Paper title:Comparing Two Early Child Development Assessment Tools in Rural Limpopo, South Africa (Milbrath et al. BMC Pediatrics (2020) 20:197)

Aim(s): 1- To determine the acceptability of a pediatric assessment tool to track early child development (ECD) in a rural health district in Limpopo, South Africa, 2- To compare the adaptability and usability of two different tools (ASQ or CAT/CLAMS assessment tool) used to detect developmental delay in children in rural South Africa, DOI: https://doi.org/10.1186/s12887-020-02101-0

This study is a qualitative report of two focused groups conducted with a specific group of nurses from Limpopo in South Africa. This is a very important and interesting research area and it is interesting to learn more about in this subject. However the study needs more clarity to ensure that the results are usable and relevant to the discussion. This study did not add anything to what was already known on this topic. Small sample size and selection of limited participants (nurses with English ability reading) were the major flaws of this article.

Major points: 1. The title of the study is not informative and appropriate because the authors seem to be considering a broader problem in selecting screening tools for early childhood development in Africa. In fact, the authors looked at two tools they specifically selected and their goal is to get feedback from nurses in a focus group. Therefore, the title is not a reflection of the study. 2. The introduction provides more information about the current situation of child development on a global scale, but does not provide information about the study area. 3. Many sentences within the introduction have no references or a relevant and recent reference. 4. The objectives of the study are not entirely clear. 5. It is not clear where this article lies in terms of the gap in literature and what the focus of research is. 6. It is not clear in the introduction what the gap is in the literature on this subject and how this study examines this gap. 7. The authors describe the need for screening tools for early detection and intervention, but this research is not about creating a screening tool or early diagnosis and intervention program, but about getting feedback on two ECD tool for screening and assessment.The gap in literature may be more related to physicians' views in different cultural contexts on the feasibility and acceptability of tools for regulating them. 8. The authors claimed: ‘Two tools were chosen together by the authors and community partners: the Ages and States Questionnaire (a screening and monitoring tool) and the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (an assessment tool)” it is not clear why and how the authors select these two tools. 9. It is not clear why only two focused group discussions took place. Two focus groups are usually not enough to achieve saturation. 10. What’s your method for this qualitative study? 11. There are many tools to have chosen from ECD monitoring programs, why did the ASQ and the CAT/CLAMS select ? What was the reasoning? 12. The authors claimed: “The senior author of the study has experience using ASQ in the local community and CAT/CLAMS during pediatric exams.“ is not adequate for selection of tools. 13. The authors claimed: “All the nurses that volunteered met these criteria, and no participants were excluded or dropped out of the study prior to its completion.” Isn’t it a study bias? What’s the reading and writing English grade of the nurses working in this district? by selection of the nurses that know English reading and writing, you did not access many expert health workers in this region without this criteria. 14. The authors claimed: “Volunteer participants were recruited from nurses working in rural areas of the Vhembe Health District of Limpopo, South Africa. Nurses were chosen specifically as they are the primary community health providers in this region and are responsible for referring patients to physicians or hospitals as needed.” What are other primary community health providers in this region, and what percent of them were nurses? 15. The authors claimed: “Due to time constraints of participants, follow-up interviews or additional sessions were not able to be conducted with participants, and it is probable data saturation was not reached in this sample.” It is a methodological fault. 16. The authors claimed: “In total, eleven female nurses (eight professional nurses and three nursing students) were interviewed with nursing experience ranging from 0 – 28 years.” what are the weaknesses of this wide range of experience selection? 17. I am not clear about what is a statistically significant result. As authors claimed: “Due to time constraints of participants, follow-up interviews or additional sessions were not able to be conducted with participants, and it is probable data saturation was not reached in this sample.” 18. The authors claimed: “Based on the results of this study, the ASQ was identified as the most appropriate for this setting because it is more time efficient, and is less expensive than the CAT/CLAMS tool.” In the first paragraph of discussion section, this result has been stablished in previous studies and is not a new data. 19. The references are not relevant and update. 20. As authors claimed in the 5th paragraph of discussion: “However, it is unknown if these findings are applicable to Limpopo due to cultural differences in parent-child interactions.” the authors have not certainty of the results of this study, so I think that the study question has not been answered. 21. As authors claimed on limitation of the study, I think that the limitations of the study are fatal. 22. The first and second paragraphs of the conclusion are not due to the results of this study and must be revised.

Minor points: 1. The authors claimed: ‘In previous ASQ validation studies, the ability to identify children with delay varied from 51%- 90%, depending on the age at the time of screening, with an overall sensitivity of 75% and specificity ranging from 81% to 92% [14].” But only cited to one study. 2. The authors claimed: “This research was conducted as part of a larger program, which aimed to improve the recognition and referral rates of developmental delays in young children in this region.” What’s the ref? 3. The explanation of categorizes in text are not justified to tables. 4. The comparison between ASQ and CAT/CLAMS in Usability section is not proper because these tools are different in developmental follow ups and surveillance that stablished in previous studies as the nurses mention.