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Vomiting — Clinical Guidelines

Overview

Cyclic vomiting syndrome (CVS) is characterized by recurrent episodes of severe nausea and vomiting separated by symptom-free intervals, often overlapping with migraine features. It significantly impacts quality of life and requires a multidisciplinary approach involving both gut and brain treatments 1.

Diagnosis

Clinical Criteria: Recurrent episodes of vomiting, stereotypical timing, and symptom-free intervals 3.

Differential Diagnosis: Consider Cannabinoid Hyperemesis Syndrome (CHS) due to overlapping symptoms 3.

Diagnostic Tests: No specific biomarkers; rely on symptom-based criteria 3.

Evaluation: Rule out organic causes through appropriate investigations 3.

Management

First-Line Treatments:

- Prophylactic Medications: Amitriptyline or propranolol 13. - Acute Episodes: Antiemetics such as ondansetron or metoclopramide 1 2.

Adjunctive Therapies:

- Psychological Interventions: Psychological therapies show clinical success but lack robust evidence 1. - Dietary Modifications: Stress management and dietary adjustments may be beneficial 1.

Special Populations

Pediatrics: Guidelines emphasize symptom-based management with prophylactic treatments like amitriptyline or propranolol 2 3 13.

Pregnancy: Limited data; management focuses on symptom control with caution due to potential teratogenic risks 12.

Comorbidities: Tailor management considering overlapping conditions like migraine 1 2.

Key Recommendations

Use symptom-based criteria for diagnosing CVS, considering differential diagnoses like CHS 3 (Evidence: Moderate).

Implement prophylactic treatments such as amitriptyline or propranolol in pediatric CVS 2 13 (Evidence: Moderate).

Incorporate psychological therapies despite lacking strong evidence, recognizing their clinical utility 1 (Evidence: Expert opinion).

Manage acute episodes with antiemetic medications like ondansetron or metoclopramide 1 (Evidence: Moderate).

Address CVS in pregnancy cautiously, focusing on symptom relief and safety 12 (Evidence: Weak).

References

1 Tarbell SE, van Tilburg MAL. Psychogastroenterology of cyclic vomiting syndrome: A crucial need to build evidence. Neurogastroenterology and motility 2026. link 2 Karrento K, Rosen JM, Tarbell SE, Issenman RM, Gelfand AA, Gamboa H et al.. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition 2025 guidelines for management of cyclic vomiting syndrome in children. Journal of pediatric gastroenterology and nutrition 2025. link 3 Karrento K, Rosen JM, Gelfand AA, Parikh S, Tarbell SE, Issenman RM et al.. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition 2025 guidelines on the diagnosis of cyclic vomiting syndrome in children. Journal of pediatric gastroenterology and nutrition 2025. link 4 Levinthal DJ, Staller K, Venkatesan T. AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary. Gastroenterology 2024. link 5 Langeroudi H, Feint G, Smith CH. Developing a care bundle for children who are eating and drinking with acknowledged risk: A Delphi study with speech and language therapists. International journal of language & communication disorders 2024. link 6 Isoldi S, Di Nardo G, Mallardo S, Parisi P, Raucci U, Tambucci R et al.. Cyclic vomiting syndrome in children: a nationwide survey of current practice on behalf of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP). Italian journal of pediatrics 2022. link 7 Li L, Zhou J, Yu D, Hao X, Xie Y, Zhu T. Intranasal dexmedetomidine versus oral chloral hydrate for diagnostic procedures sedation in infants and toddlers: A systematic review and meta-analysis. Medicine 2020. link 8 Venkatesan T, Levinthal DJ, Tarbell SE, Jaradeh SS, Hasler WL, Issenman RM et al.. Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Neurogastroenterology and motility 2019. link 9 Bronsky J, Campoy C, Embleton N, Fewtrell M, Mis NF, Gerasimidis K et al.. Palm Oil and Beta-palmitate in Infant Formula: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. Journal of pediatric gastroenterology and nutrition 2019. link 10 Finnemore A, Toulmin H, Merchant N, Arichi T, Tusor N, Cox D et al.. Chloral hydrate sedation for magnetic resonance imaging in newborn infants. Paediatric anaesthesia 2014. link 11 Unbeck M, Lindemalm S, Nydert P, Ygge BM, Nylén U, Berglund C et al.. Validation of triggers and development of a pediatric trigger tool to identify adverse events. BMC health services research 2014. link 12 Byers BD, Snyder CH, Saade GR. Pregnancy complicated by cyclic vomiting syndrome. Obstetrics and gynecology 2009. link 13 Haghighat M, Rafie SM, Dehghani SM, Fallahi GH, Nejabat M. Cyclic vomiting syndrome in children: experience with 181 cases from southern Iran. World journal of gastroenterology 2007. link 14 Greer FR. Do breastfed infants need supplemental vitamins?. Pediatric clinics of North America 2001. link70034-8) 15 Harnett M, Kinirons B, Heffernan A, Motherway C, Casey W. Airway complications in infants: comparison of laryngeal mask airway and the facemask-oral airway. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2000. link 16 Hvarfner A, Hammas B, Thörn SE, Wattwil M. The influence of propofol on vomiting induced by apomorphine. Anesthesia and analgesia 1995. link 17 Fleisher DR. Functional vomiting disorders in infancy: innocent vomiting, nervous vomiting, and infant rumination syndrome. The Journal of pediatrics 1994. link82931-2) 18 Keenan RL, Shapiro JH, Dawson K. Frequency of anesthetic cardiac arrests in infants: effect of pediatric anesthesiologists. Journal of clinical anesthesia 1991. link90088-5) 19 Alcalay J, Ingber A, Sandbank M. Mask phenomenon: postemesis facial purpura. Cutis 1986. link

Vomiting