Association of Stunted in Early Life and Low Child Development
Outcomes: A Retrospective Cohort Study
Nur Handayani Utami, Kencana Sari and Dwi Sisca Kumala Putri
National Agency of Research and Innovation, Jakarta, Indonesia
Keywords: Development Outcome, Early Years, Linear Growth Failure.
Abstract: Many studies have shown that stunting is associated with low development outcomes. However, study on a
low social economy outcome is still rare. This retrospective cohort study aimed to determine the role of
stunted in early life on child developmental outcomes at 49 to 79 months old. This study analyzed data from
Bogor Longitudinal Study of Child Growth and Development (BLSCGD). Subjects were divided based on
the main exposure, namely severe Linear Growth Failure (LGF) at 0-12 months. Seventy exposed and sixty-
nine non-exposed groups were randomly selected. The primary outcome in this analysis is the development
outcome at 49-79 months old as measured by the Kuesioner Pra Skrining Perkembangan (KPSP). The main
predictor is experiencing stunting at an early age (0-24 months). Multivariate analysis was done with a logistic
regression test. This study showed that children that never stunted in their early years have higher
developmental scores at 49 to 79 months old (8.4 ± 1.3 SD) than children that ever been stunted (8.1 ± 1.5
SD) in the early years. Multivariate analysis showed that experience stunted in the early years is a risk factor
of child low developmental outcomes at 49 to 79 months old, even though statistically not significant.
Maintaining good nutrition as indicated by optimal nutritional status in the early years has been found to be
one of the important factors that influence child development outcomes. Thus, many aspects should be
prioritized to achieve optimal health and nutrition in the early years.
1 INTRODUCTION
A study that published by Lancet in 2007 has
estimated that 219 million children globally continue
to face many risks such as poverty, malnutrition, and
other risks that lead to suboptimal developmental
outcomes (Lu et al., 2016). Early child development
will form the foundation of adult health and well-
being (Lu et al., 2016). Children in developing
countries who fail to achieve their developmental
potential are tend to have average deficit annual
income, that result from deficits in schooling (Lu et
al., 2016).
Stunting is the manifestation of chronic
nutritional disorders and has been used as indicators
for assessing compromised developmental progress.
National data showed that linear growth retardation
occur even when the child is born, with low birth
weight and length, which might lead increase stunting
prevalence in later age (Badan Penelitian dan
Pengembangan Kesehatan, 2019). The prevalence of
under five children that stunted has been decreased in
the last decade, but in 2022 there are 21.6% of under
five children in Indonesia that stunted, which means
that stunted still become important public health
problem need to be solved (Kementerian Kesehatan
Republik Indonesia, 2023).
Stunting has been studied and proposed as one of
the causes of child low developmental outcomes.
Especially, if it occurs during the early years, whereas
the brain development reaches its peak. Three main
pathways mentioned on which poor nutrition may
affect developmental outcomes among children.
First, nutritional deficiency can cause structural and
functional damage to the brain, second, children that
lack of energy tend to withdraw and engage less with
their environment, which will effect on how they
learn, and third, caregivers have treat them differently
so that it challenges them less (Adawiyah, R. Asyifa
& Azijah, 2020).
Many studies have been conducted to investigate
association between stunted and child development
outcomes, however, there is a limited number of
studies that employ a longitudinal design, particularly
those conducted in developing countries, such as
Indonesia. Thus, we conducted this study to
124
Utami, N. H., Sari, K. and Putri, D. S. K.
Association of Stunted in Early Life and Low Child Development Outcomes: A Retrospective Cohort Study.
DOI: 10.5220/0012901700004564
Paper published under CC license (CC BY-NC-ND 4.0)
In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 124-129
ISBN: 978-989-758-727-6; ISSN: 2975-8297
Proceedings Copyright © 2025 by SCITEPRESS – Science and Technology Publications, Lda.

investigate the role of stunted in early years to child
developmental outcome at 49 to 79 months old.
