Are you looking for reliable health information? Would you like to know more about health apps before you use them? The Health Science research unit of the Zurich University of Applied Sciences (ZHAW) has been commissioned by AXA healthcare to draw up scientifically-based health information and tips on a variety of health topics. It selects and evaluates apps that can provide you with support in these health issues. Please see the Methodology section below for details on how we arrive at these evaluations.
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A healthy start
Why are the first one thousand days so important?
A healthy start lays the foundation for a healthy life. That’s why the first one thousand days – the time from fertilization until the end of the second year of a child’s life – are so important. In this phase, the developing body is especially sensitive and environmental influences can trigger both positive and negative changes which manifest later in life and can be passed down over several generations [1, 2].
Over the past several years, researchers have looked intensively into the significance of life’s early years for health: There were breakthrough findings that the environment has a surprisingly large impact on which genes are activated (epigenetics), and that the composition of bacteria in the body (e.g. intestinal bacteria) influences the development of chronic diseases [3]. Here are some examples:
- Air: Air pollution in childhood influences lung function in to the adult years [4,5]
- Diet: Breast milk has a positive effect on the child’s intestinal flora and has many other beneficial effects [6]
- Environment: For prematurely born babies, a beneficial environment, particularly a strong bond with the parents, has a positive effect on the development of the child [7]
What should parents know?
Milestones: Helpful guides
Every child is different and has its own pace; nevertheless, there are a few development steps, so-called milestones, that should be kept in mind. To make sure that children develop as expected, there are recommended prevention appointments in obstetrics and pediatrics: A pediatrician checks the development and implements preventive measures, for example vaccinations or vision and hearing tests. Development steps can be of a motoric (e.g. crawling), socio-emotional (e.g. first targeted efforts to make contact), or intellectual nature (e.g. stacking up building blocks, understanding words) [8]. They help to assess early childhood development and to identify any deviations from comparative values (norm values). In this way, early support can be offered or treatment initiated.
Apps: Digital guides
But how should parents know what is important in these first weeks and months and how to protect and nurture their child? First-time parents, in particular, often turn to family members and friends, read parent guide books – and more and more frequently search the Internet for information [9]. In addition to the myriad of web pages on children’s health and development, there are various parenting apps with a wide range of functions and information.
Many parent guides follow the obvious system of “development steps”, as do most of the growing number of parenting apps. They are designed to assist parents in their role and provide information on the subjects of children’s health and development. The advantage of digital apps: Depending on the content of the app, parents have round-the-clock access to health information and tips as well as their own notes.
However, the range is expansive and complex. There are apps for specific areas of development, for example growth, or some that provide general information on children’s development and children’s diseases, while others focus on child-rearing and how to promote their development. Many parents have difficulties with the range of information and offers. Which apps are useful and which ones can you trust? The ZHAW Zurich University of Applied Sciences has researched and evaluated various free digital apps for parents. The following five apps evaluated won over the testers and were ranked as recommended.
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Tips
Every stage of development can entail new questions for parents: What does my child need? How can I encourage my child’s development? How do I deal with specific challenges? The questions often relate to growth, language development, or diet. But you shouldn’t forget to look after yourself. Here you can read tips on how to manage stress.
- Growth
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Growth and weight gain are important key figures for healthy development. Directly after birth, the child is measured and weighed for the first time, thereafter at every checkup at the pediatrician. Weight and height growth for children is described using growth curves, also referred to as percentile curves. These percentiles reflect typical growth trajectories, which have been set based on the growth data of many children [10, 11]. An acute or chronic disease can correlate with a deviation in the percentile curve. In most cases, the affected children recover from their disease and catch up through a larger growth spurt at a later time. In the case of chronic diseases, an additional therapy besides the treatment of the actual disease may be recommended to ensure the healthy development of the child. However, you do not need to measure and weigh your child every day! As a rule, the recommended checkups suffice to detect growth deviations at an early stage.
- Language development
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As a rule, children are born with everything they need to learn language. Babies communicate from day one. But at the beginning, they only have “crying” as a means of doing so. From the third month of life, babies develop increasingly complex babbling sounds, and by the 18th month, most children can say 2-10 words. Once children know 50 words, they will start to form their first two- to three-word sentences. Nevertheless, language development is a very individual process and can vary greatly even among siblings. Language development delays are detected in checkups and are treatable. Parents can encourage language development by talking or singing a lot, reading aloud, echoing the words and giving them meaning, and in this way expand the child's vocabulary [12] .
- Diet in the first year of life
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Just arrived and the baby is laid on the mother to be fed. The first drops of breast milk, colostrum, contain many nutrients and antibodies. For the first weeks of life, the baby consumes only milk. The experts agree: Breastfeeding promotes health, is clean, and low-cost, and therefore recommended. But bottle-fed babies also thrive well in Switzerland. Solid foods should be introduced from the fifth month at the earliest, but by the seventh month at the latest, since the milk can no longer cover the energy and nutrient needs of the baby. In the past, caution was advised when introducing new foods, especially if there were allergies, but today experience has shown: It is best to introduce a variety of tastes and foods in quick succession or even at the same time [13, 14] .
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Selected Apps
The Health Science research unit has evaluated a number of apps that can be helpful to you in respect of a particular health topic. The evaluation of an app is based on the following categories.
- Transparency
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A transparent app gives the potential user sufficient information on the use, objectives, costs, and data usage, along with an adequate site notice so that they can make an individual and collective usage decision.
- Expediency (incl. change in behavior)
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An expedient app contains functions that are appropriate for the envisaged purpose. The evaluation of the expediency of these apps is based on the use of recognized behavioral change techniques.
- Risk appropriateness
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A risk-appropriate app can be used without the user or those close to them being exposed to any disproportionate health, social, or economic risk. Aspects evaluated include low-risk default settings and access rights, along with information on reliability of diagnoses or recommendations.
- Ethical soundness
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An ethically sound app takes into account ethical principles valid in Switzerland as well as standards of good scientific practice. Among other things, the protection of the individual’s private sphere and the separation of advertising and content has been reviewed.
- Validity of content
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An app is deemed to have valid content if the health-related content used is trustworthy. The evaluation here focused on the separation of objective and subjective content and the transparency of the sources of content.
- Technical appropriateness
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An app is deemed to be technically appropriate if its development, operation, maintenance, and use corresponds to the latest state of technology and facilitates enduring maintainability and compatibility. Among other things, technical appropriateness was measured on the basis of technical reliability, possible operating systems, and data transfer options. Many aspects of technical appropriateness can only be evaluated and declared by the developer.
- Usability
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An app is deemed to have good usability if the software is appropriate to the target group in question and contributes to the user’s satisfaction. Aspects evaluated here include functionality, error messages, support options, and off-line usability.
- Health competence
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An app is deemed to be health-competent if the language, measurement units, and recommendations are clear and comprehensible.
- Resource efficiency
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An app is deemed to be resource-efficient if, during development, resource-efficient use has been taken into consideration, for example with regard to the use of electricity, storage capacity, or computing power. This category cannot be evaluated without prolonged use or developer information.
- Legal compliance
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An app is deemed to be legally-compliant if it guarantees compliance with the legal situation, encompassing areas such as medical product law, professional law, or data protection law of the relevant operating countries. This category is not always applicable / cannot always be evaluated, and is only scrutinized in the case of medical product apps.
App Ada
*Only a percentage of the fulfilled criteria is indicated.
**Criteria not applicable.
Language: English, German, Portuguese, Spanish, French, Kiswahili, Romanian
The focus of Ada is health. In this app, you can enter symptoms that your baby, child, or you yourself have and Ada will ask a number of questions. Ada evaluates this information using artificial intelligence and summarizes it in a report on what the cause of the symptoms could be and whether you should consult an expert.
- Advantages / Disadvantages
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Advantages:
The app is easy to use and it is always possible to enter “I don’t know” if you are unsure about one of the questions.
Disadvantages:For Ada, registration is required. Your data will be stored in a cloud within the EU. This allows you access to all your previous cases regardless of the device and to enter the course of the symptoms
App Baby+
*Only a percentage of the fulfilled criteria is indicated.
**Criteria not applicable.
Languages: German, English, French, Italian, Spanish, Portuguese, Czech, Polish, Dutch, Japanese, Russian, Turkish
In Baby+ from Philips, you can enter your baby’s information, such as his or her growth and meals. It is also possible to record memories with a diary or pictures. Moreover, the app offers a comprehensive guide, tips for activities, and an overview of the various steps in development.
- Advantages / Disadvantages
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Advantages:
The app is comprehensive and covers a lot of topics and functions.
Disadvantages:The growth curve is somewhat difficult to use and understand. If you want to securely save your data, you must create an account. By using the app, you pass on your personal data to Philips, and this data could possibly be connected with other data.
App CDC Milestone Tracker
*Only a percentage of the fulfilled criteria is indicated.
