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Cows' milk allergy (CMA), also known as cows' milk protein allergy (CMPA), presents with diverse and often non-specific signs and symptoms, resulting in frequent misdiagnosis or a delay in diagnosis. Guidelines and tools are available to support an early diagnosis.

CoMiSSTM awareness tool

Doctor filling out CoMiSS<sup>TM</sup> form

Introducing CoMiSSTM

Leading experts have developed the Cows' Milk-related Symptom Score (CoMiSSTM)1, which is a fast and easy-to-use tool to help healthcare professionals recognise and assess non-specific signs and symptoms that may be indicative of CMA as early as possible.

Find out more about CoMiSSTM
Doctor filling out CoMiSS® form

CoMiSSTM tutorial video

Discover how easy it is to use CoMiSSTM to assess and interpret the severity of non-specific signs and symptoms that may be related to CMA, such as crying, regurgitation, diarrhoea or constipation, skin and respiratory symptoms.

Watch the CoMiSSTM tutorial video
CoMiSS® 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
Diagnosing CMA

Your steps on the diagnosis path

Diagnosing CMA involves multiple steps: checking the infant’s symptoms and family history; performing diagnostic tests; and confirming the diagnosis with an elimination diet followed by a food challenge.

1- Check symptoms and family history

2- Proceed to diagnosis

3- Confirm your diagnosis

Step 1
Check symptoms and family history

The first step is to check for signs and symptoms that could be related to CMA. It is also important to consider the family history for atopic diseases, as the risk for allergies is higher in families with existing allergic disease.

Signs & symptoms CoMiSSTM tool
Step 2
Proceed to diagnosis

Available diagnostic methods

There are few procedures that exist to detect different types of CMA. The quality standard for diagnosing when an IgE mediated CMA is suspected from the allergy focussed clinical history is a skin prick or blood tests for IgE antibodies to the suspected food allergens and likely co-allergens. The quality standard for diagnosing non-IgE CMA is the elimination diet which is free from cows' milk protein followed by a food challenge.

Step 3
Confirm your diagnosis

Elimination diet and food challenge

The elimination diet consists of the elimination of cows' milk protein (CMP) from the infant’s diet (which means eliminating CMP from the mother’s diet in the case of breast feeding).

If elimination of the CMP from the infant’s diet does not improve symptoms, CMA is highly unlikely. If symptoms improve, an oral food challenge may be performed by controlled re-introduction of CMP to confirm the diagnosis of non-IgE CMA, depending on the severity of symptoms.4,5

When CMA has been confirmed, an elimination diet free from CMP will be required.

Guidelines for diagnosis and management

More detailed information about the diagnosis and management of CMA can be found in the International Milk Allergy in Primary Care (iMAP), British Society for Allergy & Clinical Immunology (BSACI) European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and in the European Academy of Allergy and Clinical Immunology (EAACI) guidelines.2,4

Expert corner: CMA diagnosis

Watch leading experts sharing their experience in diagnosing CMA, including investigating the likelihood of CMA with the CoMiSSTM tool, the available allergy tests, and confirming the diagnosis with an elimination diet followed by oral food challenge.


  1. Vandenplas Y, et al. A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatr. 2015;104(4):334–9.
  2. Fiocchi A et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cows’ Milk Allergy (DRACMA) Guidelines. WAO Journal. 2010.57-161.
  3. NICE. Food Allergy NICE (QS118). 2016.
  4. Venter C et al. Better recognition, diagnosis and management of non‑IgE‑mediated cow’scows’ milk allergy in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. 2017 ;7:26.
  5. Koletzko S, et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012;55(2):221–9.
  6. Muraro A, et al. EAACI Food Allergy and Anaphylaxis Guidelines: diagnosis and management of food allergy. Allergy. 2014;69:1008–25.
  7. Luyt D, et al. BSACI guideline for the diagnosis and management of cow’s milk allergy. Clin Exp Allergy. 2014;44(5):642–72.
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.