Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: Results from a four arm exploratory study.

BACKGROUND: Fibersol-2 has some beneficial effects on human health. We aimed to evaluate the digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children, as well as improvement in stool consistencies in young diarrheal children.
METHODS: Sixty children of either sex, aged 1-3 years having four groups (healthy children/low dose, healthy children/high dose, children with diarrhea/low dose and children with diarrhea/high dose) were enrolled into this exploratory study between 1st August to 23rd October 2017. Two presumptive doses, low (2.5g) and high (5g), twice daily with 50 ml drinking water for seven days were the interventions. Outcomes were to observe the development of possible abdominal symptoms, such as pain, distension, rumbling, and bloating during the intervention and post-intervention periods in healthy and diarrheal children as well as improvement in stool consistencies in diarrheal children.
RESULTS: Among the diarrheal children, the median (IQR) duration of resolution of diarrhea was 3.9 (2.9, 5.1) days vs. 3.5 (2.0, 8.0) days, p = 0.885; in low dose and high dose groups, respectively. Significant difference was observed in terms of abdominal pain (27% vs. 7%, p = 0.038) and distension (40% vs. 0%, p<0.001) in diarrheal children, compared to healthy children during the pre-intervention period. We also observed significant difference in respect of abdominal distension (23% vs. 0%, p = 0.011), rumbling (27% vs. 0%, p = 0.005) and bloating (43% vs. 3%, p = 0.001) in diarrheal children, compared to healthy children during the intervention period. However, no significant difference was observed in relation to abdominal pain (p = 0.347) and distension (p = 0.165) during the pre-intervention period, compared to the intervention period in diarrheal children. Moreover, no significant difference was observed during the post-intervention period for the diarrheal and healthy children.
CONCLUSION: Fibersol-2 was found to be well tolerated in healthy and diarrheal children aged 1-3 years. TRIAL REGISTRATION: This study was registered as part of a randomized trial at ClinicalTrials.gov, number NCT03565393. The authors confirmed that all ongoing and related trials for this drug/intervention were registered.

Introduction

Dietary fiber, a non-digestible carbohydrate, has been used for the beneficial effect on human health due to its low energy value. They usually reach the large intestine in an undigested and unabsorbed form and are often used in low-calorie food and beverages [1-3]. Previous studies on dietary fiber, especially digestive-resistant maltodextrin reported several judicious effects on human health, like modulating intestinal regularity by escalating faecal bulk, enhancing peristalsis and reducing gastrointestinal transit time [4,5]. Fibersol-2 (resistant maltodextrin) is a non-viscous, water-soluble, fermentable dietary fiber produced from corn starch. It also exhibits pre-biotic activity [6-8]. Pre-biotics act on the host by enhancing the growth large bowel bacteria, including Bifidobacterium and Lactobacillus, thus conferring beneficial effects on the health of the host [9]. Prebiotics are known to result in a decrease in pathogenic bacteria, such as Clostridium perfringens. They can act by reducing pH causing more production of short chain fatty acid resulting in enhanced competition for nutrients. As a prebiotic, Fibersol-2 gets into the large intestine and half of it undergoes fermentation by intestinal flora [10,11]. Ohkuma et al, in 1990 observed changing pattern of microbial flora caused by administration of resistant maltodextrin. Hypothetically, Fibersol-2 as a prebiotic is assumed to exert the beneficial effect on mucosal immune response to the intestine. In recent years, low-molecular-weight water-soluble dietary fiber, like inulin-type fructans have been hypothesized to induce gastrointestinal symptoms, including osmotic diarrhea. One study reported that a 5-10g single dose of inulin can cause abdominal flatulence in 42–50% subjects, and diarrhea in 19–26% cases [12]. Regarding Fibersol-2, one study in healthy adults reported that single oral ingestion up to 1.0g/kg body weight was well tolerated in both men and women, not causing diarrhea [13]. Another study in healthy adults reported that continuous ingestion of 50g Fibersol-2 per day for 24 days was well tolerated [8].The evidence showed that partially hydrolyzed guar gum in combination with oral rehydration solution can enhance quick recovery from acute diarrhea by reducing diarrheal duration and stool volume [14]. Therefore, the effects on gastrointestinal symptoms, including diarrhea, vary depending on the type of dietary fiber ingredient.

Advantages of consuming dietary fiber are the production of healthful compounds during fermentation, increased bulk of stool, softening of stool, shortening of transit time through the intestinal tract, blocking of intestinal mucosal adherence, translocation of potentially pathogenic bacteria, and modulation of intestinal inflammation [15-19]. Based on literature review we hypothesized that Fibersol-2, a fermentable, water-soluble, non- viscous and highly digestion-resistant, is digestively tolerable in adult humans [8,13], and hence may not cause gastro-intestinal symptoms, including diarrhea in young children, which has not yet been reported.

Thus, we conducted an exploratory study to determine the digestive tolerability of Fibersol-2 in terms of reducing abdominal pain, abdominal distension, abdominal rumbling, and abdominal bloating in healthy and diarrheal children, as well as improvement in stool consistencies in diarrheal children aged 1–3 years.

Materials and methods

Ethical consideration

Institutional review board of International Centre for Diarrhoeal Disease Research, Bangladesh approved the study (PR-16091). Informed written consent was attained from parents or caregivers of study participants prior enrollment.

Study design

This was a four arm exploratory study to evaluate the digestive tolerability and acceptability of Fibersol-2 at two different doses on the basis of disappearance or gradual improvement of abdominal symptoms, such as pain, distension, rumbling, and bloating in healthy and diarrheal children as well as improvement in stool consistencies in diarrheal children.

Thirty children were enrolled at home and thirty at hospital between 1st August to 23rd October 2017. We aimed to evaluate two presumptive doses, low (2.5g) and high (5g) of Fibersol-2 to determine the suitable dose for the proposed clinical trial in diarrheal children aged 1–3 years.

