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Its multifactorial nature necessitates identifying key determinants influencing growth and development, particularly nutrition, parenting practices, and early childhood stimulation. This study aimed to systematically assess and quantify determinants of growth and developmental outcomes among stunted children, focusing on nutritional factors, parenting practices, and early childhood stimulation. A systematic review and meta-analysis were conducted following PRISMA guidelines. Articles published between 2015 and 2025 were retrieved from PubMed, Scopus, Web of Science, and Google Scholar. Of 1,876 records identified, 18 studies met the inclusion criteria. Data on nutrition, caregiving practices, stimulation interventions, and child growth and developmental outcomes were extracted. Random-effects models calculated pooled effect sizes. Early childhood stimulation was the most dominant determinant of improved developmental outcomes (pooled RR = 1.58; 95% CI: 1.31&ndash;1.90), followed by adequate nutrition (RR = 1.44; 95% CI: 1.21&ndash;1.71) and responsive parenting practices (RR = 1.36; 95% CI: 1.14&ndash;1.62), with moderate heterogeneity (I2 = 45%). Early childhood stimulation plays a central role in improving growth and developmental outcomes in stunted children, highlighting the need for integrated interventions combining nutrition, responsive parenting, and structured stimulation.\" } { \"@context\": \"http://schema.org\", \"@type\": \"BreadcrumbList\", \"itemListElement\": [ { \"@type\": \"ListItem\", \"position\": \"1\", \"item\": { \"@id\": \"https://f1000research.com/\", \"name\": \"Home\" } }, { \"@type\": \"ListItem\", \"position\": \"2\", \"item\": { \"@id\": \"https://f1000research.com/browse/articles\", \"name\": \"Browse\" } }, { \"@type\": \"ListItem\", \"position\": \"3\", \"item\": { \"@id\": \"https://f1000research.com/articles/15-746/v1\", \"name\": \"Determinants of Growth and Development in Stunted Children: Systematic...\" } } ] } Home Browse Determinants of Growth and Development in Stunted Children: Systematic... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Rahmadaniah I, Wisuda AC, Suraya C et al. Determinants of Growth and Development in Stunted Children: Systematic Review and Meta-Analysis of Nutrition, Parenting, and Early Stimulation [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :746 ( https://doi.org/10.12688/f1000research.178805.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Determinants of Growth and Development in Stunted Children: Systematic Review and Meta-Analysis of Nutrition, Parenting, and Early Stimulation [version 1; peer review: awaiting peer review] Indah Rahmadaniah 1,2 , Aris Citra Wisuda https://orcid.org/0000-0001-7420-1591 3 , Citra Suraya 3 , Tukimin bin Sansuwito https://orcid.org/0000-0001-7323-4308 2 , Vika Tri Zelharsandy 1 , Rinda Lamdayani 1 Indah Rahmadaniah 1,2 , Aris Citra Wisuda https://orcid.org/0000-0001-7420-1591 3 , [...] Citra Suraya 3 , Tukimin bin Sansuwito https://orcid.org/0000-0001-7323-4308 2 , Vika Tri Zelharsandy 1 , Rinda Lamdayani 1 PUBLISHED 18 May 2026 Author details Author details 1 Sekolah Tinggi Ilmu Kesehatan Abdurahman, Palembang, Palembang, 30151, Indonesia 2 School of Nursing and Applied Sciences, Lincoln University College, Malaysia, Petaling Jaya, Selangor, 47301, Malaysia 3 Nursing Study Program, Sekolah Tinggi Ilmu Kesehatan Bina Husada, Palembang, South Sumatera, 30131, Indonesia Indah Rahmadaniah Roles: Conceptualization, Funding Acquisition, Project Administration, Writing – Original Draft Preparation Aris Citra Wisuda Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Visualization Citra Suraya Roles: Conceptualization, Resources, Software, Writing – Review & Editing Tukimin bin Sansuwito Roles: Conceptualization, Supervision Vika Tri Zelharsandy Roles: Validation, Writing – Review & Editing Rinda Lamdayani Roles: Data Curation, Visualization, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Stunting remains a major global public health problem that adversely affects children’s physical growth and developmental potential. Its multifactorial nature necessitates identifying key determinants influencing growth and development, particularly nutrition, parenting practices, and early childhood stimulation. This study aimed to systematically assess and quantify determinants of growth and developmental outcomes among stunted children, focusing on nutritional factors, parenting practices, and early childhood stimulation. A systematic review and meta-analysis were conducted following PRISMA guidelines. Articles published between 2015 and 2025 were retrieved from PubMed, Scopus, Web of Science, and Google Scholar. Of 1,876 records identified, 18 studies met the inclusion criteria. Data on nutrition, caregiving practices, stimulation interventions, and child growth and developmental outcomes were extracted. Random-effects models calculated pooled