2 METHODS
This study analyzed data from Bogor Longitudinal
Study of Child Growth and Development
(BLSCGD). Subjects were divided based on the main
exposure, namely severe Linear Growth Failure
(LGF) at 0-12 months. Seventy exposed and sixty-
eight non-exposed groups were randomly selected.
The primary outcome in this analysis is development
outcome at 49-79 months old.
The instrument used to measure children's
development is the KPSP which is part of the
implementation of the Stimulation, Detection, and
Early Intervention of Growth and Development
(SDIDTK) program from the Ministry of Health.
KPSP measures the development of gross and fine
motor, communication and language as well as social
personal which is adapted from Denver Prescreening
Developmental Questionnaires. In this study, the
KPSP form was used for age 48 to 72 months. KPSP
consists of 9-10 developmental questions/tasks based
on the existing age level. Point 1 is given if the child
can carry out the given developmental task. Children
are categorized as having developments that are
appropriate to their developmental stages if they have
a total score of ≥ 9, and are said to have developments
that are doubtful/possible for deviations if they have
a score of < 9. (Kemenkes RI, 2019)
Main exposure in this analysis is experience of
stunted (LAZ < -2 SD) in the period of 0-24 months
(early life). Categorized as 0. Never stunted and 1.
Ever stunted. The potential confounders of this
analysis are categorized into socio-demographic and
other factors. There were six variables under socio-
demographic information i.e. child gender, age of a
child in cognitive assessment, father and mother
education level, and occupation. Father and mother's
education level is completed level of education by
father and mother, categorized into “Low” (complete
education up to junior high school) and “Middle and
High” level of education (complete level of education
above junior high school/high school or college).
Psychosocial stimulation was assessed with
HOME inventory, which consist of 55 questions.
Each question is scored 0 or 1. Therefore, the total is
55. Child stimulation and quality of care is
categorized into poor (score ≤ 60%), average (score
61%-80%), and good (score ≥ 81%). Exclusive
breastfeeding is the history of exclusive breastfeeding
practice in 0-5 months.
Interviews were conducted by trained
enumerators with a health education background. All
of the interviews used pre-tested questionnaires. The
analysis was carried out using descriptive analysis,
bivariate using chi-square for categorical variables, or
one-way ANOVA for continuous variables.
Independent sample t-test or Wilcoxon Shapiro-wilk
to assess the association between continuous
variables with category of respondents (exposed or
not exposed). A logistic regression test was used to
analyze the effect of experience stunted in early life
and other factors on child cognitive development. The
statistical analysis was performed using SPSS.
Before conducting the study, the respondents
signed informed consent. This research has received
ethical approval from the Faculty of Medicine Ethics
Commission, Universitas Indonesia.
3 RESULTS
The proportion of boys and girls is slightly different.
Most children were at aged 60 – 79 months when the
data collection was taken. Around one tenth children
were exclusively breastfed. The majority of parents
exhibited educational attainment at the middle and
high levels. More than half fathers are employed as
laborers or other professions. Most of mothers are
housewives. Around one third children experience
low levels of psychological stimulation. Nearly one
third of children have never been exposed to any form
of formal/non-formal education.
Table 1: Characteristics of study subjects.
Variables n (%)
Children
Gende
r
Bo
y
67
(
48.6
)
Girl 71 (51.4)
A
g
e at data collection
47-59 months 50 (36.2)
60-79 months 88
(
63.8
)
Exclusive breastfeeding
Yes 15
(
10.9
)
Parents
Father education level
Middle and High 115 (83.3)
Low 23
(
16.7
)
Mother education level
Middle and Hi
g
h 114
(
82.6
)
Low 24 (17.4)
Father occu
p
ation
Civil servant 3 (2.2)
Private em
p
lo
y
ee 29
(
20.9
)
Enterprenue
r
18 (12.9)
Association of Stunted in Early Life and Low Child Development Outcomes: A Retrospective Cohort Study
125

Laborer/other
j
ob 89
(
64.0
)
Mother occu
p
ation
Housewife 111 (79.9)
Workin
g
mo
m
28
(
20.1
)
Ps
y
chosocial stimulation
Good and average 89 (64.5)
Poo
r
49
(
35.5
)
Received formal/informal
education
Received education ≥ 12 months 20 (14.5)
Received education 1-11 months 80
(
58.0
)
Never received education 38 (27.5)
Table 2 shows that subjects that ever stunted in
early life have lower development scores than
subjects that never being stunted. Similarly, as
subjects that were stunted at data collection have
lower scores than normal children, even though not
statistically significant.