Eligibility criteria for the exploratory study

Inclusion criteria for both healthy and diarrheal children

Age 1–3 years, (ii) Either sex, (iii) Prior informed written consent from parents or caregivers.

Exclusion criteria for both healthy and diarrheal children

(i) History of food allergy, (ii) Antibiotic or any medication that impacts the gut transit during the two weeks before the study, (iii) Chronic gastrointestinal diseases, (iv) Gastroenteritis in the two weeks before the study, (v) Critically ill children requiring resuscitation, (vi) Included in another clinical trial, and (vii) Non-consent.

Study setting

We conducted this study in a rural facility, Mirzapur located nearly sixty- kilometer northwest of Dhaka, Bangladesh. Kumudini Women’s Medical College Hospital is one of the oldest and largest tertiary level facilities in rural Bangladesh and has 750 beds. We conducted this study in rural Bangladesh as rural people represent nearly 80% of our total national population. Enrollment of the study children, interview of the caregivers and data collection took place in the same facility.

A quiet, private room was used for the one-on-one interviews and all the study related documents were kept in a secured cabinet under lock and key in the facility.

Healthy children/low dose: 15 children received 2.5g Fibersol-2 twice daily orally for 7 days

Healthy children/high dose: 15 children received 5g Fibersol-2 twice daily orally for 7 days

Children with diarrhea/low dose: 15 children received 2.5g Fibersol-2 twice daily orally for 7 days

Children with diarrhea/high dose: 15 children received 5g Fibersol-2 twice daily orally for 7 days

Outcomes

Reduction of abdominal symptoms, such as pain, distension, rumbling, and bloating during the intervention and post-intervention periods for healthy and diarrheal children as well as improvement in stool consistencies in diarrheal children.

Sample size determination

As it was an exploratory study, we purposefully enrolled 30 healthy and 30 diarrheal children from the community and hospital, respectively which was considered to be the representative of a larger population.

Patient recruitment and management

30 healthy and 30 diarrheal children each were enrolled from the community and hospital following inclusion criteria between 1st August to 23rd October 2017 (Fig 1). We collected baseline information from the parents or caregivers of the participants at home and hospital. Fibersol-2 was given to the study participants twice daily in the morning and evening with 50 ml drinking water. If any child vomited out within 10 minutes of ingestion of Fibersol-2, we repeated the dose after an hour. However, if the child vomited again after the next dose, we used to stop the intervention. Moreover, we assessed the digestive tolerability of the intervening child by examining for abdominal pain, abdominal distension, abdominal rumbling, and abdominal bloating for all the four groups in healthy and diarrheal children as well as improvement in stool consistencies for the two groups in diarrheal children. In addition to collection of baseline information from hospital, our field staff collected household information as well as information on health status by using a structured questionnaire and followed-up the study participants throughout the hospital stay. A study physician was responsible for taking informed consent as well as clinical assessment of the diarrheal children and also provided treatment as per hospital’s guideline. Study nurses were accountable for keeping the vital signs and providing Fibersol-2 to the participating children in front of their parents in the hospital and the community with appropriate dose and on time. Field research assistants and field organizers screened the children in the community as well as recorded their socio-demographic information and findings from the nutritional assessments. They also assisted the study nurses in both the community and hospital.

Fig 1

Study profile.

Measurements

Pre-testing of the questionnaire

Before starting the research protocol, structured questionnaires were developed based on objectives of the study. Content of these questionnaires and necessary modifications were discussed thoroughly during extensive field-testing in the rural community.

Data collection in the field

The study team was responsible for data-collection under the guidance of the principal investigator (PI). 2–3 respondents were interviewed in a day. The duration of each interview was approximately 45 minutes. The PI regularly supervised all aspects of data- collection, including face-to-face interviews, and anthropometric measurements.

Assessment of socio-demographic status

Potential indicators of socio-demographic status included data regarding sex, number of family members, parental level of education, toilet facilities, sources of drinking-water, lighting and fuel sources and household assets. Principal component analysis was used to calculate wealth index of household durable assets which was an estimation of socio-economic status. Based on the factor score, households were classified into socio-economic status quintiles as poor, lower middle, middle, upper middle, and rich.

Anthropometric parameters-nutritional indices

Severe acute malnutrition was defined by weight-for-height/length z-score <-3 of the WHO median or mid upper arm circumference <115 mm or presence of bipedal pitting edema, independent of anthropometric measurements [20].

Statistical analysis

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, Chicago, IL version 20) and Epi Info (Version 7.0, USD, Stone Mountain, GA). The descriptive statistics were expressed as means, standard deviations, and medians with inter quartile range. In case of analytic statistics, for the categorical variable of interest, the significance of differences was evaluated by Chi-square or Fisher’s Exact test and for continuous variable of interest by two-way ANOVA or equivalent nonparametric, Kruskal-Wallis test. The significance of the differences in the proportions of the examined variables or between two findings of the target groups was also calculated. P-value of <0.05 was considered statistically significant.

Funding statement

This research study was funded by Matsutani Chemical Industry Company Limited, Japan on behalf of ADM/Matsutani LLC, USA. The funder did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Results

Characteristics of the study children

The study included sixty participants on Fibersol-2 with 33%, 60%, 47% and 67% males, respectively in healthy children/low dose, healthy children/high dose, children with diarrhea/low dose and children with diarrhea/high dose groups, respectively. The family size and use of non-sanitary toilet facility among the groups were comparable. In case of wealth quintile, no significant difference was observed among the four groups. Other socio-demographic characteristics were comparable among the groups (S1 Table).

Age was significantly associated in the model in relation to the factors, dose and status of all the four groups (p = 0.026) (Table 1). Distribution of nutritional indices (mid upper arm circumference, stunting, underweight) as well as sex and breast feeding was comparable among the groups for the first day (Table 1). Similarly, there was no significant difference in nutritional indices among the four groups for the last day (S2 Table).

