The CoMiSS awareness tool has been developed in consensus with 11 clinicians whose expertise is in managing children with gastrointestinal problems and / or atopic diseases.

The CoMiSS, published in 2015 in Acta Paediatrica¹, increases the awareness of the most common symptoms of CMPA that in turn can aid an earlier accurate diagnosis. It also helps to minimize over- and under- diagnosis of cow's milk-related symptoms as well as evaluate and quantify the evolution of symptoms during a therapeutic intervention. It is important to note that CoMiSS is NOT a diagnostic test for cow's milk protein allergy (CMPA), and it does not replace a food challenge; its usefullness will need to be evaluated in a prospective randomized study.

The CoMiSS is intended for primary healthcare providers who are all too often very limited in time and thus need a tool that is simple, fast and easy-to-use.


Most patients with obvious CMPA, such as those with anaphylactic reactions or immediate IgE mediated reactions will not be picked-up by the CoMiSS awareness tool. However, the majority of infants present with non-IgE mediated reactions to cow’s milk protein. These infants are difficult to identify as they present with delayed reactions, often moderate to mild in severity and often in different organ systems.

Functional gastrointestinal symptoms such as regurgitation and vomiting, constipation, crying and colic are considered non-IgE mediated reactions. Atopic eczema is often not recognized as a possible consequence of ingestion of cow's milk protein.


CoMiSS quantifies the number and severity of symptoms.

Suspicion of 'cow’s milk-related symptoms' based on the presence of a combination of the following symptoms:

GENERAL DISCOMFORT
Persistent distress or colic (≥ 3 hours per day wailing/irritable) at least 3 days/week over a period of > 3 weeks.

GASTROINTESTINAL SYMPTOMS
Frequent regurgitation, vomiting, diarrhea, constipation (with/without perianal rash), blood in stool.

RESPIRATORY SYMPTOMS
Runny nose, (otitis media), chronic cough, wheezing (unrelated to infection).

DERMATOLOGICAL SYMPTOMS
Atopic dermatitis, angioedema, urticaria unrelated to acute infections, drug intake manifestations.


Many infants present with symptoms that can be related to intake of cow’s milk. Cow’s milk protein allergy (CMPA) however is often not considered as a diagnosis, mainly due to the lack of specific diagnostic marker.

There are two groups of patients:
- those with obvious CMPA
- those with unclear symptoms in different organ systems

The first group is easy to recognize:
- consists mainly of infants with immediate/ rapid reactions
- most of the time IgE mediated

However, this group represents a minority of all the infants with suspected cow’s milk-related symptoms seen by primary healthcare providers.

In many cases, parents report some or all of these symptoms:
- Infant crying, having 'colic'
- Difficult defecation or 2-3 loose stools per day
- Regurgitates 4 to 6 times a day
- Mild patches of atopic dermatitis

Due to the lack of diagnostic test for CMPA (other than the challenge test), an awareness tool to recognize cow’s milk-related symptoms for use by healthcare providers may increase the awareness and the recognition of symptoms possibly related to cow’s milk, leading to an accurate diagnosis at an earlier stage.


The majority of affected children have one or more symptom involving one or more organ system, mainly the gastrointestinal tract or the skin.^{2, 3}

The majority have at least two symptoms and symptoms in at least two organ systems.³

About 50%-70% have cutaneous symptoms, 50-60% gastrointestinal symptoms, and about 20-30% respiratory symptoms.⁴

1.Vandenplas Y, Dupont C, Eigenmann P, Host A, Kuitunen M, Ribes-Koninckx C, Shah N, Shamir R, Staiano A, Szajewska H, Von Berg A. A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatrica. 2015; 104: 334-9.
2. Lifschitz C, Szajewska H. Cow’s milk allergy: evidence-based diagnosis and management for the practitioner. Eur J Pediatr. 2015;174:141-50.
3. Høst A. Cow’s milk protein allergy and intolerance in infancy. Some clinical, epidemiological and immunological aspects. Pediatr Allergy Immunol 1994; 5(5 Suppl): 1-36
4. Vandenplas Y, Koletzko S, Isolauri E, Hill D, Oranje A, Brueton M, Staiano A Dupont C. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child. 2007;92:902-8.