NOTE: You will note that Dr. Fleisher refers to 'children' in his articles, but please keep in mind that at the time of writing, CVS was considered mostly a 'childhood syndrome'. As time goes on more and more adults are known to be suffering from this same collection of symptoms. While these articles refer to 'children' they apply just as well to 'adults'. The longer I work with CVS patients, the more I appreciate the differences and the variability of patients and their symptoms. For example, how do CVS patients behave during episodes? Some children are able to walk about or watch TV between bouts of vomiting. Others are so overwhelmed by intense nausea that they lie immobile, silent, unable to talk or respond, their eyes closed, their motionless faces concealing indiscernible internal suffering. Some patients experience, in addition to nausea, intense abdominal aching and/or heartburn. They may role about in agony. Some are unable to swallow their saliva and carry a basin or towel to spit into. Some are averse to any oral intake, while a few are driven to drink large amounts of fluids, even though they know that it will come up almost immediately. Some will drink and then try to make themselves vomit. This behavior may be misdiagnosed as "bulimic" and all too many CVS patients have been treated for eating disorders. The real reasons for this perplexing behavior is that the ingested fluids dilute the acid and bile that would otherwise bum their throats when they vomited. Moreover, successful vomiting lessens nausea for a few moments and if the nausea is intense enough, this transient relief is worth the effort required to make themselves vomit. There is great variability in how patients respond to treatment. Indeed, there is as yet no "standard treatment' for CVS. Each patient is unique in how he or she responds to the many medications and procedures that are used in CVS. It may take many tries and many failures before arriving at that which makes coping with CVS so much easier: A medication or maneuver that "works' and can be relied upon to help in relieving or preventing the onslaught of nausea and vomiting. It helps to have goals in mind while searching for effective treatment. What we'd like to do is stop episodes. If that can't be accomplished, we need to find a way to make the patient comfortable until the episode runs its course. in some patients, the episode can be aborted. Episodes can be prevented or minimized with prophylactic measures in some cases. The ultimate goal, of course, is recovery. How can episodes be stopped? A few patients are helped by nothing more than being given glucose-containing fluids intravenously. Anti-nausea agents be very effective in turning off nausea. The first medication I ever saw make a patient's nausea lift was lorazepam (Ativan). This drug may be give by vein, infection or taken by mouth, if possible. The use of Ativan was discovered nearly a decade ago by Dr. Larry Puls, an obstetrician/gynecologist. He knew of its effectiveness in treating the nausea and vomiting experienced by some women during labor. It was tried in cooperation with their pediatrician on his daughter Emily. Emily had suffered extremely long episodes which responded for quite some time to Ativan. Other agents, such as ondansetron (Zofran) are also effective in many patients. What can be done for patients whose episodes cannot be stopped? Sleep is the only state in which a CVS patient can find comfort during an episode. So, if the nausea can't be abolished, the next step is to get the patient to sleep and keep him or her asleep most of the time until the episode ends. Sedative medications administered intravenously include Chlorpromazine (Thorazine) combined with diphenhydramine (Benadryl) every 3 to 6 hours in doses sufficient to promote sleep. Chlorpromazine has anti-nausea and sedative effects, although it rarely turns off the nausea of a CVS episode. It has the potential for causing side effects knows as "extrapyramidal reactions.' These most commonly consist of involuntary movements of some muscles of the head, tongue, jaw or neck which are not dangerous, but quite frightening. Benadryl counteracts these reactions promptly and effectively. Prochlorperazine (Compazine) is similar to chlorpromazine, but it has a greater potential for causing extrapyramidal reactions. It is not superior to Thorazine in its anti-nausea or sedative effects. Parents have voiced concerns about their child choking on vomit during sleep. These sedative medications enhance sleep. I have never seen them "pushed' to the extent that they cause drug-induced coma. Intense nausea, like intense pain, interrupts sleep. 'The gag and cough reflexes are operational in properly sedated patients and they can clear any vomitus that might approach the airway. This article appeared in CVSA's Code V Newsletter in the Spring of 1996. Another goal of management is finding a way to abort episodes -- to get them to stop before they start. This is only possible if episodes are preceded by a "prodrome," i.e., a period in which there are symptoms that signal impending nausea, during which oral medications can be swallowed and retained long enough to take effect. Obviously, this isn't possible and a patient who goes to bed feeling well can awake at 4:00 a.m. and start vomiting. Some patients, especially those whose episodes are triggered by increased anxiousness, can recognize their anxiety and take a medication (e.g., Ativan or Xanax) which calms anxiety and is mildly sedative. They may then sleep for a few hours and wake up feeling well, their episodes having been aborted. Tension-reduction techniques can be learned with the help of a psychologist. They may aid the patient in making the attacks go away before they start. If the characteristic abdominal ache precedes the onset of nausea, one might try taking ibuprofen for the ache; Ativan and/or Zofran can be taken in anticipation of nausea; cisapride (Propulcid) can be taken to speed the passage of other medications from the stomach into the intestine where they can be absorbed and take effect; and rantidine (Zantac) can be taken to suppress the stomach acid that otherwise causes heartburn in the nauseated patient. If episodes are regular enough, or if the circumstances that trigger them are predictable enough, measures can be taken the day or evening before the expected onset, even in the absence of prodromal symptoms. For example, if a child's episodes are triggered by car sickness, give the child a substantial dose of Drainamine or Bonine (available over the counter) the night before and the morning of departure. If colds, flu or other infections trigger episodes, consider using effective sedative or anti-nausea medications along with whatever medications are indicated for treatment of the infection. Another goal of management is prophylaxis of episodes -- measures taken on a daily basis that make the episodes occur less often, shorter, or with lower intensity. One of the similarities between CVS and migraine is that medications used for prophylaxis of migraine headaches are often effective in CVS. These medications include cyproheptadine (Periactin), and amitriptyline (Elavil) and propranolol (Inderal). No prophylactic medication works for every patient. Completely successful prophylaxis, i.e., the prevention of all recurrences, seldom occurs. It is not advisable for a patient whose episodes are brief, infrequent and minimally incapacitating to take potent medications on a daily basis. For example, a child who suffers 6-12 hour episodes once or twice a year is helped more by having an effective way of aborting or shortening episodes than by taking a prophylactic medication everyday. CVS is not just a disorder of the central nervous system and intestinal tract. It is an illness involving a person with in a family. Therefore, the treatment of CVS must involve more than medicines and IV fluids. Emotional stress triggers episodes in many patients and anxiety is known to promote nausea. One kind of anxiety results from the dread of a recurrence of vomiting. The way to calm that anxiety is to get control of the episodes so that the patient needn't feel helpless when the attack starts and the parents needn't feet as though there is nothing they can do for their child. A caring, communicative, accessible, responsive physician who isn't defeated by failure and is willing to struggle in collaboration with the family until well-being is restored is almost essential to success. Nonetheless, gaining control over sources of anxiety or stress other than that caused by the disorder itself can be the key to progress. If relationships within the family are strained, if effective communication is replaced by arguing, lonely silences, or sadness, then CVS might be perpetuated. There is a role, in some cases, for a counselor or other mental health professional to get on board and help the family identify and deal with family and emotional issues which might otherwise never be recognized, understood or overcome. This kind of help might be needed for no other reason than that parents, preoccupied with the drudgery and stress of caring for a child with CVS may lose sight of their own needs and other family members. It greatly helps CVS children learn their diagnosis and the fact that many other children and adults have the same disorder. It also helps to see mom and dad happier. The ultimate goal of management is recovery, and that occurs in almost every case. CVS is just beginning to become widely known to the public and to the medical community. Research has just begun, largely as a result of the efforts of CVSA and its professional affiliates. Getting the word out and supporting research is the path towards overcoming this disorder. The accomplishments of the past three years have been nothing short of amazing! But, we're at the beginning. Let's press on! This article appeared in CVSA's Code V Newsletter in the Spring of 1993.

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