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Reviewers’ comments:

Comments to the Author

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

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: No

Reviewer #3: No

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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.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: No

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: The manuscript presents a large-scale population-based case-control study investigating associations between various perinatal factors and childhood cancer risk. The topic is timely, highly relevant, and aligns with PLOS ONE’s focus on scientifically rigorous, ethically conducted research that contributes meaningfully to its field.The manuscript presents a large-scale population-based case-control study investigating associations between various perinatal factors and childhood cancer risk. The topic is timely, highly relevant, and aligns with PLOS ONE’s focus on scientifically rigorous, ethically conducted research that contributes meaningfully to its field.The manuscript presents a large-scale population-based case-control study investigating associations between various perinatal factors and childhood cancer risk. The topic is timely, highly relevant, and aligns with PLOS ONE’s focus on scientifically rigorous, ethically conducted research that contributes meaningfully to its field.The manuscript presents a large-scale population-based case-control study investigating associations between various perinatal factors and childhood cancer risk. The topic is timely, highly relevant, and aligns with PLOS ONE’s focus on scientifically rigorous, ethically conducted research that contributes meaningfully to its field.

Strengths:

The study is based on a well-powered sample (1340 cases, 13,400 controls).

Comprehensive use of Swedish national registries ensures high data reliability.

The use of Cox regression with age as the underlying time scale is a strength over simple logistic regression.

Results are adjusted in a stepwise fashion, providing robustness.

Weaknesses / Suggestions:

Collider bias is acknowledged, and the strategy of multiple models (with/without GA) is commendable. Still, a more detailed justification for the modeling strategy should be included in the Discussion.

Multiple comparisons: The manuscript reports a large number of statistical tests. While correction was intentionally not applied, this choice should be more clearly defended in the limitations section.

Covariate selection: Certain known risk factors (e.g., environmental exposures, family history) are not accounted for. This should be addressed as a limitation.

IVF data: The availability from 1989-2006 and 2007-2021 in separate registries should be more clearly discussed in terms of its impact on data completeness.

Clarity of Writing

Strengths:

The manuscript is overall clearly structured and easy to follow. The English is fluent and mostly well-polished.

Suggestions:

Some paragraphs in the Discussion are overly long and could be made more concise.

Avoid repetition when reporting results, especially when hazard ratios are reiterated in both Results and Discussion.

Minor language edits are needed: Consider proofreading by a native speaker or editor for minor grammatical refinements.

Recommendation: Minor Revision

The manuscript is scientifically sound and of high relevance. The authors should address the following in their revision:

Provide a more explicit discussion on the lack of multiple testing correction.

Briefly elaborate on the implications of the limited IVF data period.

Clarify limitations such as residual confounding and registry-based constraints.

Undertake light English proofreading to enhance polish.

Reviewer #2: In this manuscript the authors have examined the association between several perinatal characteristics and the occurrence of childhood cancer using a register-based case-control data that includes all children diagnosed with cancer in southern Sweden between 1989-2021. The authors found several statistically significant associations: while these associations have been reported in previous studies, results were often conflicting. My main comment to the authors is that I believe that they should have used a conditional logistic regression model to analyze their data instead of a Cox proportional hazards model. See below for more details on this as well as additional comments on the manuscript. In this manuscript the authors have examined the association between several perinatal characteristics and the occurrence of childhood cancer using a register-based case-control data that includes all children diagnosed with cancer in southern Sweden between 1989-2021. The authors found several statistically significant associations: while these associations have been reported in previous studies, results were often conflicting. My main comment to the authors is that I believe that they should have used a conditional logistic regression model to analyze their data instead of a Cox proportional hazards model. See below for more details on this as well as additional comments on the manuscript. In this manuscript the authors have examined the association between several perinatal characteristics and the occurrence of childhood cancer using a register-based case-control data that includes all children diagnosed with cancer in southern Sweden between 1989-2021. The authors found several statistically significant associations: while these associations have been reported in previous studies, results were often conflicting. My main comment to the authors is that I believe that they should have used a conditional logistic regression model to analyze their data instead of a Cox proportional hazards model. See below for more details on this as well as additional comments on the manuscript. In this manuscript the authors have examined the association between several perinatal characteristics and the occurrence of childhood cancer using a register-based case-control data that includes all children diagnosed with cancer in southern Sweden between 1989-2021. The authors found several statistically significant associations: while these associations have been reported in previous studies, results were often conflicting. My main comment to the authors is that I believe that they should have used a conditional logistic regression model to analyze their data instead of a Cox proportional hazards model. See below for more details on this as well as additional comments on the manuscript.