Table 1

Comparison of characteristics of healthy and diarrheal children with low (2.5 gm) and high (5 gm) dose of Fibersol-2 on first day.

Variable of interest	Healthy children/low dose(n = 15) (%)	Healthy children/high dose(n = 15) (%)	Children with diarrhea/low dose(n = 15) (%)	Children with diarrhea/high dose(n = 15) (%)	p-value
*Age in months (mean, SD)	24.3±7.8	24.9±6.7	19.7±6.3	20.3±4.8	0.026*
Male sex	5 (33.3)	9 (60.0)	7 (46.7)	10 (66.7)	0.268
Breast-fed	13 (86.7)	15 (100)	14 (93.3)	10 (66.7)	0.063
Height in cm (mean, SD)	82.8±5.8	82.5±6.5	80.2±4.1	81.0±6.8	0.377
Weight in kg (mean, SD)	10.8±1.1	10.9±2.1	10.2±1.1	10.8±2.7	0.616
Mid upper arm circumference (mean, SD)	15.1±0.8	15.3±1.2	15.0±0.9	15.1±1.7	0.731
Nutritional status
Height-for-age z-score (mean, SD)	-1.37±0.76	-1.79±0.79	-0.98±1.08	-1.04±1.58	0.099
Weight-for-length/height z-score (mean, SD)	-0.16±0.78	-0.14±1.00	-0.17±0.79	-0.01±1.42	0.918
Weight-for-age z-score (mean, SD)	-0.84±0.90	-1.04±1.00	-0.65±0.96	-0.53±1.74	0.529
Stunting	4 (26.7)	7 (46.7)	2 (13.3)	4 (26.7)	0.300
Underweight	1 (6.7)	2 (13.3)	2 (13.3)	5 (33.3)	0.348
Wasting	0 (0)	0 (0)	0 (0)	1 (6.7)	1.000

*Age: Two-way ANOVA, model p-value 0.026 (Dose: 2.5 gm vs. 5 gm, p-value 0.749 and status: diarrheal vs. healthy, p-value 0.008); n = number of subjects; SD, Standard deviation.

Significant difference was observed in terms of abdominal pain (27% vs. 7%, p = 0.038) and abdominal distension (40% vs. 0%, p<0.001) in diarrheal children, compared to healthy children during the pre-intervention period (Table 2). We also observed significant difference in respect of abdominal distension (23% vs. 0%, p = 0.011), abdominal rumbling (27% vs. 0%, p = 0.005), and abdominal bloating (43% vs. 3%, p = 0.001) in diarrheal children, compared to healthy children during the intervention period. However, no significant difference was observed among the diarrheal children in relation to abdominal pain (p = 0.347) and abdominal distension (p = 0.165) during the pre-intervention period, compared to the intervention period (Table 3). Data on abdominal rumbling and abdominal bloating during the pre-intervention period for diarrheal children was not available to us. Moreover, no significant difference was observed during the post-intervention period for the diarrheal and healthy children (Table 4).

Table 2

Comparison of characteristics between healthy and diarrheal children during pre-intervention period.

Characteristics	Healthy children (n = 30)	Diarrheal children(n = 30)	p-value
Abdominal pain	2 (7)	8 (27)	0.038
Abdominal distension	0 (0)	12 (40)	<0.001
Abdominal rumbling	-	-	-
Abdominal bloating	-	-	-
Vomiting	6 (20)	17 (57)	0.003
Fever	3 (10)	11 (37)	0.015

n = number of subjects.

Table 3

Comparison of characteristics of diarrheal children during pre-intervention and intervention period.

Characteristics	Diarrheal children during the pre-intervention period (n = 30)	Diarrheal children during the intervention period (n = 30)	p-value
Abdominal pain	8 (27)	5 (17)	0.347
Abdominal distension	12 (40)	7 (23)	0.165
Vomiting	17 (57)	9 (30)	0.037
Fever	11 (37)	8 (27)	0.405

n = number of subjects.

Table 4

Comparison of characteristics between healthy and diarrheal children during intervention and post-intervention period.

Characteristics	Healthy children(n = 30)	Diarrheal children(n = 30)	p-value
Abdominal pain
Intervention	1 (3)	5 (17)	0.195
Post-intervention	0 (0)	3 (10)	0.237
Abdominal distension
Intervention	0 (0)	7 (23)	0.011
Post-intervention	0 (0)	2 (7)	0.492
Abdominal rumbling
Intervention	0 (0)	8 (27)	0.005
Post-intervention	0 (0)	0 (0)	-
Abdominal bloating
Intervention	1 (3)	13 (43)	<0.001
Post-intervention	0 (0)	5 (17)	0.052
Vomiting
Intervention	6 (20)	9 (30)	0.371
Post-intervention	3 (10)	8 (27)	0.095
Fever
Intervention	2 (7)	8 (27)	0.038
Post-intervention	3 (10)	3 (10)	1.000

n = number of subjects.

There was no change in stool consistencies (soft to formed) among the healthy children throughout the study period and no child reported onset of diarrhea among them within the study period. Diarrheal children presented with loose watery stool on the first day of enrollment and gradual improvement in stool consistency towards formed stool was observed in both the groups. The median (IQR) duration of resolution of diarrhea was 3.9 (2.9, 5.1) days vs. 3.5 (2.0, 8.0) days; p = 0.885, for low dose and high dose groups, respectively (S2 Table).

Discussion

The results of the present study on the digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children show that it is found to be safe for use. The study investigated two presumptive doses of Fibersol-2, low (2.5g) and high (5g) administered twice daily in study children. In case of healthy children, there was no change in stool consistency and none of the child reported to have diarrhea during the study period. Although the symptoms were found to be higher in diarrheal children during the intervention period, data from the pre-intervention period reflected that the observations during the intervention period may be due to the continuation of the concurrent illness and not related to the intervention. Moreover, as no significant difference was observed in relation to abdominal pain and abdominal distension during the pre-intervention period, compared to the intervention period among the diarrheal children, the overall observation supported that these symptoms were un-related to intake of Fibersol-2, rather effect of the concurrent illness. By contrast, a single intake of 5g and 10g of inulin or oligofructose (short-chain inulin) as a part of breakfast reported to increase gastrointestinal symptoms, including diarrhea that tended to persist through 24 hours in healthy adult men and women in a previously published study [12]. The difference is considered to be largely associated with the rate of fermentation by microbiota in the large intestine. Inulin-type fructans are readily fermented by the intestinal bacteria, and its rate of fermentation is so fast that it generates gas rapidly to be accumulated in the intestine, causing abdominal discomfort, such as bloating and diarrhea [21,22]. On the other hand, Fibersol-2 has been reported to be less likely to cause gastro-intestinal symptoms due to the rate of fermentation by intestinal bacteria being slow and steady, and slower than that of inulin-type fructans [13,22]. The rate of fermentation of hydrolyzed guar gum, which has been reported to improve diarrhea, is moderate and slower than that of inulin-type fructans [21,22]. Consequently, it has been suggested that the rate of fermentation is an essential factor for the development of the gastro-intestinal symptoms.

The major limitation of our study was the small sample size which might had an impact to draw statistical inference. Another important limitation was the lack of documentation of the information on abdominal bloating and abdominal rumbling for the pre-intervention period in diarrheal children that instigated the authors for evading other comparisons.

Conclusions

Fibersol-2 was found to be well tolerated in healthy and diarrheal children aged 1–3 years. A further trial with a larger sample may be done to accept or refute our observations.

TREND checklist.

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Comparison of socio-demographic characteristics among the healthy and diarrheal children with low (2.5 gm) and high (5 gm) doses of Fibersol-2.

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Comparison of characteristics of healthy and diarrheal children with low (2.5 gm) and high (5 gm) doses of Fibersol-2 on last day.

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16 Mar 2021

PONE-D-21-01326

Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study

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Reviewer #1: This exploratory Phase 1/2 study examined the digestive tolerability and acceptability of two different doses of Fibersol-2 (a fermentable, non-viscous dextrin) to relieve abdominal symptoms and improve stool consistency in both healthy children and children with diarrhea, 1-3 years old, in Bangladesh. 2.5g and 5 g of Fibersol-2 were administered twice daily to 55 children each in both groups, and there was no placebo group. This study is part of a registered efficacy trial.

Comments:

Abstract:

ll. 40-41 “No adverse events…were observed in healthy children, except for one…” Probably more accurate to state “Only one of the healthy children experienced any adverse events…”

ll. 46-47 “…devoid of any adverse events” should more correctly stated as “minimal adverse events,” since the authors report one child who experienced an adverse event. One does not equal none.

Statistical analysis

l.187 Medians should be reported with their interquartile ranges, either in place of, or in addition to the range. Because the range is sensitive to outliers, the IQR gives a better summary of where the bulk of the data lie.

ll.189-89 Please specify which non-parametric tests were used.

This is a four-arm study, but the authors have not taken advantage of this fact in the descriptive statistics or in the analyses. Rather than do two separate sets of analyses, comparing low vs. high dose within the groups of children with and without diarrhea separately, a more appropriate analysis would summarize data and perform comparisons across all four groups(Healthy/high dose, healthy/low dose, diarrheal high dose/diarrheal low dose) simultaneously. This could be done with two-way ANOVA for continuous variables (with dose as one factor and diarrheal group as the other factor) and chi square/Fisher’s exact test for categorical variables. This would allow for comparison across both the dosage and the health status of the children, which is not possible if children with and without diarrhea are examined separately. This would also eliminate the confusion that runs throughout the paper as to which groups are being compared at a given time; sometimes “groups” refers to dosage groups, at other times, to health status groups.

The authors should note that with such a small study, a finding of “no difference” could be due to a lack of power to detect a difference of a given size.

Results

See above for a suggested re-working of the analyses.

Also note that in Table S1, the comparison of wealth status between the two groups is incorrect; this calls for a Fisher’s exact test of the counts in each quintile by the groups being compared. In the table as currently reported, this represents a 5x2 table, and the test has a p-value of 0.13, indicating that there is no difference in wealth distribution between the two groups. In addition, neither family size nor number of sleeping rooms appear to be normally distributed. When this is the case, data should be summarized with medians and IQRs and compared with Wilcoxon rank sum tests.

Tables S2 and S3.

I am not sure why the authors present data on the characteristics of the children at baseline and at Day 21. This is not an efficacy study; if the authors wish to report on adverse events involving, e.g., weight loss over the one-week intervention period, they should look at changes and not aggregate before and after measurements. I would not expect that many of these measurements would change as a result of a one-week intervention, however, and the stated intention of the study is not efficacy, but tolerability and acceptability.

Tables 3 and 4. The data in these tables is primary to the goal of the study and could be presented in a more informative manner. E.g., it is probably not necessary to present results by day; summarizing by study period across the four groups would provide more easily digestible information (and even with this level of detail, it is not possible to tell whether the same or a different child suffered from given symptoms in the different periods). I’m not sure why pre-intervention symptoms are presented if the goal is to assess tolerability of the treatment during the treatment period. If the authors are not going to do an analysis in which they adjust for pre-intervention characteristics of individual children, and eligibility characteristics of the children have eliminated any serious conditions, these data are not, I think, necessary.

Conclusions

The authors purport to have shown the safety and tolerability of Fibrosol-2; it would seem that a large sample of children is not needed to confirm this, but to have sufficient power to examine efficacy outcomes.

