infants, toddlers and preschoolers: IPRAMHO Survey on Integrated Early Childhood 24- Hour Activity for infants, toddlers and preschoolers 0–6 years old (E-24). A convenience sampling method was employed to select caregivers from various study sites in Singapore. Eligible caregivers were individuals who were either Singaporean or permanent residents, responsible for children aged 0–6 years, and possessed the ability to comprehend English. Infants were categorized as children between 0 and 11 months old, toddlers as those aged between 1 and 2 years 11 months old, and preschoolers as those between 3 and 6 years 11 months old. Before taking part, caregivers needed to provide witnessed verbal consent to the research team. Subsequently, they were given an electronic version through FormSG (https://form.gov.sg/) for completion. The research procedures for this study received formal approval for an exempt review from the SingHealth Centralized Institutional Review Board (CIRB Ref No.: 2021/2610). All the authors and caregivers of the children surveyed have provided consent for the publication of this manuscript.

Data collection

Between October 2021and Jun 2022, a total of n = 901 survey responses were collected. The survey comprised 46 items that collected data on caregiver demographics, PA, SVT, sleep habits (nighttime sleep and daytime napping), parental practices, parental perceptions of the child’s health and well-being, parental awareness and knowledge of lifestyle guidelines for their infants, toddlers and preschoolers. Caregivers self-reported demographic characteristics and reported on their child’s demographics and lifestyle behaviours. They were asked to recall their children’s past 7-day lifestyle and activities while completing the survey questions. The survey questionnaire was developed and reviewed by members of the Integrated 24-Hour Activity Guidelines for Early Childhood Committee. The development of the survey questionnaire went through an expert review and thorough literature review which establishes content validity. Items on PA captured the total amount of tummy time for infants, total light and energetic play for toddlers and preschoolers using previously published questions [22], while the items on sleep were adapted from the Child Sleep Habits Questionnaire [23]. Recreational SVT was captured as the average time a child spends on a screen [10]. The survey took 10–15 minutes in total duration.

Assessment of physical activity

Caregivers were asked to report the average duration per day of the child’s tummy time or time spent in floor-based play on a typical weekday or weekend if the child was 0–11 months old [24]. For toddlers and preschoolers, light physical activity (LPA) and energetic physical activity (EPA) during the weekday and weekend were assessed using questions: “How much time did your child spend in light physical activity (Total per day on average)?” and “How much time did your child spend in energetic physical activity (Total per day on average)? “. LPA was defined as: “Low energy activities such as walking at a leisurely or moderate pace, biking/cycling or jumping at an easy pace and swimming with support of an adult, playing with a sibling or an adult indoors, dancing to music or attending a music and movement class”, and EPA was defined as: “Activities that make your child breathe faster/harder than normal, (e.g. skipping, hopping, swimming and dancing with moderate to hard effort, riding a scooter/balance bike/cycling at the moderate to hard speed, attending a structured indoor class like Kinder Gym or My Gym or any other indoor sports).” Total PA for toddlers and preschoolers were the sum of LPA and EPA duration (in minutes) separately, on weekdays and weekends based on the recommended guidelines to meet 180 minutes or more of LPA and EPA combined per day [12].

Assessment of screen time

SVT duration (in minutes) during the weekday and weekend was assessed using the questions “How much time did your child spend on recreational screen time (Total per day on average)?” SVT captured did not include home-based learning, but included the following screen devices: televisions (viewing or playing television games); computers; and handheld devices (e.g., video games and hand phones including tablets for watching videos) [10].

Assessment of sleep

Caregivers reported their child’s total amount of nighttime sleep and naptime duration (in hours and minutes) separately for weekdays and weekends. Nighttime sleep duration was captured with the questions adapted from the Child’s Sleep Habit Questionnaire [23]: “Child’s usual amount of sleep each night (Total per night on average, not including daytime naps)”. Naptime duration was captured with the question: “What is the total average time spent on nap(s) (Total per day on average)?” Total sleep time was calculated by taking the sum of night and daytime naps.

Parental practices

Parental practices with their infants, toddlers and preschoolers were assessed with seven questions: (1) “I am active with, or in front of my child”; (2) “My child is restrained daily from free spontaneous movement”; (3) “My child has a consistent bedtime routine and bedtime”; (4) “I limit my own recreational screen time use when I am spending time with my child”; (5) “I prepare or provide meals for my child that are well-balanced and generally healthy”; (6) “I limit my own intake of unhealthy food and beverages”; and (7) “My child has at least one meal with the family (refers to family members or relatives living under the same roof) each day”. The response options were on a 5-point Likert Scale of “Never”, “Rarely”, “Occasionally”, “Frequently” and “All the time”.

Parental perception of child’s health

Parental perception of their child’s weight, calorie intake, PA, SVT exposure and sleep were assessed with the questions previously published [25] “Do you think your child is …”, with the response options of “Overweight”, “Normal weight”, “Underweight” and “Not sure”. The other 3 questions were (1) “Do you feel that your child receives an adequate amount of physical activity to benefit his/her growth, development and health?”; (2) “Are you concerned about the amount of recreational screen time your child is currently exposed to?”; and (3) “Do you think your child is getting adequate sleep to support his/her growth, development and health?”, with response options of “Yes”, “No” and “Not sure”.

Parental awareness and knowledge of guideline recommendations

To assess parental awareness of available lifestyle guidelines for children, caregivers were asked 3 separate questions regarding PA, sleep and SVT: “Are you aware that there are guidelines on the amount of physical activity your child should be receiving per day as a toddler/preschooler, and the limit on the restraint time for your infant?”; “Are you aware that there are guidelines on the amount of sleep your child should be receiving per day as an infant/toddler/preschooler?”, and “Are you aware that there are guidelines on the amount of screen time your child should be receiving per day as an infant/toddler/preschooler?” with the response options of “Not aware” and “Aware but not practising” and “Aware and practising”. In addition, caregivers were also asked to estimate what they think is the current guideline recommendation for PA, sleep and SVT with questions: (1) “What do you think is the current guideline of the amount of time toddlers and preschoolers should spend in a variety of physical activities at any intensity throughout the day? For infants, what do you think is the guideline for amount of time in tummy-time or floor-based play?” (2) “What do you think is the guideline for the total amount of sleep your infant/toddler/preschooler requires per day?” (3) “What do you think is the guideline for recreational screen viewing time allowance (maximum limit) for your infant/toddler/preschooler per day?”. Knowledge of guideline recommendations was assessed by questions, and based on their answers, caregivers were categorized into two groups: accurate and inaccurate.

Meeting guideline recommendations for infants, toddlers and preschoolers

Infants were classified as meeting physical activity guidelines if they met ≥30 minutes/day of tummy time or floor-based play. Toddlers and preschoolers were classified as meeting physical activity guidelines with total PA of ≥180 minutes/day. Infants and toddlers younger than 2 years were classified as meeting the SVT guidelines if they engaged in no screen time, while toddlers between 2 years and younger than 3 years, and preschoolers between 3 years and 6 years 11 months met the SVT guidelines if they engaged in <1 hour/day. Children were classified as meeting sleep guidelines if they slept a daily total amount of 14–17 hours (for 0–3 months of age) and 12–16 hours (for 4–11 months of age), 11–14 hours (1–2 years of age), 10–13 hours (for 3–5 years of age) and 10–11 hours (for 6 years of age). Guideline adherence was in-line with the Singapore Integrated 24-Hour Guidelines for early childhood [12].

Statistical analyses

Continuous datasets that were normally distributed are presented as the mean and standard deviation (SD), while nonnormally distributed datasets are presented as the median and interquartile range (IQR). The Mann-Whitney U-test for nonnormally distributed datasets, T-Tests for normally distributed datasets, and the chi-square test were used to compare continuous and categorical variables, respectively, between weekdays and weekends. Frequencies and percentages were used to describe the proportion of children meeting the movement behaviour guidelines. Sex- and age-specific body mass index (BMI) z-scores were derived using the WHO references for children 0–5 years of age [26] and children 5–6 years of age [27]. Statistically significant results were determined at 2-sided p<0.05. All analyses were performed using STATA software version 13 (StataCorp, College Station, US).