**Criteria not applicable.
Languages: English, Spanish
In the app CDC Milestone Tracker – developed by the US health authorities – the focus is on milestones in child development. After you enter your child’s/children’s date(s) of birth, you can fill out a checklist for various points in time and enter the development steps they have already achieved. What’s more, the app has an overview and tips and activities for the corresponding stage of development. You can make a summary of the milestones your child has achieved available to a specialist.
Detailed app rating CDC Milestone Tracker
- Advantages / Disadvantages
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Advantages:
The app is clearly structured and there is no transfer of personal data. It can help to document developmental delays and to discuss these with a specialist at an early stage.
Disadvantages:You cannot enter personal notes or memories.
App Kind&Essen
*Only a percentage of the fulfilled criteria is indicated.
**Criteria not applicable.
Language: German
The app Kind&Essen was developed by the Child Health Foundation in Munich. Here you will find recommendations, videos, and weekly tips on diet and exercise, tailored to the age of your child, between 12 and 36 months. You can also complete a diet and weight check for your child. In addition, the app provides information on children’s health and allergies and includes a collection of recipes. Pictures, voice recordings, and notes can also be added.
Detailed app rating Kind&Essen
- Advantages / Disadvantages
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Advantages:
The app is engaging and motivating, and covers a lot of subjects. Your data is only saved on your device and is not transferred to third parties.
Disadvantages:The app store lacks information on the app, including the disclaimer that the app does not replace a doctor’s advice.
App Parentu
*Only a percentage of the fulfilled criteria is indicated.
**Criteria not applicable.
Languages: German, Albanian, Arabic, Bosnian/Croatian/Serbian, English, French, Italian, Portuguese, Spanish, Tamil, Tigrinya, Turkish, Farsi
Parentu is made available by the Eltern-PushApp association, which receives support from foundations and the public sector. Some content is created in collaboration with cantons and municipalities. The app offers you a collection of age-specific information on the entire spectrum of childhood development from the ages of 0 to 15 years. To use the app, you must enter the birth date of your child and the postcode of your place of residence. The app’s default settings are predefined so that you receive push notifications with tips and information on various age-specific development steps and local events. You can also deactivate this under “Settings”. By entering the postcode, local assistance services can be shown.
- Advantages / Disadvantages
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Advantages:
The app is available in all Swiss national languages and in 10 additional languages. The data recorded in the app cannot be traced back to the user.
Disadvantages:Although there are no appreciable disadvantages with this app, there were deductions in the app ratings because its description in the app store contains little information regarding transparency and risk suitability.
The content on the subject of children’s health was scientifically compiled by the ZHAW. The commission for this and the financing was provided by AXA.
Methodology – evaluation and selection
- How did we arrive at the app criteria?
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Where the catalog of criteria for the evaluation of apps is concerned, we have focused on three key resources.
- “Einheitlichen Kriterienkatalog zur Selbstdeklaration der Qualität von Gesundheits-Apps” (Standardized catalog of criteria for self-declaration of quality of healthcare apps)
This catalog by ehealthsuisse, the relevant center of competence and coordination for the Confederation and cantons in Switzerland, formulates nine categories for quality review, of which we have used seven for the purposes of our evaluation criteria. The two criteria not taken into account were “resource efficiency” and “legal compliance”, as these are only partially applicable or reviewable. The category “health competence” was newly created by the Health Science research unit.
- APPKRI-Kriterien für Gesundheits-Apps” [APPKRI criteria for health apps”], drawn up by the Fraunhofer Institute for Open Communication Systems
These app evaluation criteria have been developed on behalf of the Federal Ministry of Health in Germany. This meta-criteria catalog currently encompasses 290 criteria and forms the basis for our evaluation criteria. The ZHAW research team has identified 56 criteria as key to the app evaluation process.
- “The behavior change technique taxonomy” by Susan Michie and colleagues [15]
One focus of our app evaluation is the techniques of behavior change. When evaluating the “Expediency” category, the 93 behavior techniques of this taxonomy were reviewed for their use in the app. For example, the display of duration of relaxation exercises by an app constitutes a form of “behavior feedback” and therefore a recognized behavior change technique.
- How have we evaluated the app criteria?
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- The criteria have been evaluated with yes (applies) or no (does not apply) and irrelevant. The evaluations of the individual criteria for each app are available in PDF form.
- The bar charts correspond to the percentage proportions of the criteria per category that were evaluated with a “yes” or “no”. Only applicable criteria are used in the calculation.
