PONE-D-24-09885Micronutrients absorbed via the oral mucosa reduce emotion dysregulation in 5-10-year-old children: A three-phased randomized wait-list-controlled trialPLOS ONE

Dear Dr. Rucklidge,

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Ebenezer Wiafe, PhD, MPharm, Pharm D

Academic Editor

PLOS ONE

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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: Yes

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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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: This manuscript presents data analysis from a 3-phase, randomized, open-label, waitlist-controlled trial to compare

the effectiveness of orally-absorbed micronutrients intervention in 5-10 year old children. The topic is of importance, and the study was registered as a RCT, and was approved by the respective IRB/Ethics Committee. While the study objectives sound interesting, is important, and on target, some shortcomings were observed, in regards to abiding by the CONSORT guidelines for conducting and reporting results of high-quality randomized controlled trials (RCTs). Some other (statistical) comments were also provided.

1. Abstract:

For a better presentation, Abstract needs to follow the Objective/Methods/Results/Conclusion framework.

2. Methods:

Methods reporting need some work. An orderly manner is suggested, following CONSORT guidelines, without repeating information, such as Trial Design, Participant Eligibility Criteria and settings, Interventions, Outcomes, sample size/power considerations, Interim analysis and stopping rules, Randomization (details on random number generation, allocation concealment, implementation), Blinding issues, etc, should be mentioned. The authors are advised to create separate subsections for each of the possible topics (whichever necessary), and that way produce a very clear writeup. They are advised to write it carefully, following nice examples in the manuscript below:

https://www.sciencedirect.com/science/article/pii/S0889540619300010

Specific comments:

(a) For instance, the randomization and allocation concealment should be made very clear (they are NOT the same thing); the trial staff recruiting patients should NOT have the randomization list. Randomization should be prepared by the trial statistician, and he/she would not participate in the recruiting.

(b) More details on the randomization is needed; saying "a computer-generated randomization" was used is half-hearted.

(c) Sample size: The sample size/power statement appeared pretty vague; in usual waitlist-controlled trials, there are previous attempts of producing a desirable sample size/power statements, using the ANCOVA design; see here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109669/ The authors are recommended to do the same. If not possible, then some power/sample size statements should be produced, based on an objective effect size, and at a reasonable 5% level of significance.

(d) Statistical Analysis:

(d1) The section Data Analysis should be renamed Statistical Methods. While mentioning tests, whether a 1-sided, or a 2-sided test will be used needs to be mentioned. Furthermore, t-test was used (for continuous variables) which is heavily based on normality assumptions. Under violations, alternative nonparametric tests, such as Wilcoxon rank sum tests, should be mentioned. There is no mention of such alternative testing methods.

(d2) ANOVA was used, however, it is once again heavily based on Gaussian assumptions. No nonparametric alternatived to ANOVA mentioned.

(d3) Is there any reason why a ANCOVA was not used, which is typically the model for waitlist-controlled trials, incorporating covariates.

3. Results & Conclusions:

(a) The authors should check that any statement of significance should be followed by a p-value in the entire Results section. Otherwise, the Results section look OK; it's pretty straightforward.

(b) Conclusions should state that the current findings are ONLY based on the random samples derived from a New Zealand population, and should allude to future studies with much larger sample sizes and collected at other geographical areas to confirm the effectiveness of the intervention.

Reviewer #2: This is a well-written manuscript that contributes to the literature on the use of alternative therapy in emotional dysregulation/ADHD symptom amelioration.

Below are some suggestions for revisions/clarifications:

1. The study’s justification for focusing on children ages 5-10 yr old, need to be made clear. One possible assumption is that it is because this age group has difficulty with pill swallowing. This needs to be clarified in the write-up.

2. It is suggested that the authors clarify the level of involvement of supplement providers with regards to study design, implementation, reporting, etc.

3. CL-ARI is supposed to be administered by a clinician. It is not clear if the study coordinator is a clinician and was therefore qualified to administer this measure. Also, it is not clear if the PTP and CGI-S were completed by clinicians or the research coordinator.

4. Similar to the above comment, it is not clear who completed the CGI and how the determination of treatment response was made.

5. There are about 10 secondary outcomes. What was the justification for assessing all of these? For example, it is not clear why the EBQ was assessed since the study was not targeted at improving diet.

6. Were the reported PTPs similar for all participants? If not, it is not clear how the individual PTPs were classified and grouped to determine symptom improvements per group (i.e ITG vs. IWLG)?

7. The assessment of safety is one of the study goals , however, the methods is missing how safety was operationalized and assessed.

8. Figure ( esp 2 & 3) titles/notes are separated from the actual figures (pages 15 vs. 47/48), which made comprehending the tables difficult.

9. Suggest minimizing reporting results in discussion.

Reviewer #3: ### Review Comments for Manuscript PONE-D-24-09885

#### 1. Technical Soundness and Data Support

The manuscript is technically sound and presents a well-conducted study on the effects of micronutrients absorbed via the oral mucosa on emotion dysregulation in children. The study design, including the randomized wait-list-controlled trial and three-phased approach, is robust and appropriate for the research question. The data support the conclusions, demonstrating significant improvements in emotion dysregulation for children receiving the intervention compared to the control group. The study also includes appropriate controls, replication, and sample sizes to ensure the validity of the findings.

#### 2. Statistical Analysis

The statistical analysis is performed rigorously and appropriately. The authors use a range of statistical tests, including t-tests, ANOVA, and effect size calculations, to analyze the data. The reporting of results includes confidence intervals and effect sizes, providing a clear understanding of the magnitude and significance of the findings. The use of Modified Brinley Plots to display individual changes over time is a valuable addition that enhances the interpretation of the data.

#### 3. Data Availability

The authors have made a commendable effort to make the data underlying the findings available, in line with PLOS ONE's data policy. While the raw data are not included in the manuscript to protect participant privacy, the authors have provided a clear statement that de-identified data will be available upon reasonable request. This approach balances the need for data transparency with ethical considerations regarding participant confidentiality.

#### 4. Manuscript Presentation and Language

The manuscript is presented in an intelligible fashion and is written in clear, standard English. The structure is logical, and the flow of information is easy to follow. There are no significant typographical or grammatical errors, and the language is appropriate for a scientific audience.

#### 5. Review Comments to the Author

- The manuscript is a valuable contribution to the field of child psychology and nutrition, addressing a relevant and timely research question.

- The introduction provides a thorough background, highlighting the need for alternative treatments for emotion dysregulation in children and the potential of micronutrient interventions.

- The methodology is well-detailed, ensuring that the study can be replicated. The randomization process, intervention details, and measurement tools are clearly described.

- The results are presented comprehensively, with appropriate use of tables and figures to illustrate key findings. The inclusion of both primary and secondary outcome measures strengthens the study.

- The discussion section effectively interprets the findings, placing them in the context of existing literature. The authors acknowledge the limitations of the study, including the open-label design and potential biases, and suggest directions for future research.

- The ethical considerations and adherence to data availability policies are well-handled, demonstrating a commitment to ethical research practices.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: sherif kamal

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Micronutrients absorbed via the oral mucosa reduce emotion dysregulation in 5-10-year-old children: A three-phased randomized wait-list-controlled trial

PONE-D-24-09885R1

Dear Dr. Rucklidge,

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Kind regards,

Ebenezer Wiafe, PhD, MPharm, Pharm D

Academic Editor

PLOS ONE