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May 2013, Volume 63, Issue 5

Letter to the Editor

Developmental milestones: Even the Physicians don’t know enough and what we need to do?

Farooq Azam Rathore  ( Department of Rehabilitation Medicine, Combined Military Hospital, Lahore Cantt. )
Sahibzada N. Mansoor  ( Department of Rehabilitation Medicine, Combined Military Hospital, Kohat Cantt. )

Madam, we thank Dr Ahmad Zaheer Qureshi for his comments on our letter to editor. While we agree with his recommendation of "Opinion based articles and observations may be narrated with great caution", we would like to emphasize that our correspondence should have been read in the context of the specific background we explained.1 We had the opportunity to work together and independently in different areas of Pakistan in the last seven years. We worked at the Armed Forces Institute of Rehabilitation Medicine, Rawalpindi (The largest tertiary care referral Rehabilitation Institute of Pakistan with a separate Cerebral Palsy clinic)2 and interior Sindh where FR used to be the only Rehabilitation physician in a radius of 400 km.  Although we didn\\\'t document every case of delayed milestones we saw, but there were some common observations we noticed and shared with the readers. We were unable to quote references to national and international studies on this topic because childhood disability in Pakistan just like adulthood disability is neglected and the research is lacking.3 And we didn\\\'t want to lose an opportunity to provide food for thought and stimulate debate on an important topic usually not addressed in Pakistan based biomedical research e.g a Medline search (on 8th March 2013)  with the key words "Developmental delay" and "Pakistan" generated seventeen results only.
As for the use of high dose multi-vitamins, it should be evidence based and for specific diseases with documented nutritional deficiencies only as pointed by the author. There is no scientific rationale in prescribing cocktails of vitamins and Calcium to a child with autism, cerebral palsy, neurodegenerative disorder and mental and motor delay for prolonged period (another common observation supported by discussion with paediatric and rehabilitation medicine colleagues in Pakistan).
We would also like to point out that "such mere observations" are also an accepted form of evidence (albeit weak) in the scientific literature. Personal communications (based on observations and personal experiences) although not preferred, but are accepted as a form of reference.4 Many reputed journals encourage publications of personal views and experiences in special dedicated sections. e.g British Medical Journal allows publication of "personal views".5 An extensive list of similar journals can be viewed at http://www.kevinmd.com/blog/2013/03/medical-journals-accept-stories-essays-physicians.html.
We have tried to share our observations with other colleagues working in Pakistan. The aim was   to identify the pitfalls in detection of developmental delay; disadvantages of providing false hopes to the parents resulting in  wastage of time and resources which often results in  missing the window of opportunity in order to prevent further complications and improve function in an already compromised child. These observations and personal views should not be dismissed, as many a time they provide food for thought and lead to a scientific discussions (as is the case in this letter).
In the end we will stand by our observations that most of the physicians dealing with delayed milestones in Pakistan are not well versed in the assessment and management of these disorders, till the time any future "Original scientific research" or survey proves otherwise.

References

1. Rathore FA, Mansoor SN. Developmental milestones: Even the Physicians don\\\'t know enough and what we need to do? J Pak Med Assoc 2013; 63: 132-3.
2. Rathore MF, Hanif S, Farooq F, Ahmad N, Mansoor SN. Traumatic spinal cord injuries at a tertiary care rehabilitation institute in Pakistan. J Pak Med Assoc 2008; 58: 53-7.
3. Rathore FA, New PW, Iftikhar A. A report on disability and rehabilitation medicine in Pakistan: past, present, and future directions. Arch Phys Med Rehabil 2011; 92: 161-6.
4. International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts Submitted to Biomedical Journals. (Online) (Cited 2013 March 7). Available from URL: http://www.icmje.org/urm_full.pdf.
5. British Medical Journal. Article types. (Online) (Cited 2013 March 7). Available from URL: http://www.bmj.com/about-bmj/resources-authors/article-types.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: