Comment
The necessity of using direct measures of child development
More than half of the world’s poor are children,1 and
one crushing consequence of growing up in poverty is
the subsequent loss of human potential.2 A common
metric used to quantify the effects of poverty on human
capital is the use of child growth, or stunting, as a proxy
measure for poor cognitive development.3 This crucially
important approach allows researchers and advocates
to push for government action. However, despite the
standard assumption that improvements in growth
lead to improvements in cognitive development,
the associations between these two variables are not
consistent. In two studies using data from multiple
countries,4,5 child growth and cognitive development
were associated, but findings differed by context (eg,
associations ranged from non-existent in Barbados,
Lebanon, and Moldova to r=0·36 in Nigeria)5 and child
age (eg, associations were stronger for children aged
2 years or younger than for those older than 2 years).4
Furthermore, a large amount of variation in child
development was unexplained by child length-for-age or
height-for-age.
In The Lancet Global Health, Elizabeth Prado, Leila
Larson, and colleagues6 add to this existing literature
by doing a meta-regression of randomised trials done
during pregnancy and with children aged 0–5 years to
understand the shared versus independent intervention
effects on linear growth and neurological development.
Their approach differed from that of a typical meta-
analysis in that the major inclusion criteria were
based on reported outcomes rather than intervention
type. Therefore, all interventions that reported child
linear growth and outcomes on motor, cognitive (or
mental), language, or social-emotional (or behavioural)
development were included, which resulted in substantial
heterogeneity in intervention type, context, and
population. The meta-analysis included 75 studies with
122 comparisons between intervention and control
groups and outcomes reported for 72 275 children.
Prado and colleagues reported no overall association
between intervention effects on growth and cognitive
(β 0·18, 95% CI –0·36 to 0·72; p=0·51), language (0·12,
–0·07 to 0·31; p=0·21), and motor development scores
(0·23, –0·05 to 0·50; p=0·11), but found an association
between effects on growth and social-emotional scores
(0·23, 0·05 to 0·41; p=0·02).
www.thelancet.com/lancetgh Vol 7 October 2019 1300
Among nutrition supplementation studies, Prado See Articles page e1398
and colleagues found a significant association between
effects on growth and cognitive (β 0·40, 95% CI
0·04–0·77; p=0·049) and motor (0·43, 0·11–0·75; p=0·01)
scores. Using pooled analyses, the authors found a small
pooled effect of nutrition interventions on both growth
and development, and a larger pooled effect size of
caregiving interventions on child development, but no
corresponding effects on growth.
A key message of Prado and colleagues’ study is
that intervention effects on child growth and child
development do not always co-occur, and this is
important for researchers, practitioners, and policy
makers alike. As the authors emphasise, the standard
practice of using child growth as a proxy for intervention
effects on child development is not accurate or
appropriate. Although in some contexts, stunting can
be an indicator of social and environmental influences
in early life, interventions designed to improve child
growth outcomes might be grossly suboptimal when
the desired intervention outcome is also improved
child development. Among the examined studies
that measured both development and growth, child
development was more responsive to intervention
effects than growth. Prado and colleagues report
differential pooled effects of nutrition interventions on
outcomes on the basis of supplementation type and
timing and economic context, although they were not
able to explore these issues in detail.
This study was well designed and implemented and
is a substantial and important addition to the existing
literature. However, some key questions remain that
still need to be answered. First, how do effects vary
across subgroups? The study had vast heterogeneity
in intervention types and details across all of the
interventions included in the primary analysis, even
within the nutrition and caregiving intervention
subgroups. Differences included duration and intensity
of the intervention, target population (eg, child age,
sociodemographic factors, and baseline nutritional
status), and broader country context (eg, economic,
political, and cultural factors). Existing studies
have shown differential effects of interventions for
malnourished children compared with those for non-
malnourished children,7 and nutrition intervention
 Comment
For the Global Scale for Early
Development see
https://earlychildhoodmatters.
online/2019/the-global-scale-
for-early-development-gsed/
1301 www.thelancet.com/lancetgh Vol 7 October 2019
effects on growth have been shown to vary by income
status.8 Furthermore, in the analyses reported here,
children’s age at assessment ranged from 6 months to
12 years, and effects were not disaggregated by age or
gender, although previous studies have found varying
effects when disaggregating by age and gender. Another
question that emerges from the findings relates to
pathways. Nutrition interventions might have direct
effects on brain development and growth, whereas
responsive caregiving might have indirect effects
on child development through changing parental
caregiving behaviours and maternal mental health,
and no direct or indirect effects on child growth.9
Better understanding the various pathways through
which early life interventions affect child growth and
development, either together or independently, would
allow for the development of more targeted and
effective interventions for vulnerable children.
Prado and colleagues’ study clearly reinforces the
idea that, wherever possible, direct measures of child
development should be incorporated into research
studies to avoid an overreliance on proxy measures.
Multiple measures of child development exist and
have been adapted, translated, modified, and used
in low-income and middle-income countries.10 Given
the importance of measuring child development
for programme assessment and population-level
monitoring, an effort is underway to develop the
Global Scale for Early Development, a reliable, easily
interpretable tool that would allow for valid cross-
national comparisons. More broadly, accurate
measurement is crucial to generate information on
progress and challenges in reaching development goals
and can add to effective assessments of programmes
and interventions to inform evidence-based policies to
improve outcomes for children at risk.
*Lia C H Fernald, Helen O Pitchik
School of Public Health, University of California-Berkeley, Berkeley,
CA 94720, USA
fernald@berkeley.edu
We declare no competing interests.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY 4.0 license.
1 Fenz K, Hamel K. More than half of the world’s poor are children. 2019.
https://www.brookings.edu/blog/future-development/2019/06/20/more-
than-half-of-the-worlds-poor-are-children/ (accessed Aug 18, 2019).
2 McCoy DC, Peet ED, Ezzati M, et al. Early childhood developmental status in
low- and middle-income countries: national, regional, and global prevalence
estimates using predictive modeling. PLoS Med 2016; 13: e1002034.
3 Lu C, Black MM, Richter LM. 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. Lancet Glob Health 2016;
4: e916–22.
4 Sudfeld CR, McCoy DC, Danaei G, et al. Linear growth and child development
in low- and middle-income countries: a meta-analysis. Pediatrics 2015;
135: e1266–75.
5 Tran TD, Holton S, Nguyen H, Fisher J. Physical growth: is it a good
indicator of development in early childhood in low- and middle-income
countries? BMC Pediatr 2019; 19: 276.
6 Prado EL, Larson LM, Cox K, Bettencourt K, Kubes JN, Shankar AH.
Do effects of early life interventions on linear growth correspond to effects
on neurobehavioral development? A systematic review and meta-analysis.
Lancet Glob Health 2019; 7: e1398–413.
7 Schroeder DG, Pachón H, Dearden KA, Ha TT, Lang TT, Marsh DR.
An integrated child nutrition intervention improved growth of younger,
more malnourished children in northern Viet Nam. Food Nutr Bull 2002;
23: 50–58.
8 Lassi ZS, Das JK, Zahid G, Imdad A, Bhutta ZA. Impact of education and
provision of complementary feeding on growth and morbidity in children
less than 2 years of age in developing countries: a systematic review.
BMC Pub Health 2013; 13: S13.
9 Prado EL, Yakes Jimenez E, Vosti S, et al. Path analyses of risk factors for
linear growth faltering in four prospective cohorts of young children in
Ghana, Malawi and Burkina Faso. BMJ Glob Health 2019; 4: e001155.
10 Fernald LCH, Prado E, Kariger P, Raikes A. A toolkit for measuring early
childhood development in low- and middle-income countries. World Bank.
2017. https://openknowledge.worldbank.org/handle/10986/29000
(accessed Aug 18, 2019).