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CoMiSSTM Awareness Tool

A simple, fast and easy-to-use awareness tool to recognize cows' milk-related
symptoms in infants and young children
The CoMiSSTM awareness tool has been developed in consensus with 11 clinicians whose expertise is in managing children with gastrointestinal problems and / or atopic diseases.

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

The CoMiSSTM is intended for healthcare professionals 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 CMA, such as those with anaphylactic reactions or immediate IgE mediated reactions will not be picked-up by the CoMiSSTM awareness tool. However, the majority of infants present with non-IgE mediated reactions to cows' 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, constipation, crying and colic are considered non-IgE mediated reactions. Atopic eczema is often not recognized as a possible consequence of ingestion of cows' milk protein.

Download the CoMiSSTM user guide
CoMiSS<sup>TM</sup> awareness tool is available in print and online version

CoMiSSTM awareness tool


If you suspect your patient is suffering from symptoms that may be suggestive of CMA, use the CoMiSSTM tool to score and assess the likelihood of CMA.

Start scoring

CoMiSSTM quantifies the number and severity of symptoms.

Suspicion of cows' milk-related symptoms based on the presence of a combination of the following symptoms:

Digestive symptoms of cow’s milk protein allergy



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

Respiratory symptoms of cow’s milk protein allergy



Runny nose (rhinitis), chronic cough, wheezing (unrelated to infection).

Skin-related symptoms of cow’s milk protein allergy



Atopic dermatitis, angioedema, urticaria unrelated to acute infections and drug intake manifestations. ​​​​​​​​​​​​​​

General symptoms of cow’s milk protein allergy


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

Expert corner: CoMiSSTM

Many infants present with symptoms that can be related to intake of cows' milk. Cows' milk allergy (CMA) 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 CMA
- those with unclear symptoms in different organ systems

The first group is easy to recognise:
- 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 cows' milk-related symptoms seen by healthcare professionals.

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 non-IgE CMA (other than the challenge test), an awareness tool to recognise cows' milk-related symptoms for use by healthcare professionals may increase the awareness and the recognition of symptoms possibly related to cows' milk, leading to an accurate diagnosis at an earlier stage.



Prevalence of digestive symptoms

Up to 60% of affected infants have digestive symptoms.3



Prevalence of respiratory symptoms

Up to 30% of affected infants have respiratory symptoms.3



Prevalence of skin-related symptoms

Up to 70% of affected infants have skin-related symptoms.3



Inconsolable crying is very common in infants with CMA, while anaphylaxis is rare.3


  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. 
IMPORTANT NOTICE: Mothers should be encouraged to continue breastfeeding even when their babies have cows' milk protein allergy. This usually requires qualified dietary counselling to completely exclude all sources of cows' milk protein from the mothers’ diet. If a decision to use a special formula intended for infants is taken, it is important to follow the instructions on the label. Unboiled water, unboiled bottles or incorrect dilution can make babies ill. Incorrect storage, handling, preparation and feeding can eventually lead to adverse effects on the health of babies. Formula for special medical purposes intended for infants must be used under medical supervision.