Table 1

Characteristics of the studies meeting the inclusion criteria

SourceStudy design
Sample		Population
age at enrolment		Study durationComponents of integrated nutrition and stimulation interventionsComparisonOutcome measures
Growth outcomesDevelopmental outcomes
Mckay et al30RCT
Five treatment arms: 1a, 1b, 2, 3 and 4 based on treatment periods
n=449		Colombia,
Undernourished children
Age 36 months		February 1971 to August 1974Macronutrient and micronutrient supplementation and nutrition education: Protein and calories and vitamin A thiamine, riboflavin, niacin and iron provided to children in three meals daily.
Education programme: Provided education to mothers to support language development, social abilities, and psychomotor skills.		Detail not availableHAZ
WAZ		Language usage, memory, motor control, manual, dexterity, information and vocabulary, quantitative reasoning, logic, verbal and non-verbal production
Waber et al44RCT
Six arms: Nutrition (third trimester to 36 months age), Nutrition (age 6 to 36 months), Nutrition (third trimester to 6 months age), Stimulation, Nutrition+Stimulation and Control
n=433		Colombia,
Age 6–36 months		Detail not availableMacronutrient supplementation: Food distribution from local store sufficient for the entire family.
Education programme: Offered mothers education about developmental processes to improve their responsiveness towards children.		Detail not availableLength
Weight

  1. Griffiths mental development scale: locomotor, eye-hand coordination, language, performance developmental quotient

  2. Corman–Escalona Einstein Scale: cognitive competence

Grantham-McGregor et al45RCT
Four arms: Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=129		Jamaica,
Stunted children with LAZ <-2 SD
Age 9–24 months		Detail not availableMacronutrient supplementation: 1 kg milk-based formula and 20 g protein/d to all children.
Psychosocial stimulation: Taught mothers to play with their children in structured play sessions. Lent homemade toys and simple picture books.		Weekly health visit and free medical careWLZGriffiths mental development scale: locomotor, eye-hand coordination, language, performance developmental quotient
Powell et al31Cluster RCT (18 clusters)
Two arms
n=139		Jamaica,
Undernourished children
Age 9–30 months		June 2009 to March 2012Nutrition education: Gave nutrition education to mothers through existing health services.
Psychosocial stimulation: Demonstrated play activities, used homemade toys and books/materials and discussed parenting issues.		Provide health and nutrition education to mothers and monitor the growth of children.Height
Weight		Griffiths mental development scale: locomotor, eye-hand coordination, hearing and speech, performance developmental quotient
Gardner et al32RCT
Four arms: Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=126		Jamaica,
Undernourished children (WAZ≤1.5 SD)
Age 9–30 months		February 2010 to December 2011Micronutrient supplementation: 10 mg elemental zinc in a flavoured syrup in 7 vials, each containing one dose, was given daily to all children.
Psychosocial stimulation: Encouraged play and mother-child interaction, lent homemade toys and exchanged new toys in the next visit.		Placebo and routine careLAZ
WAZ
WLZ		Griffiths mental development scale: locomotor, eye-hand coordination, hearing and speech, performance developmental quotient
Hamadani et al33Cluster RCT (20 clusters)
Two arms
n=206		Bangladesh,
Undernourished children (WAZ <-2 SD)
Age 6–24 months		2000 to 2002Macronutrient supplementation: Referred undernourished children to community nutrition centres, where they received food packets.
Psychosocial stimulation: Discussed child development and the importance of play, then demonstrated play activities to the mothers using low-cost toys.		They provided food packets to severely undernourished children at Community Nutrition Centres.HAZ
WAZ
WHZ

  1. Bayley Scales of Infant Development (BSID) II: mental development index and motor development index

  2. Wolke’s behaviour rating

Nahar et al34Time-lagged controlled study
Two arms
n=110		Bangladesh, Undernourished children (<50% WAZ or <70% WLZ or oedema)
Age 6 to 24 months		October 2002 to June 2004Nutrition education and micronutrient supplementation at Hospital Nutritional follow-up unit (HNFU) to all enrolled children for 6 months.
Psychosocial stimulation: Demonstrated play activities to mothers, encouraged them to play and chat with their children, give positive feedback and continue to play between sessions.		Health and nutrition education at HNFU, growth monitoring and micronutrient supplementationLAZ
WAZ
WLZ		1)BSID II: mental development index and motor development index
Lozoff et al35RCT
Two arms (infants were stratified by iron-deficient anaemia status)
n=277		Chile,
Children with (Iron Deficiency Anaemia) IDA and without IDA
Age 6–12 months		–Micronutrient supplementation: 15 mg ferrous sulphate for 6 months infants and 30 mg of ferrous sulphate for 12 months old infant on a weekly basis.
Support mother–child relationship: Modelled positive feedback, provided play activities and information about child development.		Surveillance:
Record iron intake, feeding and health information.		LAZ
WAZ