Caregiver characteristics

A total of 901 caregivers participated in the E-24 study and caregiver characteristics are presented in Table 1. In summary, 70.9% of the caregivers were mothers, of Chinese ethnicity (64.2%), with university-level education (66.5%), and 56.4% were between 30 and 35 years old. Of all the children, 69.3% were first-born, approximately half were males (51.3%), 24.3% were infants (0–11 months), 42.1% were toddlers (1 year- 2 years 11 months) and 33.6% were preschoolers (3 years– 6 years 11 months). On average, infants were 5.8 months old (SD 3.3), toddlers were 24.6 months old (SD 6.5) and the preschoolers were 55.0 months old (SD 13), with BMI Z-scores of 0.5 (SD 1.4), 0.4 (SD 1.3) and 0.5 (SD 1.3), respectively. The proportion of children attending childcare was 11.4% of infants, 38.2% of toddlers and 58.5% of preschoolers. Almost all the children in this study were free from any chronic illnesses (>97%) (Table 2).

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Table 1. Characteristics of the participants in the E24 study (N = 901).

https://doi.org/10.1371/journal.pone.0298968.t001

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Table 2. Characteristics of the infants, toddlers and pre-schoolers in the E24 study.

https://doi.org/10.1371/journal.pone.0298968.t002

Caregiver-reported physical activity, sedentary behaviour and sleep durations

Table 3 describes the caregiver-reported PA, SVT and sleep of their infants, toddlers and preschoolers. Infants engaged in a median tummy time of 45 (IQR 30–120) minutes/day in a week, whereas toddlers and preschoolers had higher total PA duration during weekends, compared to weekdays (p<0.001). There was higher SVT during weekends than on weekdays across all age groups (p<0.001). In only the preschoolers, total sleep durations were higher on weekends, than on weekdays [mean 11.2 (SD1.5) vs 10.9 (1.3) hours/day, p<0.001].

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Table 3. Physical activity, screen viewing time and sleep on weekdays and weekends by age group.

https://doi.org/10.1371/journal.pone.0298968.t003

Adherence to guideline recommendations for physical activity, sedentary behaviour and sleep

Table 4 describes the proportion of children meeting the PA, SVT and sleep guidelines according to age group. In infants, the proportions meeting tummy time (76.8%), SVT (83.0%) and sleep (72.0%) guidelines did not differ between weekdays and weekends (p>0.05). A higher proportion of infants met all three guidelines during weekdays (45.2% vs 44.2%, p<0.001).

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Table 4. Meeting guidelines for physical activity, screen viewing time and sleep on weekdays and weekends by age group.

https://doi.org/10.1371/journal.pone.0298968.t004

On a weekend compared to a weekday, a higher proportion of toddlers met PA guidelines (68.9% vs 50.1%, p<0.001); conversely, a lower proportion met SVT guidelines (21.8% vs 38.8%, p<0.001), and there were no differences in meeting sleep guidelines (79.1% vs 82.6%, p>0.05). A higher proportion of toddlers met all three guidelines on weekdays, than on weekends (18.3% vs 13.2%, p<0.001).

On weekends compared to weekdays, a higher proportion of preschoolers met the PA guidelines (78.9% vs 55.4%, p<0.001), but there were no differences in meeting SVT (21.5% vs 21.5%, p>0.05) or sleep guidelines (82.5% vs 80.7%, p>0.05). In contrast, for infants and toddlers, a higher proportion of preschoolers met all three guidelines during weekends compared to weekdays (10.4% vs 8.3%, p<0.001).

Parenting practices, perceptions, awareness and knowledge

S1 Table describes parenting practices across all age groups. Caregivers of preschoolers exhibited the lowest likelihood of frequently engaging in physical activities with their children or restricting their children from spontaneous movement (p<0.001). Moreover, caregivers of preschoolers were also the most likely to occasionally restrict their own screen time and their consumption of unhealthy food and beverages (p<0.001). On the other hand, caregivers of toddlers were more inclined to provide well-balanced and generally healthy meals to their children, while caregivers of preschoolers were most likely to have at least one daily family meal together, frequently (p<0.001) (S1 Table). S2 Table provides insights into parental perceptions of their child’s health. Caregivers of toddlers were more inclined to perceive their child as being underweight and receiving sufficient physical activity, whereas caregivers of preschoolers expressed greater concerns about their child’s SVT and were less likely to believe their child was getting enough sleep (p<0.01) (S2 Table).

S3 Table, on the other hand, describes parental awareness of guideline recommendations and their knowledge of specific activity guideline recommendations. Interestingly, caregivers of infants were most likely to think they were aware of and adhering to sleep and SVT guidelines, but only 58.9% and 27.1% of them, respectively, were accurate in their knowledge. Caregivers of toddlers were more prone to thinking they were aware of and complying with physical activity (PA) guidelines, although only 38.4% had accurate knowledge in this regard (S3 Table).

Our study addressed the existing knowledge gap regarding adherence to 24-hour activity guidelines in a culturally diverse Asian population within Singapore, focusing on infants, toddlers and preschool children below 7 years of age. Notably, two significant findings emerged from this study. First, there was a decline in the percentage of children who met all three criteria for PA, SVT, and sleep as they transitioned from infancy (~45%), toddlerhood (~18%) to preschool age (~10%). Second, while a larger proportion of infants and toddlers adhered to all three recommendations on weekdays, the opposite trend was observed among preschoolers.

The adherence to the 24-hour activity guidelines in this sample of infants (mean age:5.6 months) is higher (~45%) than what has been reported in other studies. For instance, in a study involving Australian infants with an average age of 3.6 months, only 4% met all the overall guidelines, which included the addition of meeting infant restraint guidelines [28]. Similarly, in a study involving Canadian infants, the percentages meeting all three guidelines were 12.4%, 18.0%, and 27.6% at 2 months, 4 months, and 6 months of age, respectively [29]. It is noteworthy that the primary distinction between our study and the previously mentioned studies was the notably higher compliance with the recommendation of zero screen time, which was approximately 83% in our sample, in contrast to the lower percentages reported in Australian infants (27.9% at age 3.6 months) [28] and Canadian infants (37.2% at age 6 months) [29]. In this study, infants were found to have a daily screen time exposure ranging from a median of 0.5 to 1 hour around the age of 6 months. A local study indicated that infants, by the age of 12 months, had a higher daily screen time exposure averaging 2.01 hours [30]. Interestingly, a lower proportion of infants between ages 0–3 months old (~45%) met sleep recommendations compared to infants between ages 4–11 months old (~72%). These findings concur with data from the Growing Up in Singapore Toward Healthy Outcomes (GUSTO) study where only 30% of infants at 3 months old met sleep recommendations, compared to 47% at 6 months and 56% at 9 months [31]. The average sleep duration in infants from this study was also similar to that in previously published local studies [32, 33]. A study in Canadian infants displayed a similar trend of higher parent-reported adherence to sleep guidelines in 4 (73.6%) and 6 (80.4%) months old, than in 2-month-olds (49.2%). These findings could imply that sleep-wake patterns during the early stages of infancy tend to be unpredictable until infants develop day-night (circadian) rhythms [34]. This unpredictability might lead to reduced adherence to sleep recommendations during the initial months or make it challenging for caregivers to accurately assess the overall duration of their infants’ sleep.

