-->PONE-D-25-29078-->-->Changes in Infant Head Shape: Developmental Trends During the First Year of Life and Secular Changes Observed in Recent Years-->-->PLOS ONE

Dear Dr. Lee,

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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Taher Babaee

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?

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: No

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 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

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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: This manuscript presents a large dataset of manual head measurements in Japanese infants to analyze changes in cranial shape during the first year of life. While the topic is relevant and the sample size robust, the study lacks methodological innovation and relies on simplistic geometric assumptions. The proposed Globularity Index (GI), though conceptually interesting, is not adequately supported by validation or comparison with 3D imaging methods. Figures and tables need improvement, and the discussion fails to explore the clinical or physiological implications of the findings. Overall, the manuscript would require substantial revision to be suitable for publication.

The following points should be addressed:

The data used in the study, was already published? If so, please, add link to data and specify the additions of this study to the already available information.

Table 1 have several mismatches and needs to be corrected or clarified:

When talking about age, the sentence “excluding 155 age groups other than 2, 3, 6, and 12 months” is repeated. Please, clarify this as the final number matches the total number of the dataset (1980 infants). Is there really an exclusion? Why? (Other ages could have been included) .

If only infants with certain ages are taken into account it should be stated and clarified at the beginning, and not repeated for each table.

In table 1 b the total number of infants is different for birth weight and birth year. There’s no reason to not show mean and median in age.

In table 1c total number of infants (sum of all tables) is 914, that does not match previous numbers.

I consider that exclusions need to be stated at the beginning, and then, used data needs to be detailed.

Subsections in table 1 are difficult to understand, I consider the information should be clarified and separated in different tables. Journal submission guidelines specify that subsections in tables should have a consistent number of columns or be divided.

Lines 518-532 are not interpretable, a better way to present the information must be found.

The resolution of all the figures needs to be improved. I cannot evaluate figure 5 as it is not visible. Explain the upper part of boxplots (Figures 3 and 4).

No discussion is made on the importance of GI and its advantages in comparison with CI.

Conclusions or discussion should include the implications of the results.

Reviewer #2:  First of all, I would like to thank the editors for the opportunity to review this manuscript. The study addresses an interesting and relevant topic; however, it requires substantial revisions before it can be considered for publication.”

1) Abstract

-Authors should specify the design (cross-sectional with repeated measures in a subset), inclusion/exclusion criteria, and the variables used to estimate CI/GI/volume (HC, LT-RT, G-O).

-Authors should flag upfront the non-independence limitation: records are treated as distinct individuals despite 95 infants with repeated visits.

-Authors shpuld add n by age group and effect sizes/95% CI for the main results to improve interpretability.

2) Introduction

-Authors should define more precisely the novelty of the Globularity Index (GI) relative to prior sphericity/compactness metrics and justify why the chosen approximation (ellipsoid surface via Knud Thomsen) is appropriate for infant crania, with references and/or validation.

3) Methods

3.1. Data and design

-Authors state that each record was treated as a single infant; however, 95 infants had measurements at multiple visits. This violates independence and likely underestimates the variance. Authors should reanalyze the data using mixed-effects models (with infant identification as a random effect) or, at a minimum, provide a sensitivity analysis that excludes repeated cases.

-Auhors should provide more detail on how HC, LT-RT, and G-O were collected, and define precisely the age bins (30-day windows), including ranges and the distribution per group in the text (not only in tables).

3.2. Geometric approach and assumptions

-The ellipsoidal model infers a1, a2, and h from HC, LT-RT, and G-O. Authors introduce a factor α = 0.8 to adjust LT-RT per the 10–20 system. This assumption is highly influential yet no sensitivity analysis (e.g., α = 0.75–0.85) nor external validation (a small 3D substudy) is presented. Please add both.

-3.3. GI definition and statistical handling

-GI is defined as the ratio between the surface of an ellipsoid (Knud Thomsen) and that of a volume-equivalent sphere—geometrically fine.

-Authors apply Fisher’s z transformation to GI “because values cluster near 0.9–1.0.” Fisher’s z is intended for correlation coefficients; for bounded indices, logit or arcsin-sqrt transforms or beta regression are more appropriate. Please re-analyze GI using an appropriate transformation/model and report whether inferences change.

3.4. Statistical strategy

-Authors describe a large battery of tests (Shapiro–Wilk, Bartlett, ANOVA/Welch, Kruskal–Wallis, Nemenyi, Tukey/Games–Howell, Wilcoxon/Fligner-Policello). This multiplies univariate contrasts without global type-I error control. I recommend:

Linear/multilevel models for CI/GI/volume with exact age (days), sex, year (and, if available, rater) as covariates; FDR (Benjamini–Hochberg) correction for families of comparisons.

-Restricting to 3 months may induce bias (exact age within that month, changing composition by year). Please expand with models that include continuous age and test year×age interactions.

3.5. Reproducibility

-Authors list R packages but provide no code/seed or fully reproducible analysis plan. Please deposit scripts and “session info.”

4) Results

4.1. Changes with age (2, 3, 6, 12 months)

Authors shoud add effect sizes and 95% CI for pairwise age comparisons, not only p-values.

4.2. Sex differences

-Authors ahould provide standardized effects (e.g., Cohen’s d) and 95% CI to aid interpretation.

4.3. Secular changes (2010–2019; 3 months)

-Authors report antero-posterior elongation in recent years (a1↓, a2↑; CI↓; h/a2↓) with stable volume. This section would be stronger with adjusted models (exact age in days, sex, rater if applicable), multiplicity control, and visualizations showing means + 95% CI per year.

5) Discussion

Authors should incorporate into Limitations the pseudoreplication, the inappropriate use of Fisher’s z for GI, and sensitivity to α. Current limitations mention inter/intra-observer variability and the lack of volume validation, but not these issues.

6) Tables and figures

Global assessment: low quality. Substantial improvements in design and content are required to allow unambiguous evaluation of the findings.

Specific actions:

- Readability and formatting: Increase resolution and line thickness; export in vector formats (PDF/SVG); standardize fonts and sizes.

- Axes and units: Label units (e.g., mm) clearly; use consistent scales across all figures.

- Statistical information: Add n per group, means/95% CIs, and effect sizes next to box plots.

- Clarity of the GI: Avoid displaying "GI (z-transformation)" in figures and legends; present the GI on its original scale of 0 to 1 to facilitate clinical interpretation, and if transformation is necessary, show the raw scale and report the transformation only secondarily.

Key recommendations:

- Independence: Reanalyze using mixed-effects or sensitivity models, excluding repeat visits (identification of the infant as a random effect).

- GI handling: Replace Fisher's z test with logit/arcsine-square root or beta regression; recheck inferences.

Assumption of -α = 0.8: Include a sensitivity analysis and, if possible, external validation.

- Multiplicity/modeling: Reduce reliance on numerous univariate tests; use (multi)variable models with FDR control.

- Secular trends: Model the year, adjusting for exact age (days), sex, and assessor (if applicable); report the 95% CI.

- Presentation: Improve the quality of tables/figures, add effect sizes/CIs, clarify units and n per group; avoid the "z-transformed GI" in graphs.

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Reviewer #1: No

Reviewer #2: No

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-->PONE-D-25-29078R1-->-->Changes in Infant Head Shape: Developmental Trends During the First Year of Life and Secular Changes Observed in Recent Years-->-->PLOS One

Dear Dr. Lee,

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.

==============================

Thank you for revising the text. As noted by Reviewer #2 in the previous review round, the study design should be explicitly stated. This study is a retrospective longitudinal observational study based on medical record review. Please ensure that this is clearly highlighted in both the abstract and methods sections.

==============================

Please submit your revised manuscript by Mar 27 2026 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 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,

Taher Babaee

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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)

**********

-->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

**********

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

Reviewer #1: 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

**********

-->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

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-->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: Firstly, I would like to thanks the authors for taking into account most of my comments. I consider that the paper has been greatly improved. However, there are some further improvements I have to mention:

-Figures are still low resolution

- Figure captions need to be expanded to properly explain what the reader is seeing, some examples:

• Figures 3 and 4: As I mentioned in my previous comments the symbols at the top are not explained. The explanation is in the response but not in the manuscript.

• Fig 7. What is government? I assume it is official data but it is not mentioned.

-The authors mention that no other sphericity metrics are employed in other studies. Some studies exist and should be mentioned and discussion could be improved, for example:

Grieb, J., Barbero-García, I., & Lerma, J. L. (2022). Spherical harmonics to quantify cranial asymmetry in deformational plagiocephaly. Scientific Reports, 12(1), 167.

I agree that the method presented in the manuscript has the advantage of “Easiness of extracting information” but it should be discussed by comparison with other methods

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Reviewer #1: No

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Changes in Infant Head Shape: Developmental Trends During the First Year of Life and Secular Changes Observed in Recent Years

PONE-D-25-29078R2

Dear Dr. Lee,

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. For questions related to billing, please contact billing support .

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,

Taher Babaee

Academic Editor

PLOS One

Additional Editor Comments (optional):

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

**********

-->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

**********

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

Reviewer #1: 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

**********

-->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

**********

-->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 Response)

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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.

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Reviewer #1: No

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