Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.
com
Review
1
University of Glasgow Division
of Developmental Medicine,
Yorkhill Hospitals, Glasgow,
Scotland; 2 University of
Glasgow Institute of Biomedical
and Life Sciences, Glasgow,
Scotland; 3 Queen Margaret
University, Edinburgh, Scotland
Correspondence to:
Professor John J Reilly,
University Division of
Developmental Medicine, 1st
Floor Tower Block QMH, Yorkhill
Hospitals, Glasgow G3 8SJ,
Scotland; jjr2y@clinmed.gla.ac.
uk
Accepted 6 February 2008
Published Online First
27 February 2008
614
Objective measurement of physical activity and
sedentary behaviour: review with new data
J J Reilly,1 V Penpraze,2 J Hislop,3 G Davies,1 S Grant,2 J Y Paton1
ABSTRACT
Objective methods are being used increasingly for the
quantification of the amount of physical activity, intensity
of physical activity and amount of sedentary behaviour in
children. The accelerometer is currently the objective
method of choice. In this review we address the
advantages of objective measurement compared with
more traditional subjective methods, notably the avoid-
ance of bias, greater confidence in the amount of activity
and sedentary behaviour measured, and improved ability
to relate variation in physical activity and sedentary
behaviour to variation in health outcomes. We also
consider unresolved practical issues in paediatric accel-
erometry by critically reviewing the existing evidence and
by providing new evidence.
It is becoming increasingly clear that variations in
physical activity and sedentary behaviour are of
enormous importance to the current and future
health of children and adolescents.1 2 Sedentary
behaviour is not simply the absence of physical
activity, but involves purposeful engagement in
activities that involve minimal movement and low
energy expenditure.3 4 Increased awareness of the
importance of physical activity and sedentary
behaviour, combined with technological advances
that have improved our ability to measure these
variables in free-living children, have led to
increased interest in paediatric physical activity
and sedentary behaviour.
While subjective methods for measurement of
physical activity and sedentary behaviour will
continue to provide useful evidence on the context
of these behaviours, and on the subjective percep-
tion of these behaviours by study participants,
objective methods are now being regarded as
optimal for quantification of the amount and
intensity of physical activity and amount of
sedentary behaviour. Recent reviews have con-
cluded that accelerometry (motion sensing) pro-
vides an objective, practical, accurate and reliable
means of quantifying the amount (‘‘volume’’) and
intensity of habitual physical activity and the
amount of sedentary behaviour in children.5–10
These reviews also highlighted research needs,
but did not consider the advantages of using
accelerometry for quantifying the amount and
intensity of physical activity compared with
traditional alternative methods (such as question-
naires), and these advantages are not widely
appreciated beyond the research community using
accelerometry at present. In addition, the recent
reviews on accelerometry have highlighted uncer-
tainty over several fundamental practical issues
concerning the optimum approach to using
accelerometers in children, but did not provide
new evidence to address this uncertainty or make
evidence-based recommendations that might
resolve these practical problems. This review, based
on a synthesis of evidence cited in recent reviews of
accelerometry,5–10 combined with new empirical
studies and secondary analysis, therefore aims to:
1. Make the case for objective measurement of
physical activity in children, using examples
from studies published recently.
2. Provide new evidence to address the uncer-
tainty over practical issues in accelerometry.
IMPORTANCE OF OBJECTIVE MEASURING
METHODS
Avoidance of reporting bias
Objective methods are unlikely to produce biased
measures of the amount of physical activity or
sedentary behaviour, in contrast to subjective self
or proxy reports, which are the traditional methods
of measuring physical activity in children and
adolescents.
Children (or their families) involved in lifestyle
modification-intervention studies have a tendency
to over-report their physical activity, with the
result that interventions may favour the interven-
tion group; objective measures of physical activity
made on the same children have suggested that
such differences can be spurious.11 12 Biases of this
kind should be expected — children and families
involved in dietary interventions tend to report
their intake in a biased manner, under-reporting in
obesity-prevention studies, for example, while
over-reporting intake of energy in trials aimed at
increasing energy intake.12 13 Assessment of inter-
ventions aimed at physical activity and sedentary
behaviour change should therefore use objective
methods,11 both to confirm that apparent changes
in physical activity are real and to quantify the
magnitude of any change with confidence.
The problem of biased self-reporting of amount
and intensity of physical activity using subjective
methods – such as questionnaires — almost
certainly extends to observational studies and
surveys of physical activity in children carried out
for surveillance purposes. In the United Kingdom,
national surveillance of paediatric physical activity
in health surveys still involves subjective (parental)
reporting of physical activity and is associated with
relatively high apparent levels of physical activity.
In the Scottish Health Survey 2003, for example,14
.75% of 6–10 year olds were reported to exceed
the public health target1 2 of an accumulated
60 min of moderate to vigorous physical activity
(MVPA) per day every day, but recent UK studies
that have measured MVPA by accelerometry
Arch Dis Child 2008;93:614–619. doi:10.1136/adc.2007.133272
 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com
suggest that ,5% of children and adolescents meet this
target.15–17 Subjective measures appear to quantify the percep-
tion of physical activity, rather than physical activity per se, and
current methods for national surveillance of the amount and
intensity of habitual physical activity in the United Kingdom
may provide a false sense of reassurance concerning population
levels of physical activity.
Objective measurements of physical activity in children and
adolescents have often produced counter-intuitive results,
confirming the value of accelerometry. For example, interven-
tions designed to promote physical activity such as walking to
school and increasing the time allocated to school or pre-school
physical education have been reported to be unrelated to total
physical activity (as measured objectively by accelerometry18–20).
Promotion of active transport to school and increasing physical
education may seem strategies that are so obviously effective at
increasing physical activity as to not require evaluation, but the
empirical evidence suggests that objective evaluation is essen-
tial.
Improved understanding of relationships between physical
activity, sedentary behaviour and health
Accelerometry has the potential to improve our understanding
of relationships between physical activity and health. For
example, recent systematic reviews have concluded that
relationships between childhood physical activity and obesity
were unclear, largely because older studies (which used
subjective methods) were unable to quantify physical activity
adequately.21 Recent accelerometry studies have identified
relationships between physical activity, sedentary behaviour,
obesity and cardiovascular risk factors, in part because physical
activity and sedentary behaviour have been measured with
higher accuracy and precision using accelerometry.17 22 In
addition, because accelerometers provide data on amount and
intensity of activity, the methodology allows investigation of
‘‘dose–response’’ relationships between health and physical
activity, providing important practical evidence that can be
used to produce clinical or public-health recommendations with
much greater confidence and which are quantitative.17
Discrepancies in findings from objective versus subjective
methods
Accelerometry can provide insights that are not available from
traditional self-reporting of physical activity in observational
studies. For example, the influence of socio-economic status on
child or adolescent physical activity is topical. Some recent UK
studies that used self or parent reports23 24 found significant
socio-economic differences in physical activity and/or sedentary
behaviour. In contrast, recent UK accelerometry studies have
found no significant differences between socio-economic
groups.16 25–27
AREAS OF UNCERTAINTY IN ACCELEROMETRY: EVIDENCE-
BASED ANSWERS TO COMMON PRACTICAL QUESTIONS
Choice of accelerometer
The first practical issue facing users of accelerometry is which
accelerometer to use. A recent systematic review found that the
device most widely used, the MTI Actigraph (MTI, Florida), is
also the device that has the greatest body of consistent and
high-quality evidence to support its use:5 it is feasible, reliable
and valid. In addition, there is a large body of evidence on
‘‘calibration’’ of the Actigraph. Accelerometers produce output
in counts per unit time (epoch), but these counts have no
Arch Dis Child 2008;93:614–619. doi:10.1136/adc.2007.133272
Review
biological meaning per se and must be converted to biological
constructs such as MVPA or sedentary behaviour by empirical
studies of their relationships to energy expenditure or direct
observation of activity or some health outcome such as bone
health in ‘‘calibration studies’’.3 28 29 Supportive validation and
calibration evidence is emerging for devices other than the
Actigraph, and the field of accelerometry changes rapidly.
Table 1 summarises the accelerometers used in paediatric
studies and provides access to manufacturer’s websites for
further information, including technical details relating to the
devices and references to primary literature.
A variety of important methodological issues confront users
of accelerometry: these are summarised in table 2. The evidence
base that addresses some of these issues is limited and
contentious, and we address three issues below by providing
new empirical evidence. The practical approaches to accelero-
metry taken should be fully described in future studies, a
practice that a previous review noted has not been common.30
Choice of epoch
Older accelerometry studies have tended to use 1-minute
sampling intervals (epochs). It is widely believed that shorter
epochs would be more appropriate in children because of the
perception that children’s patterns of physical activity are
highly intermittent, based on a single study31 in which 15 6-to-
10 year olds were observed over 3 days. More recent studies
using direct observation and heart-rate monitoring to measure
patterns of physical activity in children suggest a much more
sedentary pattern of behaviour with limited physical activity
and patterns of physical activity much more like adults.32 33 If
children do undertake high-intensity activity only in very short
bouts, ‘‘long’’ epochs of around 1 min might mis-classify high-
intensity activity as being of lower intensity, by averaging with
bouts of lower intensity activity within the same epoch.
Only two empirical studies appear to have addressed this
issue. Rowlands et al34 compared apparent intensities of activity
measured with 1 sec and 60 sec epochs with the RT3
accelerometer in 25 7-to-11 year olds over 1 h. Rowlands et al
reported that differences between the two epochs were
minimal, affecting only ‘‘very hard’’ intensity activity (mis-
classified as ‘‘hard’’).34 Nilsson et al35 found no significant effect
of epoch on amounts of light and moderate intensity physical
activity with the Actigraph in 16 7 year olds, although vigorous
intensity activity was misclassified as moderate intensity to
some extent in the longer epochs. One practical solution to this
potential problem when using longer epochs is to classify
moderate and vigorous activity together, as MVPA:15 this is also
biologically and clinically meaningful because public-health
targets for physical activity in children and adolescents are
currently expressed in terms of MVPA.1 2
To add to the evidence base on the question of epoch using
the Actigraph, we undertook a secondary analysis of existing 7–
10 day accelerometry data from 32 free-living children (age 5
and 6 years) using the same methods adopted by Nilssen et al:34
data from a previous study, originally saved in 15 sec epochs but
reported using 60 sec epochs,15 were reintegrated in 15, 30, 45
and 60 sec epochs. We then expressed MVPA using the cut-
points of Puyau et al.29 and sedentary behaviour using the cut-
point derived from our previous calibration study3 for data
summarised in the four epochs. The results are shown in
figure 1. We found that the differences between the epochs for
sedentary behaviour were not statistically significant. For
MVPA, the differences were significant statistically, but the
differences were small, consistent with the other two studies to
615
 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com

Review

Table 1 Accelerometers used in published paediatric studies*

Accelerometer Manufacturer Website Type Size Weight

Actigraph Actigraph LLC, www.theactigraph.com Uniaxial 38637618 mm 27 g

(Previously CSA Pensacola, FL, USA
and MTI. Current
model is GT1M)
Actiheart Cambridge www.camntech.com Uniaxial 33 mm diameter 10 g
Neurotechnology, 67 mm, connected to
Cambridge, UK smaller sensor by wire
Actical Mini-Mitter, Bend, www.minimitter.com Omni-directional 28627610 mm 17 g
OR, USA
Actitrac Individual Monitoring www.imsystems.net Biaxial 37655612 mm 23 g
Systems, Baltimore,
MD, USA
ActivTracer GMS, Tokyo, Japan Triaxial 70650615 mm 57 g
Actiwatch Mini-Mitter, Bend, www.minimitter.com Omni-directional 28627610 mm 16 g
OR, USA
BioTrainer Pro Individual Monitoring www.imsystems.net Biaxial 76651619 mm 51 g
Systems, Baltimore,
MD, USA
Caltrac Muscle Dynamics www.muscledynamics.net Uniaxial 70670620 mm 78 g
Fitness Network,
Torrance, CA, USA
Kenz Lifecorder Suzuken Co. Ltd, www.suzuken.co.jp Uniaxial 62646626 mm 42 g
Nagoya, Japan
Mini-logger Series Mini-Mitter, Bend, www.minimitter.com Omni-directional 120665622 mm 125 g
2000 OR, USA
Mini-Motionlogger Ambulatory Monitoring, www.ambulatory-monitoring. Triaxial 44633610 mm 57 g
Inc, Ardsley, NY, USA com
TriTrac R3D Professional Products, No longer available (see RT3) Triaxial 108668633 mm 170 g
Madison, WI, USA
RT3 Stayhealthy Inc., www.stayhealthy.com Triaxial 71656628 mm 65 g
Monrovia, CA, USA
Tracmor2 Philips Research, Not commercially available Triaxial 7062868 mm 30 g
Eindhoven, The
Netherlands
*Details of published paediatric studies, papers or abstracts, using these devices can be obtained from manufacturer’s websites or
from the corresponding author.

address this question summarised above. The biological
significance of the differences in MVPA observed is unclear.
In summary, despite a widespread perception that shorter
epochs are essential to measure physical activity in children, the
empirical evidence on the topic is limited and does not support
the notion that ‘‘short’’ epochs are essential. One exception to
this conclusion might be in circumstances where the outcome of
interest is vigorous intensity physical activity.
Effect of different accelerometry cut-points on apparent levels of
physical activity and sedentary behaviour
To measure the amount of sedentary behaviour (no trunk
movement, largely consisting of time spent seated3) and the
amount of time in activities of moderate to vigorous intensity
(equivalent to energy expenditures above around three times
their energy expenditure at rest), accelerometry counts are
interpreted using cut-points derived from calibration studies for
the reasons noted above. There is currently enormous variation
in practice between researchers in the use of cut points, and
widespread use of cut-points derived from adult studies, from
the manufacturers of accelerometers (with provenance
unknown), from calibration studies (which set out to derive
cut-points) and observational studies (which simply report
mean cut-points during particular activities).
The first practical issue to consider is whether meaningful
differences in the amount of measured MVPA and sedentary
behaviour arise from the use of the different cut-points. This
question has not been examined systematically to date. For the
present review we have re-analysed previously published data15
from CSA Actigraph accelerometry in 72 children (31 boys: 41
girls: mean age 5.8, SD 0.5 years) studied over 7 days (mean
10.5 h/day: SD 1.1). We took the data set and applied three
commonly used cut-points for MVPA: Puyau et al29 from a
calibration study based on free-living energy expenditure in 26
6–14 year olds; the Trost/Freedson cut-point36, apparently based
on extrapolation from adult treadmill data, and age-dependent
(for our sample MVPA was defined as a cut-point of 630 cpm);
Treuth et al37 from a calibration study based on free-living
energy expenditure in 74 13–14 year old girls, cut-off 3000 cpm.
The effect of the three different cut-points on min/day and % of
daily time in MVPA are shown table 3. For sedentary behaviour
we took the same approach, comparing the three most popular
cut-points from calibration studies in the literature: 800 cpm
from the study of Puyau et al;29 1100 cpm from the study of
Reilly et al3 from a study in which accelerometry was calibrated
to sedentary behaviour (measured by direct observation);
Treuth et al,37 100 cpm, based on an energy-expenditure study
in 64 13–14 year-old girls. Table 3 shows statistically and
biologically significant differences in amounts of sedentary
behaviour and MVPA when the various cut-points were applied
to the same data.
These new findings illustrate the extent to which engage-
ment in MVPA and sedentary behaviour is dependent on the
cut-point applied to the data and provide evidence as to the
magnitude of the differences that can be expected. This leads to
the question of which cut-points are most appropriate. Several
lines of evidence are relevant to this question. First, biological
plausibility — is it plausible that children engage in .4 h/day

616 Arch Dis Child 2008;93:614–619. doi:10.1136/adc.2007.133272

 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com

Review

Table 2 Evidence-based answers to common practical questions in Table 3 Effect of different cut-points on sedentary behaviour and
paediatric accelerometry moderate to vigorous intensity physical activity (MVPA) in 72 4-to-7
Question Evidence Reference cited/ comments year-olds: mean minutes per day* (95% CI)
Puyau et al28 Reilly et al3 Treuth et al36 Trost/Freedson35
How much monitoring is 3–7 days desirable 43; number of days and hours
necessary for stable per day need to be Sedentary 448 501 180 N/A
measures of physical determined for each setting behaviour (95% CI 441 (95% CI 488 (95% CI 167
activity and sedentary and application to 461) to 514) to 198)
behaviour? MVPA 28 N/A 41 266
Where should the Right-hip placement 3 5–9 (95% CI 27 (95% CI 33 (95% CI 254 to 281)
accelerometer be evidence-based, to 33) to 48)
placed? alternative placements
need justification and *Differences between MVPA and sedentary behaviour significant between all cut-
greater evidence points (p,0.01 in all cases). Cut-points per min for sedentary behaviour: 650 (Treuth
et al36); 800 (Puyau et al28); 1100 (Reilly et al3). Cut-points per min for MVPA: 630
What activity sampling Lack of evidence See later in this review; the
(Trost/Freedson35); 3000 (Treuth et al36); 3200 (Puyau et al28).
interval (epoch) should effect of epoch smaller than
be used? is appreciated
Which cut-points(s) Wide variation in See text; critique of existing counting).32 33 Second, what is the nature and quality of the
should be used to practice; implications of evidence and new evidence
convert accelerometry using different cut-points provided
evidence on paediatric cut-points? We make a marked distinc-
output to physical not widely appreciated tion between calibration versus observational studies.
activity and sedentary Calibration studies aim specifically to determine the most
behaviour, and to what appropriate cut-points by relating accelerometry output to
extent does it matter?
How should data be Collection of additional 5–9
energy expenditure and/or direct observation of movement, and
reduced and information, eg, parent with the most appropriate statistical analysis used to calculate
interpreted ? or child log-sheets the ‘‘diagnostic accuracy’’ of various cut-points. By contrast,
Missing data helpful. Distinct lack of
consistency in practice;
observational studies simply describe typical accelerometry
Strings of zeros output for a given activity, and typical output may not
greater transparency in
methods would be represent the optimal diagnostic cut-point to identify that
helpful activity when the child is free-living, particularly given the
Are cut-points age Lack of empirical New evidence in present text
dependent? evidence in children suggests that cut-points are
marked variation in accelerometry output that exists between
largely independent of age individuals for the same activity.3 38 39 A hierarchy of calibration
Uniaxial measurement Theoretical advantage 5–9 studies exists; the calibration evidence that is most applicable to
in (vertical plane) to tri-axial accelerometry. free-living activity in children will come from paediatric studies
Or bi-axial (two planes) Empirical evidence shows
no improvement in
where children participate in a range of usual activities. Cut-
Or tri-axial points on the basis of adult data, or extrapolated from adult or
accuracy with tri-axial
accelerometry?
systems treadmill data, should be viewed with caution: biomechanics of
(all three planes)?
movement differ between treadmill and non-treadmill move-
ment and cut-points differ markedly between treadmill and
MVPA, a common observation in studies which use low cut- non-treadmill-based calibration studies.40 Cut-points should also
points to define MVPA (table 3 summarises data using the be based on published studies so that their provenance can be
Trost/Freedson cut-point36)? This seems implausible to us given considered critically. Finally, the mass and consistency of
secular trends of increased fatness of children, even among non- evidence is important: confidence in cut-points requires a mass
obese children,11 evidence from accelerometry carried out of high quality and consistent evidence from published
simultaneously with total energy expenditure measured using paediatric calibration studies. Current evidence from high-
doubly labelled water,15 (where both methods independently quality calibration studies in children and adolescents is fairly
suggested that MVPA was low), and other evidence suggesting consistent in suggesting that the most appropriate cut-point
that MVPA is low in children from studies using direct when using the Actigraph, with 1 min epochs, lies in the range
observation, heart rate monitoring and pedometry (step 3000–3600 counts/min.29 37 41 42

Figure 1 (A) Minutes per day in

sedentary behaviour in 32 5 and 6 year
olds with data expressed in 15, 30, 45
and 60 sec epochs. No significant
difference between epochs (Kruskal
Wallis, p = 0.907). (B) Minutes per day in
moderate to vigorous physical activity
(MVPA) in 32 5 and 6 year olds, with data
expressed in 15, 30, 45 and 60 sec
epochs. Differences between categories
are statistically significant (Kruskal Wallis
test followed by paired Mann–Whitney
tests, p,0.01 in all cases), ranging from
median of 28 min/day (interquartile range
19 to 42) to 17 minutes per day (inter-
quartile range 10 to 28) at 15 and 60 sec
epochs, respectively.

Arch Dis Child 2008;93:614–619. doi:10.1136/adc.2007.133272 617

 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com
Review
Effect of age on accelerometry output
A concern among users of accelerometry in children and
adolescents is the possibility that accelerometry output may
vary systematically with age, as a result of age-related changes
in height or weight, or biomechanics of movement.7 This
important practical issue has not been studied systematically in
children. If accelerometry output was fairly independent of
body size or age then the practical utility of the method would
be enhanced, since there would be no need to adjust output for
age/size. To address this gap in the literature, we conducted a
study in which we recruited 108 children in three distinct age
groups (3–4 years n = 35; mean height 1.08 m, mean weight
18.8 kg), 5–8 years (n = 42; mean height 1.20 m, weight
34.1 kg), 9–10 years (n = 31; mean height 1.40 m, weight
37.1 kg) who were participating in 45–55 min physical activity
classes at the University of Glasgow. The work had ethics
approval from the Yorkhill Hospitals Research Ethics
Committee, and informed written consent was obtained. We
observed children while they undertook a wide range of
activities during the classes and quantified the intensity of
movement using direct observation with the ‘‘Children’s
Physical Activity Form’’ (CPAF).3 During the classes participants
wore the Actigraph accelerometer at the right hip and
accelerometry output data were collected in 1 min epochs. We
synchronised our 1 min epochs from the CPAF with the
Actigraph accelerometer by video recording the classes and
setting the camera and accelerometer time to the PC clock. We
then extracted epochs, on the basis of direct observation, which
were entirely sedentary (CPAF category 1, stationary with no
trunk movement) such as watching TV or moderate intensity
(CPAF category 3, movement of the trunk at low-moderate
speeds) such as ball games. Even with three groups of children
who differed so markedly and significantly in height, weight
and age, we found no evidence of systematic variation in
accelerometry output across the three groups during either
sedentary behaviour or MVPA. Mean (SD) accelerometer
output was 666 cpm (418), 716 (694) and 607 (515) during
sedentary behaviour in the groups from youngest to oldest
respectively. During CPAF-classified moderate intensity physi-
cal activity, mean (SD) accelerometry output was 2650 (841),
2524 (688) and 2688 (773) from youngest to oldest groups
respectively.
The present study therefore suggests that accelerometry
output (at least with the Actigraph) has little age- or size-related
systematic variation for the same behavioural input across a
wide age/size range (3–10 years in the present study). This
observation should increase the practical utility of the metho-
dology by simplifying data interpretation.
CONCLUSIONS
Accelerometry now provides a practical, reliable and valid
means of quantifying the amount and intensity of physical
activity, and amount of sedentary behaviour, in children. For
most applications where the amount and intensity of physical
activity is of interest, accelerometry will offer a marked
improvement over more traditional methods. Use of accelero-
metry should avoid bias in physical activity measurement and
should improve our understanding of relationships between
physical activity, sedentary behaviour and health. While a
degree of uncertainty remains over certain practical issues,
evidence-based accelerometry measurement protocols are now
available.
618
Acknowledgements: The research referred to in the present review was funded by a
variety of bodies including Sport Aiding Medical Research for Kids, the University of
Glasgow Chancellors Fund, and the Scottish Executive Health Department. We thank
the parents and children for their enthusiastic participation. We also thank the
University of Glasgow Active Play Programme and Mr J Penman in particular for help
with the study of the effect of age on accelerometry output.
Competing interests: None.
REFERENCES
1. Strong WB, Malina RM, Blimkie CJR, et al. Evidence-based physical activity for
school-age youth. J Pediatr 2005;146:732–7.
2. Department of Health. At least five a week. Evidence on physical activity and its
relationship to health. A report from the Chief Medical Officer. London: Department of
Health, 2004 http://tinyurl.com/332mf (accessed 4 April 2008).
3. Reilly JJ, Coyle J, Kelly LA, et al. An objective method for measurement of
sedentary behavior in 3–4 year-olds. Obes Res 2003;11:1155–8.
4. Biddle SJ, Gorely T, Marshall JJ, et al. Physical activity and sedentary behaviours in
youth issues and controversies. J Roy Soc Health 2004;124:29–33.
5. De Vries SI, Bakker I, Hopman-Rock M, et al. Clinimetric review of motion sensors in
children and adolescents. J Clin Epidemiol 2006;56:670–80.
6. Rowlands AV. Accelerometer assessment of physical activity in children: an update.
Pediatr Exerc Sci 2007;19:252–66.
7. Oliver M, Schofield GM, Kilt GS. Physical activity in pre-schoolers: understanding
prevalence and measurement issues. Sports Med 2007;32:1045–70.
8. Corder K, Brage S, Ekelund U. Accelerometers and pedometers: methodology and
clinical application. Curr Op Clin Nutr Metab Care 2007;10:597–603.
9. Ward DS, Evenson KR, Vaughn A, et al. Accelerometer use in physical activity: best
practices and research recommendations. Med Sci Sports Exerc 2005;37:s582–8.
10. Trost SG. State of the art reviews: measurement of physical activity in children and
adolescents. Am J Lifestyle Medicine 2007;1:299–314.
11. Reilly JJ. Tackling the obesity epidemic: new approaches. Arch Dis Child
2006;91:724–6.
12. Caballero B, Clay T, Davis S, et al. Pathways: a school-based randomized controlled
trial for the prevention of obesity in American Indian school children. Am J Clin Nutr
2003;78:1030–8.
13. Poustie VJ, Russell JE, Watling RM, et al. Oral protein-energy supplements for
children with cystic fibrosis. Br Med J 2006;332:632–6.
14. Scottish Executive. Scottish health survey 2003: Summary of key findings.
Edinburgh: Scottish Executive The Stationery Office, 2005.
15. Reilly JJ, Montgomery C, Jackson D, et al. Total energy expenditure and physical
activity in young Scottish children: mixed longitudinal study. Lancet 2004;363:211–2.
16. Riddoch CJ, Mattocks C, Deere K, et al. Objective measures of levels and patterns
of physical activity. Arch Dis Child 2007;92:963–7.
17. Ness AR, Leary SD, Mattocks C, et al. Objectively measured physical activity and fat
mass in a large cohort of children. PLOS Med 2007;4:e97.
18. Mallam KM, Metcalf BS, Kirkby J, et al. Contribution of physical education to
physical activity in primary school children: cross-sectional study. Br Med J
2003;327:592–3.
19. Metcalf B, Voss L, Jeffery A, et al. Physical activity cost of the school run: impact on
school children of being driven to school. Br Med J 2004;329:832–3.
20. Reilly JJ, Kelly L, Montgomery C, et al. Physical activity to prevent obesity in young
children: cluster randomised controlled trial. Br Med J 2006;333:1041–3.
21. Wareham NJ, van Sluis EMF, Ekelund U. Physical activity and obesity prevention: a
review of the current evidence. Proc Nutr Soc 2005;64:229–47.
22. Andersen LB, Nacro M, Sardinha LB, et al. Physical activity and clustered
cardiovascular risk in children. Lancet 2006;368:299–304.
23. Mutunga M, Gallagher AM, Boreham C, et al. Socio-economic differences in risk
factors for obesity in adolescents in Northern Ireland. Int J Pediatr Obes 2006;1:114–
9.
24. Broedersen NH, Steptoe A, Boniface DR, et al. Trends in physical activity and
sedentary behaviour in adolescence: ethnic and socio-economic differences.
Br J Sports Med 2007;41:140–4.
25. Kelly LA, Reilly JJ, Fisher A, et al. Effect of socio-economic status on objectively
measured physical activity. Arch Dis Child 2006;91:35–8.
26. Voss LD, Metcalf BS, Jeffery AN, et al. Children’s physical activity levels are not
determined by socio-economic status. Obes Rev 2006;7(suppl 2):80.
27. Trayers T, Cooper AR, Riddoch CJ, et al. Do children from an inner city British school
meet the recommended levels of physical activity? Arch B Child 2006;91:175–6.
28. Janz KF, Gilmore JM, Levy SM, et al. Physical activity and femoral neck bone
strength during childhood: the Iowa Bone Development Study. Bone 2007;41:216–
22.
29. Puyau MR, Adolph AL, Firoz AV, et al. Validation and calibration of activity monitors
in children. Obes Res 2002;10:150–7.
30. Masse LC, Anderson CB, Mathews CE, et al. Accelerometer data reduction. Med Sci
Sports Exerc 2005;37:s544–5.
31. Bailey RC, Olson J, Pepper SL, et al. The level and tempo of children’s physical
activities: an observational study. Med Sci Sports Exerc 1995;27:1033–41.
32. Cardon G, De Bourdeauhuij I. Comparison of pedometer and accelerometer
measures of physical activity in pre-school children. Pediatr Exerc Sci
2007;19:205–14.
Arch Dis Child 2008;93:614–619. doi:10.1136/adc.2007.133272
 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com

