Skip to main content

Recovery from stunting and cognitive outcomes in young children: evidence from the South African Birth to Twenty Cohort Study

  • D. Casale (a1) and C. Desmond (a2) (a3)

In this study we analyse the implications for cognitive function of recovery from stunting in early childhood. More specifically, we test whether children who met the definition for stunted at age 2, but not at age 5, perform better in cognitive tests than children who remain stunted over this period. The sample is drawn from the Birth to Twenty Cohort Study, a prospective data set of children born in 1990 in urban South Africa. The measure of cognitive function that we use is based on the Revised Denver Prescreening Developmental Questionnaire implemented when the children were age 5. We employ multivariate regression in the analysis to control for child-specific characteristics, socio-economic status, the home environment and caregiver inputs. We find that recovery from stunting is not uncommon among young children in our sample. However, children who recover from stunting by age 5 still perform significantly worse on cognitive tests than children who do not experience early malnutrition, and almost as poorly as children who remain stunted. These findings suggest that the timing of nutritional inputs in the early years is key in a child’s cognitive development, with implications for school readiness and achievement.

Corresponding author
*Address for correspondence: D. Casale, School of Economic and Business Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa. (Email
Hide All
1. de Onis, M, Blössner, M, Borghi, E. Prevalence and trends of stunting among pre-school children, 1990–2020. Public Health Nutr. 2012; 15, 142148.
2. Dewey, KG, Begum, K. Long-term consequences of stunting in early life. Matern Child Nutr. 2011; 7, 518.
3. Walker, SP, Chang, SM, Powell, CA, Grantham-McGregor, SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet. 2005; 366, 18041807.
4. Victora, CG, Adair, L, Fall, C, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008; 371, 340357.
5. Victora, CG, de Onis, M, Hallal, PC, Blossner, M, Shrimpton, R. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010; 125, e473e480.
6. Cameron, N, Preece, MA, Cole, TJ. Catch-up growth or regression to the mean? Recovery from stunting revisited. Am J Hum Biol. 2005; 17, 412417.
7. Martorell, R, Horta, BL, Adair, LS, et al. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J Nutr. 2010; 140, 348354.
8. Prentice, AM, Ward, KA, Goldberg, GR, et al. Critical windows for nutritional interventions against stunting. Am J Clin Nutr. 2013; 97, 911918.
9. Stein, AD, Wang, M, Martorell, R, et al. Growth patterns in early childhood and final attained stature: data from five birth cohorts from low- and middle-income countries. Am J Hum Biol. 2010; 22, 353359.
10. Golden, MH. Is complete catch-up possible for stunted malnourished children? Eur J Clin Nutr. 1994; 48(Suppl. 1), S58S71.
11. Nelson, CA, Thomas, KM, de Haan, M. Neuroscience of Cognitive Development: The Role of Experience and the Developing Brain. 2012. John Wiley & Sons: Hoboken, NJ.
12. Morgan, B, Gibson, KR. Nutritional and environmental interactions in brain development. In Brain Maturation and Cognitive Development (eds. Gibson KR, Peterson AC), 1991; pp. 91106. Aldine de Bruyter: New York, NY.
13. Shonkoff, JP, Garner, AS, Siegel, BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012; 129, e232e246.
14. Glewwe, P, King, EM. The impact of early childhood nutritional status on cognitive development: does the timing of malnutrition matter? World Bank Econ Rev. 2001; 15, 81113.
15. Hoddinott, J, Maluccio, JA, Behrman, JR, Flores, R, Martorell, R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet. 2008; 371, 411416.
16. Mendez, MA, Adair, LS. Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. J Nutr. 1999; 129, 15551562.
17. Crookston, BT, Schott, W, Cueto, S, et al. Postinfancy growth, schooling, and cognitive achievement: young lives. Am J Clin Nutr. 2013; 98, 15551563.
18. Crookston, BT, Penny, ME, Alder, SC, et al. Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition. J Nutr. 2010; 140, 19962001.
19. Crookston, BT, Dearden, KA, Alder, SC, et al. Impact of early and concurrent stunting on cognition. Matern Child Nutr. 2011; 7, 397409.
20. Casale, D, Desmond, C, Richter, L. The association between stunting and psychosocial development among preschool children: a study using the South African Birth to Twenty cohort data. Child Care Health Dev. 2014; 40, 900910.
21. Norris, SA, Richter, LM, Fleetwood, SA. Panel studies in developing countries: case analysis of sample attrition over the past 16 years within the Birth to Twenty cohort in Johannesburg, South Africa. J Int Dev. 2007; 19, 11431150.
22. Richter, L, Norris, S, Pettifor, J, Yach, D, Cameron, N. Cohort profile: Mandela’s children: the 1990 Birth to Twenty study in South Africa. Int J Epidemiol. 2007; 36, 504511.
23. Richter, LM, Yach, D, Cameron, N, Griesel, RD, Wet, T. Enrolment into Birth to Ten (BTT): population and sample characteristics. Paediatr Perinat Epidemiol. 1995; 9, 109120.
24. Frankenburg, WK, Fandal, AW, Thornton, SM. Revision of Denver Prescreening Developmental Questionnaire. J Pediatr. 1987; 110, 653657.
25. Hsiao, C, Richter, LM. Early mental development as a predictor of preschool cognitive and behavioral development in South Africa: the moderating role of maternal education in the Birth to Twenty Cohort. Infants Young Child. 2014; 27, 7487.
26. Luiz, DM, Foxcroft, CD, Tukulu, AN. The Denver II Scales and the Griffiths Scales of Mental Development: a correlational study. J Child Adolesc Ment Health. 2004; 16, 7781.
27. World Health Organization. WHO Child Growth Standards: Methods and Development: Head Circumference-for-Age, Arm Circumference-for-Age, Triceps Skinfold-for-Age and Subscapular Skinfold-for-Age. 2007. WHO: Geneva.
28. Shisana, O, Labadarios, D, Rehle, T, et al. South African National Health and Nutrition Examination Survey (SANHANES-1). 2013. HSRC Press: Cape Town.
29. World Health Organization. Global database on child growth and malnutrition, 2012. Retrieved 10 September 2015 from
30. Adair, LS. Filipino children exhibit catch-up growth from age 2 to 12 years. J Nutr. 1999; 129, 11401148.
31. Berkman, DS, Lescano, AG, Gilman, RH, Lopez, SL, Black, MM. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. Lancet. 2002; 359, 564571.
32. Adair, LS, Fall, CH, Osmond, C, et al. Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Lancet. 2013; 382, 525534.
33. Boersma, B, Wit, JM. Catch-up growth. Endocr Rev. 1997; 18, 646661.
34. Leroy, JL, Ruel, M, Habicht, JP. Critical windows for nutritional interventions against stunting. Am J Clin Nutr. 2013; 98, 854855.
35. Lundeen, EA, Stein, AD, Adair, LS, et al. Height-for-age z scores increase despite increasing height deficits among children in 5 developing countries. Am J Clin Nutr. 2014; 100, 821825.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of Developmental Origins of Health and Disease
  • ISSN: 2040-1744
  • EISSN: 2040-1752
  • URL: /core/journals/journal-of-developmental-origins-of-health-and-disease
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed