Cyclic Vomiting Syndrome (CVS)

What is cyclic vomiting syndrome (CVS)?

Cyclic vomiting syndrome (CVS) is a disorder in which a child has repeated episodes of intense nausea and vomiting, with long stretches of feeling completely well in between. These episodes can often follow a pattern for each child — they often start the same way, last about the same amount of time and happen at similar intervals. CVS is considered a disorder of “gut–brain interaction,” meaning the nervous system and digestive system are not working together the way they should.

Although CVS is rare, it can be very disruptive for families. Episodes may last from a few hours to several days and can be severe enough that a child needs emergency or hospital care for fluids and medicine.

What are the signs and symptoms of cyclic vomiting syndrome (CVS)?

CVS has a very recognizable pattern. Children are usually completely well between episodes. Then, often in the early morning, they suddenly develop intense nausea followed by repeated bouts of vomiting, sometimes several times an hour. Many children become very pale and sweaty, feel weak and want to lie in a dark, quiet room. Belly pain, headache and extreme tiredness are also common symptoms along with the vomiting episodes.

Each episode tends to look similar for an individual child — the same early warning signs, the same severity and a similar length, which may range from a few hours to several days. Some children can still drink small sips of fluid, while others cannot keep anything down. When vomiting is this severe, dehydration can develop, with signs such as a very dry mouth, no tears when crying, fewer wet diapers or not urinating for 6 to 8 hours. In those situations, children often need IV fluids and medicine in an emergency department or hospital.

What causes cyclic vomiting syndrome (CVS)?

The exact cause of CVS is not fully understood. Many children with CVS — or their close family members — also have migraine headaches, which suggests the brain and nervous system play a key role.

Common triggers include:

• Viral illnesses, colds or infections
• Stress, anxiety or excitement
• Lack of sleep or overexertion
• Going too long without food or fluids
• Certain foods in some children

Keeping a symptom diary that tracks when episodes happen, what your child ate, sleep patterns and stress can help identify triggers.

How is cyclic vomiting syndrome (CVS) diagnosed?

There is no single test for CVS. Diagnosis is based on:

• A detailed history of your child’s symptoms and how often they occur
• A careful physical exam
• Tests to rule out other causes of vomiting, such as stomach or intestinal blockage, infection or metabolic conditions

Your child’s provider may order blood and urine tests and an upper GI X-ray series or other imaging. These tests can help make sure there is not another serious problem causing the vomiting. Updated pediatric guidelines recommend focused screening tests rather than many unnecessary studies, so children are not over-tested.

At Nationwide Children’s, evaluation is performed by pediatric gastroenterologists — doctors who specialize in children’s digestive disorders.

How is cyclic vomiting syndrome (CVS) treated?

There is no single cure for CVS, but most children improve over time with the right plan. Treatment has two main parts:

During an episode:

• IV or oral fluids to prevent or treat dehydration
• Medicines to reduce nausea and vomiting
• Medicines for pain or migraine-like symptoms
• A dark, quiet room to reduce light and sound, which can make nausea worse

Between episodes:

• Preventive medicines (often migraine-type, anti-seizure or certain antidepressant medicines used at low doses for pain control)
• Careful attention to regular meals, hydration and sleep habits
• Managing stress and anxiety, sometimes with help from a psychologist
• School and home plans so teachers and caregivers know what to do if an episode starts

Your child’s care team will work with you to build an emergency plan that tells you when to give medicines at home and when to seek urgent or emergency care.

When to seek immediate care

Call your child’s provider or seek emergency care right away if:

• Your child cannot keep down any fluids
• There are signs of dehydration, such as very dry mouth, no tears when crying or not urinating for 6–8 hours
• Vomit is bloody or looks like coffee grounds (brown)
• Your child has severe belly pain, a stiff neck, confusion or unusual sleepiness

Care for CVS at Nationwide Children’s Hospital

Children with suspected or confirmed CVS at Nationwide Children’s are seen in our Neurogastroenterology and Motility Disorders Center, part of our nationally ranked Gastroenterology, Hepatology and Nutrition program. Families from across the country and around the world come here for answers when vomiting episodes have not responded to standard care.

Our team includes pediatric gastroenterologists, psychologists, dietitians and nurses who focus on disorders of gut–brain interaction. Together, we provide:

• Expert evaluation based on the latest pediatric CVS guidelines
• Advanced testing when needed, along with careful efforts to avoid unnecessary procedures
• Individualized treatment plans that address medical, nutritional and emotional needs
• Close coordination with your child’s primary care provider and school

Our goal is to shorten episodes, prevent future attacks when possible and help your child return to school, activities and everyday life with confidence