Review

33. McKee DP, Boreham CAG, Murphy MH, et al. Validation of the Digiwalker
pedometer for measuring physical activity in young children. Pediatr Exerc Sci
2005;17:345–52.
34. Rowlands AV, Powell SM, Humphries R, et al. The effect of accelerometer epoch on
physical activity output measures. J Exerc Sci Fit 2006;4:52–8.
35. Nilsson A, Ekelund U, Yngve A, et al. Assessing physical activity among children
with accelerometers using different time sampling intervals and placements. Pediatr
Exerc Sci 2002;14:87–96.
36. Freedson PS, Sirard J, Debold E, et al. Calibration of the Computer Science
Application (CSA) accelerometer. Med Sci Sports Exerc 1997;29(suppl 1):S45.
37. Treuth MS, Schmitz K, Catellier DJ, et al. Defining accelerometer thresholds for
activity intensities in adolescent girls. Med Sci Sports Exerc 2004;36:1259–66.
38. Trost SG, Ward DS, Moorehead SM, et al. Validity of the CSA activity monitor in
children. Med Sci Sports Exerc 1998;30:629–33.
39. Ekelund U, Aman J, Westerterp K. Is the ARTEACC index a valid indicator of free-
living physical activity in adolescents ? Obes Res 2003;11:793–801.
40. Freedson P, Pober D, Janz KF. Calibration of accelerometer output for children. Med
Sci Sports Exerc 2005;37(suppl 11):s523–30.
41. Sirard JR, Trost SG, Pfeiffer KA, et al. Calibration and evaluation of an objective
measure of physical activity in preschool children. J Phys Act Health 2005;3:324–36.
42. Mattocks C, Ness A, Leary SD, et al. Calibration of an accelerometer during free-
living activities in children. Int J Pediatr Obes 2007;2:218–27.
43. Penpraze V, Reilly JJ, MacLean CM, et al. Monitoring of physical activity in young
children: how much is enough ? Pediatr Exerc Sci 2006;18:483–491.

