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Peer-Review Record

The Importance of an Adequate Diet in the Treatment and Maintenance of Health in Children with Cystic Fibrosis

Int. J. Transl. Med. 2025, 5(3), 38; https://doi.org/10.3390/ijtm5030038
by Michał Mazur 1, Agnieszka Malik 2, Monika Pytka 2 and Joanna Popiołek-Kalisz 1,3,*
Reviewer 1: Anonymous
Reviewer 2:
Int. J. Transl. Med. 2025, 5(3), 38; https://doi.org/10.3390/ijtm5030038
Submission received: 2 July 2025 / Revised: 29 July 2025 / Accepted: 15 August 2025 / Published: 20 August 2025

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript titled The importance of an adequate diet in the treatment and maintenance of health in children with cystic fibrosis by MichaÅ‚ Mazur et all discussed the need for a comprehensive and individualized approach for diagnosis and treatment of CF patients. 
The manuscript's aim is crucial as it tries to highlight the critical role of nutrition in children with CF. 
While the title focuses on the treatment of CF in children, the abstract does not specifically mention children, but rather generalizes to CF patients. 
Some topics discussed repeatedly in different sections, 
It primarily focused on European recommendations; however, it should be discussed more broadly. 
The risk of obesity and the proposed diet for therapeutic use were not discussed in depth. Additional guidance for age-related issues was not provided in a detailed discussion. 

 

Author Response

Comments 1. While the title focuses on the treatment of CF in children, the abstract does not specifically mention children, but rather generalizes to CF patients.

Response 1. We have revised the abstract to explicitly indicate that the review focuses on pediatric patients with CF, ensuring alignment with the title. The opening sentence of the abstract now reads: “This review focuses specifically on pediatric patients with cystic fibrosis...”

Comments 2.  Some topics discussed repeatedly in different sections

Response 2. We carefully revised the structure of the manuscript to eliminate repetition. Cross-references between sections (e.g., “as detailed in Section 7”) have been added to clarify where specific issues are addressed and to avoid redundant explanations.

Comments 3. It primarily focused on European recommendations; however, it should be discussed more broadly.

Response 3. While the ESPEN-ESPGHAN-ECFS guidelines remain a core reference, we have broadened the discussion by incorporating North American recommendations (e.g., Cystic Fibrosis Foundation guidelines) and highlighted challenges in lower-resource settings (e.g., access to modulator therapies and PERT), acknowledging regional disparities in implementation.

Comments 4. The risk of obesity and the proposed diet for therapeutic use were not discussed in depth.

Response 4. This concern has been thoroughly addressed in Section 8. We have expanded the discussion on the increasing prevalence of overweight and obesity in CF patients, especially in high-income countries, and the need to balance high-calorie diets with nutrient density. Evidence-based recommendations for adjusting dietary strategies in the context of obesity and modulator therapy are now included.

Comments 5. Additional guidance for age-related issues was not provided in a detailed discussion

Response 5. 

We have added detailed age-specific dietary guidance throughout the manuscript. This includes:

  • Table 1 summarizing nutritional requirements and supplementation by age group.

  • Expanded discussion on the unique needs of infants, toddlers, and adolescents (Section 8).

  • A clinical case example demonstrating tailored nutritional intervention for a 9-year-old patient (Section 8.1).

Reviewer 2 Report

Comments and Suggestions for Authors

Reviewer Report

Title of the manuscript: The importance of an adequate diet in the treatment and maintenance of health in children with cystic fibrosis

Journal: International Journal of Translational Medicine

 

General Assessment:

The manuscript presents a narrative review summarizing nutritional aspects in the care of children with cystic fibrosis (CF). While the topic is relevant and certainly important for clinical practice, the present version of the article does not add substantial novel insights or original perspectives that would justify publication in a high-standard peer-reviewed journal. The manuscript heavily relies on summarizing existing consensus and guidelines, without developing new analysis, critical discussion, or providing new data synthesis.

Additionally, the manuscript lacks any figures, tables, or visual aids that could help readers interpret and compare the recommendations and evidence cited — which is essential for a review article. This significantly reduces the impact and clarity of the paper.

 

Major Concerns:

Lack of Innovation:

The manuscript predominantly repeats well-known data and guidelines (e.g., ESPEN-ESPGHAN-ECFS) without offering an updated meta-analysis, systematic approach, or new conceptual frameworks.

The narrative does not highlight regional differences, implementation barriers, emerging therapies, or specific research gaps that could enrich the field.

Without any new insights or strong comparative analysis, the paper reads like an educational summary rather than a scholarly review.

 

Absence of Figures and Tables:

The manuscript would greatly benefit from including:

A table summarizing nutritional requirements by age.

A visual flowchart for diagnostic or therapeutic decision-making.

Comparative graphs or infographics to illustrate trends in malnutrition, obesity, or vitamin deficiencies in CF.

The lack of such visual elements makes it difficult for readers to retain and contextualize the information.

