The Brussels Infant and Toddler Stool Scale: A Study On Inter-Observer Reliability

Objectives: The Bristol Stool Form Scale (BSFS) is inadequate for non-toilet trained children. The Brussels Infant and Toddler Stool Scale (BITSS) was developed, consisting of 7 photographs of diapers containing stools of infants and toddlers. We aimed to evaluate inter-observer reliability of stool consistency assessment among parents, nurses and medical doctors (MDs) using the BITSS. Methods: In this multicenter cross-sectional study (2016–2017), BITSS photographs were rated according to the BSFS. The reliability of the BITSS was evaluated using the overall proportion of perfect agreement and the linearly weighted κ statistic. Results: A total of 2,462 observers participated: 1,181 parents (48.0%), 624 nurses (25.3%) and 657 MDs (26.7%). The best-performing BITSS photographs corresponded with BSFS type 7 (87.5%) and type 4 (87.6%), followed by the BITSS photographs representing BSFS type 6 (75.0%), BSFS type 5 (68.0%), BSFS type 1 (64.8%), and BSFS type 3 (64.6%). The weakest performing BITSS photograph corresponded with BSFS type 2 (49.7%). The overall weighted κ-value was 0.72 (95% CI 0.59–0.85; good agreement). Based on these results, photographs were categorized per stool group as hard (BSFS type 1–3), formed (BSFS type 4), loose (BSFS types 5&6) or watery (BSFS type 7) stools. According to this new categorization system, correct allocation for each photograph ranged from 83–96% (average: 90%).The overall proportion of correct allocations was 72.8%. Conclusions: BITSS showed good agreement with BSFS. Using the newly categorized BITSS photographs, the BITSS is reliable for the assessment of stools of non-toilet trained children in clinical practice and research. A multi-language translated version of the BITSS can be downloaded at https://ift.tt/2OKXKuz. Address correspondence and reprint requests to Yvan Vandenplas, Prof. Dr., Department of pediatrics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium (e-mail: yvan.vandenplas@uzbrussel.be); Koen Huysentruyt, Ph.D;, MD, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, BELGIUM (e-mail: koen.huysentruyt@uzbrussel.be). Received 17 April, 2018 Accepted 25 June, 2018 Koen Huysentruyt and Ilan Koppen: Both authors contributed equally BITSS working group: A. Chogle: Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Orange County, Orange County, CA, USA C.A. Velasco-Benítez: Department of Pediatrics, Universidad del Valle, Cali, Colombia C.R. Hernández: Hospital Maria Inmaculada, Florencia, Colombia E. Játiva Mariño: Universidad Central del Ecuador, Quito, Ecuador E. Privat: Department of Pediatrics, Centre Hospitalier Régional Universitaire de Lille, Lille, France J.M. Łukasik: Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland M. Mejía-Castro: Hospital Infantil de Nicaragua Manuel de Jesus Rivera, Managua, Nicaragua R. Canís: Servicio de Gastroenterología Pediátrica y Endoscopia Digestiva, Hospital del Niño Dr José Renán Esquivel, Ciudad de Panamá, Panamá R. Zablah, Hospital Nacional de Niños Benjamin Bloom, San Salvador El Salvador Trial Registration Number: NCT02913950 Financial disclosure statement: The authors have no financial relationships relevant to this article to disclose. Funding source: No funding was received for this study Conflicts of interest statements: K. Huysentruyt has no conflicts of interests to declare. I.J.N. Koppen has no conflicts of interest to declare. M.A. Benninga is a scientific consultant for Shire, Sucampo, Astrazeneca, Norgine, Zeria, Coloplast, Danone, Friesland Campina, Sensus, United Pharmaceuticals. T. Cattaert has no conflict of interests to declare. J. Cheng has no conflict of interests to declare. C. De Geyter has no conflicts of interest to declare. C. Faure has participated as clinical investigator, and consultant for Sucampo F. Gottrand has no conflicts of interest to declare. B. Hegar has no conflicts of interest to declare. I. Hojsak has participated as a speaker for Medias Adria and GM Pharma. M.S. Miqdady has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Danone, Nestle, Nutricia, Merck, and Wyeth. S. Osatakul has no conflicts of interest to declare. C. Ribes-Koninckx has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Shire, Nestle Health Science, Nutricia and Mead Johnson Nutrition. S. Salvatore has participated as a consultant and/or speaker for Deca, IMS Health, Danone, Menarini, Nestlé Health Science. M. Saps is a scientific consultant for Sucampo, Forest, Quintiles, Ardelyx, QOL Medical, IMHealth Science, Nutricia. R. Shamir has participated as a consultant and/or speaker for Abbott, Danone, Enzymotec, Nestle Nutrition Institute, NG Solutions and Nutrinia. A. Staiano is clinical investigator for Aboca, was clinical investigator for Nestlé, is advisory board member for Sucampo, and consultant for Aboca and D.M.G. Italy, and speaker for Angelini, Danone, Miltè, Valeas. H. Szajewska has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for companies manufacturing infant formulas, i.e., Arla, Danone, HiPP, Nestle, Nestle Nutrition Institute, Nutricia and Mead Johnson. M.C. Vieira has participated as a consultant and/or speaker for Danone, Nestlé Nutrition Institute and Aché Laboratories R. Chanis Aguila has no conflicts of interest to declare. M. Mejía-Castro has no conflicts of interest to declare. A. Chogle has no conflicts of interest to declare. R. Zablah Córdova has no conflicts of interest to declare. C.R. Ramírez Hernández has no conflicts of interest to declare. J.M. Łukasik has no conflicts of interest to declare. E. Játiva Mariño has no conflicts of interest to declare. E. Privat has no conflicts of interest to declare. C.A. Velasco-Benítez has no conflicts of interest to declare. Y. Vandenplas has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Aspen, Biocodex, Danone, Nestle Health Science, Nestle Nutrition Institute, Nutricia, Mead Johnson Nutrition, Merck, Phacobel, Rontis, United Pharmaceuticals, Wyeth and Yakult. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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