- Abstract: please indicate that the numbers in parentheses represent hazard ratios and 95% confidence intervals.

- Abstract: add to the abstract that the 1340 cancer cases were born in southern Sweden between 1989-2021

- Regarding controls selection, the authors wrote “The inclusion criteria were being born between 1989 and 2021 with no prior history of cancer diagnosis or recorded death before the age of 19 while allowing for cancer diagnosis at the age of 19 or older.” I guess that also controls did not emigrate before age 19, or otherwise you wouldn’t know whether they died or got a cancer diagnosis. However, since the controls cannot die before age 19 and some of the assessed perinatal characteristics are linked to childhood mortality (especially infant mortality) I wonder whether the decision to select controls only among children who didn’t die before age 19 could have led to a slight overestimation of the risk estimates, as these controls likely had more normal perinatal characteristics than the general population (that includes children who died during childhood). Moreover, I think that this sentence should be rephrased since it is not possible to check whether potential controls born in the more recent years are cancer free at age 19 (or have not died by age 19) since they have not reached this age during the study period

- Small for gestational age is defined as a birth weight below the 10th percentile for a specific gestational age, and these percentiles are usually estimated separately for boys and girls. This means that, in the general population, there are approximately 10% of children that are born SGA. However, when defining SGA as SD < -2, there will be a bit more than 2-3% of children defined as being born SGA (in Table 1 the authors reported that it was 4%, which is much lower than the definition of SGA). The same reasoning applies to LGA. Can the authors explain why they have defined SGA/LGA in a different way?

- Information regarding child infections was obtained from the National Patient Register. Why did the authors use only the inpatient register and did not use the outpatient register data (that started in 2001)? Moreover, the authors should write in the text that they use inpatient care data, this is reported only in Table 1

- The authors wrote that “Traditional case-control analyses using logistic regression do not allow estimation of time-varying associations” and therefore used Cox regression models to analyze their matched case-control data. However, I disagree with them because in a case-control study you can assess time varying associations, for example the effect of an exposure on childhood cancer risk during the first five years of life, by restricting the analyses to the cases diagnosed during the age period of interest and their matched controls. It is with time-varying covariates/exposures that one should use Cox regression when analyzing case-control data. I am not an expert on using Cox regression on case-control data but from the study below from Statistics in Medicine it seems that the naïve approach (analyzing the case-control data using the standard Cox regression model as if the data were obtained from a cohort study) could lead to an underestimation of the association. I therefore suggest to the authors to re-run the analyses using a conditional logistic regression model, as all the exposures that they have analyzed (perinatal factors) are not time varying.

Reference: Statistics in Medicine (2003) - Evaluation of Cox’s model and logistic regression for matched case-control data with time-dependent covariates: a simulation study

- The authors wrote “The models were not assessed for characteristics or categories with fewer than ten observations.” Please clarify whether with “ten observations” you mean ten cancer cases for a specific category or if with ten observations you meant a combination of cases and controls

- Why did the authors add a quadratic term for BMI in the regression models? In the main analysis BMI was used as a categorical variable rather than a continuous one

- Did the authors have information regarding genetic syndromes? As these are linked to childhood cancer risk and could also be linked to some perinatal characteristics, is it possible to additionally adjust for genetic syndromes, at least for the most common ones such as Down syndrome, neurofibromatosis type 1, etc.?

- In the discussion the authors wrote “However, several studies, including a large cohort with over 11 thousand cases from Sweden, Denmark and Finland, reported null associations (65,66).”. However, references 65 and 66 refer to studies performed in the UK and the US. Please check that all references are cited correctly.

- I agree with the authors’ decision to not adjust for multiple comparisons. However, the authors should mention in the discussion section that because of the low number of cases and the several associations analyzed, it is possible that some of the reported statistically significant associations could be chance findings.

