Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials

Qiong-Nan Bao; Zi-Han Yin; Yuan-Fang Zhou; Ya-Qin Li; Xin-Yue Zhang; Man-Ze Xia; Zheng-Hong Chen; Wan-Qi Zhong; Jin Yao; Ke-Xin Wu; Zhen-Yong Zhang; Shao-Jun Xu; Fan-Rong Liang

doi:10.1371/journal.pone.0303948

Peer Review History

Original SubmissionAugust 10, 2023
17 Oct 2023 Decision Letter - Benjamin Jun Jie Seng, Editor PONE-D-23-25490Efficacy and safety of acupuncture for postpartum hypogalactia: a systematic review and meta-analysis of randomized controlled trialsPLOS ONE Dear Dr. Liang 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. Please submit your revised manuscript by Dec 01 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Benjamin Jun Jie Seng, MD Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ Additional Editor Comments: Dear Professor Liang, Thank you for the submission to PLOS One. Below are the reviewers' comments for your consideration. Methods - The search period is slightly outdated and nearly done 1 year from date of submission -> It will benefit from an update Table 2 - Standardize the reporting and number of significant figures reported for the results - Suggest to put the actual treatment instituted in the control group -> This has implications on the suitaibility of meta-analyses as if there are drastically different control measures implemented, the pooling of the results may not be appropriate. -> the authors may need to check on this Discussion - Brief discussion should be made with regards to role of acupuncture in postpartum hypogalactia as to how it should be used in current practice - Are there any patients whom acupuncture should not be used? [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously Reviewer #1: No Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 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: No Reviewer #2: Yes ****** 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: Were there any attempts made to look for unpublished data which could have affected the evaluation of the meta-analysis? Table 2: what is TCM syndrome differentiation? Table 2 is also difficult to read with many acronyms and many different outcomes being reviewed. Are there certain standardized or commonly used parameters we can focus on instead of evaluating such a wide range of efficacy and safety parameters? Table 5: Inappetence > can be replaced with "Loss of appetite" "Dizzy" > can be replaced with "Dizziness" "Breast distending" > can be replaced with "breast distension" Please complete what "3 cases of gastrointestinal" means. Do you mean "gastrointestinal discomfort"? Reviewer #2: Interesting study. Some issues need clarifications. 1 Write the full details of search strategy with the keywords used and results of each data base individually 2. Study characteristics add the inclusion and exclusion criteria of participants 3. Add the registration details of each study prospective or retrospective or not registered 4. Subgroup analysis according to time frequency type and duration of intervention should be added ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Ahmed M Maged ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0303948.r001
Revision 1
18 Nov 2023 Author Response Dear Editors and Reviewers: We sincerely appreciate for the editors and reviewers’ comments concerning our manuscript entitled “Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials”. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our review. We have studied comments carefully and have made correction which we hope meet PLOS ONE’s publication criteria. Revised portions are marked red in the paper. The main corrections in the paper and the responds to the editor and reviewers’ comments are as following: Editor’s Comments: MD. Benjamin Jun Jie Seng: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at. Response: Many thanks for your kindly comment. We have carefully read the PLOS ONE style templates you provided, and revised our manuscript according to the requirements, including file naming, title, authors, affiliations and main body. 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Response: Thanks for your significant comment. We have checked and revised the grant information in the ‘Funding Information’ section. This study was financially supported by the “Central Financial Transfer Payment to Local Projects in 2022 of National Administration of Traditional Chinese Medicine”, which does not have a specific grant number. Fanrong Liang was the study funder. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ Response: Thanks for this important guidance. I have seen the instructed video and linked an ORCID iD in my Editorial Manager account. Additional Editor Comments: 1. Methods - The search period is slightly outdated and nearly done 1 year from date of submission -> It will benefit from an update Response: Thanks for your significant comment. We have performed an updated search on October 19, 2023. 1 more RCT was included in this systematic review and relevant results have been updated. 