 

Insufficient Critical Discussion:

The discussion section merely restates known facts rather than critically analyzing controversies, conflicting evidence, or future directions for research and clinical practice.

There is no exploration of practical implementation challenges, cost-effectiveness, or potential cultural barriers.

 

Language and Structure:

Although generally clear, the manuscript could be further refined for precision and academic tone.

Some sections are overly descriptive without synthesizing the information or drawing connections between sections (e.g., microbiome, probiotics, supplementation).

 

Recommendation:

Given the concerns above, I do not recommend acceptance of the manuscript in its present form.

 

Suggestions for Major Revision (Should the Authors Wish to Resubmit):

Develop Clear Figures and Tables:

Add at least 2–3 well-designed tables summarizing:

Dietary requirements across age groups.

Prevalence and management of specific deficiencies.

Practical enzyme replacement dosing guides.

Include one or two conceptual diagrams (e.g., gut-lung axis, CFTR impact pathways).

 

Enhance Originality:

Include a critical section discussing emerging therapies, regional implementation challenges, or novel research areas such as microbiome modulation.

Add practical insights into gaps in current guidelines and how new evidence could inform future updates.

 

Consider Adding a Case Illustration or Practice Example:

Even in a narrative review, a short illustrative case or practical scenario could provide clinical relevance.

 

Improve Structure and Synthesis:

Use concise summaries at the end of each section.

Add a future perspectives section highlighting unmet needs.

 

Final Decision: Reject in current form. Resubmission may be considered only if the article is substantially revised with stronger critical depth, updated evidence synthesis, and clear, high-quality visual materials.

Comments for author File: Comments.pdf

Author Response

We would like to thank you for taking the time to evaluate our work and for your detailed comments, which have helped to significantly improve the manuscript. We address each of the objections below and indicate what changes were actually made.

Comments 1. Lack of innovation and dominance of summarisation of existing guidelines

Response 1. We agree that the earlier version of the paper was mainly based on a discussion of the ESPEN-ESPGHAN-ECFS guidelines. In response to the allegation:
We have supplemented the manuscript with up-to-date, less well-known data on:
changes in nutritional approaches in the era of modulator therapy (e.g. increasing obesity), inadequate supplementation coverage despite standard recommendations, regional differences (availability of drugs, cultural dietary preferences). We added reflections on gaps in current guidelines and the need to personalise dietary recommendations. Although no new quantitative analyses were introduced, the paper gained more critical depth and practicality, taking into account real clinical challenges.

Comments 2. Brak tabel i materiaÅ‚ów graficznych

Response 2. We fully agree with this comment and have significantly expanded the visual layer of the work. The current version includes:
Table 1 - summarising energy requirements, macronutrient ratios and recommendations for fat-soluble vitamin supplementation, broken down by age group.
Table 2 - showing the most common micronutrient deficiencies, clinical manifestations, monitoring and supplementation strategies.
Table 3 - pancreatic enzyme (lipase) dosage recommendations by age.
Figures (Figures 1-4): diagram of the gut-pancreas axis, simplified diagnostic and therapeutic algorithm in CF, clinical case with BMI growth chart, changes in nutritional status (malnutrition, obesity, vitamin deficiencies) over two decades.

Comments 3. Too superficial a discussion and no analysis of controversies or practical challenges

Response 3. In response to this comment:
We expanded the discussion of controversial areas such as:
the role of probiotics and the inconclusive nature of the research findings, the possible negative effects of a high-fat diet in the era of CFTR modulator therapy, the lack of evidence for the efficacy of some supplementation strategies. We highlighted implementation challenges, such as the availability of modulators and PERT in low-income countries, cultural differences and the possibility of adapting recommendations to local nutritional realities. We also added a short section summarising the need for further research and future directions.

Comments 4. Excessively descriptive passages, lack of coherence between sections

Response 4.  Thank you for this comment. In response to it, we have done a thorough linguistic and structural editing of the manuscript ourselves.
The content has been reorganised thematically to ensure a better flow of information and logical consistency between sections.
Short summaries were added at the end of the main sections (e.g. on probiotics, supplementation and diet therapy) to increase clarity.
Unnecessary repetition has been removed and sections that are too descriptive in nature have been shortened and simplified.
All changes have been made by the authors' own efforts.

Comments 5. No clinical example

Response 5. We have taken this comment into account by adding section 8.1, which includes a detailed case report of a 9-year-old boy with CF, including: nutritional status (BMI, symptoms), interventions implemented (increase in dietary calories, probiotic), effects observed (improvement in BMI, reduction in exacerbations).
A figure (Figure 3) with visualisation of the process and BMI pathway is included.

Comments 6. No section with future directions / outlook

Response 6.In the conclusion of the paper, we added a reflection on:
the lack of long-term data on the impact of a high-fat diet, the growing need to personalise nutrition in CF,
the lack of consideration of regional variation in current guidelines, the role of microbiota and supportive therapies in the future.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for improving the manuscript.

