PONE-D-24-15995Prevalence and Factors associated with Severe Acute Malnutrition among children under the age of 15 years.PLOS ONE

Dear Dr.  Masenga,

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PLOS ONE

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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 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: Partly

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

Reviewer #2: No

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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

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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: General comment

This paper describes the prevalence and identifies factors associated with severe acute malnutrition (SAM) among children <15 years in a regional hospital in Zambia. This is indeed a topic of public health importance given that severe malnutrition is the underlying cause of several childhood morbidities and contributes to mortality in Africa and other lower-resource settings.

The main problem of this paper is how the definition of SAM is applied in the study. Whereas the WHO definition of SAM applies to children between 6 months <5 years with specific criteria (presence of either WHZ <-3 standard deviation or MUAC<115mm or bilateral pitting oedema) the authors have applied only one of these parameters to define SAM, and have broadly used the definition to include children =>5 years with BMI for age <-3 SD who although technically are severely undernourished but they do not meet the definition of SAM.

I suggest the authors apply the definition as per WHO definition to children 6 months < 5 years and only include children in this age category in their analysis or use the term that can broadly encompass all forms of malnutrition or undernutrition if they wish to understand malnutrition more broadly in children <15 years.

Below are specific recommendations for each section:

Abstract

Background: Include a statement with the aim or hypothesis of the study.

Methods: Provide the definition of SAM and state inclusion criteria in this section

Results: Provide a summary of how many records were screened, and found eligible and clearly state the number of children the analysis is based on.

Introduction

Paragraph 3, Line 1: Review figures for the prevalence of undernutrition in Zambia which are much lower than those provided in the Zambia Demographic and Health Survey (https://www.zamstats.gov.zm/portfolio/zambia-demographic-and-health-survey-zdhs/) which provides a more countrywide representative figure than the reference used.

Methods

#Study design and setting:

A brief description of the hospital and the type of population served by the facility would help understand the settings in which this study was conducted.

#Eligibility/sampling:

Explicitly state what the study inclusion and exclusion criteria used. Were the participants selected hospitalised or recruited from ambulatory settings as well?

#Variables:

As stated in the general comments, the WHO criteria for SAM is: WHZ<-3 or MUAC<115 or the presence of bilateral pitting oedema in children 6mo <5years. Technically BMI for age <-3 in children above 5 years is described as “severe thinness” (https://www.who.int/tools/growth-reference-data-for-5to19-years/indicators/bmi-for-age )and is not interchangeable with SAM although it does provide a measure of severe undernutrition in this age group.

Were the classifications of SAM/malnutrition based on clinician diagnosis or the parameter (WHZ, BMI for age) calculated by the investigators using the clinical data? How were the data on the other parameters for SAM (MUAC or pitting oedema) dealt with?

# Sample size calculation:

• What was the rationale for inclusion of 10% non-response rate in a study that was primarily a retrospective review of patient records?

#On data collection:

• The procedures for data collection should be sufficiently described. How was the review of medical records structured? Was the SAM information extracted from the most recent medical visit or did it include any previous hospital visit? If there were multiple visits which instance was used?

• How was the screening of SAM structure in this institution? Do all children attending the hospital get a weight, height, and MUAC measurement?

• Did this review include hospital records over the stated study period only? If yes, how many <15 years were seen over this period in the hospital?

Results:

#Baseline characteristics

• Provide a summary of how many participant records were screened, found eligible, included, and analyzed. A flow chart could provide reason for exclusions of medical records.

• How many medical records were included in this analysis? Every 2nd record from a sample of 3000 implies there were 1,500 screened. How were the 695 finally selected for inclusion?

• Provide summary statements of the measures of malnutrition (WHZ, BMI) in the text or Table 1 to help understand the general nutritional status of the study cohort.

• The HIV prevalence among participants was approximately 9.2% (n=62). What was the denominator used here? 62/695 = 8.9%

• How many cases of tuberculosis were in this cohort? It’s not explicitly stated the number of tuberculosis cases in this cohort but only the proportion with pulmonary disease is provided in line 5 of the results.

• Both tables included are not referenced in the text in the results section to allow the reader to refer to the appropriate table.

• Table 1: Could you include how many TB cases were confirmed(bacteriologically) within the table or in the footnote?

Discussion:

• In paragraph 2, on the association between HIV and malnutrition, the authors reference adult studies only and do not refer to any relevant pediatric studies.

• In paragraph 6, apart from the retrospective nature of the study, where there any other limitations? How about the methods used to identify children with SAM? Some discussions on the limitations of the methods used to identify children with SAM should be included in this section.

• What is the implication of the findings for the care of children with malnutrition in this region or setting?

Reviewer #2: General comments:

The authors have chosen an important topic with high public importance and written the manuscript evaluating the prevalence and factors associated with SAM among children under the age of 15 years in an African country. The authors performed this study among under-15 children instead of under-5 children, although no rationality or data in favor of conducting this study in under-15 children are shown. The rationality should be elaboratively discussed in the background and briefly in abstract and need to have reflection all through the manuscript.

