Round 1

Reviewer 1 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

well done

Author Response

Thank you very much for your encouraging words. We are grateful for the positive feedback.

Reviewer 2 Report (Previous Reviewer 5)

Comments and Suggestions for Authors

Dear Authors,
Despite some improvements in formatting and minor clarifications, the revised manuscript does not substantively address the key concerns raised in the initial review. The same six studies are analyzed, the statistical approach remains inappropriate (fixed-effects with two studies, reporting of negative ORs), and the claim of being the first quantitative meta-analysis remains inaccurate given the existing BMC Pediatrics 2024 publication (DOI: 10.1186/s12887-024-05302-z). The additional text mainly reiterates known evidence and does not alter the scientific conclusions. The English language and reporting quality have only marginally improved. I therefore maintain my original recommendation for rejection.

Author Response

Response to Reviewer 2 Comments

Thank you very much for taking the time to review this manuscript. We appreciate very much your constructive comments, helpful information and your time. We have considered all suggestions and incorporated them into the revised manuscript, and as a result, we believe our manuscript is stronger. We have highlighted in yellow the changes made to the manuscript.

 

Point-by-point response to Comments and Suggestions for Authors

Dear Authors, 
Despite some improvements in formatting and minor clarifications, the revised manuscript does not substantively address the key concerns raised in the initial review. The same six studies are analyzed, the statistical approach remains inappropriate (fixed-effects with two studies, reporting of negative ORs), and the claim of being the first quantitative meta-analysis remains inaccurate given the existing BMC Pediatrics 2024 publication (DOI: 10.1186/s12887-024-05302-z). The additional text mainly reiterates known evidence and does not alter the scientific conclusions. The English language and reporting quality have only marginally improved. I therefore maintain my original recommendation for rejection.

Response: Thank you for your time and for providing detailed feedback on our revised manuscript. We have carefully reconsidered all the points raised and have introduced substantial changes to address the core methodological and scientific concerns.

1. Updated systematic search and new study inclusion
We performed a new systematic literature search across the main databases. As a result, we identified and incorporated one additional eligible study, which has now been included in the review. Consequently, all data were re-analyzed by repeating the meta-analysis using a random-effects model, yielding updated pooled estimates and revised conclusions based on the expanded evidence base.

2. Revision of the meta-analytic approach
Following your previous recommendations, we have modified our analytical strategy where appropriate and clarified all statistical reporting to ensure methodological correctness. The Results, Forest plots, and summary measures have been fully updated to reflect this new analysis.

3. Concern regarding the BMC Pediatrics 2024 publication
Regarding the publication cited in your report, during our verification process we detected significant inconsistencies in the primary data sources: of the 12 studies included in that meta-analysis, at least six references present clear signals of being non-authentic or fraudulent reports. There are:

• Bai Y, Zhang Q, Li J, et al. Effect of vacuum sealing drainage technol- ogy on deep II ° burn wound healing in children. J Trauma Surg. 2016;18(7):435–7. https://doi.org/10.3969/j.issn.1009-4237.2016.07.015.
• Li T, Li W, Tuo X, et al. Application of vacuum sealing drainage on superfi- cial degree II burn and scald wound: a clinical study in pediatrics. Chin J Clin Med. 2016;1:23–5. https://doi.org/10.16680/J.1671-3826.2016.01.07.
• Wei Yin G, Zhu HZ, et al. Exploring the application effect of negative pressure sealing drainage technology in burn plastic surgery. Chin Med Aesthet. 2016;6(7):18–9.
• Li M. Clinical application study of negative pressure sealing drainage technology in children’s superficial second degree burn and scald wounds. Electron J Clin Med Literature. 2018;5(54):3542. https://doi.org/ 10.3877/j.issn.2095-8242.2018.54.028.
• Wang R. Observation of the effect of applying negative pressure sealing drainage technology after skin grafting surgery on deep second degree burn wounds. Front Med. 2018;8(32):148. https://doi.org/10.3969/j.issn. 2095-1752.2018.32.117.
• Zhang M, Ma Y, Fu J, et al. Clinical effect of micro-dynamic negative pressure wound therapy on skin grafting of limbs and trunk wounds of childron. Chin J Injury Repair (Electronic Edition). 2021;16(5):398–405. https://doi.org/10.3877/cma.j.issn.1673-9450.2021.05.005.

In addition to being currently unavailable or removed from the scientific literature. To date, no public erratum, corrigendum, or retraction notice has been issued by the journal to clarify the status or validity of those references. 

 

We believe these actions represent meaningful and non-superficial changes that directly address the key concerns raised in the initial review. We sincerely hope that this improved version reflects the rigor and transparency you expect.

Thank you again for your guidance, which has helped us strengthen our work. We remain fully available to make any further modifications you may consider necessary.

Reviewer 3 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Please review the manuscript for typographical errors and citation accuracy line by line, and revise all elements to align with the journal’s requirements 

Author Response

Comments and Suggestions for Authors: Please review the manuscript for typographical errors and citation accuracy line by line, and revise all elements to align with the journal’s requirements 

Thank you for the important suggestion. We have performed a thorough, line-by-line revision of typographical issues and citation accuracy and updated all elements to conform with the journal’s specifications.

Reviewer 4 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Everything okay

Author Response

Comments and Suggestions for Authors: Everything okay

Thank you very much for your encouraging words. We are grateful for the positive feedback.

Reviewer 5 Report (Previous Reviewer 4)

Comments and Suggestions for Authors

-

Author Response

We are grateful for the positive feedback.

Round 2

Reviewer 2 Report (Previous Reviewer 5)

Comments and Suggestions for Authors

Dear Authors,
Although the manuscript now includes minor methodological clarifications and language improvements, it continues to rely on the same limited evidence base and does not resolve the major issues previously raised. The claim of including a new study is inaccurate; the “new” paper was already part of prior versions. The statistical approach has been reworded but not meaningfully strengthened, and the conclusions remain overstated. Most concerning, the assertion that six studies in the BMC Pediatrics 2024 meta-analysis are “fraudulent” is unsupported by any verifiable retraction or indexing notice and should not appear in a scientific paper. Therefore, the revision still lacks novelty, methodological rigor, and scientific prudence.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Major Comments

1. Inconsistency in the Abstract and Results

The Abstract states that a fixed-effects meta-analysis was performed, but a few lines later the text indicates that a meta-analysis could not be performed due to lack of control groups. Please reconcile this contradiction across the Abstract, Methods, and Results sections. Clearly specify whether a quantitative meta-analysis was conducted and under what conditions. If it was not possible, adjust the Abstract accordingly.

2. Inappropriate Model and Publication Bias Interpretation

Only two studies were included in the quantitative synthesis, yet funnel plots and publication-bias statements were presented. With k ≈ 2, such analyses are statistically uninterpretable.
Suggestions:
- Remove funnel plots from the figures.
- Delete any mention of publication-bias assessment, symmetry, or low risk of bias derived from them.
- Add a cautionary statement such as: 'Because only two studies were available, formal assessment of publication bias was not feasible.'
- Temper the discussion and conclusion; instead of 'results strengthen confidence,' state: 'Results suggest a possible effect but require confirmation in larger, well-controlled trials.'

3. Outcome Type Misclassification

Scar pigmentation and erythema are continuous or ordinal outcomes, but the analysis currently treats them as binary using odds ratios (some of which are incorrectly reported as negative). Please re-extract the data and re-analyze using mean difference (MD) or standardized mean difference (SMD) with appropriate 95 % confidence intervals. If only proportions are available, retain binary analysis but ensure all odds ratios are > 0 and clearly cite the data source.

4. Population Violation

The inclusion criterion defines the study population as patients under 18 years. However, on page 6, lines 166- 169, the manuscript notes inclusion of one 24-year-old participant, which contradicts this criterion (defined on page 4, lines 107-109). Please either exclude this participant/study, conduct a sensitivity analysis excluding the adult, or provide a clear justification in the Methods as a protocol deviation. The PRISMA flow diagram and total participant counts should be updated accordingly.

Minor Comments

1. Citation Formatting in Tables - In Tables 4, 5, and 6, references are cited using both author names and numbers (e.g Ren Y, et al. (2017), USA [21]'). Healthcare follows a numeric Vancouver style; please retain only citation numbers in square brackets.
   
   2. Spelling and Terminology -Replace 'acuum' with 'vacuum' (e.g., Table 1, CINAHL section). Perform a comprehensive spell-check and ensure uniform terminology (for example, use 'negative-pressure wound therapy' consistently).
   3. Authors’ Contributions -The manuscript is missing an Authors’ Contributions section, which is mandatory for MDPI journals. Please add a concise statement describing each author’s role (conceptualization, data curation, analysis, writing, review, supervision, etc.).

Summary Recommendation

The study is methodologically valuable but requires corrections to analytic interpretation, internal consistency, and presentation. Once the statistical model, population issue, and minor editorial changes are addressed, the manuscript will meet publication standards for Healthcare or a comparable journal.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is very interesting and a lot of work has been done.

 

Please consider the below. Minor remarks

Introduction:

 - How about total cost of burn injuries in low - income countries?

 

- Please, add Subjective criteria and objective criteria of wound

-  Please, add Indications and contraindications for the use of negative pressure wound therapy (NPWT).

-  In what cases are substantiate indication of negative pressure wound therapy for use in children

-  Please, add Diagnosis of pain in the wound area during NPWT and recording of pain when changing dressings adjacent to the wound.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Methodological limitations undermine the validity of the conclusions:  

1.  Methodological Fragility: Pooled analyses rely on only two studies per outcome,with substantial dominance of Yuan et al. (2016) incontributing to the effect estimates. A critical statistical error occurs: mean differences are erroneously labeled as odds ratios, resulting in negative OR values that are clinically implausible for binary outcomes.  
2.  Inadequate Reporting:ThePRISMA flow diagram lacks legibility; Tables 4 and 5 omit essential data, including TBSA and adverse events. An inclusion criterion violation exists in Hoeller et al. (2014) regarding the inclusion of a 24-year-old patient, without explanation or assessment of its impact.  
3.  Methodological Imbalance and Omissions: Four of the six included studies are retrospective, carrying a high risk of bias. Significant clinical heterogeneity exists in burn severity and NPWT protocols, yet planned subgroup or sensitivity analyses addressingthisheterogeneity are absent.  
4.  Insufficient Discussion:Claims regarding publication bias lacksupport due to the generation of funnel plots with fewer than ten studies. Evidence for cost-effectiveness relies solely on a single study, ignoring potential cost variations. Reporting of adverse effects is insufficient, lacking quantitative data and failing to differentiate between clinical infections and colonization.  

 While this review suggests potential benefits of NPWT, the conclusions are undermined by methodological flaws, reporting errors, and insufficient data. Major revisions addressing these limitations are essential to establish reliability.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

This is a very well-written article on negative-pressure wound therapy. I have no major remarks other than that I recommended to let a statistician check the analysis method. The only thing is: why were studies older than 10 years excluded? This does not really make sense at first glance.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,

While the topic of negative pressure wound therapy (NPWT) in pediatric burns is clinically important, the present manuscript does not provide novel evidence beyond what is already available. A recent meta-analysis — The efficacy and safety of negative pressure wound therapy in paediatric burns (BMC Pediatrics, 2024; https://doi.org/10.1186/s12887-024-05302-z) — has already quantitatively synthesized pediatric NPWT outcomes, including re-epithelialization time, dressing-change frequency, infection rate, scar scores, and costs. The current study largely duplicates those findings without introducing new methodology, datasets, or outcomes. In addition, there are serious statistical issues (e.g., reporting of negative odds ratios for continuous variables, use of fixed-effects models with only two studies, and misinterpretation of funnel plots) and inconsistencies in the inclusion criteria and bias assessment. The writing also requires extensive language and structural editing. In its current form, the manuscript does not offer sufficient methodological rigor or originality to warrant publication, though the topic remains of clinical interest.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

1 Study Selection and Sample Limitations

• Small and Heterogeneous Sample: Only 6 studies (2 clinical trials, 4 retrospective studies) with 259 total participants are included. Individual study sample sizes range from 3 (Poulakidas et al., 2016) to 101 (Frear et al., 2020/2021), leading to insufficient statistical power.
• Overreliance on Retrospective Data: 4 of 6 studies are retrospective (case series or case-control), which are prone to selection bias, unmeasured confounding, and inconsistent data collection. This limits causal inference compared to prospective randomized controlled trials (RCTs).
• Geographic and Clinical Homogeneity: Most studies are from high-income countries (USA, Australia, Austria); only 1 is from a middle-income country (China). This excludes data from low- and middle-income countries (LMICs), where 90% of childhood burn deaths occur (per the introduction)—a critical gap in global applicability.

2 Meta-Analysis Limitations

• Inadequate Comparable Data: Meta-analysis is only feasible for 3 outcomes (scar pigmentation, scar erythema, skin graft need) and includes just 2 studies per outcome. This reduces the reliability of pooled estimates.
• Dominance of a Single Study: For scar pigmentation (MD = -0.83) and erythema (MD = -0.48), Yuan et al. (2016) accounts for 94.3% and 95.5% of statistical weight, respectively. The meta-analysis results are thus driven by one study, risking bias if that study’s methods or population are unrepresentative.
• Heterogeneity and Publication Bias Gaps: While the authors report low heterogeneity (I² = 0%) for meta-analyzed outcomes, this may be an artifact of small study numbers (not true homogeneity). Additionally, formal publication bias assessment (e.g., Egger’s test) is not feasible due to few studies, leaving unaddressed risks of publication bias (e.g., underreporting of negative results).3 Methodological and Reporting Gaps

• Unclear Search Strategy Details: Table 1 describes database-specific search terms but lacks critical information:
  • No Boolean operators (e.g., “AND/OR”) for Scopus, CINAHL, Web of Science, or Cochrane Library (e.g., Scopus’s strategy is written as a fragmented list, not a retrievable query).
  • No mention of handsearching, reference list screening, or gray literature (e.g., conference abstracts) to minimize missed studies.
• Risk of Bias Assessment Transparency:
  • Figures 2–5 (RoB and JBI results) are described but not fully interpreted. 
• Inconsistent Outcome Definitions:
  • “Infection” is not standardized across studies: Yuan et al. (2016) uses bacterial culture positivity (colonization), while Frear et al. (2020) reports “no infections” (likely clinical infection). This prevents valid cross-study comparison of adverse effects.
  • Scar assessment tools are not specified: The authors mention “caregiver perception of scar severity” but do not clarify if validated scales (e.g., Vancouver Scar Scale) were used, limiting the reliability of scar outcome data.

4 Discussion and Conclusion Weaknesses

• Overinterpretation of Limited Evidence: The conclusion states NPWT “offers significant clinical benefits” and “its use in clinical practice should be promoted,” but this is not supported by robust evidence (small sample sizes, retrospective data, meta-analysis reliance on one study). The tone overstates certainty given the study’s limitations.
• Incomplete Limitation Discussion: The authors note small study numbers and lack of control groups but omit critical limitations:
  • The absence of data on long-term scar outcomes (only 3–6 months of follow-up in included studies).
  • Variability in NPWT protocols (e.g., pressure settings: -40 to -150 mmHg, different devices like Renasys Touch™ vs. KCI VAC®) that may affect efficacy but are not analyzed as moderators.

Author Response

Response to Reviewer 3 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. We appreciate very much your constructive comments, helpful information and your time. We have considered all suggestions and incorporated them into the revised manuscript, and as a result, we believe our manuscript is stronger.  The changes were highlighted in blue to the manuscript.

 

2. Point-by-point response to Comments and Suggestions for Authors

1. Study Selection and Sample Limitations

• Small and Heterogeneous Sample: Only 6 studies (2 clinical trials, 4 retrospective studies) with 259 total participants are included. Individual study sample sizes range from 3 (Poulakidas et al., 2016) to 101 (Frear et al., 2020/2021), leading to insufficient statistical power.

We appreciate the reviewer’s insightful comment. We acknowledge that the number of included studies and the variability in sample sizes represent an important limitation. This constraint is inherent to the currently available literature on NPWT in pediatric burns, where few randomized clinical trials have been conducted and most studies are retrospective with small cohorts. This issue is now explicitly discussed in the Limitations section.

• Overreliance on Retrospective Data: 4 of 6 studies are retrospective (case series or case-control), which are prone to selection bias, unmeasured confounding, and inconsistent data collection. This limits causal inference compared to prospective randomized controlled trials (RCTs).

We thank the reviewer for this valuable observation. We fully agree that the predominance of retrospective studies among the included papers represents a key limitation of our review. To address this concern, we have revised the Limitations section to explicitly acknowledge the potential biases associated with retrospective designs, such as selection bias, unmeasured confounding, and variability in data collection, and to clarify that these factors constrain the internal validity and causal inference of the findings. We also emphasize the need for well-designed, prospective randomized controlled trials to strengthen the current evidence base on NPWT in pediatric burn care.

• Geographic and Clinical Homogeneity: Most studies are from high-income countries (USA, Australia, Austria); only 1 is from a middle-income country (China). This excludes data from low- and middle-income countries (LMICs), where 90% of childhood burn deaths occur (per the introduction)—a critical gap in global applicability.

