The Role of the Pediatrician in the Promotion of Healthy, Active Living

This clinical report replaces the 2015 American Academy of Pediatrics clinical report “The Role of the Pediatrician in the Primary Prevention of Obesity.”¹ It complements the fourth Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents² and the 2023 “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.”³ This clinical report provides guidance to help pediatricians promote healthy, active living in all children and adolescents. Healthy, active living includes behavioral patterns supporting high-quality nutrition, physical activity, sleep, screen use, and social-emotional wellness.

Practical strategies to promote healthy, active living are urgently needed. Few children and adolescents meet federal recommendations for nutrition⁴ or physical activity,⁵ and rates of poor or inadequate sleep,⁶ negative health effects from screen use and social media,⁷ and mental health concerns⁸ in children and adolescents have increased. Childhood obesity and disordered eating, including binge eating disorder and atypical anorexia nervosa, remain complex biopsychosocial illnesses with many genetic, environmental, and social drivers; healthy lifestyle remains an important component of both prevention and treatment. Currently, families and social media may harbor myths or misinterpret definitions of “healthy.” Pediatricians and other primary pediatric health care providers have a crucial role in helping to promote lifestyle factors beneficial for the health of children of all weights, shapes, and sizes.

This clinical report addresses the multiple factors—nutritional, physical activity, sleep, media and screen use, and social emotional wellness—that promote healthy, active living for infants, children, and adolescents across several domains of influence, including the individual, interpersonal, institutional, community, and public policy levels. This framework is based on the socioecological model (Fig 1), a proposed model to use in the delivery of pediatric preventive care.⁹ 

Pediatricians and other primary pediatric health care providers play an essential role in the promotion of healthy, active living for infants, children, and adolescents across each domain of the socio-ecological model. At the individual and interpersonal levels, pediatricians often have a long-term relationship with children and their families, in many cases helping to monitor and support a child’s health and well-being from infancy through adolescence. As leaders of the patient-centered medical home, pediatricians can promote the prevention and early identification of conditions such as childhood obesity, eating disorders, modifiable and unmodifiable risk factors for chronic disease, and related comorbidities influenced by lifestyle factors. Outside the clinical setting, pediatricians can be influential role models and advocates for institutional, community, and policy changes that help promote a healthier environment for children and adolescents to live, grow, and thrive.

Social determinants of health (SDOHs) are the conditions in the environment where children are born, live, learn, work, play, and worship that affect a wide range of health and quality of life outcomes.¹⁰ SDOHs affect everyone and may be supportive or detrimental. SDOHs warrant special consideration as they impact and may be addressed at every level of the socioecological model. They heavily influence health behaviors, including nutrition, physical activity, sleep, screen use, and social and emotional wellness. They are impacted most by upstream institutional, community, and policy factors.¹⁰ 

SDOHs include economic stability and factors, such as education, income, employment, poverty, and food insecurity; social and community context, including support systems and nurturing relationships, community engagement, discrimination, the effects of trauma, toxic stress, and adverse childhood experiences (ACEs); neighborhood and built environment, including safety, housing, walkability, healthy food access, transportation, and accessibility and accommodations for children and adolescents with disabilities; education access and quality, including literacy, language, and higher education; and health care system factors, including access, quality, linguistic concordance, and cultural humility.¹⁰ Cultural humility includes clinician self-questioning, openness and inquiry, active listening, and flexibility to foster a greater understanding of a child’s and family’s perspective while also increasing awareness of one’s own cultural biases and assumptions.¹¹ 

Racism is an SDOH that strongly impacts child and adolescent health as a driver of poverty and health inequities.^12,–14 Systemic racism limits access to society’s resources, including economic opportunities, safe housing, and capital accumulation, all of which impact the resources families have to support child health. Racism also negatively affects access to preventive care and quality evidence-based treatments, education opportunities, and participation in extracurricular activities conducive to maintaining good health in youth.¹⁵ 

Inequitable care contributes to higher morbidity and mortality among individuals of racial and ethnic groups disproportionately affected by many chronic diseases, including obesity¹⁶ and disordered eating.¹⁷ Strategies are needed to advance equity and inclusion to promote the well-being of minoritized families and eliminate structural barriers to economic security. Costs of health care and lack of access to resources, healthy foods, and space for physical activity exacerbate disparities in preventive care. Equitable preventive care requires the practice of cultural humility and family- and patient-centered care that is supportive of the values and cultural practices of the community, family, and child or adolescent. Partnering with community-based organizations and families to codesign solutions to problems that are endorsed by the community is a strategy grounded in the socioecological model.¹⁶ Increasing the diversity of organizations and leaders who address healthy, active living can improve outcomes and policy.^16,18 

Pediatricians can implement screening in the clinical setting to help identify SDOHs, such as poverty, food insecurity,¹⁹ and exposure to trauma or adverse experiences^20,21 together with referral sources in place to help connect with community resources such as 2-1-1; the Special Supplemental Nutrition Program for Women, Infants, and Children; the Supplemental Nutrition Assistance Program (SNAP); and mental health supports, as applicable. One of Healthy People 2030s 5 overarching goals is related to SDOHs: create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.¹⁰ 

Individual-level factors, including genetics and in utero environment, early childhood exposures and experiences, knowledge, and attitudes shape a child’s taste preferences and nutrition choices,^22,23 activity level,²⁴ sleep,²⁵ and temperament.²⁶ Many individual-level factors are influenced by interpersonal considerations, including family and home environments, routines, structure, and relationships with family members, siblings, peers, and other caregivers.^27,28 Additionally, the relationship a child or adolescent or family has with a pediatrician can affect how health promotion messages are received and acted upon. In the clinical setting, pediatricians have a great and unique opportunity to impact a child’s health behaviors through supportive guidance and education around modifiable individual and interpersonal factors.

Normal growth and development are essential physical health indicators in children and adolescents. Thus, a fundamental component of each primary care visit is monitoring growth.² Pediatricians are encouraged to not only track a child’s growth measurements and growth trends, but also review them in a family-centered and nonstigmatizing way to identify areas of potential concern, such as poor or excess weight gain in the first year of life, the crossing of growth percentiles over time, abnormal weight loss or weight gain, increased weight for length ≥97^th percentile for sex and age in children younger than 2 years, or BMI ≥85^th percentile for sex and age in children 2 years and older.^2,29,–32 For children 2 years and older, “overweight” is defined as BMI ≥85^th percentile and <95^th percentile for age; “obesity” is defined as BMI ≥95^th percentile; and “severe obesity” is defined as BMI ≥120% above the 95^th percentile for age and sex. BMI is correlated with direct measures of body fat and is feasible to assess in the clinical setting, although it is a measure of excess weight rather than excess fat mass and should be considered in the context of a child or adolescent’s growth trends and body habitus.³³ 

Obesity is a chronic, multifactorial disease characterized by excess fat mass accumulation reflecting a disorder of the energy regulatory system, resulting in medical complications that can impact every organ system and overall health. Although common obesity is polygenic in origin, multiple risk factors have been identified that increase the likelihood of developing obesity in the context of this genetic predisposition. These risk factors include being exclusively formula fed, prenatal tobacco exposure, rapid weight gain in infancy, short sleep duration, depression, having a developmental disability, energy imbalance, and excessive antibiotic use in the first 2 years of life.^34,–38 Obesity attributable to caloric overconsumption is associated with average to accelerated linear growth velocity.³⁷ When children develop severe obesity before 5 years of age, pediatricians should consider syndromic or monogenetic causes of obesity resulting from rare genetic mutations along the leptin-POMC-melanocortin pathway, which cause impaired appetite regulation.^37,39 

When discussing weight, pediatricians should be careful to use person-first language (eg, child with obesity rather than “obese child”) and avoid weight bias and stigma.²⁹ One study found that parents of children with high BMI preferred the term “unhealthy weight” and that words such as “fat,” “obese,” and “extremely obese” were rated the most undesirable, stigmatizing, blaming, and least motivating.⁴⁰ Another study that interviewed children and adolescents 10 to 17 years of age found similar results, with youth preferring the term “healthy weight” and disliking “obese,” “fat,” and “large,” which induced feelings of sadness, shame, and embarrassment.⁴¹ 

Obtaining a family history of chronic health conditions, such as cardiovascular disease, hypertension, diabetes, obesity, fatty liver disease, sleep apnea, eating disorders, and mental health concerns, such as anxiety or depression, aids in assessing risk for developing chronic disease and increases insight into a family’s understanding, experience, and attitudes around factors such as nutrition and physical activity.

Familiarity with a child’s racial, ethnic, cultural, and socioeconomic background and SDOHs can help increase sensitivity to sociocultural context and guide conversations around behavioral routines and practices to best support healthy, active living. Additionally, the Agency for Healthcare Research and Quality notes that clinicians who learn about the SDOHs of the communities they serve may be more likely to participate in community-level efforts to address them, such as establishing farmers markets in food deserts, safe exercise space, or affordable housing.⁴² 

Pediatricians are encouraged to assess a child’s nutrition, physical activity, sleep, screen use, and social-emotional wellness at each well-child visit. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, fourth edition, offers specific sample questions and approaches that are tailored to each well visit.² This assessment can be conducted with patient-answered questionnaires in the electronic health record, paper questionnaires, or clinician interviews. Some examples are included in the Resources at the end of this report. Online and electronic screening methods that integrate into the electronic health record can help simplify information gathering and improve documentation and decision support. However, obtaining permissions to integrate copyrighted questionnaires may be cost prohibitive, and some questionnaires may not be available in a family’s first language. Additionally, although adolescents respond well to online and electronic screening methods, it is important to ensure that the adolescent is the person answering the questions, that confidentiality is maintained, and that there are systems in place to respond to a positive screen asynchronously and from a remote location if the questionnaire is completed outside of the office visit.

This baseline information enables pediatricians to compare an infant’s, child’s, or adolescent’s current reported behaviors with age-appropriate recommendations to assess where opportunities may exist to tailor guidance or work with a child or adolescent and their family to establish behavior change goals, when appropriate. Some children and adolescents will benefit from self-monitoring of dietary intake, physical activity, sleep routines, and screen use to increase their own awareness of typical habits or routines and identify priorities for behavioral change.