Table 2: Analysis of child development scores (mean±SD)
by Stunted experience.
Variables n
Child development
score
Mean SD
Experience of
stunted in earl
y
life
Never stunte
d
68 8.4 1.3
Ever stunted 78 8.1 1.5
p-value 0.169
Stunted at data
collection
No 109 8.2 1.4
Yes 12 8.1 1.2
p
-value 0.438
Having been stunted in early life was found as a
risk factor for low child development outcomes an
OR of 1.59 (0.65-3.92 95% CI) although it was not
statistically significant. The results also show that
stunted at data collection have higher OR whereas
stunted children at cognitive assessment have an OR
of 3.86 (0.85-17.45 95% CI) compared with normal
children. Other factors that significantly associated
with low child development outcomes are children
aged 60-79 months at data collection had an odd of
0.11 times (0.04-0.28 95% CI) or become a protective
factor to have low-child development outcome.
Table 3: Association of stunted experience with low child
development outcome.
Variables OR (95%
CI) crude
p-
value
OR
(95%CI)
ad
j
uste
d
p-value
Experienced
stunted in early
life
1.50
(0.59-
3.83
)
0.388 1.59
(0.65-
3.92
)
0.307
Stunted at data
collection
4.08
(0.86-
19.48
)
0.078 3.86
(0.85-
17.45
)
0.079
Girls 0.37
(0.13-
1.06)
0.065 0.45
(0.19-
1.08)
0.075
Childs aged 60-
79 months
0.13
(0.05-
0.38
)
0.000 0.11
(0.04-
0.28
)
0.000*
Not exclusive
breastfed
0.88
(0.21-
3.63)
0.858 --
Low father
education
1.16
(0.32-
4.20
)
0.818 -
Low mother
education
1.95
(0.60-
6.33)
0.264 -
Father
occupation
Civil servant
Private
employee
0.66
(0.02-
23.96)
0.822 0.74
(0.02-
22.46)
0.863
Enterprenuer 0.65
(0.01-
28.36
)
0.825 0.83
(0.02-
28.92
)
0.922
Laborer/other
job
0.42
(0.01-
14.77)
0.633 0.60
(0.02-
17.03)
0.768
Working mothers 0.88
(0.27-
2.74
)
0.809 -
Poor
Psychosocial
stimulation
2.03
(0.81-
5.12)
0.132 2.02
(0.83-
4.93)
0.122
Received
formal/informal
education
Received
education ≥ 12
months
-
Received
education 1-11
months
0.67
(0.17-
2.67)
0.567 -
Never
received
education
1.07
(0.21-
5.45
)
0.938 -
ICSDH 2023 - The International Conference on Social Determinants of Health
126

4 DISCUSSION
This study reveals that having been stunted in early
life (0-24 months) is a risk factor for low child
development outcomes (gross and fine motoric skills,
communication and language, and social personal)
among children 49-79 months old. It shows there is a
long-term effect of nutritional deprivation on child
development in later life.
The first two years after birth are a critical period
for a child's brain development. During this period, if
the children do not fulfil with nutrition, apical
dendrites will shorten in the brain. This will causes a
decrease in brain function, which then effects on
movement skills, attention, memory, and cognitive
abilities (De Onis & Branca, 2016). Moreover,
nutritional deficiencies from prenatal to early
childhood mass can cause neurological disorders and
brain development disorders that affect cognitive and
language abilities. This will limit the vocabulary and
low level of intelligence of the children with a history
of stunting in early childhood (Prado & Dewey,
2014). Nevertheless, findings from a study conducted
on animals and humans have shown that the
chronicity, timing, and severity of nutritional
deficiencies have an effect on brain development that
will have an impact on subsequent developmental
abilities (Black, 2018).
The results also supported by a study that
examining the relationship between stunting at age 2
and ability at age 4 shows there is significant
association between stunting with the Revised-
Denver Pre-screening Developmental Questionnaires
(R-DPDQ) scores while association with children’s
performance on the Vineland Social Maturity Scale
(VSMS), was not found. Furthermore, children with
low height-for-age at 2 years are worse on measures
capturing higher-order fine motor skills and cognitive
functioning but do not fall behind in terms of daily
living skills or social maturity (Casale et al., 2014).
However, another study found that stunting tends
to affect personal development and children’s ability
to socialize. Stunted children usually look apathetic
and ignorant to play with other people and these will
potentially will be carried to the later age
(Setianingsih et al., 2020). Furthermore, a study in
Mexico found a significant correlation between lower
length-for-age z-scores (LAZ) and stunting with
decreased levels of physical activity and reduced
exploration among the children. Children with
stunted growth exhibited distinct behavioural
variations, such as apathy, heightened negative affect,
and diminished levels of activity, playfulness, and
exploration (Aburto et al., 2009). Therefore, stunted
children which affecting the maturity of nerve cells
can also result in children's social abilities. A study in
a province in Indonesia, East Nusa Tenggara showed
that short school children had lower self-confidence
(C. Scheffler et al., 2020; Christiane Scheffler et al.,
2021).
Research conducted in the Narahenpita area,
Colombo also found that among children aged 36-54
months, gross motor skills, and fine motor skills in
stunting children were lower than in normal children
(Solihin et al., 2013). This result also found in a city
in Indonesia, North Padang, that children who were
stunted had a greater risk of experiencing delays in
motor development, both gross and fine motor
(Komaini & Mardela, 2018).
One explanation stated that if the muscle
mechanism has not developed properly, motor
movement will not be perfect. This eventuality occurs
in children with stunted development abnormalities,
hence will develop at a slower rate, and there can be
no coordinated voluntary action before the child is in
normal condition (Komaini & Mardela, 2018).
Decreased motor function of stunting children
without congenital errors is related to the low
mechanical ability of the triceps muscle due to the
slow maturation of muscle function (Solihin et al.,
2013). Gross motor skills encompass bodily
movements that engage the major muscle groups
located in the arms, legs, torso, and feet. Skeletal
muscle in humans is predominantly specifically in the
arms and legs, thus it is plausible to assert that leg
lengths may play a role in influencing muscle mass.
Moreover, stunted children have been observed to
exhibit a decrease in muscle mass as a result of
diminished limb length (Pomeroy et al., 2012).
Besides that, the potential cause of the poor motor
skills observed in the stunted children could be
attributed to a decrease in muscle mass (Nahar et al.,
2020).
Moreover, this study also found that current
stunted status has more effect on low child
development outcomes. It emphasizes findings by
many studies before, one of which stated children
who are stunted have an 11.98 times greater chance
of having below-average motor development
(Pantaleon et al., 2016). This might be due to stunted
at previous age that has not recovered or recurred
whose impact has carried over to the present.
Study also revealed that age over 60 months was
found to be a protective factor for low IQ. This may
be because older children have received more
stimulation either from the environment or from
formal/non-formal education so they can do
developmental tasks better.
Association of Stunted in Early Life and Low Child Development Outcomes: A Retrospective Cohort Study
127

5 CONCLUSIONS
Study emphasizes the long-term effect of nutritional
deprivation shown by the experience of stunted
during early life with low child development
outcomes at 49 - 79 months. Furthermore, children
that are still stunted at 49 – 79 months have a bigger
risk of having low development outcomes. Thus,
efforts to deal with stunting must continue to be
carried out, especially with multi-sectoral steps and
an emphasis on efforts to manage local resources
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risk for vitamin and mineral deficiencies. Journal of
Nutrition, 139(9), 1751–1757.
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ICSDH 2023 - The International Conference on Social Determinants of Health
128

Adawiyah, R. Asyifa & Azijah, I. (2020). Nutritional
Status, Development Level, and Psychosocial Function
of Preschool Children. Journal of Health Education,
25(5 (1)), 21–28.
Badan Penelitian dan Pengembangan Kesehatan. (2019).
Laporan Nasional Riskesdas 2018. Lembaga Penerbit
Badan Penelitian dan Pengembangan Kesehatan.
Black, M. M. (2018). Impact of nutrition on growth, brain,
and cognition. Nestle Nutrition Institute Workshop
Series, 89, 185–195.
https://doi.org/10.1159/000486502
Casale, D., Desmond, C., & Richter, L. (2014). The
association between stunting and psychosocial
development among preschool children: A study using
the South African Birth to Twenty cohort data. Child:
Care, Health and Development, 40(6), 900–910.
https://doi.org/10.1111/cch.12143
De Onis, M., & Branca, F. (2016). Childhood stunting: a
global perspective. https://doi.org/10.1111/mcn.12231
Kemenkes RI. (2019). Pedoman SDIDTK dI Pelayanan
Dasar. In Pedoman Pelaksanaan Stimullasi, Deteksi
dan Intervensi Dini Tumbuh Kembang Anak di Tingkat
Pelayanan Kesehatan Dasar (p. 138).
file:///C:/Users/Acer/Downloads/Pedoman SDIDTK
DI PUSKESMAS 2019.pdf
Kementerian Kesehatan Republik Indonesia. (2023). Buku
Saku : Hasil Survei Status Gizi Indonesia (SSGI) 2022.
Kementerian Kesehatan Republik Indonesia, 1–7.
Komaini, A., & Mardela, R. (2018). Differences of
Fundamental Motor Skills Stunting and Non Stunting
Preschool Children in Kindergarten in North Padang.
IOP Conference Series: Materials Science and
Engineering, 335(1). https://doi.org/10.1088/1757-
899X/335/1/012131
Lu, C., Black, M. M., & Richter, L. M. (2016). Risk of poor
development in young children in low-income and
middle-income countries: an estimation and analysis at
the global, regional, and country level. The Lancet
Global Health, 4(12), e916–e922.
https://doi.org/10.1016/S2214-109X(16)30266-2
Nahar, B., Hossain, M., Mahfuz, M., Islam, M. M.,
Hossain, M. I., Murray-Kolb, L. E., Seidman, J. C., &
Ahmed, T. (2020). Early childhood development and
stunting: Findings from the MAL-ED birth cohort study
in Bangladesh. Maternal and Child Nutrition, 16(1).
https://doi.org/10.1111/mcn.12864
Pantaleon, M. G., Hadi, H., & Gamayanti, I. L. (2016).
Stunting berhubungan dengan perkembangan motorik
anak di Kecamatan Sedayu, Bantul, Yogyakarta. Jurnal
Gizi Dan Dietetik Indonesia (Indonesian Journal of
Nutrition and Dietetics), 3(1), 10.
https://doi.org/10.21927/ijnd.2015.3(1).10-21
Pomeroy, E., Stock, J. T., Stanojevic, S., Miranda, J. J.,
Cole, T. J., & Wells, J. C. K. (2012). Trade-Offs in
Relative Limb Length among Peruvian Children:
Extending the Thrifty Phenotype Hypothesis to Limb
Proportions. PLoS ONE, 7(12).
https://doi.org/10.1371/journal.pone.0051795
Prado, E. L., & Dewey, K. G. (2014). Nutrition and brain
development in early life. Nutrition Reviews, 72(4),
267–284. https://doi.org/10.1111/nure.12102
Scheffler, C., Hermanussen, M., Bogin, B., Liana, D. S.,
Taolin, F., Cempaka, P. M. V. P., Irawan, M., Ibbibah,
L. F., Mappapa, N. K., Payong, M. K. E., Homalessy,
A. V., Takalapeta, A., Apriyanti, S., Manoeroe, M. G.,
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