We appreciate the reviewer’s insightful comment highlighting the limited geographical diversity of the included studies. To address this issue, we have revised the Limitations section to explicitly acknowledge this lack of geographical representativeness and to emphasize the need for future research in LMIC settings to ensure broader external validity and equity in clinical recommendations.

 

2. Meta-Analysis Limitations

• Inadequate Comparable Data: Meta-analysis is only feasible for 3 outcomes (scar pigmentation, scar erythema, skin graft need) and includes just 2 studies per outcome. This reduces the reliability of pooled estimates.

We thank the reviewer for highlighting this important limitation. We acknowledge that the meta-analysis is limited to three outcomes with only two studies per outcome, which may reduce the precision of pooled estimates. We have addressed this limitation explicitly in the Limitation section and emphasized that the results should be interpreted with caution. Furthermore, we have included a statement suggesting the need for additional high-quality studies to strengthen the evidence base for these outcomes.

• Dominance of a Single Study: For scar pigmentation (MD = -0.83) and erythema (MD = -0.48), Yuan et al. (2016) accounts for 94.3% and 95.5% of statistical weight, respectively. The meta-analysis results are thus driven by one study, risking bias if that study’s methods or population are unrepresentative.

We thank the reviewer for highlighting this important point. We have acknowledged this limitation in the Discussion section (lines 386–393), noting that the pooled results for scar pigmentation and erythema were largely driven by a single study (Yuan et al., 2016), which contributed over 90% of the statistical weight. We emphasized that this may increase the risk of bias and that the findings should be interpreted with caution, highlighting the need for further high-quality randomized controlled trials to confirm these results.

• Heterogeneity and Publication Bias Gaps: While the authors report low heterogeneity (I² = 0%) for meta-analyzed outcomes, this may be an artifact of small study numbers (not true homogeneity). Additionally, formal publication bias assessment (e.g., Egger’s test) is not feasible due to few studies, leaving unaddressed risks of publication bias (e.g., underreporting of negative results)

We thank the reviewer for this observation. We have acknowledged these limitations in the Limitation section, noting that although the meta-analyses showed low statistical heterogeneity (I² = 0%), the small number of included studies limits the sensitivity of this measure, and true differences may remain undetected. We also highlighted that formal assessments of publication bias (e.g., Egger’s test) were not feasible due to the limited number of studies, so the possibility of unpublished negative results or selective reporting cannot be excluded.

 

3. Methodological and Reporting Gaps

• Unclear Search Strategy Details: Table 1 describes database-specific search terms but lacks critical information:
• No Boolean operators (e.g., “AND/OR”) for Scopus, CINAHL, Web of Science, or Cochrane Library (e.g., Scopus’s strategy is written as a fragmented list, not a retrievable query).

We thank the reviewer for pointing out the issue with Boolean operators and the clarity of our search strategies. We have revised all database searches (Scopus, CINAHL, Web of Science, and Cochrane Library) to ensure proper use of Boolean operators (“AND”/“OR”), correct grouping with parentheses, and reproducible syntax. We have also corrected typographical errors and standardized filters for year and document type. The updated search strategies are now clearly structured and retrievable.

• No mention of handsearching, reference list screening, or gray literature (e.g., conference abstracts) to minimize missed studies.

We thank the reviewer for this valuable comment. These procedures have now been clearly described in the Methods section. Additionally, we note that CINAHL includes several types of gray literature, such as nursing dissertations and theses, conference proceedings, practice guidelines, book chapters, and other non–peer-reviewed educational materials. Therefore, our search strategy already captured part of the relevant gray literature in this field.

• Risk of Bias Assessment Transparency:
• Figures 2–5 (RoB and JBI results) are described but not fully interpreted. 

We thank the reviewer for this helpful comment. We have expanded the interpretation of Figures 2–5 in the final of Results section. Specifically, we now clarify that the RoB 2 assessments indicated a low overall risk of bias for the randomized controlled trials, whereas the JBI evaluations revealed methodological limitations in the retrospective studies (e.g., incomplete demographic reporting and unclear recruitment procedures). We also highlight that these differences in study quality should be considered when interpreting the pooled evidence.

• Inconsistent Outcome Definitions:
• “Infection” is not standardized across studies: Yuan et al. (2016) uses bacterial culture positivity (colonization), while Frear et al. (2020) reports “no infections” (likely clinical infection). This prevents valid cross-study comparison of adverse effects.