- In the last paragraph of the discussion, the authors wrote that “Nevertheless, as genetic predisposition explains less than 10% of childhood cancer cases (4), we believe that other perinatal factors, such as environmental factors, could contribute to our findings.” The authors also stated in the conclusion paragraph that “The reported results strongly highlight the significance of the perinatal period as a critical window, particularly for early-onset childhood cancer”. Can the authors report and comment on the proportion of childhood cancer cases that are caused by the exposure assessed in the current study? Moreover, in the abstract the authors wrote “Results indicate several perinatal characteristics associated with the risk of childhood cancer, which is important for prevention”. If the authors believe that these results are important for prevention, this should be thoroughly discussed in the discussion section, together with a discussion on the potential number of cases explained by these exposures and how these results can be used for preventive measures.

Minor comments:

- Check the spelling used throughout the manuscript as sometimes you write leukemia and other times you write leukaemia

- Table 2: Why some ICCC-3 groups are written in italic?

- Table 2: the columns percentages in some instances are not correct and when summed together gave a total > 100%

- Tables should be presented in the text in numerical order. In the text, Table 3 is mentioned before Table 2

- Footnote Table 4: did the authors mean to write inpatient register rather than incoming patient register

- Table 4: why are some numbers underlined in table 4?

Reviewer #3: This is a reasonable study design given the available sample. The major variables of perinatal characteristics, parental education and GA are well formulated as necessary. The variable exclusions for missingness, incompleteness or otherwise made sense.This is a reasonable study design given the available sample. The major variables of perinatal characteristics, parental education and GA are well formulated as necessary. The variable exclusions for missingness, incompleteness or otherwise made sense.This is a reasonable study design given the available sample. The major variables of perinatal characteristics, parental education and GA are well formulated as necessary. The variable exclusions for missingness, incompleteness or otherwise made sense.This is a reasonable study design given the available sample. The major variables of perinatal characteristics, parental education and GA are well formulated as necessary. The variable exclusions for missingness, incompleteness or otherwise made sense.

The statistical analysis section starts on line 165. The investigators give a logical rationale for the approach stating that, ‘Traditional case-control analyses using logistic regression do not allow estimation of time-varying associations. Therefore, in the present study, the Cox proportional hazards regression with child age as the underlying time scale was used to examine the association between perinatal characteristics (Table 1) and risk of childhood cancer.’ Their checking for the appropriateness of proportional hazards was followed appropriately and thus the major model for presenting the results as hazard ratios and their interpretation was reasonable in a somewhat time dependency situation.

However, their explanation of the GA as a potential risk factor of childhood cancer and for most of these characteristics the relationships with GA still remains unclear in this context from the statistical perspective. They note that to investigate GA as a potential risk factor while addressing potential collider bias, they conducted three separate models as outlined. Some detail about the process with actual variable examples would be helpful to the reader.

The Results start on line 207 and series of descriptive tables follow. The tables have so much detail that they are cumbersome to get through especially Tables S1 to S13. There is no discussion of any confounding influences (since adjustments were made as per the investigators), just a summary list of possibly associative characteristics with the outcome. Where there any competing risks in the process?

The limitations are noted on page 17. The investigators note the low numbers in some categories resulting in low power. Was the geographic coverage too small or initial sampling period too narrow. Where does power come into this situation which is a case control study? How relevant is the county of birth in the matching process or is this tied to a genetic or environmental consideration?

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Nihat Bugra AgaogluNihat Bugra AgaogluNihat Bugra AgaogluNihat Bugra Agaoglu

Reviewer #2: No

Reviewer #3: No

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<p>Parental, pregnancy and neonatal characteristics during the perinatal period as potential risk factors for childhood cancer: FeToxCancer case-control study

PONE-D-25-24435R1

Dear Dr. Broberg,

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.

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Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers’ comments:

Reviewer’s Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: (No Response)

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

Reviewer #2: Yes

Reviewer #3: (No Response)

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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.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

Reviewer #3: (No Response)

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

Reviewer #2: Yes

Reviewer #3: (No Response)

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Reviewer #2: The authors have sufficiently addressed all my previous comments.

Reviewer #3: (No Response)

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..-->

Reviewer #2: No

Reviewer #3: No

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