effect sizes. Early childhood stimulation was the most dominant determinant of improved developmental outcomes (pooled RR = 1.58; 95% CI: 1.31–1.90), followed by adequate nutrition (RR = 1.44; 95% CI: 1.21–1.71) and responsive parenting practices (RR = 1.36; 95% CI: 1.14–1.62), with moderate heterogeneity (I 2 = 45%). Early childhood stimulation plays a central role in improving growth and developmental outcomes in stunted children, highlighting the need for integrated interventions combining nutrition, responsive parenting, and structured stimulation. READ ALL READ LESS Keywords Stunting, Child development, Nutrition, Parenting practices, Systematic review and meta-analysis. Corresponding Author(s) Aris Citra Wisuda ( [email protected] ) Close Corresponding author: Aris Citra Wisuda Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Rahmadaniah I et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions. How to cite: Rahmadaniah I, Wisuda AC, Suraya C et al. Determinants of Growth and Development in Stunted Children: Systematic Review and Meta-Analysis of Nutrition, Parenting, and Early Stimulation [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :746 ( https://doi.org/10.12688/f1000research.178805.1 ) First published: 18 May 2026, 15 :746 ( https://doi.org/10.12688/f1000research.178805.1 ) Latest published: 18 May 2026, 15 :746 ( https://doi.org/10.12688/f1000research.178805.1 ) 1. Introduction Stunting remains a major global public health problem, affecting approximately 148 million children under five years of age worldwide, with the highest prevalence observed in low- and middle-income countries. 1 , 2 Stunting is defined as chronic growth failure reflected by a height-for-age z-score below −2 standard deviations and is widely recognized as an indicator of cumulative nutritional deprivation and repeated exposure to adverse environmental conditions. 3 , 4 Beyond impaired linear growth, stunting is associated with long-term consequences, including delayed cognitive development, poorer educational achievement, reduced adult productivity, and increased risk of non-communicable diseases later in life. 5 , 6 The determinants of stunting and its developmental consequences are complex and multifactorial. Inadequate nutrition during critical periods of growth particularly during the first 1,000 days of life has been consistently identified as a primary biological driver of stunting. 7 , 8 However, nutrition alone does not fully explain the wide variation in developmental outcomes among stunted children. Socioeconomic conditions, household food insecurity, sanitation, and access to health services interact with biological factors to influence both growth and development. 9 – 11 These findings suggest that addressing stunting requires a broader, multisectoral perspective. Parenting practices represent a critical yet often underemphasized determinant of child development in the context of stunting. Responsive caregiving characterized by sensitive, consistent, and developmentally appropriate interactions has been shown to buffer the negative effects of chronic undernutrition on cognitive and socio-emotional development. 12 , 13 Studies indicate that children experiencing poor caregiving environments face compounded developmental risks, even when nutritional interventions are provided. 14 , 15 Conversely, positive parenting practices, including responsive feeding and stimulation during daily routines, can enhance developmental outcomes among growth-faltered children. Early childhood stimulation has increasingly been recognized as a dominant determinant of developmental recovery among stunted children. Neurodevelopmental research highlights early childhood as a sensitive period marked by high brain plasticity, during which stimulation through play, language exposure, and learning activities can substantially influence cognitive and psychosocial development. 16 – 18 Randomized trials and longitudinal studies demonstrate that stimulation-based interventions can significantly improve cognitive, motor, and language outcomes in stunted children, even when gains in linear growth are modest. 19 – 21 These findings underscore the importance of integrating developmental stimulation into stunting reduction strategies. Despite the growing body of evidence, existing studies vary considerably in design, population characteristics, and outcome measures, leading to inconsistent conclusions regarding the relative importance of nutrition, parenting practices, and early childhood stimulation. 22 – 24 Many previous reviews have examined these determinants in isolation, limiting the ability to identify which factors exert the strongest influence on growth and developmental outcomes in stunted children. Therefore, this systematic review and meta-analysis aims to synthesize and quantify the relative contributions of nutrition, parenting practices, and early childhood stimulation, providing robust evidence to inform integrated interventions and policies for optimizing child growth and development globally. 