Federal guidelines provide age-based recommendations for nutrition and physical activity behaviors. The 2020 to 2025 Dietary Guidelines for Americans offer nutrition recommendations for optimal health for infants, children, and adolescents,⁴³ and the 2018 Physical Activity Guidelines provide recommendations for physical activity levels.⁴⁴ The American Academy of Sleep Medicine and the National Sleep Foundation provide recommended sleep patterns for infants, children, and adolescents.^45,46 The American Academy of Pediatrics (AAP) statements on media offer screen time recommendations for infants, children, and adolescents and advise families to develop a Family Media Plan.^47,48,Bright Futures provides guidance on promoting mental health and emotional well-being from infancy through adolescence.² 

For each health behavior, pediatricians are encouraged to take a family-centered approach in providing guidance that includes parents or caregivers and children or adolescents in a developmentally appropriate and culturally sensitive manner, focusing on the home environment. Additionally, pediatricians may encourage communication among the family and include other caregivers such as grandparents and child care providers.⁴⁹ Generally, authoritative parenting approaches in which a parent or caregiver demonstrates high respect for the child and emotional responsiveness as well as high control and demandingness through clear and strict boundaries are associated with improved outcomes. Authoritative parenting has been associated with increased consumption of fruits and vegetables and physical activity and reduced sedentary behavior and prevalence of smoking in adolescence.⁴⁹ Additionally, pediatricians should encourage parents and caregivers to role model healthy patterns around nutrition, physical activity, sleep, and screen use. In one study, children and adolescents whose caregivers modeled positive habits that promote well-being were more likely to adopt these behaviors.⁵⁰ Pediatricians also can serve as an important role model in these areas.

An overview of health behaviors is detailed below. Resources for additional information and clinical support are available at the end of this report.

Promotion of optimal nutrition in infants, children, and adolescents includes providing guidance on both what and how to eat.

The 2020 to 2025 Dietary Guidelines for Americans include dietary recommendations for the generally healthy population across the life course.⁴³ Pediatricians are able to access specific nutrient recommendations for children and adolescents by age, sex, and activity level using the USDA’s Dietary Reference Intakes calculator for health professionals at https://www.nal.usda.gov/human-nutrition-and-food-safety/dri-calculator. Breast milk is the optimal first food with the well-established short- and long-term health benefits for both infant and mother.⁵¹ Pediatricians can play an important role in helping families to attain support for a positive breastfeeding experience by providing breastfeeding supportive office practices, which are detailed in the AAP clinical report “The Breastfeeding Friendly Office”.⁵² As solids are introduced and advanced, dietary patterns that emphasize plant-based foods (vegetables, fruits, whole grains, nuts and seeds), lean sources of protein (poultry, fish, legumes), and moderate amounts of dairy products while strictly limiting or eliminating sugary drinks and highly-processed foods are associated with better long-term health outcomes across the life span.⁵³ Many traditional cultural food practices are consistent with these recommendations. Pediatricians can counsel families to focus on consuming appropriate portions of a wide variety of foods they both enjoy eating and that support their health and well-being. MyPlate is the translation of the Dietary Guidelines into an easy-to-understand visual (Fig 2). Families can obtain individualized MyPlate guidance at myplate.gov/myplateplan. It is generally appropriate for all age groups to reduce added sugars, saturated fat, and sodium.⁴³ 

Many children, adolescents, and families consume large amounts of ultraprocessed foods—ready-to-consume products made with refined ingredients and additives extracted from foods or derived from food constituents but containing little or no whole foods.⁵⁴ Ultraprocessed foods are typically high in added sugars, sodium, and refined starches and low in fiber, protein, vitamins, and minerals. The ingredients and processes used to make ultraprocessed foods make them hyperpalatable and shelf stable.⁵⁴ An analysis of the NHANES found that children and adolescents 2 to 19 years of age consumed approximately 67% of their total caloric intake from ultraprocessed foods.⁵⁵ Meta-analyses show that high consumption of ultraprocessed foods is associated with a greater risk of overweight, obesity, all-cause mortality, metabolic syndrome, depression in adults, metabolic syndrome in adolescents, and dyslipidemia in children.⁵⁶ Although more studies are needed to better define the health impacts of ultraprocessed foods in children and adolescents, there is little benefit to consumption of ultraprocessed foods, and potential risks are high; therefore, pediatricians are advised to encourage families to limit their intake.

The Dietary Guidelines advise that children younger than 2 years consume no added sugars and that children and adolescents 2 years and older consume less than 10% of total calories from added sugars. Sugary drinks are the largest sources of added sugars consumed, accounting for 24% of added sugar intake in the US diet in people 1 year and older.⁴³ Consumption of sugary drinks contributes significantly to excess caloric intake and increased cardiovascular disease risk, childhood overweight and obesity, dental caries, type 2 diabetes mellitus, and other health risks.^57,58 Water and unflavored milk are preferred beverage choices for children and adolescents. Juice is not recommended for children younger than 1 year and should be strictly limited for older children and offered only when a child does not have access to whole fruit (fresh, frozen, canned, or dried).⁵⁹ 

Parenting approaches play an important role in the establishment of a child’s eating practices. The authoritative parenting style provides structure and consistency to meal and snack times and supports a child’s use of hunger and fullness cues to guide their own intake. Responsive feeding is an authoritative parenting approach applied to feeding in infancy. It is a reciprocal process between parent and child in which an infant or young child communicates hunger and fullness cues and the caregiver recognizes and responds to those cues. This helps an infant or child to rely on hunger cues to guide intake and satiety. A randomized controlled trial found that teaching parents to feed in response to hunger and satiety cues, use alternatives to food to soothe, provide age-appropriate portion sizes, and delay introduction of solids until after 4 months of age resulted in significant positive behavioral changes. Parents were more likely to use structure-based feeding practices, including limit setting and consistent feeding routines, and less likely to use nonresponsive feeding practices like pressuring the infant to finish the bottle, using food to soothe, propping the bottle, and putting the baby to bed with the bottle at 1 year of age.⁶⁰ Pediatricians have an important role in helping caregivers engage in responsive feeding and recognition of cues for hunger and fullness. Resources to facilitate this process are included at the end of this report.

