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Rome IV Diagnostic Criteria for Child Cyclic Vomiting Syndrome

Official Rome IV criteria for the diagnosis of child cyclic vomiting syndrome.

Use in patients with symptoms suggestive of cyclic vomiting such as intense, paroxysmal, stereotypical episodes of vomiting, separated by weeks or months of usual health.

Patients with any of the following alarm features must be evaluated clinically for other diagnoses even though cyclic vomiting may be present:

  • Severe abdominal pain.
  • Persistent right upper or right lower quadrant pain.
  • Pain radiating to the back.
  • Dysphagia or odynophagia.
  • Persistent or bilious vomiting.
  • Gastrointestinal blood loss.
  • Chronic, unexplained or nocturnal diarrhea.
  • Involuntary weight loss.
  • Deceleration of linear growth.
  • Delayed puberty.
  • Recurrent or unexplained fever.
  • Dysuria or hematuria.
  • Personality changes.
  • Severe headaches.
  • Ataxia.
  • Altered mental status.
  • Any neurologic abnormality.

Must have the following:

Diagnostic Result

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Advice

If diagnosis not met (negative):

Current symptoms are unlikely to be caused by cyclic vomiting syndrome. Consider further assessment as clinically indicated. Also, see pearls and pitfalls above. 

If meets diagnosis (positive):

Likely diagnosis of cyclic vomiting syndrome. Consider initiating treatment.

Management

Management of Cyclic Vomiting Syndrome (CVS) is determined by the age of the child, frequency, severity, and impact of the symptoms on daily life. It consists of nonpharmacologic and pharmacologic interventions. A multidisciplinary treatment approach should be taken.

Management includes: 

  • Education. 

  • Providing reassurance and anticipatory guidance.

  • Lifestyle changes including good sleep hygiene, regular exercise and meals, adequate hydration, avoidance of caffeine or other patient-specific triggers of CVS episodes (see pearls and pitfalls above).

  • If the fasting state is a trigger, regular meals and high-carbohydrate snacks can be helpful.

  • Abortive treatment for acute episodes should be initiated as soon as possible: 

    • Migraine abortive treatments (e.g. Intranasal sumatriptan).

    • Antiemetics (e.g. Ondansetron, aprepitant).

    • Hydration (IV fluids may be needed).

    • Avoidance of external stimuli.

  • Supportive treatment during an episode: 

    • Hydration including IV fluids if necessary.

    • Antiemetics (e.g. Ondansetron, aprepitant).

    • Prokinetics (e.g. Erythromycin).

    • Sedatives (e.g. Benzodiazepines, Clonidine).

    • Analgesics in case of abdominal pain (e.g. famotidine, ketorolac, morphine).

  • Prophylactic treatment in case of frequent and/or severe episodes: 

    • First line: Cyproheptadine for children <5years, Amitriptyline or Nortriptyline for older children.

    • Second line: Propranolol.

    • Supplements (e.g. L-Carnitine and Coenzyme Q10, Riboflavin).

    • Pizotifen.

    • Anticonvulsants (e.g.phenobarbital, topiramate, gabapentin, valproic acid, levetiracetam).

    • Acupuncture.

    • Psychological treatments (e.g. CBT, learning of coping strategies, relaxation techniques).

    • Low dose estrogen oral contraceptives for menses-related episodes.

The choice of therapy is outside the scope of this calculator and will depend on clinical context.

Critical Actions

This calculator should only be used in patients who do not have signs or symptoms suggestive of a structural, metabolic or systemic cause of their symptoms based on clinical history, physical exam and initial work-up.

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