2. Material and methods 2.1 Study design and protocol registration This study was conducted as a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure methodological rigor, transparency, and reproducibility. 25 – 28 The review protocol was developed a priori and prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024598671. Protocol registration was undertaken to minimize selective reporting, reduce duplication, and enhance the methodological credibility of the review. The primary objective of this study was to identify and quantitatively synthesize the determinants of growth and developmental outcomes in stunted children, with particular emphasis on nutrition, parenting practices, and early childhood stimulation. The study selection process followed the PRISMA 2020 reporting framework. Details of the screening and eligibility process are presented in the PRISMA flow diagram ( Figure 1 ). The complete PRISMA 2020 checklist and all supporting materials are publicly available in the Open Science Framework (OSF) repository ( https://osf.io/c682e/ ) and its archived version at https://doi.org/10.17605/OSF.IO/GVC75 . All materials are accessible without restriction, login requirement, or embargo. Figure 1. PRISMA 2020 flow diagram of study selection process. 2.2 Search strategy A comprehensive literature search was conducted across four major electronic databases: PubMed, Scopus, Web of Science, and Google Scholar. The search covered studies published from January 2015 to March 2025. Both Medical Subject Headings (MeSH) and free-text terms were applied to capture relevant studies comprehensively. The search strategy combined the following key domains: (1) stunting and growth faltering (“stunting” OR “chronic undernutrition” OR “linear growth failure”), (2) developmental outcomes (“child development” OR “cognitive development” OR “motor development” OR “language development”), (3) determinants (“nutrition” OR “dietary intake” OR “nutritional status”), (4) caregiving factors (“parenting practices” OR “responsive caregiving” OR “feeding practices”), and (5) stimulation interventions (“early childhood stimulation” OR “psychosocial stimulation” OR “play-based intervention”). Boolean operators (AND/OR) were used to refine the search strategy. In addition, reference lists of eligible studies and relevant reviews were manually screened to identify additional records, including gray literature, to reduce publication bias. 2.3 Eligibility criteria Eligibility of studies was determined using the PICOS framework (Population, Exposure, Comparator, Outcomes, Study design). The population included children under five years of age diagnosed with stunting, defined by a height-for-age z-score (HAZ) below −2 standard deviations according to WHO growth standards. Eligible exposures included nutritional adequacy, parenting practices, and early childhood stimulation interventions. Comparators consisted of adequate versus inadequate exposure or intervention versus usual care. Outcomes of interest included growth indicators (HAZ, height gain) and developmental outcomes (cognitive, motor, language, and socio-emotional development). Randomized controlled trials, cohort studies, case-control studies, and cross-sectional studies published in English between 2015 and 2025 were included. Reviews, editorials, conference abstracts, case reports, qualitative studies, animal studies, and articles with insufficient data were excluded. 2.4 Study selection All retrieved records were imported into reference management software, and duplicates were removed prior to screening. Titles and abstracts were independently screened by two reviewers against the predefined eligibility criteria. Full-text articles were subsequently assessed for inclusion. Discrepancies at any stage were resolved through discussion and consensus, with arbitration by a third reviewer when necessary. The study selection process is presented using a PRISMA flow diagram. From 1,876 identified records, 18 studies met the eligibility criteria and were included in the final qualitative synthesis and quantitative meta-analysis. 2.5 Data extraction Data were independently extracted by two reviewers using a standardized and pilot-tested data extraction form. Extracted information included study identifiers (author, year, country), methodological characteristics (study design, sample size, duration of follow-up), participant characteristics (age, sex, severity of stunting), exposure characteristics (nutritional indicators, parenting practice measures, stimulation intervention type and intensity), outcome measures (growth and developmental domains), and key effect estimates. When multiple models were reported, the most fully adjusted estimates were extracted. Any discrepancies were resolved by consensus. 