Among toddlers with an average age of 2 years old, we observed a decline in overall adherence to activity guidelines compared to infants, possibly attributed to the reduced adherence to physical activity and screen time guidelines. Overall, the trends observed in this study align with findings from an Australian study in toddlers with an average age of 26.9 months where higher proportions adhered to physical activity (81.6%) and sleep (82.3%), while the lowest adherence was noted in screen time use (30.5%) [35]. So far, toddlers’ compliance with 24-hour activity guidelines have only been researched in three Western populations. The proportions conforming to all guidelines exhibited minimal variation, aligning closely with our established ranges of 13.2% on weekdays and 18.3% on weekends. Notably, Australia reporting a proportion of 8.9% in the lower end [36] and 20.1% on the higher end [35], while Canada observed 11.9% meeting all three guidelines [37]. Local evidence has indicated that children between 12 and 24 months old typically accumulate an average of 2 hours of screen time daily [10]. As they progress into toddlerhood (18 to 24 months), approximately 90% of children engage in daily passive screen viewing [10]. Our findings on screen time adherence concur with studies undertaken in other countries [38, 39]. What is intriguing is that our study revealed a significant increase in screen time viewing (up to 2 hours per day) during weekends, due to children spending more time at home, as opposed to weekdays when nearly a quarter of children attend childcare centres. This also explains the higher adherence to screen time guidelines during the weekdays, as screen time use in childcare is supervised. Furthermore, it is postulated that engagement in higher durations of screen time might displace engagement in physical activity [40]. However, the lower engagement in physical activity observed from our study during the weekdays despite the lower engagement in screen time use could be due to the inability of caregivers to gauge total physical activity per day in children who were attending childcare. The average sleep duration of approximately 12.9 hours/day among toddlers concurs with other studies conducted in Singapore children aged 2 years old [33, 41]. The lower nighttime sleep duration on weekdays could be explained by the longer daytime nap durations, possibly contributed by compulsory naptime practices in all childcare centres in Singapore [41]. A study published in Japanese children reported similar findings in the association between longer afternoon naps and shorter nighttime sleep-in toddlers as young as 1.5 years old [42].

At 4.5 years of age, the collective adherence to the three activity guidelines decreased to a range of 8.3% to 10.4% among preschoolers. This aligns with findings from a study involving Singaporean children aged 5.5 years old, where only 5.5% were observed to meet all three guidelines [9]. In densely populated Asian cities like Hong Kong and Japan, only 2.9% [43] and 7.2% [44] respectively, of preschoolers were reported to comply with all three guidelines, a proportion lower than the rates observed in Singapore [45]. In Western populations, two studies revealed higher percentages of children adhering to all three guidelines [45, 46], while one observed very low rates of adherence [47]. In a study conducted in rural Brazil, 10% of children aged between 3–6 years met these criteria which concurred with our study observations [46]. In Australia, the proportion was slightly higher at 14.9% [45], whereas a study in the United States reported a percentage of 1.6% [47]. In our study, overall reduction in adherence to all three guidelines was accompanied by a further reduction in the adherence to screen time especially on weekdays to only 21.8%, while the adherence to physical activity and sleep guidelines remained relatively similar to that of toddlers. Again, similar to our findings, the study from Brazil has observed that approximately half of the children were meeting physical activity guidelines, while only approximately 20% were meeting screentime guidelines [46]. The trend of lower physical activity engagement during the weekdays concurs with the observations from the study conducted in Hong Kong [43], but contrasts with another study conducted in Singapore preschoolers, which reported higher engagements on weekdays, whether it was parent-reported data or objectively measured using wrist-worn accelerometers [13]. The study collected parent-reported data, which might not be as accurate as objectively measured data. Additionally, the variability in childcare arrangements for children at this age—some not in childcare, some in full-time childcare, and others spending half a day in childcare with the rest of the day with noncaregivers (helpers, or grandcaregivers)—could make it challenging to accurately gauge the amount of physical activity engagement spread throughout the day [48]. Preschoolers engaged in as much as 3 hours per day to screen activities on weekends. This pattern of escalating screen time as children age mirrors observations made in a local study involving children aged 6 to 24 months [32], and aligns with findings from a study in the United States concerning children aged 0 to 8 years [49]. Our nighttime sleep duration in this age group is consistent with findings from other local studies [33, 41]. At this stage, a notable disparity emerged in the total sleep duration children were obtaining, with greater amounts during weekends (11.2 hours per night) in contrast to weekdays (10.9 hours per night), primarily due to extended nighttime sleep. It is worth highlighting that nearly 60% of children had commenced either full-day or half-day childcare by this age. Compulsory naptimes at schools would explain the longer daytime naps during the weekdays, which might have been attributed to shorter weekday nighttime sleep. Thus, longer day sleep might lead to later bedtime, shorter nocturnal sleep and possibly, poorer night sleep quality [50]. A study conducted with children aged 50–72 months yielded comparable findings. It noted that children who were required to nap for more than 60 minutes during childcare had notably less nighttime sleep in comparison to those who had nap durations of 0–60 minutes [51].