The paper would also benefit from editing to correct grammatical and sentence structure errors.

Reviewer #2: Interesting study about dextrin compound - fibersol2 use in healthy children and children with diarrhea (1-3 years of age). Study is executed well with a control and study population and with an N of 60 however not a randomized trial. Well written manuscript.

**********

6. 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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

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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. Please note that Supporting Information files do not need this step.

15 Sep 2021

Date: 15th September, 2021

To

Ivan D. Florez, MD, MSc, PhD

Academic Editor, PLOS ONE

From:

Dr. Abu Sadat Mohammad Sayeem Bin Shahid

Corresponding Author

Subject: Response to the comments of the reviewers of PLOS ONE on manuscript Ref: PONE-D-21-01326 titled “Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study.”

Dear Ivan D. Florez,

Thank you for evaluating our manuscript and providing us with the opportunity to submit the revised manuscript after addressing academic editor’s and reviewers comments. We also express our sincere thanks to them for evaluating our manuscript. We are sending both the track change and clean versions of the manuscript that highlights the changes we have made from the previous version. We are also attaching this letter outlining a point-by-point response to the each point kindly raised by the respected academic editor and respected reviewers.

We hope that our response will be appropriate to qualify the manuscript for publication in your well-reputed journal.

We look forward to kindly hearing from you.

Thank you.

Journal Requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: Thank you. It has been revised accordingly.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: Thank you. It has been uploaded as Supporting Information.

3. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation.

Response: Thank you for the comment. As this was an exploratory study, we purposefully enrolled 30 healthy and 30 diarrheal children to see the digestive tolerability and acceptability of Fibersol-2 to find out the suitable dose for the proposed randomized trial (line no.141-142 in the clean version).

4. Please provide additional details about your study design in your Methods, including randomisation methods and outcomes measured.

Response: Thank you for the comment. As it was an exploratory study, there was no randomization and masking. We measured the episodes of abdominal symptoms, such as pain, distension, rumbling and bloating during the intervention and post intervention period for both healthy and diarrheal children for both the low (2.5g) and high (5 g) doses to see the outcomes (line no. 137-139 in the clean version).

5. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

a) the recruitment date range (month and year)

Response: Thanks for the suggestion. It has already been mentioned under study design (line no. 108-109 in the clean version).

b) a table of relevant demographic details

Response: Thanks for the suggestion. It has been incorporated in Table S1.

c) a statement as to whether your sample can be considered representative of a larger population

Response: Thank you for the suggestion. It has been incorporated in line no.142-143 (clean version).

d) a description of how participants were recruited

Response: Thank you for the suggestion. It has been incorporated in line no.144-147 (clean version) and also Figure 1.

6. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly.

Response: Thank you for the comment. Our data contain a lot of personal information where we de-identified them during analysis. As per institutional policy data with personal information will be remained with our Research Administration (RA) due to ethical constraint and if someone wants to make the availability of the de-identified data, he/she may kindly communicate with the head of RA (aahmed@)icddrb.org).

7. Thank you for stating the following in the Financial Disclosure section:

'This research study was funded by Matsutani Chemical Industry Company Limited, Japan on behalf of ADM/Matsutani LLC, USA. The International Centre for Diarrhoeal Disease Research, Bangladesh, receives unrestricted support from the Government of the People's Republic of Bangladesh, Global Affairs Canada, the Swedish International Development Cooperation Agency and the UK Department for International Development.'

We note that one or more of the authors have an affiliation to the commercial funders of this research study, Matsutani Chemical Industry Co. Ltd

a. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

Response: Thank you for the suggestions. It has been incorporated in line no.200-207 (clean version).

b. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.

Response: Thank you for the suggestion. It has been incorporated in line no. 289-291 (clean version).

c. Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

Response: Thank you for the suggestion. It has been incorporated accordingly.

8. Please include a separate caption for each figure in your manuscript.

Response: Thank you for the suggestion. It has been incorporated accordingly in line no.146 (clean version)

9. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure.

Response: Thank you for the suggestion. It has been incorporated accordingly in line no. 146 (clean version)

10. Please include your tables 1-6 as part of your main manuscript and remove the individual files. Please note that supplementary tables should remain as separate "supporting information" files.

Response: Thank you for the suggestion. Tables have been incorporated in the revised manuscript as well as supplementary tables have been uploaded as supporting information.

11. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly.

Response: Thank you for the suggestion. It has been incorporated in line no.355-362 (clean version).

Review Comments to the Author

Reviewer #1:

This exploratory Phase 1/2 study examined the digestive tolerability and acceptability of two different doses of Fibersol-2 (a fermentable, non-viscous dextrin) to relieve abdominal symptoms and improve stool consistency in both healthy children and children with diarrhea, 1-3 years old, in Bangladesh. 2.5g and 5 g of Fibersol-2 were administered twice daily to 60 children each in both groups, and there was no placebo group. This study is part of a registered efficacy trial.

Response: Thanks for the overall positive comments.

Comments:

Abstract:

l. 40-41 “No adverse events…were observed in healthy children, except for one…” Probably more accurate to state “Only one of the healthy children experienced any adverse events…”

Response: Thank you for the suggestion. It has been revised in line no. 44-46 (clean version).

ll. 46-47 “…devoid of any adverse events” should more correctly stated as “minimal adverse events,” since the authors report one child who experienced an adverse event. One does not equal none.

Response: Thank you for the suggestion. It has been revised accordingly in line no.51 (clean version).

Statistical analysis

l. 187 Medians should be reported with their interquartile ranges, either in place of, or in addition to the range. Because the range is sensitive to outliers, the IQR gives a better summary of where the bulk of the data lie.

Response: Thank you for the suggestion. It has been incorporated in line no.189 (clean version).

ll. 189-90 Please specify which non-parametric tests were used.

