Journal of Pediatric Gastroenterology & Nutrition:
Letters to the Editor
*Departments of Paediatrics
†Paediatric Dietetics, St Richard's Hospital, Chichester, UK
To the Editor: Cyclic vomiting syndrome (CVS) is considered to be a functional gastrointestinal disorder characterised by stereotypical episodes of acute vomiting lasting <1 week with ≥3 discrete episodes in the previous year and absence of nausea and vomiting between the episodes. CVS has been managed with antiemetics and intravenous fluids with reasonable success (1,2).
CVS is increasingly being recognised as a brain–gut disorder and has been associated with a high familial prevalence of migraine or considered to be a migraine variant in children (2,3). As with migraine, CVS has been associated with the ingestion of foods such as cheese, chocolate, citrus fruits, caffeine, yeast extract, and pork (2). A study in Italy showed improvement with the exclusion diet in CVS symptoms in 7 of 8 children. These children showed positive skin prick tests and specific immunoglobulin E to cow's-milk protein, egg whites, and soya; however, there was no history of specific food allergies (4).
We describe a low-amine diet (LAD) as prophylactic therapy for CVS, which avoids all of the food groups previously implicated as migraine triggers (5). The food groups that need to be avoided include cheese, chocolate, citrus fruit and their juices, pork and pork products, peas, broad beans, game, shellfish, yeast extract, beef extract, gravies, drinks containing caffeine (tea, coffee, cola-based drinks), and alcohol (5).
The single-centre cohort consisted of 21 children (9 girls [43%]) between 2 and 16 years who presented to the paediatric gastroenterology clinic with recurrent stereotypic episodes of frequent vomiting. A total of 17 children (81%) were reported as having abdominal pain and 6 children (29%) had nausea during the episodes. A total of 16 children (76%) came from families with a strong history of migraine. These children remained symptom free between the episodes.
The rationale of LAD and expected benefits were discussed by a paediatric dietitian with the family before starting the therapy, which was continued for a minimum of 6 to 8 weeks. If adverse effects such as worsening of frequency or severity of vomiting or abdominal pain were noted, then the therapy was stopped earlier. A total of 18 children (86%) responded to the LAD therapy and the results are shown in Figure 1. In the group of children who had complete resolution of vomiting, 2 of 13 children continued to have abdominal pain and 1 child developed migraine symptoms later. In the 5 children who showed partial resolution of symptoms, the episodes of CVS were less frequent, less severe, and of shorter duration. Our preliminary findings suggest that LAD may be useful in some children with CVS.
1. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology 2006; 130:1466–1479.
2. Li BU, Misiewicz L. Cyclic vomiting syndrome: a brain-gut disorder. Gastroenterol Clin North Am 2003; 32:997–1019.
3. Lin YP, Ni YH, Weng WC, et al. Cyclic vomiting syndrome and migraine in children. J Formos Med Assoc 2011; 110:382–387.
4. Lucarelli S, Corrado G, Peliccia A, et al. Cyclic vomiting syndrome and food allergy/intolerance in seven children: a possible association. Eur J Pediatr 2000; 159:360–363.
5. Hannington E. Migraine. In: Lessof MH, ed. Clinical Reaction to Food. Chichester, UK: John Wiley & Sons; 1983:155–80.