2. Table 2 - Standardize the reporting and number of significant figures reported for the results - Suggest to put the actual treatment instituted in the control group -> This has implications on the suitability of meta-analyses as if there are drastically different control measures implemented, the pooling of the results may not be appropriate. -> the authors may need to check on this Response: Thanks a lot for your significant suggestion. We have standardized the reporting and number of significant figures reported for the results. Based on currently available original data, sham acupuncture, conventional treatment (breast sucking, postpartum routine care, breastfeeding education) and Chinese herb were included as control in this systematic review. Studies used interventions such as drugs, galactagogues, massage, or any other complementary therapy in control group were not included. The pooled data from included RCTs are divided into comparators including acupuncture + control vs. control and acupuncture vs. control. We have described the detailed control measures and treatment in the Methods and Results section. 3. Discussion - Brief discussion should be made with regards to role of acupuncture in postpartum hypogalactia as to how it should be used in current practice - Are there any patients whom acupuncture should not be used? Response: Thank you for this precious suggestion. Our findings may provide guidance for the clinical treatment of PH. We have discussed how to use acupuncture to treat postpartum hypogalactia in practice from the perspective of better combination modality, treatment duration, acupoint selection, and traditional Chinese medicine (TCM) syndrome differentiation. Concerning safety, minor adverse effects of acupuncture were recorded in three studies, and these responses returned to normal after treatment. Therefore, acupuncture could be considered a relatively safe intervention to improve milk supply for women with PH. Considering that few participants in the acupuncture group experienced skin itching and negative sensations, it may not suitable for those who fear of needling or allergic to metal. We have added the in the Discussion section. Reviewer #1: 1. Were there any attempts made to look for unpublished data which could have affected the evaluation of the meta-analysis? Response: Thanks a lot for your important comment. We have retrieved clinical registry platform for unpublished data, and no available unpublished data was found. 2. Table 2: what is TCM syndrome differentiation? Table 2 is also difficult to read with many acronyms and many different outcomes being reviewed. Are there certain standardized or commonly used parameters we can focus on instead of evaluating such a wide range of efficacy and safety parameters? Response: Thanks for your significant suggestion. Treatment based on TCM syndrome differentiation is the core principle of TCM; that is means taking the individual as the study’s starting point and analyzing the pathophysiological characteristics, nature of lesions and development trend according to their clinical signs and symptoms, so as to develop the corresponding TCM treatments. Many studies have demonstrated that TCM syndrome differentiation have value in predicting prognosis and improving intervention effects in various diseases. In this systematic review, thirteen of the included studies included participants based on the TCM syndrome differentiation, including deficiency of Qi and blood syndrome; liver-Qi stagnation syndrome; deficiency of spleen-Qi syndrome; phlegm dampness and blood stasis syndrome; Qi deficiency and blood stasis syndrome. We have added information regarding Traditional Chinese medicine (TCM) syndrome differentiation in study characteristic. We have revised the Table 2. It was complicated and hard to understand. For outcome measures, we retained some standardized and commonly used parameters, including serum prolactin level, milk secretion volume, mammary fullness degree, total effective rate, exclusive breastfeeding rate, and adverse events. 3. Table 5: Inappetence > can be replaced with "Loss of appetite" "Dizzy" > can be replaced with "Dizziness" "Breast distending" > can be replaced with "breast distension" Please complete what "3 cases of gastrointestinal" means. Do you mean "gastrointestinal discomfort"? Response: Thank you very much for your careful review. We have modified the above inappropriate words in the Table 3. Reviewer #2: Interesting study. Some issues need clarifications. 1. Write the full details of search strategy with the keywords used and results of each data base individually Response: Many thanks for your significant comment. We have added the detailed search strategies of each database in the S1 file. 2. Study characteristics add the inclusion and exclusion criteria of participants Response: Thanks for your important comment. We have added information regarding the inclusion and exclusion criteria of participants in the Study characteristics section. A total of eleven of the included studies described the inclusion and exclusion criteria of participants in detail. 3. Add the registration details of each study prospective or retrospective or not registered Response: Thanks for your kindly recommendation. All the included studies in this systematic review have not registered in the clinical registry platform in advance. We have added related information in the Results and Discussion section. 4. Subgroup analysis according to time frequency type and duration of intervention should be added Response: Thanks a lot for your advice. We have added subgroup analyses according to duration of intervention, the results have been presented in the Results section. But subgroup analysis based on time frequency type cannot be performed, because all studies except 1 were treated once a day. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0303948.r002