Response: Thank you for the comment. It has been incorporated in line no.192 (clean version).

This is a four-arm study, but the authors have not taken advantage of this fact in the descriptive statistics or in the analyses. Rather than do two separate sets of analyses, comparing low vs. high dose within the groups of children with and without diarrhea separately, a more appropriate analysis would summarize data and perform comparisons across all four groups (Healthy/high dose, healthy/low dose, diarrheal high dose/diarrheal low dose) simultaneously. This could be done with two-way ANOVA for continuous variables (with dose as one factor and diarrheal group as the other factor) and chi square/Fisher’s exact test for categorical variables. This would allow for comparison across both the dosage and the health status of the children, which is not possible if children with and without diarrhea are examined separately. This would also eliminate the confusion that runs throughout the paper as to which groups are being compared at a given time; sometimes “groups” refers to dosage groups, at other times, to health status groups.

The authors should note that with such a small study, a finding of “no difference” could be due to a lack of power to detect a difference of a given size.

Response: Thank you for the suggestions. It has been revised in Tables 1, S1 and S2.

Results

See above for a suggested re-working of the analyses.

Also note that in Table S1, the comparison of wealth status between the two groups is incorrect; this calls for a Fisher’s exact test of the counts in each quintile by the groups being compared. In the table as currently reported, this represents a 5x2 table, and the test has a p-value of 0.13, indicating that there is no difference in wealth distribution between the two groups. In addition, neither family size nor number of sleeping rooms appears to be normally distributed. When this is the case, data should be summarized with medians and IQRs and compared with Wilcoxon rank sum tests.

Response: Thanks for the suggestions. It has been revised accordingly in Table S1.

Tables S2 and S3.

I am not sure why the authors present data on the characteristics of the children at baseline and at Day 21. This is not an efficacy study; if the authors wish to report on adverse events involving, e.g., weight loss over the one-week intervention period, they should look at changes and not aggregate before and after measurements. I would not expect that many of these measurements would change as a result of a one-week intervention, however, and the stated intention of the study is not efficacy, but tolerability and acceptability.

Response: Thanks for your valuable suggestions. It has been revised in Table S2.

Tables 3 and 4. The data in these tables is primary to the goal of the study and could be presented in a more informative manner. E.g., it is probably not necessary to present results by day; summarizing by study period across the four groups would provide more easily digestible information (and even with this level of detail, it is not possible to tell whether the same or a different child suffered from given symptoms in the different periods). I’m not sure why pre-intervention symptoms are presented if the goal is to assess tolerability of the treatment during the treatment period. If the authors are not going to do an analysis in which they adjust for pre-intervention characteristics of individual children, and eligibility characteristics of the children have eliminated any serious conditions, these data are not, I think, necessary.

Response: Thanks for your valuable suggestions. It has been revised in Table 2.

Conclusions

The authors purport to have shown the safety and tolerability of Fibrosol-2; it would seem that a large sample of children is not needed to confirm this, but to have sufficient power to examine efficacy outcomes.

Response: Thank you for the comment and we completely agree. The statement has been revised in line no. 269-70 (clean version).

The paper would also benefit from editing to correct grammatical and sentence structure errors.

Response: Thanks for the suggestion. We tried to improve the grammatical and sentence structure errors in the revised version.

Reviewer #2:

Interesting study about dextrin compound - fibersol2 use in healthy children and children with diarrhea (1-3 years of age). Study is executed well with a control and study population and with an N of 60 however not a randomized trial. Well written manuscript.

Response: Thank you for overall positive comments.

Submitted filename: Response to reviewers_Shahid ASMSB_15.09.2021.docx

Click here for additional data file.

4 Nov 2021

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 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,

Ivan D. Florez, MD, MSc, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

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: No

**********

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

Reviewer #1: No

**********

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: 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 #1: No

**********

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: I think that the authors, while purporting to have tolerability and feasibility as their primary outcomes, have confused these concepts with efficacy. For tolerability and feasibility, the important question is whether or not children had an unacceptable reaction to the Fibersol, and whether this was associated with health state or dosage. Therefore, the period that is of most importance is the period during which the children are taking the Fibersol (not before, or after, when it is no longer being given to them). Looking at changes in/alleviation of symptoms as a result of taking Fibersol is actually a different question, and would require comparing pre-intervention symptoms to end of intervention symptoms.

I would suggest a rehaul of the paper. The authors stand a better chance of making conclusions about tolerability than they do about efficacy. This is not an efficacy analysis, nor was it powered to be. So what about the responses to the Fibersol during the time it was taken? Is it actually feasible and tolerable as the authors conclude? Looking at Table 2, the authors observed the following:

Abdominal pain during intervention: 20% of D/L kids; 7% of D/H kids

Abdominal distention: 27% of D/L kids; 20% of D/H kids

Abdominal rumbling: 27% of D/L kids; 27% of D/H kids

Abdominal bloating: 40% of D/L kids; 47% of D/H kids

Vomiting: 33% of H/H, D/L, D/H kids

Fever: 7% of H/L and H/H kids, 27% of D/L and D/H kids

I would argue that these are some alarming side effects in children so young, and most of them (except for vomiting) occur much more frequently in the diarrheal group. I am not sure how the authors conclude that “Regarding the digestive tolerability, there were some symptoms observed for both [diarrheal] groups during the study period.” Isn’t that the crux of the paper?

I would suggest the following steps:

1. Look at each outcome (as listed above), comparing WITHIN groups across dosages. For no one does the dosage appear to come into play.

2. Because of the fact that dosage doesn’t matter, compare healthy to diarrheal kids, who have a much lower tolerance for Fibersol.