  1. BSID II: cognitive and motor development

  2. Behaviour rating scale: object orientation, motor quality, negative affect, and positive social responsiveness

Aboud et al36Cluster RCT (45 clusters)
Three arms:
Nutrition only, Nutrition+Stimulation and Control
n=302		Bangladesh,
Very poor population
Age 8–20 months		–Multiple micronutrient supplementation (Sprinkles) provided to all enrolled children, one sachet daily with a meal.
Responsive Feeding and Stimulation (RFS): Demonstrated responsive stimulation and responsive feeding and coaching as the mothers practiced with their children.		Regular health, nutrition, and child development programme.LAZ
WAZ

  1. BSID II: receptive and expressive language skills

  2. Home inventory:

Home environment,
3) Mother–child picture talk task: mother-child responsive talk
Ogunlade et al37RCT,
Two arms
n=151		South Africa,
Children with Hb≤12.5 g/dL
Age 36–79 months		September to November 2008.Macro- and micronutrient supplementation: Enrolled children received stiff maize-meal porridge with added micronutrient powder (<8 g).
Psychosocial stimulation: All children attended preschool for 52 days.		Received soft maize-meal porridge with added placebo powder (<8 g) containing only maize maltodextrin.HAZ
WAZ		KABC-II: learning scale, sequential scale, simultaneous scale, mental processing index, nonverbal index.
Nahar et al19RCT
Five arms:
Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=507		Bangladesh,
Severely malnourished children (WAZ <-3 SD)
Age 6–24 months		–Macronutrient supplementation: Supplied food packets (Pushti Packet) during clinic visits for the first 3 months.
Play sessions and education: Offered play sessions and parental education using a semistructured curriculum.		Routine clinical management: growth monitoring and promotion, health education, micronutrient supplementation and immunisations.LAZ
WAZ
WLZ		BSID II: mental development index and psychomotor development index
Vazir et al38Cluster RCT (60 clusters)
Three arms:
Nutrition only, Nutrition+Stimulation and Control
n=600		India
Age 3 months		–Nutrition education:
Provided nutrition education on breastfeeding and complementary feeding using PAHO/WHO guidelines.
Playgroup and educational session: Provided messages and skills on responsive feeding and developmental stimulation messages.		Standard of care: received ICDS services programmeHeight
Weight		BSID II: mental and motor development index
Aboud et al39Cluster RCT (47 clusters)
Two arms
n=463		Bangladesh
Age 6–12 months and 12–24 months		November 2010 to February 2012Nutrition education: Provided 10 min of counselling on feeding and child development.
Parenting programme: Discussed parenting practices related to communication, play and nutrition.		Standard care: Sharing messages about feeding and hygiene.LAZBSID III: cognitive, receptive language and expressive language, fine motor
Tofail et al46Cluster RCT (30 clusters)
Two arms (infants in each group stratified by their iron status)
n=434		Bangladesh,
Children with mild to moderate IDA.
Age 6–24 months		–Micronutrient supplementation: One bottle of 35 mL ferrous sulphate syrup to children with IDA, parent, fed their child 5 mL syrup daily for first 6 months (seven doses).
Psychosocial stimulation: Provided mothers with demonstrations of how to play with toys and interact with their children.		Weekly visit in a control group to ask the mother about the health status of their child.HAZ
WAZ
WHZ

  1. BSID II: mental development Index and Psychomotor Development Index

  2. Modified version of scale developed by Wolke al.: behaviour

Yousafzai et al40Cluster RCT (80 clusters)
Four arms:
Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=1489		Pakistan
Age birth to 24 months		June 2009 to March 2012Multiple micronutrient supplementation (Sprinkles) daily for 33 months for all children and nutrition education (strengthened existing nutrition education services)
Responsive stimulation: Illustrated play and communication activities, encouraged parents to practice activities with their child through play and communication counselling, provided coaching and feedback.		Standard-of-care services: health, hygiene, and basic nutrition education and immunisation through a monthly home visit and occasional group meetings.HAZ
WAZ
WHZ		BSID III: cognitive, language, motor and socioemotional development
Attanasio et al47Cluster RCT (96 clusters)
Four arms:
Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=1429		Colombia
Age 12–24 months		February 2010 to December 2011Multiple micronutrient supplementation (Sprinkles) for all children for 18 months.
Psychosocial stimulation: Demonstrated play activities using low-cost or homemade toys, picture books and form boards to improve maternal-child interactions, changing play materials weekly.		Cash payments for complying with regular health check-ups for children<6 years age and regular school attendance for children>5 years ageHeight
Weight		BSID III: cognition, receptive language, expressive language, fine motor and gross motor
Singla et al41Cluster RCT (25 clusters)
Two arms
n=319		Uganda
Age 12–36 months		December 2012 to November 2013Nutrition education: Reviewed messages on a diverse diet.
Parent education sessions: Focused on five messages on childcare, including play, talking, diet, hygiene, love and respect and maternal well-being.		Preschools were created for older children with support from Plan Uganda and received nutritional information.HAZBSID III: cognitive and receptive language
Rockers et al27Cluster RCT (30 clusters)
Two arms
n=526		Zambia
Age 6–12 months		August 2014 to October 2015Educational sessions and nutrition education: Discussed parenting skills, child nutrition and cooking demonstration, forms of play, cognitive stimulation and language development activities.Baseline end line evaluations of health and developmental status of children.HAZ
WAZ