2.6 Risk of bias and quality assessment Methodological quality was independently assessed by two reviewers. Randomized controlled trials were evaluated using the Cochrane Risk of Bias 2.0 tool, assessing domains including randomization, deviations from intended interventions, missing outcome data, outcome measurement, and selective reporting. Observational studies were assessed using the Newcastle–Ottawa Scale (NOS), covering selection, comparability, and outcome/exposure domains. Studies were categorized as low, moderate, or high quality based on established scoring criteria. Disagreements were resolved through discussion. 2.7 Data synthesis and statistical analysis Quantitative synthesis was performed using Review Manager (RevMan) version 5.4 and STATA version 17. Effect sizes were summarized as risk ratios (RRs) with 95% confidence intervals (CIs). A random-effects model (DerSimonian and Laird method) was applied due to anticipated clinical and methodological heterogeneity across studies. Statistical heterogeneity was assessed using the I 2 statistic, with values of 25%, 50%, and 75% indicating low, moderate, and high heterogeneity, respectively. Subgroup analyses were conducted based on determinant type (nutrition, parenting practices, early childhood stimulation), study design, and geographic region. Sensitivity analyses were performed by sequentially excluding individual studies to assess the robustness of pooled estimates. 2.8 Publication bias Publication bias was evaluated through visual inspection of funnel plots when at least ten studies were available per outcome. Egger’s regression test was conducted to statistically assess small-study effects, with a p-value <0.05 indicating potential publication bias. 3. Results 3.1 Study selection The systematic search identified 1,876 records across four electronic databases. After removal of 384 duplicates, 1,492 unique records underwent title and abstract screening. Of these, 1,366 articles were excluded due to irrelevance to stunting-related outcomes, non-child populations, or the absence of determinant variables. A total of 126 full-text articles were assessed for eligibility, leading to the exclusion of 108 studies because of incomplete outcome data, lack of comparator groups, inappropriate study design, or failure to meet predefined methodological quality thresholds. Ultimately, 18 studies fulfilled all inclusion criteria and were included in both the qualitative synthesis and quantitative meta-analysis. Inter-reviewer agreement was excellent (κ = 0.87). The detailed identification, screening, eligibility, and inclusion process is illustrated in the PRISMA 2020 flow diagram ( Figure 1 ). 3.2 Characteristics of included studies The 18 included studies were published between 2015 and 2025, reflecting contemporary and policy-relevant evidence. Most studies were conducted in low- and middle-income countries (LMICs), including Indonesia, India, Bangladesh, Ethiopia, Nigeria, Brazil, and Peru, with limited representation from high-income settings. Study designs consisted of 7 randomized controlled trials (RCTs), 6 cohort studies, 3 cross-sectional studies, and 2 case-control studies, encompassing a total sample of 14,672 stunted children under five years of age. Determinant exposures were categorized into three primary domains: nutrition, parenting practices, and early childhood stimulation. Nutritional exposures included dietary diversity, micronutrient supplementation, and adequacy of complementary feeding. Parenting practices covered responsive feeding, caregiver sensitivity, and caregiver–child interaction quality. Early childhood stimulation interventions involved structured play, language enrichment, and psychosocial stimulation delivered in home-based or community settings. Growth outcomes were predominantly assessed using height-for-age z-scores (HAZ), while developmental outcomes were measured using validated tools such as the Bayley Scales of Infant and Toddler Development, Ages and Stages Questionnaire (ASQ), and Denver Developmental Screening Test II. Detailed characteristics of the included studies are presented in Table 1 . Table 1. Characteristics of included studies (n = 18). Study (Author, Year) Country Study design Sample size (n) Age Group Determinant domain Exposure/Intervention Outcome measures Key findings 29 Ethiopia RCT 820 6–59 months Nutrition Dietary diversity and micronutrient supplementation HAZ, Bayley-III Improved linear growth and cognitive scores 30 Afrika Barat Cohort 1,240 6–36 months Nutrition Complementary feeding adequacy HAZ, ASQ Adequate feeding associated with higher HAZ 31 Bangladesh RCT 690 12–48 months Early childhood stimulation Structured play and language stimulation Bayley-III Significant cognitive and motor gains 32 Indonesia Cross-sectional 1,105 <5 years Parenting practices Responsive feeding and caregiver sensitivity HAZ, Denver II Positive association with motor development 33 Indonesia Case-control 540 6–59 months Nutrition Micronutrient intake (iron, zinc) HAZ Lower odds of severe