Implementing a division of responsibility model is an authoritative parenting approach. In this approach, a parent determines what foods are offered (ideally in alignment with the Dietary Guidelines), when (such as 3 meals and 1–2 snacks per day), and where (such as at the table in the kitchen without distractions such as electronic devices or other media), and the child is allowed to determine what and how much they will eat of the food that is offered. This approach provides a child with autonomy in a structured environment supporting healthy eating.⁶¹ When children reject a particular food (such as a green vegetable), parents are encouraged to avoid forcing the child to eat the food. Instead, parents should continue to offer it in the future, because repeated exposures of 8 to 10 times or more can facilitate acceptance of a previously rejected food.⁶² Additionally, children may be more likely to try a food if they have a role in helping to choose, grow, or prepare it.⁶³ 

Family mealtimes and frequent home-cooked meals support improved dietary intake in children and adolescents of all ages and their caregivers. A review found that children with a higher frequency of family meals had less fussiness and emotional eating, more food enjoyment, and better nutrient intake.⁶⁴ Children and adolescents in another study in which family meals took place at least 3 times per week had healthier eating patterns and were more likely to have a healthy weight.⁶⁵ Additionally, a literature review found higher family meal frequency to be inversely associated with disordered eating, alcohol and substance use, violence, and feelings of depression or thoughts of suicide.⁶⁶ A population-based survey found that frequent family meals were associated with higher family functioning, greater self-esteem, and lower depressive symptoms and stress levels among parents and adult caregivers.⁶⁷ Links to tools and resources that pediatricians can share to promote increased family mealtimes and home-cooked meals, such as Cooking Matters and ChopChop, are included in the Resources at the end of this report.

The 2018 Physical Activity Guidelines advise that preschool-aged children (3–5 years of age) be physically active throughout the day to enhance growth and development, with the goal of 15 minutes of physical activity per 1 hour. Adult caregivers should encourage active play of a variety of activity types. Children and adolescents 6 to 17 years of age should engage in at least 60 minutes of physical activity per day, with the majority of time being moderate- or vigorous-intensity cardiovascular activity with at least 3 days per week of vigorous-intensity exercise. Part of their 60 minutes should include muscle strengthening and bone strengthening activities at least 3 days per week.⁴⁴ Although the Physical Activity Guidelines do not address physical activity in children 0 to 2 years of age, the AAP recommends that pediatricians monitor and encourage the development of gross motor skills and physical literacy throughout childhood. Specific guidance is available in the AAP statement on assessing and promoting physical activity in the pediatric clinical setting.⁶⁸ 

Habitual physical activity and reduced sedentary time promote better cardiovascular, metabolic, and musculoskeletal health as well as optimal cognitive functioning and positively impact mental health and social functioning in all children and adolescents, including those with disabilities, in whom the benefits of physical activity are often overlooked by pediatricians and caregivers.^44,69 The AAP clinical report “Promoting the Participation of Children and Adolescents With Disabilities in Sports, Recreation, and Physical Activity” provides pediatricians with tools to better support and promote activity.⁶⁹ 

Promotion of activity at early ages involves providing time for children to explore independently and safely. Pediatricians should discuss and encourage physical activity starting in infancy with an emphasis on tummy time.⁶⁸ Initially, this means avoiding restriction of movement by minimizing time in confining equipment such as strollers, car seats, walkers, and “exersaucers.” In toddlers, active play facilitates improved gross motor development and the development of physical literacy. Working on ball skills, jumping, and climbing encourages continued activity and preparation for preschool joint play. Play in toddlerhood is followed by joint play with family members and others, including other children. As children progress developmentally from parallel play to joint play, pediatricians can help families develop activity regimens incorporating community resources and personal interests and preferences. Pediatricians can encourage both organized activities and free play for school-aged children to build enjoyable and accessible physical activities into daily routines. For many families, walking can be an ideal physical activity that can be done together as a family at low or no cost with numerous physical and mental health benefits, provided families have access to safe places to walk.

The pediatrician has an essential role in protecting unstructured play time and promoting the safety and importance of outdoor play. The pediatrician can encourage families to avoid early commitment to a single sport for children participating in organized activities.⁷⁰ In adolescence, the focus should be on the development of a habit promoting a lifetime of sustainable activity. As is often said, “the best exercise plan is the one you can follow.” Encouragement of physical activity should not be limited to athletic children and adolescents. Moderate physical activity promotes health, and more prolonged and vigorous activity should be encouraged for children and adolescents across all ability levels, taking into account and addressing family, financial, and societal barriers to participation.⁶⁹ 

As with advice around nutrition, pediatricians should tailor advice on increasing physical activity to individual children, adolescents, and their families. The AAP encourages pediatricians to create “physical activity prescriptions” for children and adolescents based on their interests, abilities, need for adaptation of the activity, and opportunities available in their community.⁶⁹ Additionally, pediatricians are encouraged to advocate for low- and no-cost sports and recreation programs in their communities, so all children and adolescents have the opportunity to be active.

The American Academy of Sleep Medicine and the National Sleep Foundation advise the following age-based sleep recommendations:

• Newborns and young infants (0–3 months old): 14 to 17 hours of sleep per day

• Older infants (4–11 months): 12 to 16 hours of sleep (including naps)

• Toddlers (1–2 years): 11 to 14 hours (including naps)

• Preschool-age children (3–5 years): 10 to 13 hours (including naps)

• School-age children (6–12 years): 9 to 12 hours

• Adolescents (13–18 years): 8 to 10 hours^45,46 

These recommendations allow for a wide range of healthy sleep duration. Whether a child or adolescent feels well rested upon waking and throughout the day can help determine whether they got enough sleep. Sleeping the recommended number of hours is associated with improved health and academic outcomes including improved attention, behavior, learning, memory, emotional regulation, quality of life, and mental and physical health.⁴⁶ Inadequate or excessive sleep is associated with adverse health outcomes including obesity, hypertension, diabetes, and depression.⁴⁶ A study of 8300 children 9 to 10 years of age participating in the Adolescent Brain Cognitive Development study observed that sleeping less than 9 hours per night was linked to changes in brain regions associated with depression, thought problems, and memory.⁷¹ Sleep disorders, insufficient sleep, and poor sleep habits are widespread among children and adolescents, with the prevalence of obstructive sleep apnea ranging from 1% to 3% in the pediatric population and 20% to 30% of children affected by pediatric insomnia.^72,73 The AAP clinical practice guideline on the diagnosis and management of obstructive sleep apnea advises pediatricians to screen all children for snoring and refer those who demonstrate signs of obstructive sleep apnea for polysomnography or referral to a specialist if polysomnography is not available.⁷⁴ Pediatricians may also provide guidance or referral to children and adolescents who express other sleep problems, such as difficulty going to sleep or staying asleep, excessive daytime sleepiness, awakenings during the night, or irregular wake and bedtimes.⁷⁵ Pediatricians can help support healthy sleep by encouraging children and families to provide a sleep-promoting environment, including infants and children learning to fall asleep by themselves in their own bed and following a consistent bedtime routine free of screen time, such as the “4Bs” of bathe, brush (teeth), (read) books, and bedtime.

AAP recommendations for screen use include the following guidance:

• For children younger than 18 months, discourage screen media except for interactive video chatting.

• For children 18 months to 2 years of age, encourage parents to choose high-quality programs viewed together with their children and avoid allowing children to use media by themselves.

• For children 2 to 5 years of age, limit media to 1 hour or less per day of high-quality programming.

• For children and adolescents 6 years and older, adopt an individualized Family Media Plan (www.healthychildren.org/MediaUsePlan) that outlines the boundary between screen time and other activities and can be tailored by a child’s age.⁴⁷ 

Notably, only 1 in 4 children younger than 2 years and 1 in 3 children 2 to 5 years of age meet these screen time guidelines.⁷⁶ Screen use among children and adolescents is high, with a cross-sectional analysis conducted early in the coronavirus disease 2019 (COVID-19) pandemic finding mean total daily screen use of 7.7 hours per day, an increase from 3.8 hours per day prepandemic.⁷⁷ A nationally representative sample of 1000 children and adolescents found that 32.6% of children 6 to 10 years of age and 38.8% of 11- to 17-year-olds engaged in media use classified as “problematic” based on the Problematic Media Use Measure-short form, which measures behaviors such as media preoccupation, withdrawal, and unsuccessful parental attempts to control use. Children and adolescents with parents who were employed full-time, were present at home (eg, working from home), had low levels of formal education, and had higher psychological distress were more likely to have problematic media use.⁷⁸ 

Overall, the relationship between screen time and health is complex and believed to result from a combination of factors, including screen time displacing physical activity and contributing to inadequate sleep, and exposure to food commercials impacting dietary intake and quality.⁷⁹ A systematic review of the effects of screen time on health and well-being of children and adolescents found the following:

• Moderately strong evidence of an association between increased screen time and greater risk of obesity and more significant depressive symptoms

• Moderate evidence for an association between increased screen time and increased caloric intake, decreased diet quality, and decreased quality of life

• Weak evidence for an association of increased screen time with behavior problems, anxiety, hyperactivity and inattention, poorer self-esteem, poorer well-being and poorer psychological health, metabolic syndrome, poorer cardiorespiratory fitness, poorer cognitive development and lower educational attainment, and poor sleep outcomes

• Weak evidence that small amounts of daily screen use are not harmful and may have some benefits⁷ 

Although trends of increased screen time may be challenging to reverse, the AAP Family Media Plan provides prompts to help families develop a positive approach to screen use and cope with screen use challenges. Best practices include having areas of the home that are “screen free zones,” such as bedrooms and the kitchen or dining area, and “screen free time,” such as in the 1 hour before bed or during mealtimes. These strategies facilitate improved sleep and reduced grazing or “mindless eating.” The Family Media Plan also has suggestions for balancing online and offline time to incorporate more physical activity and in-person social connections in the course of the day. These strategies improve active time, reduce sedentary time, and buffer against social and emotional mental health effects that can result from excess screen time, especially in adolescents. Prompts and strategies for digital citizenship, online safety, and manners are also included in the plan.

Evidence for and further discussion of this tailored approach to media use is described in detail in the AAP policy statement “Media Use in Children and Adolescents.”⁴⁷ The AAP partnered with AT&T to offer additional resources for families, including the online PhoneReady Questionnaire to help parents determine whether their child is ready for a cell phone, information on parental controls, and parent guides (https://screenready.att.com/digital-parenting/).

Anxiety, depression, and eating disorder symptoms are increasingly prevalent and severe among children and adolescents since the onset of the COVID-19 pandemic.^80,81 In 2021, the AAP, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a National State of Emergency in Children’s Mental Health⁸² and the Surgeon General released an advisory on youth mental health.⁸ 

Mental health and social-emotional wellness are intricately linked to other health behaviors and outcomes. Overall, there is an association between healthy dietary patterns, lower levels of depression, and improved mental health.⁸³ Physical activity is associated with lower concurrent depressive symptoms⁸⁴ and may be an effective treatment of depression for some children and adolescents.⁸⁵ In fact, a systematic review and meta-analysis of 21 studies including 2441 participants found that supervised exercise programs were associated with significant reductions in symptoms of depression among children and adolescents.⁸⁶ Depression and childhood obesity often coexist and show a bidirectional association.³⁵ High social media use is associated with higher rates of anxiety and depression, poorer sleep quality, and lower self-esteem.⁸⁷ Likewise, poor sleep is associated with multiple adverse health impacts, including mood disorders and worsened mental health.⁸⁸ 

The Surgeon General’s advisory outlined several recommendations to address youth mental health that apply to pediatricians in the clinical setting, including:

• Recognize that mental health is an essential part of overall health.

• Empower youth and their families to recognize, manage, and learn from difficult emotions.²¹ 

• Ensure that every child has access to high-quality, affordable, and culturally competent mental health care.

• Address the economic and social barriers that contribute to poor mental health for young people, families, and caregivers.⁸ 

The AAP recommends pediatricians receive education and training in depression identification and treatment, establish collaborations with community-based mental health resources, and screen adolescents 12 years and older annually for major depressive disorder using a formal screening tool on paper or electronically.⁸⁹ The US Preventive Services Task Force recommends screening adolescents 12 to 18 years of age for depression and suicide risk⁹⁰ as well as screening children and adolescents 8 years and older for anxiety disorders.⁹¹ The AAP also advises pediatricians to develop competency and efficacy in identifying and treating eating disorders, including care coordination and advocacy for access to appropriate services.⁹² Depression, anxiety, and disordered eating frequently cooccur, and the prevalence of all 3 conditions increased with the COVID-19 pandemic.^80,81,93 Delayed recognition of disordered eating in youth with obesity can result in life-threatening medical complications similar to those that occur with delayed recognition of youth who are underweight.^92,94 

At the individual and interpersonal levels, addressing existing mental health concerns and providing guidance that leads to improved nutrition, physical activity, sleep, and screen use behaviors is likely to improve social-emotional wellness and mental health among children and adolescents.

Table 1 summarizes age-based strategies pediatricians can deploy in the clinical setting to address nutrition, physical activity, sleep, screen use, and social-emotional wellness while taking into account stressors and SDOHs that may be impacting a child or family’s behaviors, routines, and physical and mental health. The central role of the family in impacting health behaviors, including material, emotional, and educational resources, should be emphasized at all ages and developmental stages and within each health behavior domain.

Children, adolescents, and their families arrive for medical care in varying stages of readiness to make behavioral changes. These stages of change have been well described in the transtheoretical model of behavioral change. In summary, they are precontemplation (not ready), contemplation (considering or ambivalent about change), preparation (planning for change in the next 6 months), action (in the process of making change), maintenance (has maintained a change for more than 6 months), and termination (change ingrained). Lapses frequently occur throughout the stages of change.⁹⁵ Pediatricians may consider assessing a child’s or family’s readiness to change and match anticipatory guidance and tailor anticipatory guidance and counseling approaches to a child’s, adolescent’s, or family’s stage of change to help a family move toward the next stage.

Motivational interviewing (MI) provides a helpful framework to guide conversations on behavioral change. The spirit and tools of MI apply across all stages of change. The spirit of MI includes 4 components: compassion, collaboration, autonomy, and evocation. It emphasizes the partnership between child or adolescent and clinician in that, ultimately, the child and family are the experts on themselves and their lives and the clinician’s role is as a guide.⁹⁶ For children and families in precontemplation, clinicians may deploy the spirit of MI by acknowledging that a child or family may not be ready for change at this time, asking for permission to provide some information (often in the form of a handout), offering to be a resource if the child or family have any questions or would like to explore further, and arranging for follow-up, at which time the clinician may reassess a child or family’s readiness for change.

MI is most effective in helping people who are ambivalent (contemplation stage) to develop increased readiness for change. MI consists of 4 processes of change: engaging, focusing, evoking, and planning.⁹⁶ Engaging consists of establishing a connection with a child or family and gaining a deeper understanding of their values and life experience. The engaging process might uncover the impacts of SDOHs on health behaviors or underlying personal or cultural beliefs surrounding nutrition or physical activity. Focusing, the second process of MI, involves selection of appropriate priorities for behavior change. In families in which several behaviors regarding nutrition, activity, sleep, or screen use might benefit from the change, focusing might include providing a menu of possible priorities for change and the family choosing one area of focus. Evoking, the third process, uses open questions, affirmations, reflective listening, and summarizing to help bring forth a person’s own internal motivation for change. Planning, the fourth process of MI, refers to pediatricians and families collaborating to create and implement an effective plan that promotes healthy, active living. At this point, families are at the preparation stage of change. Plans can involve small changes, and the emphasis should be on practical changes that are likely to be sustainable for the child and family.⁹⁶ 

MI is a learned communication approach that pediatricians can develop through training, reading, and practice.

