PONE-D-25-08095-->-->Do children allocated to different methods of food introduction have distinct feeding preferences and flavor acceptance in the first years of life? A randomized clinical trial-->-->PLOS ONE?>

Dear Dr. Bernardi,

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.

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António Raposo

Academic Editor

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?

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: No

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: General Comments

This manuscript addresses a relevant and timely research question, examining how different methods of complementary food introduction—Parent-Led Weaning (PLW), Baby-Led Introduction to Solids (BLISS), and a Mixed approach—affect food preferences and taste acceptance among young children. Given the increasing interest from both clinicians and parents regarding early dietary influences on later eating behaviors, the study's objective is particularly valuable. The authors have employed a robust randomized clinical trial (RCT) design and clearly defined interventions, which significantly strengthens the methodological rigor.

The manuscript is generally well-structured, clearly written, and includes appropriate references to prior literature. Methodological details, including randomization, blinding, and statistical analyses (robust Poisson regression adjusted via Directed Acyclic Graph \[DAG] and intention-to-treat analyses), are suitably described. The combination of parent-reported feeding preferences and an objective laboratory taste acceptance test is commendable, adding depth and rigor to the findings.

However, several issues warrant attention to enhance clarity, accuracy, and appropriate interpretation. Below I outline key points that require revisions, categorized as major and minor issues.

Major Issues

1. Clarification of Primary and Secondary Outcomes

It is currently unclear which specific outcome measures were identified as primary or secondary prior to study initiation. The manuscript evaluates multiple outcomes across taste categories and groups, raising the potential for Type I error due to multiple comparisons. It would improve clarity to explicitly state the primary outcome(s) designated a priori, or clearly acknowledge that the analyses are exploratory. Additionally, authors should discuss potential risks of Type I errors explicitly, especially given that significant findings were limited to sour taste preferences.

2. Details and Transparency of Statistical Analysis

The authors employed robust Poisson regression appropriately, but clarity regarding adjusted versus unadjusted results is needed. The manuscript should explicitly state the covariates used in adjusted models and clearly indicate in the tables and results section which comparisons were adjusted or unadjusted. This transparency will enhance rigor and interpretability.

3. Handling of Missing Data and Attrition

Attrition, particularly in the Taste Acceptance Test (with approximately 34% non-completion), raises concerns about potential bias. The authors should detail reasons for attrition clearly within the participant flow diagram and address explicitly whether attrition was balanced across groups. Additionally, discuss whether attrition may have introduced bias, potentially influencing outcomes. A brief comparison of baseline characteristics between completers and non-completers would further strengthen methodological transparency.

4. Measurement Validity and Limitations

Additional detail on the structure, validity, and potential biases of the Feeding Preferences Questionnaire is necessary. The subjective nature of parent-reported preferences and the possibility of reporting bias should be explicitly addressed. Furthermore, the authors should clarify the limitations of the Taste Acceptance Test, emphasizing that laboratory responses may not fully capture everyday food acceptance behaviors.

5. Interpretation of Findings and Practical Significance

The authors' interpretation of the findings should be tempered. Given the limited number of significant differences (only sour taste preference showed significance), conclusions suggesting broad impacts of feeding methods should be revised to reflect the modest and limited scope of the observed effects. Additionally, the manuscript should discuss the potential practical implications of these small observed differences clearly and cautiously.

6. Sample Size and Power Considerations

Clarify explicitly the primary endpoint used for the original power calculation. If taste preference was not the primary outcome, clearly acknowledge the limitations this places on detecting subtle between-group differences in taste acceptance. This clarification will aid in interpreting the largely null findings for most taste categories.

7. Adherence to Assigned Feeding Methods

The manuscript should briefly summarize adherence to feeding methods as previously published by the authors, clearly discussing how actual adherence levels may have influenced study outcomes. Recognizing variability in adherence provides essential context for interpreting the subtle differences observed.

Minor Issues

1. Language and Terminology

* Replace "mensal" with "monthly" for clarity and correct terminology.

* Clarify clearly on first mention that the "Mixed" method involved initially using BLISS but switching to spoon-feeding if necessary.

2. Data Presentation and Table Corrections

* Correct the error in Table 2 (Mixed method salty taste PR value of "0.10" should likely be "1.00"). Verify consistency in decimal places and formatting.

3. Figure and Flowchart

* Provide a clear, detailed participant flowchart illustrating numbers randomized, completed, and lost for each group.

4. Discussion Contextualization

* Emphasize explicitly the transient and limited influence early feeding methods may have on taste preferences by referencing relevant longitudinal studies and aligning findings with existing literature.

5. References and Formatting

* Use consistent terminology for "Parent-Led Weaning" and "traditional method" to avoid confusion.

The manuscript presents valuable and rigorously conducted research with the potential for publication. Addressing the outlined major and minor issues will significantly improve clarity, methodological transparency, and appropriate interpretation, thus aligning the manuscript fully with high-quality standards required for acceptance.

Reviewer #2: Abstract: need to spell out the abbreviation of “PR” for the first time.

Sample size: what test was used? Which one is the primary outcome? The calculation is based on a continuous measure (standard deviation), however, all the outcomes in Table 2 are binary. It is not clear how the 1.4 SD was selected.