Specific comments:

Abstract

1. Please provide brief justification of conducting this study in under-15 children in the background

2. Please define SAM briefly in the methods

3. Usually abstract stands alone and thus before providing 16.7% prevalence in the results of abstract, the authors should provide the exact denominator and numerator here.

Background

4. Burden and fatality of SAM and related references used here are old and there are a number of recent data on these especially after 2022 and the authors should provide the most recent references all through the background.

5. The authors are requested to provide strong justification of conducting this study in under-15 children and need to have argument on how under-5 SAM aligns/differs to/from each other.

6. The background needs to have more connectivity with aims/objectives in the last paragraph.

Methods

Sample size

7. The evidence of 5% prevalence of SAM is used in calculating sample size in the Gambia, however, the prevalence was as high as 11% (https://www.lshtm.ac.uk/research/units/mrc-gambia/news/321426/mrc-nutrition-rehabilitation-centre-caring-children-severe-acute-malnutrition). The authors need to justify the selecting the lower prevalence for calculating the sample size.

Variables

8. There should have a brief description (a paragraph) on the procedure of the anthropometric measurement (weight, length/height, BMI) in children

9. Please correct acute diarrheal diarrhea as acute watery diarrhea with its definition

10. Please also define anemia, pneumonia, sickle cell disease, tuberculosis (bacteriological/clinical)

Data collection and data analysis

11. As data is a plural noun, please revise the grammar accordingly all through the text.

Results

Basic characteristic of the study participants

12. Definition of MAM should be provided in the methods before its use in the results.

13. Elaboration of SAM has already used earlier in the text, thus, this is redundant here.

14. All statistical values shown in the text of the results (Basic characteristic of the study participants and Univariable and multivariable analysis of factors associated severe acute malnutrition) are also available in the relevant tables. Please refer the tables for the statistical values rather duplicating these values in the text.

Discussion

15. Again, the elaboration of SAM has already used earlier in the text, thus, this is also redundant here.

16. The discussion section is less organized especially this section need to focus on most important observation with more explicit evidences.

17. The authors need to provide argument with evidences on how under-5 SAM aligns/differs to/from each other.

18. The observation of the association of an increase in neutrophil count with decreased odds of SAM should be discussed with more insights especially with the relation poor inflammatory responses in SAM.

18. Conclusion should be revised (deducting severe acute malnutrition or SAM) making a link with implication of the study.

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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: No

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Attachments

Attachment

Submitted filename: PlosOne SAM ZM review comments.docx

Attachment

Submitted filename: Review reports_PONE-D-24-15995.doc

PONE-D-24-15995R1Severe Acute Malnutrition among children under the age of 5 years.PLOS ONE

Dear Dr. Masenga,

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 Aug 16 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.

We look forward to receiving your revised manuscript.

Kind regards,

Steve

Stephen Michael Graham, FRACP, PhD

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.

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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: (No Response)

Reviewer #2: (No Response)

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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 #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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: No

Reviewer #2: No

**********

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 #2: 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: The authors have addressed the issues raised in the first review> A few points for clarification and consideration below.

Thank you for considering the suggestion on the inclusion of the participants' flow chart. According to the strobe guidance flow charts describing the participants should be included in the results sections

Table 1: Include the means of the haematological parameters comparing those with SAM vs No SAM

Could the authors review the confidence intervals for the adjusted analysis for the platelet count in table 2?

Reviewer #2: The overall quality of the revised manuscript improved a lot. The authors should be congratulated for that. However, I have minor concerns about the following three definitions that need to be revised before the acceptance of this manuscript.

1. The authors mentioned that clinical diagnosis of TB was made when bacteriological criteria were not met but the authors did not mention the clinical criteria used for clinical TB diagnosis. These criteria should be precisely written.

2. The authors defined acute watery diarrhea as ‘frequent loose or watery stools lasting less than 2 weeks’ which is not precise as this should be defined as ‘more than three loose or watery stools per day lasting less than 2 weeks (WHO Pocket Book 2013, 2nd edition, page 125)’

3. The authors defined pneumonia as ‘a lung infection caused by bacteria or viruses, diagnosed using either a chest radiograph or clinically through vital sign measurement’, this is not a precise definition at all. The authors should use the better reference (PMID: 15976876) for chest radiograph defining pneumonia and must need to mention the clinical features used for diagnosing pneumonia/severe pneumonia. The authors may take the help from WHO Pocket Book 2013, 2nd edition, page 80).

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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 #2: No

**********

[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.

Severe Acute Malnutrition among children under the age of 5 years.

PONE-D-24-15995R2

Dear Dr. Masenga,

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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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,

James Mockridge

Staff Editor

PLOS ONE

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 #2: All comments have been addressed

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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 #2: Yes

**********

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

Reviewer #2: Yes

**********

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 #2: No

**********

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 #2: 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 #2: The authors kindly addressed all the issues raised by the reviewers. Thus, the revised manuscript may be accepted in its present form.

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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 #2: No

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