Cyclic Vomiting in Children and Adolescents

Do you have a child that experiences cycles of vomiting for no reason? 

You may have a few weeks of no vomiting and normal life and then, bam, here comes the vomiting. 

Cyclic vomiting syndrome (CVS) is characterized by recurrent, common bouts of vomiting with intervening periods of normal health. Some important features are:

• Recurrent episodes of vomiting
• Varying times of normal health between episodes
• Episodes are stereotypical with regard to the timing of onset, symptoms, and duration
• The vomiting is not related to other disorders

Other common features include a history in the person or a family history of migraine headaches, the self-limited nature of the attacks, associated symptoms of nausea, abdominal pain, headache, motion sickness, photophobia (discomfort in bright light), lethargy and pallor (paleness to the skin), excess salivation, diarrhea, dehydration, and social withdrawal.

Children tend to suffer from CVS for years before diagnosis, with the median age of CVS onset being 6 years of age, but a proper diagnosis is not being made on average for another 2.6 years after onset. One population-based study of 34 children who met the criteria for CVS in Scotland found that the average age was 9.6 years at the time of diagnosis, while the average age of onset was 5.3 years.

CVS is no longer considered rare. The estimated incidence is 3.2 per 100,000 population. CVS appears to slightly impact females more than males, but all genders of any age may be affected. A large case series found that CVS results in 20 missed school days and an annual cost of care of $17,035. 

In children and adolescents, CVS episodes generally begin in the early morning hours (between 2:00 and 7:00 AM) and last around the same duration for each episode. Around half of the children have attacks at regular intervals, commonly occurring every two to four weeks, while the remainder has unpredictable intervals between attacks. Around three-quarters of parents can identify triggers, which are usually psychological (more excitement, than negative stressors, for example, a happy event) or infectious events (viral illness, etc).

Are you concerned that if your child has CVS, it will be a problem their whole life? 

Well, it is thought that many children outgrow CVS by their preteen or early teenage years. Unfortunately, an estimated 75% of children with CVS will then develop migraine headaches by the age of 18.

Is there a way to diagnose CVS?

Criteria for diagnosis were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and are as follows: 

• At least five attacks or a minimum of three attacks during a six-month period
• Episodic attacks of intense nausea and vomiting lasting one hour to 10 days and occurring at least one week apart
• Stereotypical patterns/symptoms for that individual 
• Vomiting during attacks occurs at least four times per hour for at least one hour
• Return to baseline health between episodes 
• Not attributed to another disorder

If your child has these alarm symptoms, it is likely not CVS:

• GI bleeding, weight loss, stomach pain on one side
• Episodes triggered by illness, low blood sugars, or a high-protein meal
• Severe headaches, altered mental status, gait disturbances
• A change in the vomiting patterns

If your child has no alarm symptoms, minimal screening is needed to confirm a diagnosis of CVS. These screenings are basically to rule out other causes.

• Imaging: upper GI series to make sure there are no malrotations or other causes of the vomiting 
• Lab testing: to ensure all labs are within normal ranges 

Stay tuned for future articles on how to help your child manage CVS. 

1. _{CME: New hope for children with cyclic vomiting syndrome. Contemporary Pediatrics. (n.d.). Retrieved February 24, 2023.}
2. _{Abu-Arafeh, I., & Russell, G. (1995). Cyclical vomiting syndrome in children: a population-based study. Journal of pediatric gastroenterology and nutrition, 21(4), 454–458.}
3. _{JP;, L. B. U. B. (n.d.). Cyclic vomiting syndrome: Evolution in our understanding of a brain-gut disorder. Advances in pediatrics. Retrieved February 11, 2023.}  
4. _{Li, B. U. K. (n.d.). Cyclic vomiting syndrome. UpToDate. Retrieved February 11, 2023.}  
5. _{Li, B. U., Lefevre, F., Chelimsky, G. G., Boles, R. G., Nelson, S. P., Lewis, D. W., Linder, S. L., Issenman, R. M., Rudolph, C. D., & North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (2008). North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome. Journal of pediatric gastroenterology and nutrition, 47(3), 379–393.}