3. Conclude that it doesn’t appear, from your evidence, that Fibersol is tolerable for children with diarrhea.

If you compare the different dosages in healthy kids, there are no differences in symptoms while taking Fibersol. If you compare the different dosages in diarrheal kids, there are no differences in symptoms while taking Fibersol. If you lump dosages together, then you get the following, comparing healthy to diarrheal children (at any dose):

Abdominal pain: p=0.09

Abdominal distension: p=0.01

Abdominal rumbling: p=0.005

Abdominal bloating: p<0.001

Vomiting: p=0.37 (no difference, but bad in both groups!)

Fever: p=0.08.

This strongly suggests that healthy children tolerate the Fibersol much better than the diarrheal children. The fact that symptoms lessen after the treatment has been stopped doesn’t prove the treatment is efficacious, if the treatment caused the symptoms in the first place.

I believe that the authors should re-think their analysis in terms of what question they are trying to answer, and re-evaluate their conclusions.

Minor comments: summarize diarrhea duration with medians and IQRs, not means and sds. These do not appear to be normally distributed.

**********

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.

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

[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. Please note that Supporting Information files do not need this step.

19 Dec 2021

Date: 19 December, 2021

To

Ivan D. Florez, MD, MSc, PhD

Academic Editor, PLOS ONE

From:

Dr. Abu Sadat Mohammad Sayeem Bin Shahid

Corresponding Author

Subject: Response to the comments of the academic editor and reviewer of PLOS ONE on manuscript Ref: PONE-D-21-01326R1 titled “Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study.”

Dear Ivan D. Florez,

Thank you for evaluating our manuscript and providing us with the opportunity to submit the revised manuscript after addressing respected academic editor’s and reviewer’s comments. We also express our sincere thanks to him/her for evaluating our manuscript. We are sending both the track change and clean versions of the manuscript that highlights the changes we have made from the previous version. We are also attaching this letter outlining a point-by-point response to each point kindly raised by the respected reviewer.

We hope that our response will be appropriate to qualify the manuscript for publication in your well-reputed journal.

We look forward to kindly hearing from you.

Thank you.

Academic Editor

The reviewer has raised key elements that need to be addressed. Particularly, they state that the concept of efficacy is not clear. Please address their comments and provide a point by point response.

Response: Thank you. We have tried to address respected reviewer’s comments in the revised version of the manuscript.

Reviewer #1:

I think that the authors, while purporting to have tolerability and feasibility as their primary outcomes, have confused these concepts with efficacy. For tolerability and feasibility, the important question is whether or not children had an unacceptable reaction to the Fibersol, and whether this was associated with health state or dosage. Therefore, the period that is of most importance is the period during which the children are taking the Fibersol (not before, or after, when it is no longer being given to them). Looking at changes in/alleviation of symptoms as a result of taking Fibersol is actually a different question, and would require comparing pre-intervention symptoms to end of intervention symptoms.

Response: Thank you for the overall comment. We have now re-analyzed the data and presented as per suggestion of the respected reviewer in tables 2, 3 and 4.

I would suggest a rehaul of the paper. The authors stand a better chance of making conclusions about tolerability than they do about efficacy. This is not an efficacy analysis, nor was it powered to be. So what about the responses to the Fibersol during the time it was taken? Is it actually feasible and tolerable as the authors conclude? Looking at Table 2, the authors observed the following:

Abdominal pain during intervention: 20% of D/L kids; 7% of D/H kids

Abdominal distention: 27% of D/L kids; 20% of D/H kids

Abdominal rumbling: 27% of D/L kids; 27% of D/H kids

Abdominal bloating: 40% of D/L kids; 47% of D/H kids

Vomiting: 33% of H/H, D/L, D/H kids

Fever: 7% of H/L and H/H kids, 27% of D/L and D/H kids

I would argue that these are some alarming side effects in children so young, and most of them (except for vomiting) occur much more frequently in the diarrheal group. I am not sure how the authors conclude that “Regarding the digestive tolerability, there were some symptoms observed for both [diarrheal] groups during the study period.” Isn’t that the crux of the paper?

I would suggest the following steps:

1. Look at each outcome (as listed above), comparing WITHIN groups across dosages. For no one does the dosage appear to come into play.

2. Because of the fact that dosage doesn’t matter, compare healthy to diarrheal kids, who have a much lower tolerance for Fibersol.

3. Conclude that it doesn’t appear, from your evidence, that Fibersol is tolerable for children with diarrhea.

If you compare the different dosages in healthy kids, there are no differences in symptoms while taking Fibersol. If you compare the different dosages in diarrheal kids, there are no differences in symptoms while taking Fibersol. If you lump dosages together, then you get the following, comparing healthy to diarrheal children (at any dose):

Abdominal pain: p=0.09

Abdominal distension: p=0.01

Abdominal rumbling: p=0.005

Abdominal bloating: p<0.001

Vomiting: p=0.37 (no difference, but bad in both groups!)

Fever: p=0.08.

This strongly suggests that healthy children tolerate the Fibersol much better than the diarrheal children. The fact that symptoms lessen after the treatment has been stopped doesn’t prove the treatment is efficacious, if the treatment caused the symptoms in the first place.

I believe that the authors should re-think their analysis in terms of what question they are trying to answer, and re-evaluate their conclusions.

Response: Thank you for the valuable comments and suggestions. We have now reanalyzed the data and revised the manuscript accordingly (please see line no. 49-57, page no. 3; line no. 236-245, page no.11; and line no. 268-280, page no.13 in track change version of the manuscript).

Minor comments:

summarize diarrhea duration with medians and IQRs, not means and sds. These do not appear to be normally distributed.

Response: Thank you for the suggestion. We have revised accordingly (please see line no. 43-44, page no 2-3; line no. 251-252, page no.12; line no. 265-266, page no.13 in track change version of the manuscript and table S2 in supporting information).