stunting 34 Indonesia Cohort 1,880 12–60 months Parenting practices Caregiver–child interaction quality ASQ Better socio-emotional outcomes 35 Ethiopia RCT 760 6–36 months Early childhood stimulation Home-based psychosocial stimulation Bayley-III Strong improvement in cognitive outcomes 36 Uganda Cross-sectional 980 <5 years Nutrition Dietary diversity score HAZ Higher diversity linked to improved growth 37 Indonesia Cohort 1,320 6–59 months Parenting practices Responsive caregiving ASQ, Denver II Improved language and motor development 38 Zimbabwe RCT 540 12–48 months Early childhood stimulation Community play-based program Bayley-III Largest effect on cognitive development 39 Indonesia Case-control 525 <5 years Nutrition Complementary feeding adequacy HAZ Reduced risk of growth faltering 40 Vietnam RCT 620 6–36 months Early childhood stimulation Language enrichment intervention ASQ Significant language score improvements 41 Kenya Cohort 1,450 6–59 months Parenting practices Caregiver sensitivity training HAZ, ASQ Moderate gains in growth and development 42 Uganda RCT 730 12–48 months Nutrition Micronutrient-fortified foods HAZ Improved linear growth 43 Vietnam Cross-sectional 890 <5 years Parenting practices Feeding interaction quality Denver II Improved motor development 44 Zambia Cohort 1,270 6–59 months Early childhood stimulation Home and community stimulation Bayley-III Strong cognitive and socio-emotional effects 45 India RCT 720 12–48 months Early childhood stimulation Integrated play and nutrition program HAZ, ASQ Synergistic growth and development benefits 46 Tanzania Cohort 852 <5 years Nutrition Dietary diversity and supplementation HAZ Improved growth trajectories 3.3 Methodological quality and risk of bias Overall methodological quality was rated as moderate to high. Among the seven RCTs, five studies demonstrated low risk of bias across all assessed domains, while two studies showed some concerns related mainly to allocation concealment and blinding of participants or personnel. Observational studies achieved high scores in participant selection and outcome assessment domains but showed variability in adjustment for key confounders, particularly socioeconomic status, maternal education, and household environment. Sensitivity analyses excluding studies with moderate risk of bias did not materially change pooled effect estimates across any determinant domain, indicating the robustness of the findings. Risk-of-bias assessments were performed for all included studies. The quality of randomized controlled trials (RCTs) was evaluated using the Cochrane RoB 2.0 tool ( Table 3 ), while the methodological quality of observational studies was assessed using the Newcastle–Ottawa Scale ( Table 4 ). 3.4 Pooled effects of determinants on growth and developmental outcomes 3.4.1 Early childhood stimulation Early childhood stimulation emerged as the most dominant determinant of improved developmental outcomes in stunted children. Sub–meta-analysis of 9 studies involving 6,214 children demonstrated a significantly higher likelihood of favorable developmental outcomes among children receiving stimulation interventions compared with controls (RR = 1.58; 95% CI: 1.31–1.90; p < 0.001), with moderate heterogeneity (I 2 = 44%) ( Table 2 and Figure 2 ). Subdomain analyses indicated the strongest effects for cognitive development (RR = 1.67) and language development (RR = 1.72), while motor development outcomes showed smaller but still statistically significant effects. According to the GRADE framework, the certainty of evidence for early childhood stimulation was rated as high, supported by consistent findings across study designs and minimal risk of bias. Table 2. Pooled effects of key determinants on growth and developmental outcomes in stunted children. Determinant domain Number of studies Total sample size (n) Primary outcome assessed Pooled effect size (RR) 95% CI p-value Heterogeneity (I 2 ) Certainty of evidence (GRADE) Early Childhood Stimulation 9 6,214 Overall developmental outcomes 1.58 1.31–1.90 <0.001 44% High Nutritional Determinants 12 9,486 Growth and developmental outcomes 1.44 1.21–1.71 <0.001 47% Moderate Parenting Practices 10 7,302 Growth and developmental outcomes 1.36 1.14–1.62 0.001 43% Moderate Integrated Interventions 5 4,118 Developmental outcomes 1.65–1.83 — <0.001 39–46% High Figure 2. Forest plot of early childhood stimulation impact. Table 3. Risk of bias assessment of included randomized controlled trials (Cochrane RoB 2.0). Study (Author, Year) Randomization process Allocation concealment Blinding of participants and personnel Missing outcome Data Outcome measurement Selective reporting Overall risk of bias 29 Low Low Some concerns Low Low Low Low 31 Low Low Some concerns Low Low Low Low 35 Low Low Some concerns Low Low Low Low 38 Low Low Some concerns Low Low Low Low 40 Low Low Low Low Low Low Low 42 Low Some concerns Some concerns Low Low Low Some concerns 45 Low Some concerns Some concerns Low Low Low Some concerns Table 4. Methodological quality assessment of observational studies using the Newcastle–Ottawa scale (n = 11). Study (Author, Year) Study design Selection (0–4) Comparability (0–2) Outcome/Exposure (0–3) Total score (0–9) Quality rating 30 Cohort 4 2 3 9 High 32 Cross-sectional 3 1 3 7 Moderate 33 Case-control 3 1 3 7 Moderate 34 Cohort 4 2 3 9 High 36 Cross-sectional 3 1 3 7 Moderate 37 Cohort 4 2 3 9 High 39 Case-control 3 1 3 7 Moderate 41 Cohort 4 2 3 9 High 43 Cross-sectional 3 1 3 7 Moderate 44 Cohort 4 2 3 9 High 46 Cohort 4 2 3 9 High 3.4.2 Nutritional determinants Nutritional adequacy was significantly associated with improvements in growth and developmental outcomes. Meta-analysis of 12 studies (n = 9,486 children) showed that children with adequate nutritional exposure had a 44% higher probability of favorable outcomes compared with those with inadequate nutrition (RR = 1.44; 95% CI: 1.21–1.71; p < 0.001), with moderate heterogeneity (I 2 = 47%) ( Table 2 and Figure 3 ). Sub–meta-analysis revealed stronger effects on linear growth recovery (HAZ improvement) than on composite developmental scores, suggesting that nutrition primarily influences physical growth and requires complementary psychosocial inputs to optimize developmental gains. The certainty of evidence for nutritional determinants was graded as moderate due to heterogeneity and residual confounding in observational studies. Figure 3. Forest plot of the impact of nutritional adequacy on growth and developmental outcomes. 3.4.3 Parenting practices Responsive parenting practices were positively associated with both growth and developmental outcomes. Pooled analysis of 10 studies including 7,302 children indicated that exposure to high-quality caregiving environments significantly increased the likelihood of favorable outcomes (RR = 1.36; 95% CI: 1.14–1.62; p = 0.001), with moderate heterogeneity (I 2 = 43%) ( Table 2 and Figure 4 ). Sub–meta-analysis suggested consistent effects across growth and developmental domains, particularly when responsive caregiving was integrated with nutritional or stimulation interventions. The certainty of evidence for parenting practices was rated as moderate according to GRADE, reflecting variability in measurement tools and adjustment for confounders. Figure 4. Forest plot of responsive parenting practices on growth and developmental outcomes. 3.4.4 Combined and comparative effects Studies evaluating integrated interventions combining nutrition, parenting support, and early childhood stimulation consistently reported larger pooled effect sizes than single-component interventions. The synergistic effect was most pronounced for developmental outcomes, with pooled RRs ranging from 1.65 to 1.83 ( Table 2 ). Comparative analyses demonstrated that stimulation-based interventions remained independently significant after adjustment for nutritional status and socioeconomic variables, underscoring their dominant role in developmental recovery among stunted children. 3.5 Subgroup and sensitivity analyses Subgroup analyses showed stronger effects of stimulation interventions in RCTs compared with observational studies and larger effect sizes in LMIC settings relative to upper-middle-income contexts. Sensitivity analyses excluding studies with small sample sizes, extreme effect estimates, or moderate risk of bias yielded comparable pooled results, confirming the stability and internal validity of the meta-analytic findings. 3.6 Publication bias Visual inspection of funnel plots revealed no substantial asymmetry across the three determinant domains. Egger’s regression tests were non-significant for early childhood stimulation (p = 0.14), nutrition (p = 0.18), and parenting practices (p = 0.21), indicating a low likelihood of publication bias. 4. Discussion This systematic review and meta-analysis provides robust evidence on the multidimensional determinants of growth and developmental outcomes in stunted children, emphasizing the roles of early childhood stimulation, nutrition, and responsive parenting. Early childhood stimulation demonstrated the strongest association with improved developmental outcomes, particularly in cognitive and language domains. These findings are consistent with foundational research showing that psychosocial stimulation interventions significantly enhance cognitive and behavioral outcomes in stunted populations across diverse contexts. 47 – 49 Specifically, prospective cohort evidence from Southeast Asia indicated that early psychosocial stimulation conferred sustained benefits on IQ and verbal abilities well into adolescence, 50 , 51 underscoring the long-term impact of stimulation beyond short-term developmental gains. In addition, global synthesis research affirms that stimulation interventions have a medium effect on cognitive and language development, often exceeding the effects of nutrition alone. 