- The stars correspond to the aggregated total of the criteria answered with “yes” across all categories, e.g. four stars means that 80% of the evaluated criteria were answered with “yes”.
- How did we arrive at our app selection?
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We identified apps through the program 250 using topic-specific search terms. On the basis of various features we then made a pre-selection from the large pool of apps identified. The apps that you can find on the website also reflect the multiplicity of methods and approaches common in the healthcare area.
Selected apps had to…
- be offered both for the iOS and Android operating systems,
- exhibit a full site notice,
- only request access to the personal data needed for use of the app,
- require no additional hardware.
- clearly define the goal achievable through use of the app in the App Store,
- References
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- Gluckman PD, Buklijas T, Hanson MA. Chapter 1 - The Developmental Origins of Health and Disease (DOHaD) Concept: Past, Present, and Future. In: Rosenfeld CS, Hrsg. The Epigenome and Developmental Origins of Health and Disease. Boston: Academic Press; 2016: 1–15. https://doi.org/10.1016/B978-0-12-801383-0.00001-3
- Wadsworth MEJ, Kuh D. Epidemiological Perspectives on the Life Course. In: Shanahan MJ, Mortimer JT, Johnson MK, Hrsg. Handbook of the Life Course. Springer International Publishing; 2016: 639–659. https://doi.org/10.1007/978-3-319-20880-0_28
- Stiemsma LT, Michels KB. The Role of the Microbiome in the Developmental Origins of Health and Disease. Pediatrics 2018; 141. https://doi.org/10.1542/peds.2017-2437
- Zemp E, Elsasser S, Schindler C, et al. Long-Term Ambient Air Pollution and Respiratory Symptoms in Adults (SAPALDIA Study). Am J Respir Crit Care Med 1999; 159: 1257–1266.
- Cai Y, Hansell AL, Granell R, et al. Prenatal, Early-Life, and Childhood Exposure to Air Pollution and Lung Function: The ALSPAC Cohort. Am J Respir Crit Care Med 2020; 202: 112–123.
- Horta BL, World Health Organization. Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva: World Health Organization; 2007.
- Puthussery S, Chutiyami M, Tseng P-C, et al. Effectiveness of early intervention programs for parents of preterm infants: a meta-review of systematic reviews. BMC Pediatr 2018; 18: 223. https://doi.org/10.1186/s12887-018-1205-9
- Lindenberger U. Entwicklungspsychologie. 69 469 Weinheim: Beltz Verlagsgruppe. http://www.content-select.com/index.php?id=bib_view&ean=9783621286237
- Jaks R, Baumann I, Juvalta S, et al. Parental digital health information seeking behavior in Switzerland: a cross-sectional study. BMC Public Health 2019; 19: 225. https://doi.org/10.1186/s12889-019-6524-8
- Schweizerische Gesellschaft für Pädiatrie (ssp, sgp). Wachstumskurven. Empfohlen von der Schweizerischen Gesellschaft für Pädiatrie. Im Internet: (Zugriff am 22.03.2021).
- WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP, Onis, Mercedes de. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatrica 2006; 95: 76–85. doi:https://doi.org/10.1111/j.1651-2227.2006.tb02378.x
- Bockmann A-K, Sachse S, Buschmann A. Sprachentwicklung im Überblick. In: Sachse S, Bockmann A-K, Buschmann A, Hrsg. Sprachentwicklung: Entwicklung – Diagnostik – Förderung im Kleinkind- und Vorschulalter. Berlin, Heidelberg: Springer; 2020: 3–44. https://doi.org/10.1007/978-3-662-60498-4
- Bundesamt für Lebensmittelsicherheit und Veterinärwesen BLV, Schweizerische Gesellschaft für Ernährung SGE, Schweizerische Gesellschaft für Pädiatrie SGP. Einführung der Lebensmittel beim Säugling. 2018. Im Internet: (Zugriff am 22.03.2021)
- Kersting M, Schweizerische Gesellschaft für Pädiatrie (ssp, sgp). Empfehlungen für die Kleinkindernährung im Alter von1 bis 3 Jahren. 2017. Im Internet: Zugriff am 22.03.2021)
- Michie, Susan, Michelle Richardson, Marie Johnston, Charles Abraham, Jill Francis, Wendy Hardeman, Martin P. Eccles, James Cane, und Caroline E. Wood. „The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions“. Annals of Behavioral Medicine 46, Nr. 1 (August 2013): 81–95. https://doi.org/10.1007/s12160-013-9486-6