We analysed data on parenting attitudes, practices, and awareness of guidelines, particularly focusing on variations among infants, toddlers, and preschool-age children. Interestingly, we observed a decline in the proportion of caregivers frequently engaging in physical activities and preparing healthy foods from infancy to preschool age. At preschool age, half of the caregivers did not think their child was receiving adequate physical activity or were not sure, and one tenth were concerned about their children being underweight. Our findings concurred with a study that showed that caregivers of children aged 5–7 years believed that promoting physical activity was not necessary, and that their children were sufficiently active [52]. Conversely, the proportion of caregivers who would only occasionally limit their own screen time or discretionary food intake was highest in the preschooler age group. At this age, half of the caregivers expressed concerns about their child’s excessive screen time. A local study has shown that at least 70% of caregivers of preschool-aged children expressed concern for child digital media use [53]. Caregivers are key contributors to shaping a child’s lifestyle behaviour [54, 55], specifically caregivers influence children by modelling healthy behaviours and providing an environment necessary for the child’s growth and development. Children tend to engage in more physical activity when caregivers are supportive and encouraging of such behaviours [56], and a study has shown that a child is 5.8 times more likely to be involved in physical activity if caregivers actively participate as well [57]. Screen time viewing in children below 7 years of age [58], and as young as 2 years of age [10] are found to be highly correlated with parental practices. In Singapore, a quarter of toddlers and over half of preschoolers received childcare from sources outside the home, and a local study has highlighted the impact of diverse childcare arrangements on children’s health behaviours. Notably, children who spend more time with nonparent caregivers, such as domestic helpers or grandcaregivers, exhibit increased adiposity and engage in higher levels of sedentary behaviours, including extended screen time, compared to children who were placed in an all-day childcare [48].

Recognizing a caregiver’s understanding of child development as a crucial aspect of caregiver support is a widely recognized central theme. Acquiring specific knowledge is a fundamental caregiver skill. In our study, we noted that, concerning PA, caregivers who were aware about the guidelines but opted not to implement them were most prevalent among preschoolers. Additionally, accuracy in knowledge of PA guidelines was lowest within this age group. Similarly, caregivers who were aware of SVT guidelines, but chose not to adhere to them were most common among preschoolers. Interventions aimed at improving parents’ understanding, abilities, and social support related to infant feeding, diet, physical activity, and television watching, have been shown to be related to a reduced likelihood of unfavourable behaviours. These included the consumption of sugary snacks and the amount of time spent watching television [59]. In older age groups of children, caregiver practices seemed to exhibit fewer positive trends. This could be attributed to a decrease in their level of knowledge regarding lifestyle recommendations for their child, possibly because they tend to rely more on childcare centers to oversee their child’s education, dietary choices, and physical activity. At least 50% of all children attending childcare by the age of 5 were there for at least five full-days a week [48]. Nonetheless, prioritizing parental engagement and involvement with children remains essential. This is because, despite the decreased fast-food and deep-fried food intake that has been associated with childcare attendance in Singapore [48], there were no associations with increased intake of fruits or vegetables. Moreover, overall physical activity engagement remains low in preschoolers even across school and non-school days [13].

The strengths of this study include the comprehensive data collected on all movement behaviours, and the collection of data across three different age groups from 0 years to 6 years of age. This allowed for the comparison of these lifestyle behaviours, including parenting knowledge, attitudes and practices of lifestyle recommendations for infants, toddlers and preschoolers. This study also has limitations, that need to be addressed. These include the subjective self-reported responses of caregivers in the survey about their children’s activities, which may not be as accurate as objective measurements using motion sensors. Another constraint lies in the adoption of the convenience sampling method in this research, potentially leading to the sample’s lack of representativeness when compared to the entire population of Singapore. Additionally, the sample was made up mostly of caregivers with at least a university-level degree and might not be reflective of caregivers with other educational qualifications.