Most of the time, when a child's presenting complaint is nausea and vomiting, the diagnosis and treatment plan are straightforward. In the vast majority of cases, these symptoms are caused by infection, most commonly viruses, which result in gastroenteritis (inflammation of the gastrointestinal tract). Ill these cases, vomiting is usually associated with fever and diarrhea as well as various degrees of malaise.
Occasionally, a child will present with vomiting that appears to have no clear cause. Once infections, obstructions and various other ailments are eliminated as a cause, other, more exotic diagnoses must be entertained. It should be noted that, along with conditions that affect the GI tract, other conditions need to be considered. Any abnormality which results in increased pressure within the cranium can cause vomiting. These conditions can range from a simple concussion to an intracranial bleed to brain cancer. Any child who has unexplained vomiting for more than a few days should receive a head CT scan or MRI.
There is another condition, cyclic vomiting, which is sometimes considered in children whose vomiting has gone on for a significant period of time with no other diagnostic explanation. This unusual condition has no known cause, and no clear treatment. It can be seen in adults but is most common in kids aged three to seven years old. It is probably more common than some may think, occurring in one out of fifty children with prolonged vomiting, and the symptoms can be quite profound.
Severe nausea, unrelenting vomiting and retching (dry heaves) begin without warning. Occasionally, a child with this condition may experience a triggering event or symptom such as abdominal pain, overeating before bedtime or emotional upheavals such as birthdays or family traumas. Once a bout of vomiting commences, it may last for a prolonged period of time. Retching and vomiting may go on for so long that dehydration becomes a risk. Episodes may be as brief as one day, or last for as long as five to ten days. Obviously, in a small child, if vomiting continues this long, hospitalization and IV fluids will be required to stem the effects of certain dehydration.
For any child that has a recurring pattern of episodes of unrelenting vomiting with no clear anatomic explanation, cyclic vomiting must be considered. Unfortunately there is no specific test to snake this diagnosis. It is considered a diagnosis of exclusion, meaning other more easily diagnosable conditions must be ruled out before cyclic vomiting can be considered.
Once the diagnosis of this unusual disorder is diagnosed, however, there are no clear treatment options. There has been some research that demonstrates a connection between cyclic vomiting and migraine headaches, another disorder of uncertain cause and challenging treatment choices. Some migraine headache medicines, like propanolol, cyproheptadine and amitriptyline, have been tried with mixed success. In some cases, Zantac or Prilosec have been effective. If triggers for cyclic vomiting, like abdominal pain, can be treated early with pain medications or antacids, an episode can sometimes be prevented.
Sufferers of cyclic vomiting, and their families, should not feel that the condition is psychological or behaviorally motivated. On the contrary, it is quite real, and the results can be devastating. Any child who experiences unrelenting vomiting and possible dehydration should be taken to his doctor or health care provider. In these cases, the exact diagnosis is less important than effective and sometimes life-saving treatment.
For more information on this unusual disorder, interested readers are encouraged to contact the Cyclic Vomiting Syndrome Association or the National Organization for Rare Disorders, Inc.
John E. Monaco, M.D., is board-certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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