18 Dec 2023 Decision Letter - Benjamin Jun Jie Seng, Editor PONE-D-23-25490R1Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trialsPLOS ONE Dear Dr. Liang, 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. Please submit your revised manuscript by Feb 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Benjamin Jun Jie Seng, MD Academic Editor PLOS ONE Additional Editor Comments: Dear authors Pls refer to comments by the reviewers and provide your point by point reply. Thank you [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? 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 #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: No ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes ****** 5. 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 #3: Yes ****** 6. 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: No further comments, my comments have been addressed. This topic is of interest as PH is a prevalent issue among breastfeeding mothers. It is useful to know the utility of accupuncture in this area as this is something that is not commonly considered by layman as treatment for PH Reviewer #3: 1. The studies differ significantly in terms of interventions and control arms. Authors should present data as following comparators (MA+CT vs CT, MA+CH vs CH, MA vs CH and MA vs CT, etc) in one forest plot as subgroup or refrain from conducting meta-analysis and present finding as systematic review only. This will reduce the number of figures and give better clarity to manuscript. 2. Other concern is inclusion of selection of studies that did not report the selection criteria (8 studies) and treatment duration (3 studies) besides high concern in randomization. The findings of meta-analysis depend on kind of included studies. Overall, poor quality studies are included in the meta-analysis. 3. I do not agree with GRADE evidence quality of outcome. Authors has considered publication bias “undetected” for the outcomes “PRL, MSV, MFD and EBR”. However, authors have made no attempt to detect publication bias for these outcomes due to less than 10 studies. I do not agree with this assessment. Funnel plots are most likely asymmetrical for these outcomes. Publication should be “suspected” for these outcomes. The quality of evidence must be downgraded to “Very low/critically low”. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: Yes: Tejas K. Patel ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0303948.r003
Revision 2
16 Feb 2024 Author Response Dear Editors and Reviewers: We sincerely appreciate the editors and reviewers’ comments concerning our manuscript entitled “Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials”. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our review. We have studied the comments carefully and have made corrections to meet PLOS ONE’s publication criteria. The revised portions are marked red in the paper. The main corrections in the paper and the response to the editor and reviewers’ comments are as follow: Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Response: We greatly appreciate your review and support for the study. Reviewer #3: (No Response) Response: We are grateful for your significant comments. We have carefully read and addressed the manuscript in this round according to your comments. 2. Is the manuscript technically sound, and do the data support the conclusions? 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 Response: Thank you very much for your agreement. Reviewer #3: Partly Response: We extend our many thanks for your review. We have further modified the results of the meta-analysis and presented it. 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Response: Thank you very much for this approval. Reviewer #3: No Response: We sincerely thank you for your comments. We have revised the statistical analysis in a more appropriate manner. 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Response: Many thanks for your consent. Reviewer #3: Yes Response: Many thanks for your consent. 5. 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 Response: Thank you very much for this ratification. Reviewer #3: Yes Response: Thank you very much for this ratification. 6. 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: No further comments, my comments have been addressed. This topic is of interest as PH is a prevalent issue among breastfeeding mothers. It is useful to know the utility of acupuncture in this area as this is something that is not commonly considered by layman as treatment for PH. Response: Thank you very much for your acceptance and approval. Reviewer #3: 1. The studies differ significantly in terms of interventions and control arms. Authors should present data as following comparators (MA+CT vs CT, MA+CH vs CH, MA vs CH and MA vs CT, etc) in one forest plot as subgroup or refrain from conducting meta-analysis and present finding as systematic review only. This will reduce the number of figures and give better clarity to manuscript. Response: Thank you for your comments. We have modified the meta-analysis. For each outcome, different comparators (MA+CT vs CT, MA+CH vs CH, MA vs CH and MA vs CT, etc) were presented as subgroups in one forest plot. The number of figures has been reduced, and all results of meta-analysis have been corrected. 