Written by Hannah Harp
Spoon Feed
A cows’-milk-related symptom score (CoMiSS*) can be used to track an infant’s response to elimination diet in cows’-milk-protein-associated proctocolitis.
Don’t cry over (spilled) milk!
Let’s review: Cows’ milk protein allergy (CMPA) is a spectrum of IgE- and non-IgE-mediated allergic reactions to cows’ milk protein in infants. Non-IgE-mediated CMPA includes food-protein-induced enterocolitis syndrome (FPIES) and cow’s-milk-protein-associated proctocolitis (CMPAP). CMPAP manifests as mucus or blood in stool, frequent vomiting, and fussiness, and is addressed by eliminating cows’ milk from the infant’s diet. For breastfed babies, this means the person providing breastmilk eliminates cows’ milk and dairy products from her diet. For formula-fed babies, this means switching to an extensively hydrolyzed formula like Enfamil Nutramigen or Similac Alimentum. CoMiSS is a screening tool used in the evaluation of suspected CMPA, but could it also be used to monitor response to an elimination diet for infants with CMPAP?
This case-control study examined whether CoMiSS can monitor elimination diet response in infants with CMPAP. Thirteen CMPAP infants and 22 controls were followed across four visits. CoMiSS scores in CMPAP infants decreased significantly after four weeks (−3.92 ± 4.31; p = 0.031) and twelve weeks (−6.69 ± 4.39; p = 0.003) of elimination diet compared to baseline, suggesting its utility in tracking symptom improvement. This study is limited by its size – only 13 CMPAP babies and 22 healthy controls. Also, the CMPAP application of this tool would ideally be updated to include scoring for blood- or mucus-containing stool. Additionally, the scoring is largely subjective, and diagnosing CMPAP is subjective to begin with. The study also did not include babies switched to extensively hydrolyzed formula, only babies who were exclusively breastfed, so results may be confounded by diet non-adherence or cross-reactivity with other food proteins.
How does this change my practice?
Trying to gauge whether crying or pooping is pathologic or just normal baby behavior can be frustrating for the clinician and the parent (probably for the baby, too). I think I will try to use CoMiSS to track improvements when I put babies on Nutramigen, just to bring some sort of objectivity to the CMPAP process.
*Here’s the score.
Source
Evaluating the effectiveness of elimination diet in infants with CMP-induced allergic proctocolitis using CoMiSS. Pediatr Res. 2025 May 13. doi: 10.1038/s41390-025-04117-7. Epub ahead of print. PMID: 40355543
