Vomiting and Retchingadmin2021-01-29T15:27:47+00:00
Vomiting occurs frequently in children who need feeding tubes. In many cases, the vomiting is caused by the same medical problems that require a child to have a feeding tube, but in some cases, vomiting may be due to how a child is being tube fed. Changes in formula, the feeding schedule, and the tube type can make a huge difference. See our page on Feeding Intolerance for more information on identifying ways you can adapt tube feeding to relieve vomiting and other symptoms.
Retching occurs when a child tries to vomit but can’t (as in children who have had a Nissen or fundoplication surgery), or when a child tries to vomit but has nothing to vomit. If retching is occurring, you may need to vent the stomach more often.
There are many variables to consider. Of course, you will need to discuss your child’s situation with your doctors. It may take some trial and error to figure out the cause of the vomiting. More likely than not you have to adjust a number of different things. However, only change one thing at a time, so you know what is working and what isn’t.
What is the most common cause of vomiting in children with feeding tubes?
Feeding intolerance, such as too fast a rate, too many calories, or using the wrong type of formula, is the most common cause of vomiting. Often, vomiting can be lessened or eliminated by changing the feeding regimen. See our page on Feed Intolerance for more information.
Causes of Retching and Vomiting
If vomiting only occurs occasionally, it may be due to illness. Young children get sick as frequently as once a month, and children who need feeding tubes are often more prone to vomiting during respiratory illnesses. Motility (meaning how food moves through the GI tract) slows down with illness, which can lead to increased vomiting even as a child is starting to get sick. It can remain slow for a week to 10 days (or more) after the illness has cleared, if the illness was significant. Coughs and congestion may also cause young children to vomit. For detailed information on handling illnesses, see our page on Illness.
Reflux Versus Vomiting
Often, vomit gets blamed on reflux or GERD. But, when you see a lot of vomit, it is likely that it is more than reflux going on. It is also important to try to determine if a child is actually refluxing (passive regurgitation of stomach contents) or vomiting. Air in the stomach needs to be expelled in the form of a belch, and the lower esophageal sphincter (LES) that serves as the gate between the esophagus and stomach must open up to allow air out. In some people, this sphincter opens too far, stays open too long, or opens too frequently, allowing stomach contents to be refluxed repeatedly and causing symptoms such as spitting up in babies or heartburn in older children and adults. While children with reflux do vomit occasionally, chronic and forceful vomiting, especially when accompanied by symptoms like paleness, sweating, salivation, or retching, is probably more than straightforward reflux.
While reflux is thought to be related to the belch reflex, in which stomach contents are expelled as if the body was going to belch, vomiting is triggered by the “vomiting center” of the brain, setting off a series of events involving muscles and nerves. Salivation in the mouth, narrowing of blood vessels, a fast heartrate, and paleness or sweating may occur. Then the muscles in the abdomen and diaphragm contract while the glottis (area where the vocal cords are) closes, creating retching. Finally, pressure inside the abdomen forces the contents of the stomach out through the mouth. Clearly, this is a much more complicated process than simple reflux, involving multiple body systems.
To complicate matters, reflux can sometimes trigger the gag reflex, which sets off vomiting. Children with neurological disorders may be extra sensitive, and may vomit as a result of gut hypersensitivity, an overactive gag reflex, an extra sensitive emetic or vomiting reflex in the brain, or motility problems in the gut.
Does your child have a condition that is linked with vomiting? Has she been tested for these conditions? Has his anatomy been checked for any abnormalities such as pyloric stenosis or a fistula? A lot of things mimic reflux or cause vomiting. Here are some of the chronic conditions that can cause repeated vomiting:
Motility Disorders, especially Esophageal Motility Disorders, Delayed Gastric Emptying or Gastroparesis, and Chronic Intestinal Pseudo-Obstruction
Anatomical or Structural Problems
Food Allergies and Intolerances
Autonomic Nervous System Issues or Dysautonomia
Eosinophilic Esophagitisand other Eosinophilic Disorders
Cyclic Vomiting Syndrome
Functional Abdominal Disorders, such as Visceral Hyperalgesia, Dyspepsia, or Irritable Bowel Syndrome
Constipation is one of the most common causes of vomiting in young children. Constipation backs up the whole GI tract, so that food that is coming in moves more slowly. It can cause the stomach to empty more slowly, and can lead to additional vomiting. Addressing constipation can improve feed tolerance considerably. See our page on Constipation for more information.
Retching Without a Fundoplication
Retching that occurs in a child with GI problems but without a fundoplication typically has one of two causes: a motility problem, or hypersensitivity of the stomach or other parts of the GI tract. In these children, retching is often followed by vomiting, though the two symptoms can happen separately as well.
Children who retch and have a motility problem often have abnormal motility of the esophagus, such as esophageal spasm or dysmotility, or a motility problem in their stomach or small intestine, such as a lack of contractions, spasmodic contractions, or the absence of “housekeeping” contractions in the stomach. See more information about Motility Disorders.
Other children may have a hypersensitive gut. The most common cause of hypersensitivity, often called visceral hyperalgesia, is reduced gastric volume capacity. In children with hypersensitivy, the stomach feels “full” and may even feel painful at a much lower volume than would be expected. This hypersensitivity may extend to other parts of the gut in some children, causing symptoms with even the smallest amount of fluid or food in the belly. The brain perceives the gut as painful or overfull, triggering discomfort, retching, and vomiting.
In other children, the emetic or vomiting reflex in the brain may be on a hair trigger, and almost anything, from a bad smell to 5ml of formula in the belly, may cause retching. It is very common for these problems to occur in tandem, and many children with motility problems have concurrent visceral hyperalgesia.
Tip: Seeing a GI doctor who has specialized training in Motility Disorders, Functional GI Disorders, or Neuro-gastro Disorders may be helpful in eliminating retching.
Addressing Retching and Vomiting
There are a variety of different medications that can help children who vomit. Here are a few options to consider:
Anti-reflux medications. While research has not shown anti-reflux medications usually improve vomiting, parents routinely see that a reduction in reflux often also brings a reduction in vomiting, probably because reflux triggers vomiting in many children. If possible, stick to the simpler medications like Pepcid or Zantac. Long term use of other reflux medications like Prevacid or Prilosec can have significant side effects.
Motility medications. These days most motility medications are banned due to side effects, and those still on the market have lots of potential side effects and black box warnings. For certain children, however, they may be worthwhile. Old-fashioned medications like low-dose antibiotics may be a good place to start.
Anti-emetics. In some children, quieting down the vomiting center in the brain makes a big difference. Anti-nausea medications, including Zofran, Phenergan, and Benadryl, may be helpful.
Medication for hyperalgesia. Children who have oversensitive guts sometimes respond very well to medications designed to blunt their nervous system overreactions. Common choices include Neurontin, Lyrica and Elavil.
Anti-spasmodics and anti-spasticity medications. These classes of medications often improve vomiting. Baclofen, a medication usually used for spasticity, is especially helpful in reducing both reflux and vomiting. These medications do tend to make kids sleepy, and some of them also slow down motility.
Improve Medical Conditions and Mechanical Issues
Treat underlying conditions. All underlying conditions should be treated as much as possible to reduce vomiting. This may include structural issues, gastrointestinal disorders, neurological conditions, respiratory problems, and endocrine disorders.
Get a handle on constipation. The GI tract cannot function if one end is blocked. Make sure that constipation is not causing problems. Treat constipation aggressively with laxatives and stimulants, if needed, in order to get things moving. See our Constipation page.
Improve swallowing. If vomiting is triggered by a poor swallow and choking, swallowing therapy may be helpful. Both traditional speech therapy and newer electrical stimulation techniques may be helpful.
Eliminate problem textures and get feeding therapy in to help. Children who vomit due to feeding or sensory/texture issues often improve considerably with feeding therapy, which may be provided by an occupational therapist or a speech language pathologist. It takes time, but it can work.
Address Feed Intolerance
Our page on Feeding Intolerance presents many different methods to change tube feedings in order to improve symptoms. Some of the more relevant ones for kids who vomit include the following:
Slow down the feeding
Give smaller, more frequent feedings
Thicken feedings for older kids
Try a blended diet
Eliminate problem foods or formulas
Try a GJ or NJ tube that goes into the intestine
Try venting the feeding tube more often
Venting the stomach can help retching tremendously. See the videos below or visit our Gastrostomy (G) Tube page for more information.
Farrell Valve bags allow for venting the stomach while feeding. Moreover, these bags gives formula a place to go until the stomach is better able to handle it. The food enters the bag and then is gravity fed back into the stomach.
How to Vent
Using a Farrell Bag
Retching After Fundoplication
In theory, retching after a fundoplication occurs because the fundoplication stops the child from vomiting, meaning that any attempt at vomiting will lead to persistent retching since the gastric contents are not able to be released upwards out of the stomach and mouth. While this may be true for a child with a fundoplication who has a stomach virus, it does not explain why some children retch continuously after a fundoplication.
Doctors have begun to realize that persistent retching after a fundoplication may instead be the result of either a preexisting hypersensitivity or changes in the gut from the fundoplication. Children who vomit or retch before a fundoplication usually continue to retch afterwards. Most of these children have a hypersensitive emetic reflex or visceral hyperalgesia.
In some cases, a motility problem or other condition like eosinophilic esophagitis was mistaken for reflux pre-operatively, and was only discovered after the fundoplication failed to eliminate symptoms. Unfortunately, surgery not only does not improve symptoms in children with motility or hypersensitivity issues, but it also makes them worse in many cases.
Some children begin to retch after surgery even without pre-surgical vomiting. While this is not entirely understood, researchers have hypothesized that this retching may be due to sensitization of the emetic reflex from vagus nerve damage during surgery, or development of gastric dysrhythmia or uncoordinated gastric contractions as a result of surgery.
Take Note of What Is and Isn't Working
Once feeding becomes so medical, parents are scared to do the wrong thing. We defer to medical professionals, which is understandable and expected. If you spent a lot of time in the hospital early on, you may not really trust your parenting skills at first.
However, take a step back and remember this is feeding your child and you are with this child day in and day out. You get the most immediate feedback on how feeds are going – vomit, retching, discomfort. Trust that parent instinct if you think that something is wrong, or if things are working well. Keep detailed notes of the changes you make and their impact. It will allow you to have a more informed conversation with your doctor, nurse or dietitian. Your input is important to the process and can help mold feeding plans that your child can better tolerate.