Koen Huysentruyt1, Ilan Koppen2, Marc Benninga2, Tom Cattaert3, Jiqiu Cheng3, Charlotte De Geyter1, Christophe Faure4, Frédéric Gottrand5, Badriul Hegar6, Iva Hojsak7, Mohamad Miqdady8, Seksit Osatakul9, Carmen Ribes-Koninckx10, Silvia Salvatore11, Miguel Saps12, Raanan Shamir13, Annamaria Staiano14, Hania Szajewska15, Mario Vieira16, Yvan Vandenplas1. 1. KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium. 2. Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands. 3. DICE, Brussels, Belgium. 4. Department of Pediatric Gastroenterology, Sainte-Justine Hospital, Montreal, Quebec, Canada. 5. Department of Pediatric Hepatology, Gastroenterology and Nutrition, CHU Lille, University Lille, France. 6. Department of Child Health University of Indonesia, Jakarta, Indonesia. 7. Children's Hospital Zagreb, University of Zagreb School of Medicine, University J.J. Strossmayer School of Medicine Osijek, Osijek, Croatia. 8. Department of Pediatric Gastroenterology, Hepatology and Nutrition, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates. 9. Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand. 10. Department of Pediatric Gastroenterology, Hepatology and Nutrition, La Fe University Hospital, Valencia, Spain. 11. Department of Pediatrics, University of Insubria, Ospedale "F. Del Ponte," Varese, Italy. 12. Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Miami, Miller School of Medicine, Miami, FL. 13. Schneider Children's Medical Centre of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. 14. Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy. 15. Department of Pediatrics, The Medical University of Warsaw, Warsaw, Poland. 16. Department of Pediatrics, Pontifical University of Paraná and Center for Pediatric Gastroenterology-Hospital Pequeno Príncipe, Curitiba, Brazil.
Abstract
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 interobserver 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 2462 observers participated: 1181 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 and 6), or watery (BSFS type 7) stools. According to this new categorization system, correct allocation for each photograph ranged from 83 to 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 multilanguage translated version of the BITSS can be downloaded at https://bitss-stoolscale.com/.
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 interobserver 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 2462 observers participated: 1181 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 and 6), or watery (BSFS type 7) stools. According to this new categorization system, correct allocation for each photograph ranged from 83 to 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 multilanguage translated version of the BITSS can be downloaded at https://bitss-stoolscale.com/.