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

17 Feb 2022

14 Jun 2022

Date: 14 June, 2022

To

Ivan D. Florez, MD, MSc, PhD

Academic Editor, PLOS ONE

From:

Dr. Abu Sadat Mohammad Sayeem Bin Shahid

Corresponding Author

Subject: Response to the comments of the reviewer of PLOS ONE on manuscript Ref: PONE-D-21-01326R2 titled “Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study.”

Dear Ivan D. Florez,

Thank you for evaluating our manuscript and providing us with the opportunity to submit the revised manuscript after addressing respected reviewer’s comments. We also express our sincere thanks to the reviewer for evaluating our manuscript. We are sending both the track change and clean versions of the manuscript that highlights the changes we have made from the previous version. We are also attaching this letter outlining a point-by-point response to each point kindly raised by the reviewer.

We hope that our response will be appropriate to qualify the manuscript for publication in your well-reputed journal.

We look forward to kindly hearing from you.

Thank you.

Reviewer#1 Thank you for addressing most of my concerns; however, I still find the paper a bit confusing in part and suggest the following:

When summarizing with the median and IQR, please indicate in text, e.g.: the median (IQR) duration of resolution… (l. 43).

Response: Thank you for the suggestion. It has been revised in line no.44, page no.3 in track change version.

l. 62. Did children in the diarrheal group have more bloating after the intervention than before? If so, I would question the conclusion of “well-tolerated.” I see that this is addressed in the Discussion but the lack of pre-intervention data should be mentioned here if you are going to talk about it with respect to the other symptoms.

Response: Thank you for the comment. It has been mentioned in line no.239-240, page no 12 and line no 291-293, page no.14 in track change version.

ll. 102-03. I believe that the authors are confusing tolerability with efficacy. Tolerability=any side effects of use? Efficacy=reduces symptoms. This should be clarified.

Response: We quite agree with your insight thoughts about tolerability. We have also examined whether there were any side effects occurred after the introduction of intervention drug. We admit that during pre-intervention period we failed to document the information of abdominal rumbling and bloating. As like as other features shown in table 3, it is expected that these were also present at enrolment and improved during the intervention as observed in all other features. On the other hand, as there were no new episodes of illness (side effect) and simultaneously all the documented features (available both in pre-intervention and during intervention) shown in table 3 improved during intervention, we may infer that the drug didn`t cause any side effects. Hope this clarifies.

l. 114. Should add …Fibersol-2 at two different doses…

Response: Thank you for the suggestion. It has been revised in line no.107, page no 5 in track change version.

l. 145. Reduction of symptoms is different from tolerability. This should be clarified. See above.

Response: Thank you for the comment. We quite agree with your insight thoughts about tolerability. We have also examined whether there were any side effects occurred after the introduction of intervention drug. We admit that during pre-intervention period we failed to document the information of abdominal rumbling and bloating. As like as other features shown in table 3, it is expected that these were also present at enrolment and improved during the intervention as observed in all other features. On the other hand, as there were no new episodes of illness (side effect) and simultaneously all the documented features (available both in pre-intervention and during intervention) shown in table 3 improved during intervention, we may infer that the drug didn`t cause any side effects. Hope this clarifies.

ll. 162-164. Here the outcome is stated in terms of symptoms, not efficacy. This needs to be cleaned up throughout the paper.

Response: Thank you for the comment. Again, we quite agree with the respected reviewer. It is one of the big limitations of our study that unfortunately we didn`t document the information on abdominal bloating and rumbling during the pre-intervention period but documented those only during the intervention period. Thus, we don`t know whether these are increased or decreased after the intervention. As the information on other features such as abdominal pain, abdominal distension, and vomiting are available and these symptoms decreased during the intervention, we can speculate that if the pre-intervention information of bloating and rumbling were available, these two might also be improved.

ll. 220. I think it would be clearer to call the groups: healthy children/high dose, healthy children/low dose, children with diarrhea/high dose, children with diarrhea/low dose

Response: Thank you for the suggestion. It has been revised accordingly (please see line no.31-32, page no.2, line no.137-140, page no.7, line no.221-222, page no. 11 and Table 1, page no.18 in track change version).

Discussion, ll. 268-273. This information is in the Results and should not be repeated here. The authors should state as a limitation the fact that no data on bloating or rumbling were available for the pre-intervention period, but that these were increased in the group of children with diarrhea after the intervention. Then the authors can discuss why they think this was not related to the intervention, if that is what they believe.

Response: Thank you for the comment and suggestion. It has been revised accordingly (please see line no. 261-269, page no. 13 in track change version). Again, we quite agree with the respected reviewer. It is one of the big limitations of our study that unfortunately we didn`t document the information on abdominal bloating and rumbling during the pre-intervention period but documented those only during the intervention period. Thus, we don`t know whether these are increased or decreased after the intervention. As the information on other features such as abdominal pain, abdominal distension, and vomiting are available and these symptoms decreased after intervention, we can speculate that if the pre-intervention information of bloating and rumbling were available, these two might also be improved. However, to eliminate any confusion, we have decided not to show these two features in the table 3 due to lack of their pre-intervention information.

Overall, the paper should be edited for grammar and coherence.

Response: Thank you for the suggestion. We have tried to improve the grammar and coherence in the revised version of the manuscript.

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

26 Aug 2022

Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study

PONE-D-21-01326R3

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9 Sep 2022

PONE-D-21-01326R3

Digestive tolerability and acceptability of Fibersol-2 in healthy and diarrheal children 1-3 years old at a rural facility, Bangladesh: results from a four arm exploratory study

Dear Dr. Shahid:

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State	Cut-off (moderate)	Cut-off (severe)
Wasting	weight-for-height/length between –3 and –2 z-scores	weight-for-height/length z-score<-3 of the WHO median
Stunting	height/length-for-age between –3 and –2 z-scores	height/length-for-age z-score <-3 of the WHO median
Underweight	weight-for-age –3 and –2 z-scores	weight-for-age z-score <-3 of the WHO median