Cyclic vomiting syndrome

Related links:

• Our services: Caring for children with cyclic vomiting syndrome
• Find a cyclic vomiting syndrome expert

Related tests and treatments:

• Abdominal ultrasound
• Upper GI series
• Endoscopy
• Magnetic resonance imaging
• Cognitive behavioral therapy

The Cyclic Vomiting Syndrome Program at Children's Wisconsin is the first and largest program of its kind that specializes in treating children who are experiencing severe, recurring vomiting episodes. All of our providers lead CVS research and QI initiatives. Our program director, Dr. Katja Karrento, spearheaded the international guidelines for pediatric cyclic vomiting syndrome (CVS). (Link to upcoming JPGN article)

Children's offers an integrated approach to CVS treatment, connecting patients and their families with specialists in genetics, psychology, and other areas, depending on patients' needs. Our experts work together to deliver the very best care to your child. As a result, our program offers strong outcomes and is able to significantly reduce vomiting episodes for the average patient.

About cyclic vomiting syndrome

Cyclic vomiting syndrome is one of the more unrecognized, misdiagnosed and mysterious childhood diseases. Children with CVS experience severe, recurring vomiting episodes but return to baseline without vomiting for weeks or even months between the episodes. Anywhere between hours and several days, a child could have more than 30 vomits and a few can vomit hundreds of times per episode.

Cyclic vomiting syndrome episodes can sometimes lead to dehydration and visits to the emergency room, where doctors commonly mistake CVS for illnesses like gastroenteritis (i.e. ‘stomach bug’) or food poisoning. One characteristic that distinguishes CVS is that the vomiting bouts usually follow a specific pattern — they often start at the same time of day (such as early morning), have the same symptoms and last the same amount of time

Cyclic vomiting syndrome is closely associated with abdominal migraines and migraine headaches, and about 80 percent of children with CVS will also have abdominal migraines.

What causes cyclic vomiting syndrome?

The specific causes of CVS are unknown, but researchers believe the problem resides in the brain, which is home to the body’s vomiting center. With the stomach flu or a bowel obstruction, a child will vomit until his or her stomach is empty. But with CVS, the child will continue to vomit or retch long after that point. Other factors include a heightened stress response, autonomic nervous system dysfunction and mitochondrial (energy) dysfunction.

How common is cyclic vomiting syndrome?

Some research suggests that this condition affects 2 percent of school-aged children.

What are the symptoms of cyclic vomiting syndrome?

Vomiting episodes often begin in the early morning, and children may be pale and curled in a fetal position. In addition to severe vomiting and nausea, children with CVS could also experience:

• Loss of appetite
• Low-grade fever
• Dizziness
• Abdominal pain
• Headache
• Sensitivity to light
• Diarrhea
• Sweating

Relentless vomiting can lead to significant dehydration. Signs of dehydration include thirst, much less urination, a dry mouth, and irritability or difficulty staying awake. A child with symptoms of dehydration should see a health care provider immediately.

Who is at risk of developing this condition?

CVS can begin at any age, but in children it typically begins between the ages of 3 and 7, with the peak age around 5. Sixty percent of those with CVS are female, and 70 to 80 percent have a family history of migraines.

Why is cyclic vomiting syndrome a concern?

Vomiting can cause severe dehydration that can be life threatening and lead to hospitalization. Cyclic vomiting attacks can last for days and be extremely debilitating for the child and disruptive to family life. On average, these children miss about three weeks of school annually and suffer from significant anxiety due to their condition.

How is cyclic vomiting syndrome diagnosed/evaluated?

The medical provider will thoroughly study your child’s medical history to see if the vomiting episodes fit the typical pattern for this condition. CVS is diagnosed based on symptoms as there is no test to diagnose the condition. Providers may also use selected tests to exclude some serious surgical disorders that may mimic CVS.

Diagnostic tests could include an upper GI series to rule out an anatomical reason for the symptoms, such as intestinal twisting or blockage, or an abdominal ultrasound to exclude kidney blockage or obstruction. Because the body’s vomiting center is based in the brain, occasionally your child’s doctor might use magnetic resonance imaging to look for a growth or blockage in the brain, though that is very rarely the cause of cyclic vomiting. Depending on the child’s symptoms, the doctor might also use endoscopy to look for inflammation caused by food allergies or bacterial infection of stomach, as well as blood tests to check for metabolic, liver and pancreatic disorders.

What is the treatment for cyclic vomiting syndrome?

Treatment for CVS is a combination of lifestyle and medications. Neuromostimulation is also an effective treatment. Healthy lifestyle such as in migraine management is also helpful for kids living with CVS.  Strategies include ensuring consistent sleep routines, eating nutritious meals on a schedule, addressing triggers for CVS episodes, and using stress management tools as needed. Your child’s CVS provider will give you a comprehensive treatment plan. might prescribe anti-migraine medications or supplements for prevention, as well as anti-vomiting or pain medications. If a child is in the emergency room or hospitalized during an episode, providers might add IV fluids and sedation. 

Pediatricians should consider the possibility of CVS in children who experience:

• Recurrent vomiting episodes that start with severe vomiting despite emptying of stomach contents — several times per hour — and last less than one week
• Four or more separate episodes of vomiting in the past 12 months
• Migraine headaches in child or a family member (supports diagnosis)

What is the long-term outlook for cyclic vomiting syndrome?

Many children will outgrow CVS around puberty, but about 75 percent will likely develop migraine headaches later in life. Some children develop chronic daily nausea.

How do I live with cyclic vomiting syndrome?

It’s important to track and understand the triggers for your child’s vomiting episodes. Triggers can include infectious illness, negative or positive stress/excitement, poor sleep, fatigue and occasionally excess sugar/junk food, caffeine, nitrites, or monosodium glutamate (MSG) in foods. Nearly 60 percent of school-aged children with CVS meet the criteria for an anxiety disorder, and cognitive behavior therapy can help your child stay calm and reduce stress, which in turn can have a positive effect on your child’s CVS symptoms.

If your child has been missing school for CVS or other symptoms, it is important to talk to your health care team about ways to limit the impact of CVS on school and daily life.  Sometimes this includes support from the psychologist and help with developing a pro-active plan for school. 

Learn more and find additional parent and patient resources through the Cyclic Vomiting Syndrome Association.