PONE-D-23-26307Maternal body mass index and necrotizing enterocolitis: A case-control studyPLOS ONE

Dear Dr. Stumpf,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. 1. Introduction:  Please include pathophysiological basis on the association of maternal BMI and NEC2. Method: Kindly include 'lack of gastrointestinal diagnosis' in the section where you describe selection of control group'3. Results: Pleas provide better quality figures4. Conclusion: Kindly change the subheading to discussion and include a separate subheading for the conclusion5. Discussion: Please explain why the large number of Hispanic women is a limitation.7. References: Kindly review reference number 9

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We look forward to receiving your revised manuscript.

Kind regards,

Hlengani Lawrence Chauke, MBCHB, BTh, Dip HIV Man, FCOG, MMED (O &G), MSc

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Professor, Stumpf

Thank you very much for submitting your manuscript to PLOSONE for consideration. We are grateful that you chose to share your research with our journal. The paper is well written, easy to follow and addresses an interesting topic. The study design and research methodology are aligned with the research questions. The introduction provides a compelling justification for the study. The choice of statistical parameters, data analysis Furthermore the data analysis, data analysis and interpretation are appropriate. The discussion section is scholarly written and demonstrates acquittance with the literature on the subject. The conclusion drawn is also appropriate. I enjoyed reading the paper. The following suggestions could further strengthen the paper:

1. Introduction: Consider including a sentence or two on the pathophysiology behind the association of maternal BMI and NEC.

2. Methodology: -Please add "lack of gastrointestinal diagnoses to the methods describing selection of the control group as recommended by one of the reviewers.

3. Results: Is there a way you can improve the quality of the figures? Please provide an explanation why you consider the number of Hispanic women to be a limitation.

4. Discussion: Please change the subheading 'conclusion to discussion) and also include a comment on the significance of the study's findings.

5. Conclusion: Suggest you add a separate subheading after discussion for the conclusion

6. References: Kindly review reference 9

Congratulations for a well written paper. Looking forward to the revised version.

Kind regards,

Lawrence Chauke

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusion? 

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript. The submission is well written with good research methodology. I have a few minor comments:

-Please add "lack of gastrointestinal diagnosis to the methods describing selection of the control group.

-The sub-heading "Conclusion" should be "Discussion."

-reference 9 is incomplete

-The image quality of the figures is poor

Reviewer #2: The authors have conducted a 10-year retrospective review of NICU admissions at a single urban delivery center to determine if Maternal BMI is associated with Stage 2/3 NEC in preterm babies <33 weeks' gestation. The methodology is a case control study, with ratios of 2 cases: 1 control.

The sample sizes are small but a power analysis was conducted to determine if the sample size available was sufficient to detect any association.

The study is important, given the current levels of obesity in all communities globally and it therefore provides an opportunity to drive the public health messages around adverse pregnancy outcomes associated with high maternal BMI.

The manuscript is well written. The data analysis is sound - and the results appropriately capture what was found in the analysis.

The manuscript however can be improved and/or enhanced by:

Introduction:

The authors need to consider making a strong case for the study by providing an explanation or pathophysiological basis (mechanism) that makes an increased maternal BMI a risk factor for NEC - with a particular focus on the effect of "fat" on placental vasculature and eventually placental insufficiency. I think this will allow even generalists to understand why this study was necessary.

Results and Conclusion

The limitations of the study are well described. It is not clear why the number of Hispanic women in the study was a limitation? Please provide clarity in the manuscript.

Reviewer #3: Dear author

This is an important topic, the results will help identify additional maternal risk factors for NEC.

However, the paper requires revision. There need to be a discussion on the significant findings from your results.

The pathophysiology of NEC and association with BMI should be described in the introduction.

Kind regards

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Reviewer #1: Yes: Daynia E. Ballot

Reviewer #2: Yes: Prof Dini Mawela

Reviewer #3: Yes: Dr Tanusha Ramdin

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Maternal body mass index and necrotizing enterocolitis: A case-control study

PONE-D-23-26307R1

Dear PROF STUMPF_KATHERINE,

Thank you for the revised manuscript. We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

 Lawrence Chauke, PhD, MMED (O &G), MSc (Clinical Research), Cert MFM(SA), FCOG(SA), MBCHB, BTh, Dip HIV MAN(SA)

Academic Editor

PLOS ONE