Solutions for Retching

Note: this is a revised version of an article originally published in 2008.

Retching, also commonly known as the dry heaves, is a very frequent complaint in children who have certain neurological or gastrointestinal conditions or who have had a fundoplication surgery. Children whose nervous systems are overly sensitive, as well as children with motility problems, are especially likely to experience retching.

Retching is basically the same process as vomiting, except nothing is actually vomited. It can be extraordinarily debilitating for children. Some may spend hours a day retching, or have dozens of retching episodes over the course of the day. Sometimes it becomes so serious that sedation is required. However, retching often can be treated effectively if a doctor has the appropriate diagnostic tests and knowledge.

Non-Fundoplication Retching

Because retching and vomiting can be symptoms of many disorders, a doctor should evaluate any child with persistent retching or vomiting to rule out other serious conditions. Conditions like a brain tumor, cyclic vomiting syndrome, eosinophilic esophagitis, or other gastrointestinal conditions can also cause retching and vomiting.

If these conditions have been ruled out, retching that occurs in a child who has not had fundoplication surgery typically has one of two causes: a motility problem, or hypersensitivity of the stomach or other parts of the GI tract. In these children, vomiting often follows retching, 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. The problem must be identified before it can be treated. Doctors typically use manometry testing of either the esophagus or the stomach/duodenum to determine the specific nature of the motility problem. Note that constipation and other problems with bowel motility may also result in slowing of the entire digestive tract, making retching worse.

Other children may have a hypersensitive gut, also called visceral hyperalgesia. This condition has many potential causes, including neurological conditions and repeated painful surgical procedures, especially in infancy. One common form of hypersensitivity is reduced gastric volume capacity. In children with this type of hypersensitivity, 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 a teaspoon 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.

Post-Fundoplication Retching

Fundoplication surgery is a procedure common in children who have persistent reflux, and may be performed in some children when they have a feeding tube placed. In this procedure, the stomach is wrapped around the esophagus, preventing reflux and vomiting. In practical terms, 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 cannot be released out of the stomach.

While this type of retching occurs in a child with a fundoplication who has a stomach virus, it does not explain why some children retch continuously after a fundoplication surgery. In these cases, 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.¹ Most of these children have a hypersensitive emetic reflex or visceral hyperalgesia, as described earlier in this article. In some cases, a motility problem or other condition was mistaken for reflux pre-operatively, and was only discovered after the fundoplication failed to eliminate symptoms. As an important study on retching post-fundoplication states, “It seems probable that the abnormalities in motility and visceral sensation existed before fundoplication, and contributed to the pathogenesis of chronic symptoms prompting surgery.”² 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 vomiting reflex from irritation of the nerves during surgery, or the development of uncoordinated gastric contractions as a result of surgery.

In the study mentioned earlier, 14 toddlers, 11 with cerebral palsy, and 3 with non-neurological disorders, were evaluated for post-fundoplication retching. All children in this study were found to have motility or sensory problems. Two children had motility problems of the esophagus, five had visceral hyperalgesia alone, seven had antroduodenal (stomach and small intestine) motility problems and visceral hyperalgesia, and one had esophageal and antroduodenal motility abnormalities as well as visceral hyperalgesia. It is likely that most of these children had these problems before surgery, but they were either unrecognized or they increased after surgery.

Diagnosing Retching

There are treatments for retching, but they depend on a proper diagnosis, which demands a motility specialist who can perform and interpret testing. The specialist must be able to recognize conditions including motility problems, hypersensitivity of the gut, or an overactive vomiting reflex.

Common tests include:

• Esophageal manometry
• Esophageal impedance study
• Antroduodenal manometry
• Colonic motility study
• Anorectal manometry
• Gastrointestinal transit studies
• Electrogastrography
• Electronic barostat
• Autonomic function studies

Treatments for Retching

There are numerous treatments available for retching, but many depend on the cause of the retching. Changing the feeding method, using medications, and treating underlying hypersentivity are some of the general ways to treat retching.

Treat Underlying Conditions

Some underlying conditions, such as reflux and constipation, can make retching and vomiting much worse. Aggressively treating these conditions may help to reduce retching. In addition, improving sensory feeding problems may also help to improve retching, especially when it is the result of gagging from textures, tastes, or smells. Finally, consider evaluating and treating for bacterial overgrowth in the gut, as that condition often worsens retching.

Change Feeding Methods

In children with mild retching, changing the feeding method may be helpful. Children who eat orally may want to eat smaller, more frequent meals and snacks. If the child has a feeding tube, feedings may be slowed down, given more frequently, or switched to continuous drip feedings.

Sometimes children, especially those with feeding tubes, are fed too much, too fast, or too calorically-dense formulas. Making sure the feeding schedule and amount are both optimized often results in improvement.

Venting the G-tube either periodically or continuously with a Farrell bag, open syringe, or other venting system is another option that may help some children, especially those who tend to swallow air or burp frequently.

Many children also find switching to a GJ-tube beneficial. This tube allows feeding directly into the intestine, bypassing the stomach. It also allows venting or draining of the stomach during feeds or continuously. Feedings must be given continuously with this type of feeding tube.

Finally, changing the type of food or formula may help considerably. Blenderized diets, either using homemade blended foods or commercial blended formulas, have been shown to reduce retching, reflux, and vomiting.³ In general, thicker foods tend to stay down better than thinner foods or formulas.

Use Medications

If changing the feeding method does not eliminate retching, medication may be helpful. Anti-emetics, such as Zofran (ondansetron), Periactin (cyproheptadine), or even Diphenhydramine, may be useful for some children.

Children who have spasmodic motility problems, such as spasms of the esophagus or intestine, may respond to medications called anticholinergic drugs or anti-spasmodics. These include Bentyl (dicyclomine), Levsin (hyoscyamine sulfate), or Donnatal (hyoscyamine sulfate with phenobarbital, atropine, and scopolamine), though these may also slow digestion, causing other GI problems. Esophageal spasms may also be treated with medications like Procardia (nifedipine). Botox is beginning to be used by some physicians to relax sphincters that spasm persistently. Baclofen is also occasionally used.

Children with delayed emptying or lack of “housekeeper” contractions in the gut can be treated with promotility medications such as Reglan (metoclopramide), erythromycin, or even Sandostatin (octreotide). In cases of pseudo-obstruction, Neostigmine or pyridostigmine may also be used.

Medications to reduce visceral or neuropathic pain should be used in children with Visceral Hyperalgesia or hypersensitivity. These include Neurontin (gabapentin), Lyrica (pregabalin), Elavil (amitriptyline), Clonidine, Tofranil (imipramine) or other tricyclic antidepressants. Some children may also benefit from an appetite enhancer like Periactin (cyproheptadine). For lower bowel issues, Linzess (linaclotide) or Amitiza (lubiprostone) may help, though these medications are not approved for children.

Treat Hypersensitivity

Children with a low gastric pain threshold or visceral hyperalgesia require a more nuanced approach.⁴ First of all, pain to the gut must be eliminated. This is commonly done by switching a child to GJ-feeds to rest the stomach, usually for a period of a few months before transitioning back to oral or G-tube feeds. Behavioral intervention may also be appropriate, especially to minimize pain and the perception of pain. Medications, such as those listed above, should be considered as part of an overall plan to reduce hypersensitivity.

Successful Treatment

In the study mentioned earlier, 13 out of the 14 patients with retching showed a dramatic improvement in symptoms. 80% were happier or more comfortable after treatment, and 43% improved their feeding, either no longer requiring tube feeds or advancing to partial G-feeds and oral feeds.

Retching can be treated, but it usually requires sophisticated testing and evaluation by a skilled motility specialist with advanced knowledge in the interaction between the brain and the gut. For children whose lives are dominated by daily retching episodes, finding a knowledgeable motility specialist is essential in regaining the child’s quality of life.

¹Richards CA, et al. Retching and Vomiting in Neurologically Impaired Children After Fundoplication: Predictive Preoperative Factors. Journal of Pediatric Surgery 2001;36, no. 9:1401-4.

²Zangen T, et al. Gastrointestinal Motility and Sensory Abnormalities May Contribute to Food Refusal in Medically Fragile Toddlers. Journal of Pediatric Gastroenterology and Nutrition 2003;37:288.

³Pentiuk, S, O’Flaherty, T, Santoro, K, Willging, P and Kaul, A. (2011). Pureed by Gastrostomy Tube Diet Improves Gagging and Retching in Children With Fundoplication Journal of Parenteral and Enteral Nutrition 2011;35: 375-379.

⁴Hauer J. Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention Children (Basel). 2017;5(1):1.