Author Response

We sincerely thank you for your kind acknowledgment. We appreciate your time and effort in reviewing the manuscript and are grateful for your helpful guidance throughout the revision process.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor and Authors,

Following the detailed comparison between the revised manuscript “The importance of an adequate diet in the treatment and maintenance of health in children with cystic fibrosis” and the initial reviewer’s report, I provide below my assessment of the improvements achieved and additional steps still needed to reach publication standards.

 

  1. Substantial improvements already made

The authors have demonstrated clear commitment to addressing the reviewer’s main concerns. The new version shows meaningful progress in several aspects:

  • Visual aids: The manuscript now includes well-structured tables summarising energy requirements, nutrient deficiencies, and enzyme replacement guidelines. Conceptual diagrams (e.g., the gut–lung axis) and a diagnostic flowchart enhance the practical clarity of the review.
  • Clinical illustration: The inclusion of a relevant paediatric case example adds practical value, illustrating how theoretical recommendations can be translated into real-life care.
  • Emerging topics: The updated text discusses areas previously lacking, such as microbiome modulation, probiotic interventions, CFTR modulator therapies, and regional inequalities in access to treatment.

 

  1. Areas that still require further strengthening

Despite these notable improvements, a few aspects remain below the standard expected for a narrative review intended for an international audience:

  • Critical depth: While the paper mentions regional disparities and emerging therapies, the discussion remains somewhat descriptive. It would benefit from a more explicit critical appraisal of:
    • Implementation barriers in low-resource settings.
    • The cost-effectiveness of nutritional interventions and modulator therapies.
    • Practical strategies for integrating new evidence into existing guidelines.
  • Language and structure: The general clarity and flow have improved, but a final round of professional English editing is strongly recommended to ensure precision in terminology, reduce redundant wording, and polish transitions between sections.
  • Figures and tables: The current visuals meet basic expectations but would benefit from more polished graphic design and clearer, stand-alone captions to maximise their educational impact.

 

  1. Recommendation for resubmission

Given the significant progress, I do not see major conceptual flaws in the current version. However, for the manuscript to meet the expectations of an international peer-reviewed journal, I recommend:

  • Expanding the critical discussion with more concrete analysis of cost, access and health policy implications.
  • Performing a thorough language review to ensure consistency and an academic tone throughout.
  • Improving the presentation of tables and figures, including high-resolution formatting and comprehensive captions.

 

  1. Final note

In summary, the authors have addressed the core concerns with serious effort and high-level content additions. If the proposed refinements are implemented carefully, this paper has the potential to serve as a useful, updated and practical reference for clinicians, nutritionists and multidisciplinary teams working with cystic fibrosis in children. I remain available to assist further with editorial suggestions, detailed text refinement or preparation of a structured point-by-point reviewer letter if required.

Comments for author File: Comments.pdf

Author Response

We sincerely thank the Reviewer for the thoughtful and constructive feedback, which greatly helped us improve the quality of our manuscript. Below we provide a point-by-point response to the issues raised. All revisions have been marked in red in the manuscript.

Comments 1. Substantial improvements already made

Response 1. We are grateful for your positive recognition of the additions made to visual aids, the pediatric case example, and the expanded discussion of emerging topics. Your comments confirm that the changes strengthened the manuscript's clinical clarity and relevance.

Comments 2. Areas that still require further strengthening

Response 2. Critical depth:
As advised, we have revised several sections of the manuscript to move beyond descriptive accounts and provide a more analytical perspective. In particular, we now:

  • Critically examine implementation barriers to CF care in low- and middle-income countries (LMICs), including issues such as reimbursement gaps, limited dietetic infrastructure, and supply chain weaknesses.

  • Discuss cost-effectiveness data where available—for example, how early nutritional interventions and PERT may reduce long-term hospitalisation rates, and the economic burden of CFTR modulators.

  • Highlight practical integration strategies, including proposals for modular, context-sensitive guidelines tailored to local resources, genotype distribution, and workforce capacity.

These enhancements aim to meet the expectations of a critical international readership.

Language and structure:
We confirm that the manuscript has undergone a final round of professional English language editing. This included the correction of terminology, reduction of redundancy, and improvement of flow and transitions between sections.

Figures and tables:
We have refined all visuals with improved layout, contrast, and consistency in formatting. Captions have been rewritten to ensure they are fully explanatory and useful as stand-alone educational tools. All images are now submitted in high resolution to meet production standards.

Comments 3. Recommendation for resubmission

Response 3. We appreciate the clarity of your recommendation and have carefully implemented all proposed refinements. We believe the revised version now reflects a well-structured, critically engaged, and internationally relevant narrative review.

Comments 4. Final note 

Response 4. We are truly encouraged by your concluding remarks and thank you again for your professional guidance throughout this revision process. Should any additional suggestions arise during the next editorial stage, we remain fully available to address them.

 

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have thoroughly revised the material, and the study can be published.

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