Community settings, such as child care systems, preschools, elementary and high schools, health care settings, and a child’s local neighborhood or community significantly shape a child’s health habits. Pediatricians are able to influence these settings and help decrease rates of childhood obesity and chronic disease with a focus on food choice and behavior, physical activity, sleep, and screen use recommendations at the level of child care systems, preschools, and school systems.^97,98 The evidence for these recommendations from randomized-controlled trials has largely focused on changing individual behaviors in child care settings, schools, and homes. Only 15% of the reported obesity prevention outcomes are from community-based interventions.⁹⁹ Nevertheless, for family-level or person-level behaviors to be maintained in the broader community (outside of school and home), it will be increasingly important to consider policies that impact the community in a more general sense, such as later school start time for increasing sleep.¹⁰⁰ 

The AAP has previously published guidance on nutrition standards to support healthy school food environments.¹⁰¹ Dietary behaviors adopted in childhood track throughout life, and community-wide policies promote small but sustainable changes toward dietary patterns conducive to good health.¹⁰² Generally, these dietary patterns emphasize the consumption of vegetables, fruits, whole-grain and plant-based carbohydrates, lean proteins and dairy products, and the limited availability of sugary drinks and ultraprocessed food products.⁵³ The availability and proximity of retailers supplying sugary drinks and processed meals (fast food) in or near schools is a deterrent to the recommendations to follow a dietary pattern conducive to good health.¹⁰² Further research should include a broader range of community settings for children and adolescents who spend more time with peers and adults outside the school system (eg, in faith-based settings or work programs).

A review of interventions to reduce the consumption of sugary drinks that included 58 studies and more than 1 million individuals found the following to be effective: interpretative nutrition labeling (traffic-light labeling, nutrition rating scores), promotion of noncaloric beverages in retail, limiting availability of sugary drinks in schools and homes, not allowing government-issued food benefits (eg, SNAP) to be used for the purchase of sugary drinks, and increased purchase price of sugary drinks.¹⁰³ 

As recommended by the National Academy of Medicine, pediatricians are encouraged to advocate that children and adolescents obtain the majority of the recommended 60 minutes of physical activity per day within the school day or in a combination of activities at school and after school activities.¹⁰⁴ Pediatricians can advocate for safe places and green spaces for children in which to be active and engage in recreational physical activity. Pediatricians also can assist children to connect with community resources that support physical activity, such as local Ys, Boys and Girls Clubs of America, and municipal parks and recreation.

Policies at the federal, state, and local levels can promote or impede the efforts of children and families to pursue healthy, active lives. Pediatricians can support policies that promote healthy, active living for all children and adolescents, such as Safe Routes to School programs; Complete Streets transportation policies; school cafeteria standards, including what is available “a la carte”; policies in workplaces and communities that encourage and support breastfeeding; and policies that advance well-being in urban and rural environments. Pediatricians have an essential role in advocating for appropriate nutrition labeling on foods and beverages that pose a significant health risk to children and adolescents, such as ultraprocessed foods and sugary drinks.⁵⁶ The AAP statement on public policies to reduce sugary drinks consumption in children and adolescents details several additional strategies.⁵⁸ Moreover, pediatricians can exert pressure on food manufacturers to reformulate products to make them healthier.

In its statement on the impact of racism on child and adolescent health, the AAP recommends that pediatricians advocate for policies and partnerships to improve medical, economic, environmental, housing, judicial, and educational equity.¹⁴ Policy interventions to improve early childhood education parent support programs, urban planning and community development, housing, income enhancements and supplements, and employment are associated with improved population health and reduced health disparities.¹⁰⁵ 

In the health care setting, there should be adequate payment for preventive care services and team-based care to support guidance for healthy, active living and prevention of chronic disease in infants, children, and adolescents.

Recommendations of this clinical report to help guide pediatricians in the promotion of healthy, active living among all infants, children, and adolescents include the following:

1. Assess social determinants of health such as poverty; food insecurity; exposure to racism; trauma and toxic stress; and the built environment, including safety, walkability, green spaces, and healthy food access.

2. Assess parenting practices and baseline nutrition, physical activity, sleep, and screen use and compare with recommended levels of both quality and quantity of each behavior. When a gap exists between advised and reported behaviors, assess a child, adolescent, and family’s readiness to make a change, and work together to develop a change plan, when appropriate.

3. Use respectful, nonstigmatizing language when addressing a child or adolescent’s weight, behaviors, or need for behavioral change.

4. Learn and implement communication approaches such as motivational interviewing to help support children, adolescents, and families to make a behavioral change.

5. Be a role model for healthy patterns around nutrition, physical activity, sleep, screen use, and self-care.

6. Refer children and adolescents to community resources such as 211, Special Supplemental Nutrition Program for Women, Infants, and Children, SNAP, Cooking Matters, Ys, Boys and Girls Clubs of America, and municipal parks and recreation.

7. Support policies to eradicate racism, address SDOHs, improve nutrition, decrease intake of sugary drinks, increase physical activity, and reduce marketing of sugary drinks and foods to children and adolescents.

8. Advocate for adequate payment for preventive care service and team-based care to support guidance for healthy active living.