2. Other concern is inclusion of selection of studies that did not report the selection criteria (8 studies) and treatment duration (3 studies) besides high concern in randomization. The findings of meta-analysis depend on kind of included studies. Overall, poor quality studies are included in the meta-analysis. Response: Thank you for your comments. The studies that did not report the selection criteria or treatment duration have been rated as “some concern” in the domain of selection of reported results. We conducted a systematic search through databases from their establishment to October 2023; unfortunately, this led to studies of poor quality being included in this systematic review and meta-analysis, which is a significant limitation of this study. We have described this limitation and put forward relevant recommendation for future research in the Discussion section. 3. I do not agree with GRADE evidence quality of outcome. Authors has considered publication bias “undetected” for the outcomes “PRL, MSV, MFD and EBR”. However, authors have made no attempt to detect publication bias for these outcomes due to less than 10 studies. I do not agree with this assessment. Funnel plots are most likely asymmetrical for these outcomes. Publication should be “suspected” for these outcomes. The quality of evidence must be downgraded to “Very low/critically low”. Response: Many thanks for your important comments. We have revised the assessment of publication bias into “strongly suspected” for the outcomes of serum prolactin level, milk secretion volume, mammary fullness degree, and exclusive breastfeeding rate, and the quality of evidence has been downgraded to “critically low”. Attachments Attachment Submitted filename: Response_to_Reviewers.docx https://doi.org/10.1371/journal.pone.0303948.r004
27 Mar 2024 Decision Letter - Benjamin Jun Jie Seng, Editor PONE-D-23-25490R2Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trialsPLOS ONE Dear Dr. Liang, 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. Multiple grammatical errors still exist. Suggest to add in the databases searched for this review We look forward to receiving your revised manuscript. Kind regards, Benjamin Jun Jie Seng, MD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Dear authors, The revision are mostly satisfactory. Minor comments - Multiple grammatical errors still remains - Dear authors, Abstract - The databases used for the review should be stipulated [Note: HTML markup is below. Please do not edit.] [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0303948.r005
Revision 3
30 Apr 2024 Author Response Dear Editors: We sincerely appreciate for the journal requirements and editor's comments concerning our manuscript entitled “Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials”. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our review. We have studied comments carefully and have made correction which we hope meet PLOS ONE’s publication criteria. Revised portions are marked red in the paper. The main corrections in the paper and the responds to the journal requirements and editor’s comments are as following: Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Response: Thank you for bringing this to our attention. We have thoroughly reviewed the reference list to ensure its completeness and accuracy. We have also verified that no retracted papers have been cited in the manuscript. Your reminder is greatly appreciated, and we are committed to maintaining the highest standards of integrity in our research. Additional Editor Comments: Dear authors, The revision are mostly satisfactory. Minor comments - Multiple grammatical errors still remains - Dear authors, Abstract - The databases used for the review should be stipulated Response: Thank you for your positive feedback and support for our study. We have taken note of your suggestions and have worked to improve the language, grammar, and overall clarity of the manuscript. We have also included the databases used in the review in the Abstract as recommended. We strive to ensure that the manuscript is error-free and meets the highest standards of quality. Thank you for your valuable input. Attachments Attachment Submitted filename: Response to Reviewers and Editors.docx https://doi.org/10.1371/journal.pone.0303948.r006
3 May 2024 Decision Letter - Benjamin Jun Jie Seng, Editor Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials PONE-D-23-25490R3 Dear Dr Fan 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Benjamin Jun Jie Seng, MD Academic Editor PLOS ONE Additional Editor Comments (optional): Minor grammatical errors. Will leave it to the editorial office staff to proofread and discuss with the primary authors https://doi.org/10.1371/journal.pone.0303948.r007
Formally Accepted
28 May 2024 Acceptance Letter - Benjamin Jun Jie Seng, Editor PONE-D-23-25490R3 PLOS ONE Dear Dr. Liang, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Benjamin Jun Jie Seng Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0303948.r008

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