  1. Savings brains Early Child development Scale: gross motor function and cognition

  2. INTERGROWTH-21st Neurodevelopment assessment tool: cognitive and socioemotional development

Helmizar et al42Cluster RCT (40 clusters)
Four arms: Nutrition only, Stimulation only, Nutrition+Stimulation and Control
n=355		Indonesia
Age 6–9 months		January to December 2013Macronutrient supplementation: Formula food packets of formula adjusted for age groups (6–8 months, 9–11 months and >12 months) for children.
Psychosocial stimulation: Delivered play sessions, encouraged mother–child interaction and taught mothers or caregivers about responsive stimulation, provided toys and picture books.		Detail not availableHAZ
WAZ
WHZ		BSID III: cognitive, language and motor development
Muhoozi et al43Cluster RCT (82 clusters)
Two arms
n=511		South-western Uganda,
Age 6–8 months		October 2013 to May 2015Nutrition and stimulation education with routine healthcare: Provided knowledge on nutrition and stimulation, demonstrated cooking and making toys using local resources, provided play activities and counselling.Routine healthcareLAZ
WAZ
WLZ		BSID III: cognitive, language and motor development
Schneider et al48RCT
Two arms
n=192		Indonesia
Age between 3 and 5 years		2014Macronutrient supplementation: Two servings per day of a fortified milk powder for children for six months.
Psychosocial stimulation: Children performed cognitive stimulation task with the assistance of the parent/caregiver. Parent/caregiver was provided standardised learning activities to perform with the child at home.

  1. Did not visit the community centre and did not receive any Psychosocial stimulation.

  2. Consumed at home two servings of an unfortified milk powder (placebo).

Height
Weight

  1. ASQ-3 & parental report: cognitive development

  2. WPPSI-IV, adapted: cognitive abilities including verbal comprehension, visual-spatial processing, working memory, fluid reasoning and processing speed

  3. CBCL 1.5–5: behaviour

Hamadani et al28Cluster RCT (90 clusters)
Two arms
n=2423		Bangladesh,
Undernourished children
(WAZ <-2 SD)
Age 5–24 months		November 2014 to April 2015Nutrition education: Provided nutrition-related messages during play sessions and provided nutrition cards with a recipe for diets for underweight children.
Psychosocial stimulation: Mothers were shown how to support their children’s development through play and interaction.		No extra attention, they used the clinic for treatment as usual, some were immunised.LAZ
WAZ
WLZ		BSID III: cognitive, language and motor development
Galasso et al20Cluster RCT (125 clusters)
Five arms: Intensive nutrition counselling (1), 1+supplementation (0–5 months age), 1+supplementation (6–11 months age), 1+stimulation and Control
n=3738		Madagascar
Age: pregnant women, women with children 0–5 months and 6–11 months		June 2014 to November 2016Intensive nutrition counselling and micronutrient supplementation: Lipid-based nutrient supplementation to children 6–18 months and pregnant and lactating mothers.
Early stimulation counselling: Stimulation messages were provided to parents.		Standard-of-care programme: community-based health and nutrition services with growth monitoring and education.LAZ
WAZ
WLZ		ASQ-I: gross motor, fine motor, problem-solving, socioemotional development, communication skills
Grantham-McGregor et al29Cluster RCT (192 clusters)
Four arms: Nutrition only, Nutrition+Stimulation (Home visits), Nutrition+Stimulation (Group sessions), Control
n=1449		India
Age 7–16 months		August 2015 to November 2017Health and Nutrition Service Link
Nutrition education: Education provided to improve feeding and hygiene practices in the household through games, stories and cooking demonstration.
Psychosocial stimulation: Demonstrated play activities and encouraged mothers to play with their child using locally available toys.		Health and Nutrition Service Link: Discussed the availability of services such as growth monitoring and food supplementation in the community.HAZ
WAZ		BSID III: cognitive, language and motor development
Strengths and difficulties Questionnaire

  • ASQ, ages and stages questionnaire; CBCL, child behaviour checklist; ICDS, integrated child development services programme; IDA, iron deficiency anemia; KABC II, Kaufman assessment battery for children-second edition; LAZ/HAZ, length-for-age/height-for-age z score; PAHO, Pan American Health Organization; RCT, randomised control trial; WAZ, weight-for-age z score; WLZ/WHZ, weight-for-length weight-for-height z score; WPPSI, weschler preschool and primary scale of intelligence.