Vomiting is a primary symptom in many paediatric gastrointestinal conditions. It is technically defined as forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. However, for individuals who present to both paediatric and gastrointestinal specialty offices, this term often becomes synonymous with many other behaviours, including ‘regurgitating’, ‘dry-heaving’, ‘ruminating’ and other behaviours that have both different phenotypes as well as underlying physiological mechanisms. Vomiting is often associated with functional gastrointestinal disorders (FGIDs). The purpose of this review is to discuss the evidence for psychological treatments of children with vomiting due to FGID. We will briefly discuss FGIDs associated with vomiting, the biopsychosocial model as a guiding principle to treatment and finally focus on cognitive behavioural therapy (CBT), hypnotherapy, diaphragmatic breathing and sleep hygiene for the treatment of vomiting.
VOMITING IN FUNCTIONAL GASTROINTESTINAL DISORDERS
FGIDs are considered common in children and adolescents and result in significant impairment and costs. FGIDs are diagnosed following Rome Criteria, currently in its fourth edition , and include specific diagnostic criteria for child and adolescent FGIDs that fall under three primary categories: functional nausea and vomiting disorders, functional abdominal pain disorders (FAPDs) and functional defecation disorders. Although vomiting is the predominant symptom in the first category, it is also prevalent in FAPDs, including abdominal migraine. The diagnostic criteria are based on the biopsychosocial model and require clinical history and physical examination. Specific diagnostic criteria are summarized in Table 1.
Cyclic vomiting syndrome (CVS) is characterized by stereotypical and repeated episodes of intense and repeated vomiting with a return to baseline health between episodes . Prevalence rates have varied from 0.2 to 6.2% in population-based samples , and with updated diagnostic criteria from Rome IV as 2% in children above 4 years old [3▪], although it is believed that the disorder is largely under-recognized and frequently misdiagnosed [4▪▪]. CVS is associated with lower health-related quality of life in the affected child as compared to both healthy controls as well other gastrointestinal disorders  and has more recently been associated with poor family health-related quality of life as well . A case of warning that CVS can be due to cannabinoid hyperemesis syndrome (CHS) , increasingly recognized in areas that have legalized recreational cannabis use [8,9]. CHS will not be a focus of this review.
Functional vomiting is newly described in the Rome IV  criteria and affects only a small number of children and adolescents (1.4% in a US population, 3). The Rome IV committee adopted criteria previously described in the adult population based on clinical experience, particularly in children with co-occurring anxiety and depression .
Rumination syndrome is characterized by the repeated regurgitation of recently ingested gastric contents and has been likened to a tic or an exaggerated belch reflex . Regurgitated food can be swallowed or spit out. The latter is not considered vomiting, by the definition given above, although some patients and their families may call it such. For this reason, we will include rumination in this review. Prevalence of rumination syndrome has ranged from 0 to 5.3% in population-based studies [2,3▪], although these rates may be minimized due to decreased accuracy of parent report of youth symptoms. Rumination syndrome has been associated with significant impairment with one study finding 73% of children having missed school or work due to symptoms and 46% requiring hospitalization for the evaluation or treatment of symptoms .
Vomiting can also be associated with FAPDs. Nausea is reported in almost half of all children and adolescents with FAPDs . A recent prospective study of adolescents with FAPD identified that vomiting was present in 27% of patients who reported comorbid nausea, compared with only 3% of individuals with FAPD without nausea [3▪,12▪▪]. Abdominal migraine, in particular, is often associated with nausea and vomiting, but this is a fairly uncommon condition affecting only a small number of all functional abdominal pain patients [3▪]. The presence of nausea in children with functional abdominal pain is associated with worse health outcomes in young adulthood and a higher extraintestinal symptom burden, worse quality of life and impaired functioning [11,12▪▪], which is notable in that nausea and vomiting are frequently comorbid.
Avoidant restrictive food intake disorder (ARFID) is a new diagnosis included in the DSM-5. ARFID is characterized by fear of consuming food secondary to postprandial nausea or discomfort, and subsequent severe food intake restriction. In addition to compromising their nutrition, the increased restriction will likely inadvertently worsen nausea and other digestive sensitivities. A recent retrospective chart review of adolescents and young adults admitted to an intensive treatment programme found that a majority of patients with ARFID were vomiting regularly at admission, and most stopped during treatment and responded to behavioural interventions such as psychoeducation and relaxation training . ARFID is distinct from other diagnoses of disordered eating (e.g. anorexia nervosa) in that body image concerns are not typically reported. In a recent study, 21% of adult patients with FGID also met criteria for ARFID .
BIOPSYCHOSOCIAL MODEL TO EXPLAIN VOMITING
Each of these conditions is best understood from a biopsychosocial conceptualization . Briefly, early life factors including genetics, culture and the environment, shape the individual's psychological, social and physiological functioning. The central and enteral nervous system coordinate bidirectional interaction of these numerous psychosocial and physiological factors. This results in the FGID presentation as well as clinical and quality of life outcomes. Suggested mechanisms include bidirectional relationships between the stress response system and immune and inflammatory response systems and the gut microbiome and psychological symptoms [16▪▪,17].
Research has shown that functional vomiting disorders have biological, psychological and social underpinnings. For example, presenting symptoms for children with CVS may include a family history of migraine headaches , mitochondrial abnormalities and/or hypothalamic disturbances , and a high concurrent prevalence of anxiety disorders  and school difficulties. Similarly, rumination syndrome is also driven by biopsychosocial processes.
Rumination is primarily a behavioural disorder, in which there is a developed reflexive response during digestion of increased intragastric pressure by contraction of abdominal muscles and associated opening of the lower oesophageal sphincter. Rumination is typically the result of a triggering event, such as a previous infection (biological) boredom (social) or anxiety (psychological) or a combination of these factors [1,10]. As the current review focuses on psychological treatments, it is important to understand the role of both child and parent psychological factors in FGIDs. This literature is reviewed in detail elsewhere [19▪▪,20–22].
Compared with healthy children, patients with FGIDs as well as their parents have been found to have higher rates of psychological distress and somatization. Furthermore, psychological distress, somatization and coping (especially catastrophizing) are associated with more negative FGID outcomes such as increased symptoms and disability as well as decreased quality of life. Parents who model or reinforce illness behaviours rather than wellness behaviours also exacerbate symptoms and disability in their child. In CVS patients specifically, 47–82% suffer from anxiety [5,23] and the presence of anxiety predicts family health-related quality of life beyond physical symptom severity . Although much of the research has focused on FGIDs more broadly, the results may be extrapolated to the specific symptom of vomiting given our broad understanding of the brain-gut axis.
Given that vomiting associated with FGIDs is best understood within a biopsychosocial framework, treatment should be multidisciplinary and may include psychological interventions. Little research is available supporting the efficacy of psychological interventions for these disorders. However, vomiting associated with FGIDs share common factors with FAPDs, and the benefits of psychological interventions is well established for these disorders [24,25]. Recent findings indicate that chronic nausea and vomiting demonstrate similar neural pathways to that of chronic pain conditions . As such, psychological interventions that have been found to be efficacious for paediatric chronic pain may also be promising for associated symptoms of nausea and vomiting. In our experience, vomiting is an increasingly common factor for referral to a medical psychologist.
COGNITIVE BEHAVIOURAL THERAPY
Cognitive behavioural therapy is based on the premise that thoughts, feelings and behaviours all influence each other. In order to address this trifecta, CBT combines behavioural therapy (e.g. relaxation training) with cognitive therapy (e.g. psychoeducation, addressing catastrophizing). CBT is versatile, as the therapists can choose from a large tool box of techniques and individualize the treatment. This means CBT varies by patient, disorder and therapist. CBT is also time limited and focuses on tools to help manage one's (mental) health, which is an attractive treatment option for patients with medical disorders. The literature is robust for the benefits of CBT in treatment of FAPDs [27▪,28,29▪▪,30], although less is known about functional vomiting. Several case studies are available supporting the use CBT in CVS as well as rumination [31–33]. CBT interventions in FGID typically begin with symptom-specific psychoeducation of the brain-gut pathway. Additional cognitive interventions focus on identifying unhelpful/unrealistic thoughts and how to replace them with more adaptive thought. Behavioural interventions may include relaxation techniques, and teaching parents how to manage symptoms.
For patients with CVS, lifestyle modifications and stress management techniques (maintaining fluids, eating regularly without skipping meals, exercise, sleep hygiene, distress tolerance, awareness of triggers and so on) implemented during the interictal phase can reduce the likelihood of attacks and need for preventive medications. As vomiting is highly aversive, children and their families try to avoid activities that may increase the risk of vomiting. Limiting avoidance of symptoms inducing activities has been shown to help reduce symptoms of nausea in children with functional dyspepsia [34▪] and may be helpful for vomiting as well. Because parents often limit child activities over fear of vomiting, including parents in therapy is of utmost importance. This strategy is used in CBT treatment for individuals with emetophobia (a specific phobia of vomiting), with gradual exposure to feared stimuli and preventing use of compensatory anxiety-reducing responses.
CBT is also incorporated into treatment plans for ARFID, a psychiatric diagnosis that may develop in the context of an FGID and in which vomiting is a prevalent symptom. Thomas and Eddy  have created CBT-AR, a modified CBT protocol informed by best practices from CBT interventions for eating disorders as well as anxiety disorders (regular eating, psychoeducation about nutrition deficiencies, exposure and response prevention, behavioural experiments, relapse prevention). This intervention is still in the early stages of testing, but early data indicates feasibility, acceptability and efficacy .
One of the most frequent avoided activities is going to school. There are currently no data on the rates of school absenteeism for students whose primary complaints are nausea and vomiting; however, our clinical experiences reveal that it is common. School refusal is complex, and vomiting can predispose, precipitate and/or perpetuate school avoidance . CBT has been effective in reducing school avoidance in general (not associated with medical symptoms specifically) [38,39]. When nausea and vomiting symptoms are more pronounced in the morning, as is often the case for youth with FGID, an entry-level intervention may be to delay the start time for students. However, if morning gastrointestinal symptoms are associated with other school-related stress (academic issues, peer difficulties and so on), then moving the morning start time will likely not address the underlying concerns. In addition, partnering with the school to identify unmet academic needs or other unrecognized burdens associated with missed exposure to content secondary to absenteeism is imperative.
Often considered the foundational tool of a paediatric coping skills toolbox within cognitive-behavioural therapy, diaphragmatic breathing is commonly recommended. Patients are instructed to inhale by contracting the diaphragm and expanding the abdomen . This remains the gold standard treatment for most cases of rumination syndrome, as the technique appears to reduce postprandial intragastric pressure and increase esophagogastric junction zone pressure, balancing the gastroesophageal pressure gradient . It should not be used as a first-line intervention for individuals with retching and vomiting unless obstruction, gastroparesis, central nervous system disorders and medication effects have been ruled out.
One of the most profound, and commonly replicated findings, is the significant role that sleep deprivation has on functional impairment experienced in youth with FGID [42,43]. Therefore, emphasizing sleep as a major therapeutic goal seems indicated. An interesting recent single-arm pilot study evaluated an innovative hybrid cognitive-behavioural therapy treatment addressing both sleep and pain outcomes in adolescents with migraine and insomnia . Their protocol included three core treatment components from CBT-I (sleep hygiene education, stimulus control, sleep restriction) and four core components from CBT for pain management (psychoeducation, relaxation training, pleasant activity scheduling and positive thought tracking, and parent operant training for reinforcing adolescent skills practice and reduction of reinforcement of pain behaviours). About 70.5% of the youth showed at least a 50% reduction in headache frequency and significant improvements in sleep quality and hygiene. These data are encouraging for individuals who present with vomiting co-occurring within paediatric FGID based on the theorized similar pathways involved in each conditions, as well as a potential early intervention to reduce likelihood of vomiting episodes [4▪▪].
Gut-directed hypnotherapy targets visceral hypersensitivity, motility disturbances and hypervigilance to normative digestive sensations. This practice incorporates gut-focused imagery and hypnotic suggestions targeting the gastrointestinal tract [29▪▪,30]. Most paediatric studies have thus far only recognized hypnotherapy's highly effective value for paediatric irritable bowel syndrome and functional abdominal pain . Recently published studies discuss the value in functional dyspepsia and also oesophageal disorders  in adults for individuals who have not responded to proton-pump inhibitor therapy. In our clinical experience, some patients with functional vomiting may benefit from hypnotherapy, but studies are needed to confirm these findings.
Chronic vomiting of functional origin is a highly aversive disorder that reduces children's quality of life and increases disability. Vomiting has psychosocial as well as biological underpinnings and multidisciplinary treatments are generally recommended. Unfortunately, most therapies have limited evidence base. Recent data have challenged the use of medications as entry-level interventions for various conditions (e.g. CHAMP study for paediatric migraine, ; abdominal pain predominant FGID ). Increased evidence is demonstrating value and efficacy of incorporating psychogastroenterology practices into ongoing treatment plans for digestive conditions [29▪▪,48▪]. Current psychological treatments are focused on prevention of vomiting through stress reduction and lifestyle modification, reduction of disability by limiting avoidance and safety-seeking behaviours, as well as counteracting biological factors (in the case of rumination). However, psychological treatments have not been developed to help during an acute vomiting episode. More research is needed to build an evidence base for psychological treatments in vomiting disorders.
Financial support and sponsorship
Conflicts of interest
Dr. van Tilburg is a consultant for Mahana Therapeutics. None of the products offered by Mahana Therapeutics are discussed in this manuscript.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
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