-->PONE-D-26-02152-->-->Parental Knowledge of Early Childhood Caries and Its Association with Bottle-Feeding Practices: A Cross-Sectional Analysis in the Riyadh Province, Saudi Arabia-->-->PLOS One

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

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: Manuscript title:

Parental Knowledge of Early Childhood Caries and Its Association with Bottle-Feeding Practices: A Cross-Sectional Analysis in the Riyadh Province, Saudi Arabia

(Manuscript ID: PONE-D-26-02152)

This manuscript addresses an important public health topic by exploring parental knowledge of early childhood caries and its association with bottle-feeding practices in the Riyadh region. The study includes a relatively large sample size and provides region-specific data that may be useful for designing targeted preventive interventions.

The manuscript is generally well structured and the results are clearly presented. However, several aspects require clarification and improvement, particularly regarding the description of the questionnaire, methodological transparency, the depth of the discussion, and the quality of figures. Addressing the comments below would strengthen the scientific rigor and readability of the manuscript.

Abstract

- The abstract is clear and adequately reflects the study objectives, methods, and main findings. No major concerns.

Introduction

- The statement “Early childhood caries (ECC) remains one of the most prevalent chronic diseases affecting infants and preschool children worldwide” should be supported by an appropriate reference.

- The introduction covers the key elements (definition, etiology, risk factors, and knowledge gap). However, it is relatively lengthy and could be condensed.

Materials and Methods

- The sections “Study Design”, “Study Setting and Duration”, and “Questionnaire Development and Content” contain overlapping information and would benefit from merging to improve the logical flow.

- The description of the questionnaire lacks sufficient detail for reproducibility. The authors should clearly specify:

o The total number of sections.

o The total number of questions.

o The number of questions within each section.

o The response format (e.g., multiple choice, Likert scale, yes/no).

o The scoring system used to generate the knowledge score (range, weighting, cut-offs if any).

- The eligibility criteria state that parents of children aged 1–5 years were included. However, the study objective and several sections refer to children under six years. This discrepancy should be clarified and the age range should be reported consistently throughout the manuscript.

Results

- The household income category 5,000–10,000 SAR should be presented with an approximate equivalent in USD or EUR to facilitate interpretation for an international readership.

- The notation “N = 465” in table titles should use lowercase (“n”), as per standard scientific reporting.

- Figure 1 is blurred and of low resolution, making it difficult to interpret.

- Figure 2 is also unclear and lacks sufficient visual quality.

- Both figures should be replaced with high-resolution versions.

- Apart from these issues, the results are clearly presented and statistically appropriate.

Discussion

- The sentence “early childhood caries (ECC)” is repeatedly written in full, although the abbreviation has already been introduced. The abbreviation alone should be used consistently after its first definition.

- The discussion relies heavily on comparisons with studies from Saudi Arabia or neighboring regions. The authors should broaden the contextualization by including evidence from other regions (e.g., Europe, Asia, Africa, or the Americas) to enhance the international relevance of the findings.

- The manuscript currently includes a limited number of recent and high-impact references. Given the extensive literature on parental knowledge, attitudes, and practices (KAP) related to ECC, the reference list should be expanded.

- The discussion should include at least ~30 recent references, particularly international studies on parental knowledge and ECC.

Conclusions

- The conclusions are consistent with the results and appropriately formulated.

The topic is relevant and the dataset is valuable, but important methodological clarifications and improvements in the discussion and presentation are required before the manuscript can be considered for publication.

Best regards!

Reviewer #2: overall, Minor English proofreading is needed to improve clarity and flow.

Keywords could be refined to enhance indexing and search visibility.

Kindly explain the questionnaire validation process (1-2 sentences)

Rewrite the conclusion section, I suggest adding more specific actionable recommendations.

Reviewer #3: Dear authors, Thank you for your effort .the study addresses a significant public health issue in the community. These are the comments regarding the manuscript:

Methoda:

- what was the sampling technique? was it a convenience sample? please mention clearly

- you mention that" A structured online-based Arabic questionnaire was developed specifically for this study based on a review of existing literature on ECC risk factors and parental awarenes". it's clear that the researchers developed the questionnaire by themselves. you calculated the reliability of the questionnaire, but the validity wasn't mentioned. please state clearly the values of the CVI and CVR

-Add a sentence explaining the scoring system of the questionnaire for the the knowledge or bahavior.

- in the statestical analysis: you mention that "Chi-square

tests or Fisher’s exact tests were employed to assess associations between parental awareness of ECC and

demographic or behavioral variables", but it the table they aren't computed , instead independant t test was calculated . please correct.

Results:

- You mention that you conduct "Multivariable linear regression." which is suitable for continuous outcomes (like a total score) , while in table 1 you only present knowledge as number and percentage. I recommend to add a raw in this table illusrating the total knowledge score of the participats.

- in the table where you represent the mean score you should present Standered Deviation (SD) as (mean±SD).

- since it's a cross sectional study : use the term predictors for knowledge isn't approporiate. replace it by factor associated in the results and discussion. This should behighlightened in the limitation of the study.

Discussion:

- You correctly identify that while knowledge is moderate, behavior (like nighttime feeding) remains risky. To strengthen this, I recommend mentioning Health Literacy vs. Health Knowledge. Suggestion: Add a sentence discussing how "Health Literacy" (the ability to apply information) might be the missing link, as convenience or child-soothing needs often override the biological knowledge of caries.

-in the results you mentioned that "60.9% of children had received dental treatment"? Since the children are aged 1–5, 60% receiving treatment is exceptionally high. Does this mean they already had caries? If so, this "previous experience" might be a huge confounder for their current knowledge. please justify this point

- your mention of the R value (3.6%) here. You touched on it by mentioning "cultural beliefs," but you could explicitly state: "the results suggests that ECC knowledge in this population may be governed more by cultural and traditional factors than by formal education or income alone."

Conclusion:

- Mention that the "Well-Child Visit" (vaccination schedule) is the golden opportunity for this integration in the Saudi healthcare system.

- Suggest a longitudinal study to see if knowledge eventually changes practice.

- please add practical implication section to demonstrate the clinical significance or the policy implications, based on your results.

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Reviewer #1: No

Reviewer #2: Yes: Nasser M Alorfi

Reviewer #3: No

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Parental Knowledge of Early Childhood Caries and Its Association with Bottle-Feeding Practices: A Cross-Sectional Analysis in the Riyadh Province, Saudi Arabia

PONE-D-26-02152R1

Dear Dr. Alshamrani,

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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Kind regards,

Geelsu Hwang, Ph.D.

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 #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?

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

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #3: Yes

**********

-->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

Reviewer #3: 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: Language needs minor proofreading for clarity.

Sampling method (convenience) limits generalizability.

Knowledge gaps (e.g., early dental visit awareness) are significant.

Low R² indicates missing influencing factors.

Stronger actionable recommendations could improve impact.

Reviewer #3: Thank you for responding to all comments. Wishing you success in this research and your future work. Goog luck

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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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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: Yes: Nasser M Alorfi

Reviewer #3: No

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