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CoMiSS: Cow’s Milk-related Symptom Score

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The CoMiSSTM is a simple, fast and easy-to-use awareness tool for non-IgE mediated cows' milk-related symptoms. It increases awareness of the most common symptoms of cows' milk allergy (CMA) that in turn can aid an earlier diagnosis. CoMiSSTM can also be used to evaluate and quantify the evolution of symptoms during a therapeutic intervention.


If there is a suspicion of cow’s milk-related symptoms, 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 2
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 of small volume
2 >5 episodes of >1 coffee spoon
3 >5 episodes of ± half of the feed in <half of the feedings
4 Continuous regurgitations of small volumes >30min after each feeding
5 Regurgitation of half to complete volume of a feeding in at last half of the feedings
6 Regurgitation of the "complete feeding" after each feeding
Stools (Bristol scale)
4 Type 1 and 2 (hard stools)
0 Type 3 and 4 (normal stools)
2 Type 5 (soft stool)
5 Type 6 (liquid stool, if unrelated to infection)
6 Type 7 (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
6 Yes
1 No
Respiratory symptoms
0 No respiratory symptoms
1 Slight symptoms
2 Mild symptoms
3 Severe symptoms


The scoring ranges from 0 to 33. Each symptom has a maximal score of 6, except respiratory symptoms where the maximal score is 3. If final score ≥ 12, the symptoms are likely cow’s milk related. This could potentially be CMPA. If final score <12, the symptoms are less likely related to cow’s milk. Look for other causes. CMPA diagnosis can only be confirmed by an elimination diet followed by an oral food challenge.

Vandenplas, Y., Dupont, C., Eigenmann, P., Host, A., Kuitunen, M., Ribes-Koninck, C., Shah, N., Shamir, R., Staiano, A., Szajewska, H. and Von Berg, A. (2015), A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatrica. doi: 10.1111/apa.12902

© 2019 Nestlé Health Science