Symptom Co-Occurrence Patterns in Healthy Infants: Assessing the Interplay Between Feeding Modalities and CoMiSS™ Profiles
DOI:
https://doi.org/10.24871/2722026155-164Keywords:
Crying, Exclusively breastfed, Feeding methods, Infant, Exanthem, FecesAbstract
Background: Breast milk is the optimal source of infant nutrition, with formula feeding serving as an alternative when exclusive breastfeeding is not feasible. Feeding modalities may influence behavioral (crying), gastrointestinal (stool consistency), and dermatological manifestations. However, population-based comparative data in Indonesia remain scarce. Therefore, this study aimed to evaluate and compare the prevalence and patterns of symptoms between exclusively and non-exclusively breastfed infants.
Methods: An analytical cross-sectional study was conducted at an outpatient clinic in Tangerang, Indonesia, utilizing structured parental interviews and clinical evaluations. A total of 290 healthy participants aged 0–12 months were enrolled, including 260 exclusively and 30 non-exclusively breastfed infants. Symptom severity over the preceding week was assessed using the standardized Cow’s Milk-related Symptom Score (CoMiSS™) framework, while chi-square and Fisher's Exact Tests were used to analyze symptom prevalence and co-occurrence patterns.
Results: No significant differences were observed between the exclusively and non-exclusively breastfed groups in terms of abnormal stool consistency (8.5% vs. 10.0% ), increased crying duration (5.4% vs. 3.3% ), or skin rashes (41.2% vs. 40.0% ). There was no co-occurring symptom between stool consistency and crying in either group. No infant showed concurrent gastrointestinal and behavioral symptoms, with or without dermatological symptoms. Skin rashes were highly prevalent across the sample (~41%), but had no statistical association with gastrointestinal or behavioral manifestations.
Conclusion: Feeding methods do not influence the clinical patterns of common infantile symptoms. Furthermore, stool abnormalities and excessive crying present as distinct entities rather than a unified cluster, offering reassurance to clinicians and parents managing these benign variations.
References
Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491–504. doi:10.1016/S0140-6736(15)01044-2.
Hegar B, Vandenplas Y. Breastfeeding for gut infant health. Indones J Gastroenterol Hepatol Dig Endosc. 2018;19(1):1–6.
Victora CG, Bahl R, Barros AJ, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–490. doi:10.1016/S0140-6736(15)01024-7.
Tunc VT, Camurdan AD, Ilhan MN, Sahin F, Beyazova U. Factors associated with defecation patterns in 0–24 month old children. Eur J Pediatr. 2018;177(5):735–742.
Hegar B, Dewanti NR, Kadim M, et al. Natural evolution of regurgitation in healthy infants. Acta Paediatr. 2009;98(7):1189–1193. doi:10.1111/j.1651-2227.2009.01343.x.
Wolke D, Bilgin A, Samara M. Systematic review and meta-analysis: fussing and crying durations and prevalence of colic in infants. J Pediatr. 2017;185:55–61.e4.
Vandenplas Y, Hauser B, Salvatore S. Functional gastrointestinal disorders in infancy: impact on the health of the infant and family. Pediatr Gastroenterol Hepatol Nutr. 2019;22(3):207–216.
Wang Z, Cai Y, Wang X, et al. The significance of an infant's cry: a narrative review of physiological, pathological, and analytical perspectives. Front Pediatr. 2025;13:1558951.
Silverberg JI, Barbarot S, Gadkari A, et al. Atopic dermatitis in the pediatric population: a cross sectional, international epidemiologic study. Ann Allergy Asthma Immunol. 2021;126(4):417–428.e2.
Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124(6):1251–1258.e23. doi:10.1016/j.jaci.2009.10.009.
Lestari LA, Wibowo Y, Mulyani C, et al. Prevalence and risk factors of functional gastrointestinal disorders in infants in Indonesia. Pediatr Gastroenterol Hepatol Nutr. 2023;26(1):58–69. doi:10.5223/pghn.2023.26.1.58.
Inchingolo F, et al. Differences in the intestinal microbiota between breastfed infants and infants fed with artificial milk: a systematic review. Pathogens. 2024;13(7):533. doi:10.3390/pathogens13070533.
Vandenplas Y, Abkari A, Bellaiche M, et al. Prevalence and health outcomes of functional gastrointestinal symptoms in infants from birth to 12 months of age. J Pediatr Gastroenterol Nutr. 2015;61(5):531–537.
Scarpato E, Salvatore S, Romano C, et al. Prevalence and risk factors of functional gastrointestinal disorders: a cross-sectional study in Italian infants and young children. J Pediatr Gastroenterol Nutr. 2023;76(2):e27–e35. doi:10.1097/MPG.0000000000003653.
Vaz SR, Tofoli MH, Avelino MAG, da Costa PSS. Probiotics for infantile colic: is there evidence beyond doubt? A meta-analysis and systematic review. Acta Paediatr. 2024;113(4):672–681. doi:10.1111/apa.17045.
Vandenplas Y, Salvatore S, Vieira MC, Savino F, Heine RG, Huysentruyt K, et al. Infantile colic: when to suspect cow's milk allergy. Nutrients. 2025;17(22):3600. doi:10.3390/nu17223600.
Solasaari T, Korpela K, Kolho KL, et al. Bowel function in a prospective cohort of 1052 healthy term infants up to 4 months of age. Eur J Pediatr. 2024;183(8):3557–3565. doi:10.1007/s00431-024-05625-0.
El Farargy MS, El Naga AA, Abo El Fotoh WMM, et al. The cow's milk-related symptom score (CoMiSS™) in presumed healthy Egyptian infants. Nutrients. 2024;16(16):2666. doi:10.3390/nu16162666.
Knockaert N, Huysentruyt K, Hegar B, et al. Difference in cow's milk-related symptom score (CoMiSS™) among presumed healthy infants in Indonesia and Brazil. Pediatr Gastroenterol Hepatol Nutr. 2025;28(2):124–134.
Bajerova K, Salvatore S, Dupont C, et al. The evolution of cow's milk-related symptom score (CoMiSS™) in presumed healthy infants. Eur J Pediatr. 2024;183(10):4329–4335. doi:10.1007/s00431-024-05693-2.
Li T, Zheng Q, Xu J, et al. Comparison of 11 formulas and breastfeeding for atopic dermatitis and growth in pediatric cow's milk protein allergy: a systematic review and network meta-analysis of 23 randomized controlled trials. J Evid Based Med. 2025;18(2):e70026.
Downloads
Additional Files
Published
How to Cite
Issue
Section
License
Authors who publish with this journal agree to the following terms:
a. Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
b. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
c. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