Pediatricians play an important role in effectively promoting healthy, active living through focused advocacy and in supporting children, adolescents, and families with healthy lifestyles while navigating the current environment. The ubiquitous presence of devices, stress, and disrupted sleep habits; food environments that do not support healthy choices; and neighborhood safety concerns that limit physical activity are very real barriers that can present an exhausting challenge as front-line pediatricians promote healthy behaviors in current society. However, the evidence shows that offering guidance in a nonjudgmental manner, knowing the many social drivers underlying family life, and providing support for positive behaviors will help to engage and encourage children, adolescents, and their families. This strategy is anticipated to help raise a healthier generation of children and prevent or mitigate chronic diseases such as childhood obesity, eating disorders, and other related comorbidities.

• CDC Adverse Childhood Experiences (ACEs) (provides information about and strategies to prevent ACEs): https://www.cdc.gov/violenceprevention/aces/index.html

• AAP Institute for Healthy Childhood Weight (provides responsive feeding, healthy/active living, and obesity prevention and treatment resources for clinicians and families): https://ihcw.aap.org

• AHRQ SDOH and Practice Improvement (list of tools to help health care organizations address SDOHs): https://www.ahrq.gov/sdoh/practice-improvement.html

• BEARS sleep screening tool (5-item sleep screening tool for sleep disorders in children and adolescents ages 2-18): https://www.med.upenn.edu/cbti/assets/user-content/documents/BEARS%20Sleep%20Screening%20Tool.pdf

• Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents: http://brightfutures.aap.org

• Childhood Obesity Cost-Effectiveness Study (CHOICES) (identifies which prevention policies and programs will help more kids achieve and maintain a healthy weight and deliver the best results for the dollars invested): https://choicesproject.org

• Choose My Plate (contains dietary recommendations to the public based on the Dietary Guidelines for Americans as well as tailored MyPlate plans): https://choosemyplate.gov

• ChopChop Family (includes resources to help kids learn to cook, recipes, ChopChop magazine, Eatable Alphabet cards, and more): https://www.chopchopfamily.org/

• Cooking Matters (a national campaign run by Share Our Strength that aims to help parents and caregivers develop skills when shopping for and cooking healthy foods on a budget): https://cookingmatters.org

• Dietary Guidelines for Americans (provides dietary recommendations for infants, children, adolescents, and adults): https://dietaryguidelines.gov

• Exercise is Medicine (contains recommendations and tools for physicians to include physical activity prescription as part of their practice): https://www.exerciseismedicine.org

• Family Media Plan (helps families select media priorities and goals to promote healthy screen use): https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx

• Family Nutrition Physical Activity Screening Questionnaire (a validated screening questionnaire that can help assess behaviors that increase risk of childhood obesity): http://www.myfnpa.org

• Food Research and Action Center (FRAC)/AAP Food Insecurity Screening Toolkit (a toolkit to help pediatricians address food insecurity): https://frac.org/aaptoolkit

• Healthychildren.org (contains dietary, activity, sleep, and screen use tips and information as well as parenting skills advice): https://healthychildren.org

• Healthydrinkshealthykids.org (an initiative of Healthy Eating Research to provide parents and caregivers and professionals resources to support healthy drinks in children ages 0–5): https://healthydrinkshealthykids.org

• Let’s Go! 5210 Questionnaire (an obesity prevention initiative that developed the 5210 anticipatory guidance and the 5210 healthy habits screening questionnaire): https://www.mainehealth.org/Lets-Go

• Physical Activity Guidelines (contains physical activity recommendations for children, adolescents, and adults): https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines

• PhoneReady Questionnaire, developed by AT&T in collaboration with the AAP (a 10-question online tool that helps parents assess whether their child is ready for the responsibilities of a cell phone): https://screenready.att.com/digital-parenting

• Problematic Media Use Measure (helps to measure indicators of screen addiction in children and adolescents): http://sarahdomoff.com/wp-content/uploads/2019/11/Domoff-et-al-2019-2.pdf

Natalie D. Muth, MD, RDN, MPH, FAAP, FACSM

Christopher Bolling, MD, FAAP

Tamara Hannon, MD, MS, FAAP

Mona Sharifi, MD, MPH, FAAP

Sarah C. Armstrong, MD, FAAP, Chairperson

Sarah E. Barlow, MD, FAAP

Claudia Fox, MD, MPH, FAAP

Jennifer Ann Groos, MD, FAAP

Matthew Allen Haemer, MD, MPH, FAAP

Fatima Cody Stanford, MD, MPH, MBA, MPA, FAAP

Joani Lea Jack, MD, FAAP, Program Chairperson

Andrew Alan Bremer, MD, PhD – National Institutes of Health

Kirk Reichard, MD, FAAP – Section on Surgery

Mala Thapar, MPH

Stephanie Womack, MA

Mark Richard Corkins, MD, FAAP, Chairperson

Cynthia Liudmilla Blanco, MD, FAAP

George Joseph Fuchs, III, MD, FAAP

Ellen S. Rome, MD, MPH, FAAP

Praveen Sundaraj Goday, MD, FAAP

Tamara S. Hannon, MD, FAAP

Amy Lynn Peterson, MD, MS, FAAP

Andrew Alan Bremer, MD, PhD – National Institutes of Health

Cheryl Funanich – US Department of Agriculture

Andrea Lotze, MD – US Food and Drug Administration

Heather Hamner, PhD, MS, MPH – Centers for Disease Control and Prevention

Cria Perrine, PhD – Centers for Disease Control and Prevention

Ana Sant’Anna, MD – Canadian Paediatric Society

Debra Burrowes, MHA

Pia Daniels, MPH, PMP

Madeline Curtis, JD

Tamar Haro

AAP

American Academy of Pediatrics

MI

motivational interviewing

SDOH

social determinants of health