Evaluation of Cow’s Milk Related Symptom Score [CoMiSS] accuracy in cow’s milk allergy diagnosis

Abstract

Background Cow’s Milk-related Symptom Score (CoMiSS) is an awareness tool to recognize cow’s milk allergy (CMA) symptoms in infants. We aimed to assess the best cut-off point of CoMiSS in our country and investigate other parameters suggested to raise the strength of CoMiSS in CMA diagnosis. Methods We enrolled 100 infants with CMA-suggestive symptoms with documentation of CoMiSS initially and 4 weeks after cow milk-free diet (CMFD) followed by an open food challenge (OFC) test. Infants with symptom recurrence upon challenge were diagnosed with confirmed CMA. Results Initial mean CoMiSS was 15.76 ± 5.29, being higher in the confirmed CMA group (84% of infants). Following CMFD, median CoMiSS significantly reduced to 1.5 in the confirmed CMA group compared to 6.5 in the negative group. Receiver operation characteristic (ROC) curve identified a CoMiSS score of ≥12 as the best cut-off value with 76.19% sensitivity, 62.50% specificity and overall accuracy of 74.00%. Mucoid stool, bloody stool and faltering growth were reported in 80, 41 and 52% of confirmed CMA infants, respectively, with considerable improvement following CMFD. Conclusions Our study revealed a CoMiSS score of ≥12 to be the best cut-off point. However, CoMiSS cannot be used alone for accurate diagnosis of CMA. Impact CoMiSS ≥12 can predict a positive response to CMFD; nevertheless, CoMiSS is a good awareness tool and cannot be regarded as a stand-alone CMA diagnostic test. CoMiSS reduction following CMFD was predictive of a reaction to OFC to diagnose CMA as well as for monitoring symptom improvement. Symptoms commonly associated with CMA as mucoid stool, bloody stool, marked abdominal distention not responding to medical treatment and faltering growth, in addition to their improvements in response to CMA are suggested parameters to be added to CoMiSS to improve its accuracy.

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

“…However, there is a lack of agreement on which cut-off to use (128). CoMiSS reduction following CM elimination was predictive for a reaction in the OFC to diagnose CMA as well as for monitoring symptom improvement (127).…”

“…CoMiSS was reported to be a simple and operable method to screen for CMA (125,126).The impact of genetic or regional difference on CMA symptoms needs to be further studied (125). According to a recent meta-analysis, CoMiSS may be a promising symptom score in CMA awareness and a useful tool in monitoring the response to a CM-free diet (126), although it cannot be regarded as a stand-alone CMA diagnostic test (127). However, there is a lack of agreement on which cut-off to use (128).…”

Clinical guideline highlights for the hospitalist: Evaluation, management, and prevention of cow's milk allergy

“…Soy formula may be considered if other elimination diets are not possible due to economic or cultural reasons (Statement 29, 7.6/9). In IgE‐mediated allergy, response to elimination diet should be expected in 1–2 weeks (Statement 30, 8.8/9) and in non‐IgE‐mediated allergy, response is expected within 2–4 weeks (Statement 31, 8.7/9). If the elimination diet was not effective in reducing symptoms and/or OFC was unable to reproduce symptoms, the diagnosis of CMA cannot be made (Statement 37, 8.8/9). The Cow's Milk‐related Symptom Score (CoMISS) is an awareness tool to alert healthcare providers that various combinations of presenting symptoms may be related to CMA 8 Reduction in CoMISS score during an elimination diet may suggest CMA, but is not diagnostic (Statement 19, 8.4/9).…”

“…The Cow's Milk‐related Symptom Score (CoMISS) is an awareness tool to alert healthcare providers that various combinations of presenting symptoms may be related to CMA 8 Reduction in CoMISS score during an elimination diet may suggest CMA, but is not diagnostic (Statement 19, 8.4/9).…”

Mexican consensus on cow’s milk protein allergy

“…The CoMISS questionnaire, developed in 2015, enables the evaluation of children with suspected CMPA through a questionnaire of general, dermatological, respiratory and gastrointestinal symptoms. 23 Voting by participants resulted in the consensus that the CoMISS questionnaire is not the only tool needed for diagnosing CMPA. This statement is in line with publications indicating that the CoMiSS questionnaire has clinical utility, as it can serve as a tool for awareness of possible CMPA when the score is ≥12, but it needs to be complemented with more clinical data and tests for diagnosing CMPA.…”