Images in paediatrics

Necrotising fasciitis complicating

varicella
A 2-year-old girl was admitted for fever, irritability and
increasing complaint of pain and swelling in the right quadrant
of the abdomen following varicella. Physical examination
revealed a few skin lesions in various stages of evolution, and
a large (1068 cm), painful, erythematous, oedematous plaque
on the right abdomen. Over the following 2 days, the lesion
rapidly increased in size and became ulcerated. The lesion was
covered by a whitish, necrotic eschar and was delimited by
raised, reddish edges (fig 1). Fasciitis was diagnosed. Group A
beta-haemolytic Streptococcus (GABHS) was isolated from the
lesion. Repeated surgical debridements and local dressing in
addition to intensive antibiotic treatment and nutritional
support were required. The patient was discharged after
2 weeks in good health condition and with healing skin lesions.
She completely recovered within a 3-month period.
Varicella is a disease that can provoke serious complications
and long hospital stays.1 Although the risk for acquiring invasive Figure 1 Lesion on child’s right abdomen.
GABHS disease, including necrotising fasciitis, in patients with
recent varicella infection is increased,2 3 patients often experi- Competing interests: None.
ence a delay in initial diagnosis.4 Early recognition of necrotising Patient consent: Parental/guardian informed consent was obtained for publication of
fasciitis by primary care physicians is critical. It should be the child’s details in this report.
suspected in any child with a recent history of varicella infection Arch Dis Child 2008;93:619. doi:10.1136/adc.2008.141994
and an increased complaint of pain and/or swelling in any body
area, associated with increasing fever, lethargy and irritability.
REFERENCES
Fatal consequences can occur when necrotising fasciitis is 1. Marchetto S, de Benedictis FM, de Martino M, et al. Epidemiology of hospital
unrecognised or diagnosed late, and when an intensive, multi- admissions for chickenpox in children: an Italian multicenter study in the pre-vaccine
disciplinary therapeutic approach is not adopted. era. Acta Paediatr 2007;96:1490–3.
2. Eneli I, Davies HD. Epidemiology and outcome of necrotizing fasciitis in children: an
active surveillance study of the Canadian Pediatric Surveillance Program. J Pediatr
F M de Benedictis, P Osimani 2007;151:79–84.
3. Cameron JC, Allan G, Johnston F, et al. Severe complications of chickenpox in
Department of Pediatrics, Salesi Children’s Hospital, Ancona, Italy hospitalised children in the UK and Ireland. Arch Dis Child 2007;92:1062–6.
4. Brogan TV, Nizet V, Waldhausen JH, et al. Group A streptococcal necrotizing fasciitis
Correspondence to: F M de Benedictis, Department of Pediatrics, Salesi Children’s complicating primary varicella: a series of fourteen patients. Pediatr Infect Dis
Hospital, Ancona, Italy; debenedictis@ao-salesi.marche.it 1995;14:588–94.

Arch Dis Child July 2008 Vol 93 No 7 619

 Downloaded from adc.bmj.com on November 22, 2013 - Published by group.bmj.com

Objective measurement of physical activity

and sedentary behaviour: review with new
data
J J Reilly, V Penpraze, J Hislop, et al.

Arch Dis Child 2008 93: 614-619 originally published online February
27, 2008
doi: 10.1136/adc.2007.133272

Updated information and services can be found at:

http://adc.bmj.com/content/93/7/614.full.html

These include:
References This article cites 41 articles, 9 of which can be accessed free at:
http://adc.bmj.com/content/93/7/614.full.html#ref-list-1

Article cited in:

http://adc.bmj.com/content/93/7/614.full.html#related-urls

Email alerting Receive free email alerts when new articles cite this article. Sign up in
service the box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/