OBJECTIVES: The Cow's Milk-related Symptom Score (CoMISS) is an awareness tool for evaluating cow's milk-related symptoms in otherwise healthy infants <1 year of age. This study assessed whether replacing the Bristol Stool Form Scale (BSFS) with the Brussels Infants and Toddlers Stool Scale (BITSS) in non-toilet-trained infants would modify the overall CoMiSS and change the clinical approach regarding potential cow's milk allergy. METHODS: Non-toilet-trained infants aged <13 months were assessed by CoMiSS using the 7 images from the BSFS (CoMiSS-BSFS) compared to the 4 images of stools from BITSS (CoMiSS-BITSS). The Wilcoxon signed-rank test and Pearson correlation coefficient were calculated. A post hoc analysis using identical tests was performed in subsets of CoMiSS-BSFS scores ≥10, ≥12, ≤5, and ≥6. RESULTS: Eight hundred forty-four pairwise scores were collected. Applying the Wilcoxon test over the complete dataset, the difference between CoMiSS-BSFS and CoMiSS-BITSS was statistically significant ( P < 0.001). However, there was no significant difference in the subsets with CoMiSS-BSFS ≥10, ≥12, and ≥6 ( P = 0.84, P = 0.48, and P = 0.81, respectively). The significant difference remained restricted to the group with CoMiSS-BSFS ≤5, considered at low risk for CM-related symptoms ( P < 0.001). CONCLUSION: Replacing BSFS with BITSS does not change the cutoff for awareness of possible CM-related symptoms and will not impact the use of CoMiSS in clinical practice. Changes in CoMiSS remained limited to the subgroup with a low risk for CM-related symptoms.

Children's Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland

From the Department of Pediatrics University Hospital Brno and Masaryk's University Brno Czech Republic

Institute of Gastroenterology Nutrition and Liver Diseases Schneider Children's Medical Center Lea and AriehPickel Chair for Pediatric Research Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel

Paris Descartes University France et Clinique Marcel Sembat Boulogne Billancourt Ramsay Group France

Pediatric Gastroenterology La Fe University Hospital and La Fe Research Institute Valencia Spain

the Department of Dietetics Winchester University Winchester UK

the Department of Internal Medicine Geriatrics and Practical Medicine University Hospital Brno and Masaryk's University Brno Czech Republic

the Department of Medicine KU Leuven Leuven Belgium

the Department of Paediatrics Imperial College London London UK

the Department of Paediatrics The Medical University of Warsaw Warsaw Poland

the Department of Paediatrics University of Insubria Varese Italy

the Department of Translational Medical Sciences University of Naples Federico 2 Napoli Italy

Vrije Universiteit Brussel UZ Brussel KidZ Health Castle Brussels Belgium

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