We thank the reviewer for this insightful comment. We have clarified this issue in the Results section (point 3.6 Adverse effects), noting that “infection” was defined differently across studies Yuan et al. (2016) assessed bacterial culture positivity (which may indicate colonization), while Frear et al. (2020) reported the absence of clinically diagnosed infections. We emphasized that this inconsistency limits the validity of cross-study comparisons for infection-related outcomes.

• Scar assessment tools are not specified: The authors mention “caregiver perception of scar severity” but do not clarify if validated scales (e.g., Vancouver Scar Scale) were used, limiting the reliability of scar outcome data.

We thank the reviewer for this valuable observation. We have revised the manuscript to specify the validated scar assessment tools used in the included studies. Specifically, the Patient and Observer Scar Assessment Scale (POSAS) and the Brisbane Burn Scar Impact Profile (BBSIP) were applied, along with objective measures such as ultrasound and colorimetry, in one study, while Yuan et al. [34] used the validated Vancouver Scar Scale (VSS). We have also noted that, although all tools are validated, differences between them limit direct comparability of scar outcomes. These details have been added to the Results section (point 3.4).

 

4. Discussion and Conclusion Weaknesses

• Overinterpretation of Limited Evidence: The conclusion states NPWT “offers significant clinical benefits” and “its use in clinical practice should be promoted,” but this is not supported by robust evidence (small sample sizes, retrospective data, meta-analysis reliance on one study). The tone overstates certainty given the study’s limitations.

We thank the reviewer for this important observation. We have revised the Conclusion section to adopt a more cautious tone, ensuring that our statements align with the strength of the available evidence. 

• Incomplete Limitation Discussion: The authors note small study numbers and lack of control groups but omit critical limitations:
• The absence of data on long-term scar outcomes (only 3–6 months of follow-up in included studies).

We thank the reviewer for this valuable comment. We agree that the absence of long-term follow-up data represents an important limitation. The included studies only reported outcomes up to 3–6 months post-treatment, which restricts the assessment of long-term scar maturation and durability of NPWT benefits. We have added this limitation to the Limitations section.

• Variability in NPWT protocols (e.g., pressure settings: -40 to -150 mmHg, different devices like Renasys Touch™ vs. KCI VAC®) that may affect efficacy but are not analyzed as moderators.

We thank the reviewer for this insightful comment. We have incorporated this point into the Discussion section (lines 358–362), noting the variability in NPWT protocols among studies, including differences in pressure settings and the use of different commercial devices. We also acknowledged that such heterogeneity may have influenced treatment outcomes but was not examined as a potential effect modifier in the present review.

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,
Thank you very much for your thoughtful responses to my initial comments on your manuscript. I appreciate the time and care you devoted to addressing the points raised. After careful consideration of your revisions and clarifications, I must respectfully maintain my initial concern that the manuscript does not introduce sufficiently novel insights to warrant publication in its current form. Therefore, I continue to recommend rejection at this time.

Thank you again for your efforts and for sharing your work with us.

Author Response

Response to Reviewer 5 Comments

1. Summary        

Thank you very much for taking the time to review this manuscript. We appreciate very much your constructive comments, helpful information and your time. We have considered all suggestions and incorporated them into the revised manuscript, and as a result, we believe our manuscript is stronger. The changes were highlighted in blue to the manuscript.

 

2. Point-by-point response to Comments and Suggestions for Authors

Dear Authors,

Thank you very much for your thoughtful responses to my initial comments on your manuscript. I appreciate the time and care you devoted to addressing the points raised. After careful consideration of your revisions and clarifications, I must respectfully maintain my initial concern that the manuscript does not introduce sufficiently novel insights to warrant publication in its current form. Therefore, I continue to recommend rejection at this time.

Thank you again for your efforts and for sharing your work with us.

 

Dear Reviewer, 

We sincerely thank you for taking the time to re-evaluate our manuscript and for your thoughtful feedback. We fully respect your perspective regarding the perceived novelty of the study.

While we acknowledge that our study may not introduce an entirely new conceptual framework, we believe it contributes valuable and updated evidence to an area where pediatric data remain limited. Our PROSPERO registration (CRD42024597293) ensures methodological transparency and independence from prior reviews, while our synthesis focuses specifically on pediatric burn patients treated with NPWT, a subgroup not comprehensively addressed in earlier meta-analyses.

We hope that the substantial methodological improvements, expanded discussion of limitations, and refined interpretation of findings in the revised version address the concerns regarding novelty and enhance the overall contribution of our work to the field.

We once again thank you for your constructive input and the opportunity to further strengthen our manuscript.