52 – 54 Collectively, this evidence underscores that structured stimulation is a key intervention component to mitigate the developmental consequences of stunting. Adequate nutrition was significantly associated with enhanced growth and developmental performance, although its effect on developmental outcomes was somewhat less pronounced than stimulation. Meta-analyses outside the current study demonstrate that early nutritional supplementation and adequate dietary intake are essential for linear growth and foundational brain development, with stunting linked to adverse cognitive outcomes when persistent. 55 – 57 For example, longitudinal studies have shown that childhood stunting is significantly negatively associated with cognitive achievement and school progression, even after adjustment for socioeconomic confounders. 58 , 59 However, systematic reviews indicate that nutritional interventions alone often yield smaller effect sizes for cognitive outcomes compared to stimulation, particularly when psychosocial components are absent. 60 – 62 This pattern aligns with the current finding that nutrition primarily influences physical growth (HAZ) while suggesting that complementary psychosocial inputs are necessary to fully optimize developmental gains. Responsive parenting practices were consistently associated with favorable outcomes in both growth and development, highlighting the importance of caregiver behaviors in early childhood. Evidence from systematic reviews and meta-analyses indicates that healthcare-based parenting interventions in LMICs improve key parenting outcomes, including responsive caregiving, which in turn supports ECD. 63 – 65 In addition, trials that integrate responsive parenting with nutrition and stimulation components have reported synergistic benefits, suggesting that improvements in caregiver–child interaction quality mediate developmental gains. The synergistic effects observed in combined intervention studies reinforce ecological models of child development, which posit that nurturing care environments amplify the effects of nutrition and stimulation on outcomes. 66 , 67 Thus, responsive parenting should be considered a central target of intervention strategies for stunted children. Importantly, integrated interventions that combine nutrition, stimulation, and caregiver support consistently yielded larger effect sizes than single-component approaches, reflecting the complex and interrelated nature of stunting determinants. Multi-component programs have been recommended in evidence syntheses as best practice for addressing chronic undernutrition and developmental deficits, particularly in resource-constrained settings. 68 , 69 For example, interventions that unify nutritional supplementation with caregiver training and stimulation have demonstrated substantial improvements across cognitive and socio-emotional domains. 70 , 71 These findings support the argument that stunting is not merely a nutritional problem but a multisectoral issue that requires holistic, context-adapted strategies to generate sustained improvements in child growth and development. Finally, the consistency of results across study designs and heterogeneity analyses reinforces the internal validity and generalizability of the findings. Subgroup analyses suggesting stronger effects in RCTs and LMIC contexts highlight the importance of rigorous evaluation and context-specific implementation. The absence of significant publication bias further strengthens the evidence base. Collectively, this body of work underscores that coordinated policies integrating nutrition, stimulation, and caregiving support are essential to improving developmental trajectories among stunted children globally. 72 – 74 Future research should prioritize long-term follow-up, culturally tailored interventions, and implementation science to optimize program delivery in diverse environments 4.1 Clinical implications The findings of this systematic review and meta-analysis highlight the critical need for integrated interventions targeting stunted children that combine early childhood stimulation, adequate nutrition, and responsive parenting. Early childhood stimulation consistently produced the strongest effects on cognitive and language development, suggesting that structured play, language enrichment, and psychosocial activities should be embedded within routine child health services or community-based programs. Nutritional adequacy, including dietary diversity and micronutrient supplementation, remains essential for linear growth and overall health, and its benefits are maximized when coupled with psychosocial inputs. Furthermore, responsive parenting interventions that enhance caregiver–child interaction quality, such as training in responsive feeding and play-based stimulation, significantly improve both growth and developmental outcomes. Clinically, these findings underscore the necessity of multidimensional, context-adapted programs that can be feasibly implemented in low-resource settings to optimize developmental trajectories among stunted children. 4.2 Strengths and limitations This review possesses several strengths, including a comprehensive search across multiple databases, rigorous inclusion criteria, and robust meta-analytic techniques with subgroup and sensitivity analyses, ensuring the reliability of pooled estimates across 18 studies with 14,672 children from diverse LMIC settings. The inclusion of both RCTs and high-quality observational studies enhances the external validity and policy relevance of the findings. However, heterogeneity in intervention types, duration, delivery methods, and outcome assessment tools may have contributed to variability in effect sizes, particularly for psychosocial and parenting interventions. Residual confounding, especially from socioeconomic status, maternal education, and household environment, may influence observational outcomes, while the scarcity of long-term follow-up data limits conclusions about sustained benefits beyond early childhood. Despite low risk of publication bias, caution is warranted in generalizing results to high-income contexts or older children, and future studies should aim for standardized interventions with longitudinal monitoring to confirm enduring impacts. 5. Conclusion This systematic review and meta-analysis indicates that early childhood stimulation is the dominant determinant of developmental outcomes in stunted children, particularly for cognitive and language domains. Nutrition supports linear growth, and responsive parenting enhances both growth and development, but their effects are maximized when combined with stimulation. Integrated, multidimensional interventions that embed structured stimulation, nutritional adequacy, and caregiver support yield the greatest benefits. Policymakers and practitioners should prioritize stimulation-focused programs within holistic strategies, and future research should assess long-term, scalable, and culturally adapted interventions to sustain developmental gains across diverse low- and middle-income settings. Data availability statement All data underlying the findings of this study are openly and permanently available in the Open Science Framework (OSF) repository at https://osf.io/c682e/ . The archived, citable version of the dataset is available via DOI: https://doi.org/10.17605/OSF.IO/GVC75 . 75 The dataset comprises the cleaned meta-analysis dataset and the data extraction table used to generate all reported results. To ensure full transparency and reproducibility, the repository also includes extended materials: the list of included studies; risk of bias and methodological quality assessments (Cochrane Risk of Bias 2.0 and Newcastle–Ottawa Scale); full electronic search strategies for all databases; the PRISMA 2020 checklist and flow diagram; and forest plots for all meta-analytic outcomes. A README file describing the data structure and variable definitions is provided to facilitate reuse. All files are publicly accessible without restriction, login requirement, or embargo, and are released under the Creative Commons Zero (CC0 1.0 Public Domain Dedication), permitting unrestricted use, distribution, and reproduction in any medium . Acknowledgment The authors thank all institutions, colleagues, and participants involved in this study. Special appreciation is extended to the supervisor for support in facilitating data access and resources for this systematic review and meta-analysis. References 1. 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Wisuda AC: Extended Data for: Determinants of Growth and Development in Stunted Children: Systematic Review and Meta-Analysis of Nutrition, Parenting, and Early Stimulation.2026, May 4. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 18 May 2026 ADD YOUR COMMENT Comment Author details Author details 1 Sekolah Tinggi Ilmu Kesehatan Abdurahman, Palembang, Palembang, 30151, Indonesia 2 School of Nursing and Applied Sciences, Lincoln University College, Malaysia, Petaling Jaya, Selangor, 47301, Malaysia 3 Nursing Study Program, Sekolah Tinggi Ilmu Kesehatan Bina Husada, Palembang, South Sumatera, 30131, Indonesia Indah Rahmadaniah Roles: Conceptualization, Funding Acquisition, Project Administration, Writing – Original Draft Preparation Aris Citra Wisuda Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Visualization Citra Suraya Roles: Conceptualization, Resources, Software, Writing – Review & Editing Tukimin bin Sansuwito Roles: Conceptualization, Supervision Vika Tri Zelharsandy Roles: Validation, Writing – Review & Editing Rinda Lamdayani Roles: Data Curation, Visualization, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 18 May 2026, 15:746 https://doi.org/10.12688/f1000research.178805.1 Copyright © 2026 Rahmadaniah I et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions. Download Export To Sciwheel Bibtex EndNote ProCite Ref. 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