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CoMiSS®: Cow’s Milk-related Symptom Score

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CoMiSS® is a simple, fast and easy-to-use awareness tool for cow’s milk-related symptoms. It increases awareness of the most common symptoms of cow’s milk allergy (CMA). CoMiSS® can also be used to evaluate and quantify the evolution of symptoms during a therapeutic intervention. CoMiSS® is intended to be used in children under 1 year.

The tool is not intended for infants with severe and life threatening symptoms clearly indicating CMA, including anaphylaxis, which requires urgent referral.
Infants presenting with failure to thrive and sick infants with hematochezia, require urgent referral and full diagnostic work up.


If the infant presents with symptoms possibly related to cow’s milk, rate the observed/reported symptoms by choosing the most appropriate score for each type of symptom. Once completed, add the scores together and put the total in the box at the bottom of the scoring form.

Symptom Score
0 ≤ 1 hour/day
1 1 to 1.5 hours/day
2 1.5 to 2 hours/day
3 2 to 3 hours/day
4 3 to 4 hours/day
5 4 to 5 hours/day
6 ≥ 5 hours/day
0 0 to 2 episodes/day
1 ≥ 3 to ≤ 5 episodes of volume < 5ml
2 > 5 episodes of > 5ml
3 > 5 episodes of ± half of the feeds in < half of the feeds
4 Continuous regurgitations of small volumes > 30 min after each feed
5 Regurgitation of half to complete volume of a feed in at least half of the feeds
6 Regurgitation of the complete feed after each feeding
Stools (Brussels Infant and Toddlers Stool Scale - BITSS)
4 Hard stools
0 Formed stools
3 Loose stools
6 Watery stools
Atopic eczema: Head, neck and trunk
0 Absent
1 Mild
2 Moderate
3 Severe
Atopic eczema: Arms, hands, legs and feet
0 Absent
1 Mild
2 Moderate
3 Severe
(Acute) Urticaria* and/or angioedema*
6 Yes
0 No
0 No respiratory symptoms
1 Slight symptoms
2 Mild symptoms
3 Severe symptoms


Total score ≥ 10: May be suggestive of cows milk-related symptoms and could potentially be CMA.

Total score < 6: Symptoms are not likely to be related to CMA. 6: Look for other causes.

The CoMiSS® scoring form is not intended to be used as a diagnostic tool and should not replace an oral food challenge.

CMA diagnosis should be confirmed by a 2 to 4 week elimination diet followed by an oral food challenge.

ADDITIONAL INFORMATION TO CONSIDER: Worsening of eczema might be indicative of CMA. If urticaria/angioedema can be directly related to cow’s milk (e.g. drinking milk in the absence of other food) this is strongly suggestive of CMA.

Vandenplas Y, Bajerova K, Dupont C, Eigenmann P, Kuitunen M, Meyer R, Ribes-Koninckx C, Salvatore S, Shamir R, Szajewska H. The Cow’s Milk Related Symptom Score: The 2022 Update. Nutrients 2022, 14, 2682.
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