The p values need to be adjusted for multiple tests, especially for Table 2.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-25-08095R1-->-->Do children allocated to different methods of complementary feeding introduction have distinct food preferences and flavor acceptance in the first years of life? A randomized clinical trial-->-->PLOS ONE?>

Dear Dr. Bernardi,

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 Oct 29 2025 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.

• 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 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,

António Raposo

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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Reviewer #1: General Comments

The revised manuscript represents a clear improvement over the initial submission. The authors have carefully and systematically addressed the major and minor points raised during the first review. The structure and readability are improved, the methods and results are clarified, and the conclusions are now more cautious and aligned with the data. The inclusion of additional details on outcomes, statistical methods, attrition, and adherence strengthens the manuscript’s transparency and rigor. The updated flowchart, supplementary materials, and data availability statements bring the submission into better compliance with PLOS ONE and CONSORT requirements.

The study remains a valuable contribution to the literature on complementary feeding methods and children’s later taste preferences. The novelty of including a “Mixed” approach, the dual use of subjective (questionnaire) and objective (taste acceptance test) measures, and the randomized trial design make the research relevant to pediatric nutrition and public health.

Major Issues – Status of Revisions

1.Clarification of Primary vs. Secondary Outcomes

Addressed. The authors now explicitly state that the trial’s primary outcomes were anthropometric z-scores, while taste preferences were pre-specified secondary outcomes. The Discussion now acknowledges Type I error risk from multiple comparisons.

2.Statistical Transparency (Adjusted vs. Unadjusted Results)

Addressed. Tables 2 and 4 now present both crude and adjusted prevalence ratios, with covariates defined via DAGs. Methods and Results have been revised for clarity.

3.Missing Data and Attrition

Addressed. The flowchart and Supplementary Table 1 now describe reasons for attrition and compare completers vs. non-completers. The Discussion explicitly states that attrition bias is unlikely.

4.Validity and Limitations of Measurement Tools

Addressed. The Methods now better describe the Food Preferences Questionnaire and the Taste Acceptance Test. The Discussion highlights potential biases and limitations.

5.Interpretation and Practical Significance

Addressed. Conclusions are now tempered: only sour taste differences in crude analysis are acknowledged, and these did not hold after adjustment.

6.Sample Size and Power

Addressed. The Methods clarify that the sample size was powered for growth outcomes, not taste preferences, which were secondary outcomes.

7.Adherence to Feeding Methods

Addressed. The Discussion now incorporates prior adherence results (Sanini Belin et al., 2023) and acknowledges crossover between groups, which may explain null findings.

Minor Issues – Status of Revisions

#Terminology (“mensal” → “monthly”): Corrected.

#Clarification of “Mixed” method: Expanded.

#Table 2 error (“0.10”): Corrected to 0.99, decimals standardized.

#Flowchart: Revised and detailed.

#Contextualization in Discussion: Added references to longitudinal evidence, reinforcing transient effects.

#Terminology consistency (PLW vs. traditional): Corrected throughout.

#Abbreviation (“PR”): Defined on first use in abstract.

All minor issues appear to have been addressed satisfactorily.

Compliance with PLOS ONE Requirements

#Trial Registration: Reasons for delayed registration added; confirmation that related trials are registered.

#Funding Statements: Now consistent; funders’ lack of role explicitly stated.

#Data Availability: Full dataset uploaded as Supplementary Information.

#Supporting Information Captions: Added.

#Copyrighted Logos: Removed from protocol file.

The manuscript now meets PLOS ONE’s editorial and ethical standards.

Minor Editorial Adjustments

・Ensure consistent tense usage throughout the manuscript, particularly when describing methods (past tense) and results (past tense).

・Double-check supplementary figure captions to ensure they are placed correctly and consistently referenced in the main text.

・Standardize abbreviation usage (e.g., consistently use “CF” for complementary feeding after first definition).

・Review for minor typographical errors (spacing, punctuation, en-dash vs. hyphen in numerical ranges).

・Verify reference formatting consistency (especially newer references added in revision; ensure full journal names or abbreviations follow PLOS ONE style).

・Confirm that tables and figures have consistent decimal places, units, and legends across the manuscript and supplementary materials.

・Check the Acknowledgments section for grammatical refinement (e.g., “thank for the commitment” → “thank the researchers for their commitment”).

Reviewer #2: All concerns are addressed.

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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

Do children allocated to different methods of complementary feeding introduction have distinct food preferences and flavor acceptance in the first years of life? A randomized clinical trial

PONE-D-25-08095R2

Dear Dr. Bernardi,

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,

António Raposo

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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Reviewer #1: I would like to sincerely commend the authors for their thoughtful and thorough revisions throughout this review process. Each of the points raised in the previous rounds has been carefully and transparently addressed. The manuscript now reads smoothly, with improved clarity, consistent terminology, and precise alignment between the data and conclusions.

The study remains an important and well-executed randomized clinical trial exploring an underexamined but meaningful question in pediatric nutrition—the influence of different complementary feeding methods on early taste preferences. The methodological rigor and balanced interpretation make this paper a valuable contribution to the field.

Thank you for your sustained efforts and patience over multiple rounds of revision. Your diligence has clearly strengthened the quality and readability of the final manuscript. Congratulations on your excellent work—I am pleased to recommend it for publication.

Reviewer #2: All concerns are addressed.

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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

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