Children with Functional Nausea—Comorbidities outside the Gastrointestinal Tract

      Objective

      To detail common comorbidities and procedures performed to evaluate functional nausea in children.

      Study design

      In total, 63 children age 7-18 years seen in a tertiary care pediatric clinic who met Rome IV criteria for functional nausea prospectively completed an Intake Questionnaire, the Pediatric and Parent-Proxy PROMIS-25 Profile v 2.0, the Pediatric and Parent-Proxy Pediatric Sleep Disturbance-Short Form 4a, and the COMPASS 31 orthostatic intolerance scale to assess comorbidities. Medical records were reviewed for diagnostic tests performed to evaluate nausea and for additional comorbidities. Summary statistics were used to determine the most common comorbidities and diagnostic yield of the procedures. Intraclass correlation coefficients assessed agreement between parent and child reports on the PROMIS scales.

      Results

      Patients with functional nausea experienced multisystem comorbidities. A majority reported abdominal pain, headache, orthostatic intolerance, fatigue, disturbed sleep, anxiety, constipation, allergies, and vomiting. Agreement between parent-proxy and child report of symptoms on PROMIS scales was good to excellent (intraclass correlation coefficients = .78-.83; all P < .001). Patients underwent extensive diagnostic testing: 96 endoscopic procedures, 199 radiologic tests, and 4 cholecystectomies. Most of the procedures were not diagnostically informative.

      Conclusions

      Children with functional nausea have comorbidities outside the gastrointestinal tract that warrant evaluation. Gastrointestinal diagnostic tests were of low-yield in identifying a cause. Understanding the relationship with comorbidities may provide insight into etiologies for the nausea and define clinical phenotypes to better tailor care.

      Keywords

      Abbreviations:

      CT ( Computed tomography), EGD ( Esophagogastroduodenoscopy), EHR ( Electronic health record), EoE ( Eosinophilic esophagitis), FGID ( Functional gastrointestinal disorder), GI ( Gastrointestinal), HIDA ( Hepatobiliary iminodiacetic acid), HUT ( Head-up tilt), ICC ( Intraclass correlation coefficient), MRI ( Magnetic resonance imaging), OH ( Orthostatic hypotension), OI ( Orthostatic intolerance), POTS ( Postural orthostatic tachycardia syndrome)
      To read this article in full you will need to make a payment

      References

        • Hyams J.S.
        • Di Lorenzo C.
        • Saps M.
        • Shulman R.J.
        • Staiano A.
        • van Tilburg M.
        Functional disorders: children and adolescents.
        Gastroenterology. 2016; 5: 181-185
        • Kovacic K.
        • Williams S.
        • Li B.U.
        • Chelimsky G.
        • Miranda A.
        High prevalence of nausea in children with pain-associated functional gastrointestinal disorders: are Rome criteria applicable?.
        J Pediatr Gastroenterol Nutr. 2013; 57: 311-315
        • Russell A.C.
        • Stone A.L.
        • Walker L.S.
        Nausea in children with functional abdominal pain predicts poor health outcomes in young adulthood.
        Clin Gastroenterol Hepatol. 2017; 15: 706-711
        • Sullivan S.D.
        • Hanauer J.
        • Rowe P.C.
        • Barron D.F.
        • Darbari A.
        • Oliva-Hemker M.
        Gastrointestinal symptoms associated with orthostatic intolerance.
        J Pediatr Gastroenterol Nutr. 2005; 40: 425-428
        • Kovacic K.
        • Miranda A.
        • Chelimsky G.
        • Williams S.
        • Simpson P.
        • Li B.U.
        Chronic idiopathic nausea of childhood.
        J Pediatr. 2014; 164: 1104-1109
        • Tarbell S.E.
        • Shaltout H.A.
        • Wagoner A.L.
        • Diz D.I.
        • Fortunato J.E.
        Relationship among nausea, anxiety, and orthostatic symptoms in pediatric patients with chronic unexplained nausea.
        Exp Brain Res. 2014; 232: 2645-2650
        • Dhroove G.
        • Chogle A.
        • Saps M.
        A million-dollar work-up for abdominal pain: is it worth it?.
        J Pediatr Gastroenterol Nutr. 2010; 51: 579-583
      1. PROMIS. Obtain & Administer Measures.
        • Sletten D.M.
        • Suarez G.A.
        • Low P.A.
        • Mandrekar J.
        • Singer W.
        COMPASS 31: a refined and abbreviated composite autonomic symptom score.
        Mayo Clin Proc. 2012; 87: 1196-1201
        • DeWalt D.A.
        • Gross H.E.
        • Gipson D.S.
        • Selewski D.T.
        • Morgan DeWitt E.
        • Dampier C.D.
        • et al.
        PROMIS® pediatric self-report scales distinguish subgroups of children within and across six common pediatric chronic health conditions.
        Qual Life Res. 2015; 24: 2195-2208
        • Irwin D.E.
        • Gross H.E.
        • Stucky B.D.
        • Thissen D.
        • DeWitt E.M.
        • Lai J.S.
        • et al.
        Development of six PROMIS pediatrics proxy-report item banks.
        Health Qual Life Outcomes. 2012; 10: 22
        • Black L.I.
        • Benson V.
        Tables of Summary Health Statistics for U.S. Children: 2018.
        National Health Interview Survey, 2019
        https://www.cdc.gov/nchs/nhis/SHS/tables.htm
        Date accessed: November 15, 2020
        • Freeman R.
        • Wieling W.
        • Axelrod F.B.
        • Benditt D.G.
        • Benarroch E.
        • Biaggioni I.
        • et al.
        Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
        Clin Auton Res. 2011; 21: 69-72
      2. Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_C-6.pdf. Accessed November 15, 2019.

        • Park J.W.
        • Cho Y.S.
        • Lee S.Y.
        • Kim E.S.
        • Cho H.
        • Shin H.E.
        • et al.
        Concomitant functional gastrointestinal symptoms influence psychological status in Korean migraine patients.
        Gut Liver. 2013; 7: 668-674
        • Schurman J.V.
        • Friesen C.A.
        • Dai H.
        • Danda C.E.
        • Hyman P.E.
        • Cocjin J.T.
        Sleep problems and functional disability in children with functional gastrointestinal disorders: an examination of the potential mediating effects of physical and emotional symptoms.
        BMC Gastroenterol. 2012; 12: 142
        • Kovacic K.
        • Chelimsky T.C.
        • Sood M.R.
        • Simpson P.
        • Nugent M.
        • Chelimsky G.
        Joint hypermobility: a common association with complex functional gastrointestinal disorders.
        J Pediatr. 2014; 165: 973-978
        • Zarate N.
        • Farmer A.D.
        • Grahame R.
        • Mohammed S.D.
        • Knowles C.H.
        • Scott S.M.
        • et al.
        Unexplained gastrointestinal symptoms and joint hypermobility: is connective tissue the missing link?.
        Neurogastroenterol Motil. 2010; 22: 252-e278
        • Boccia G.
        • Del Giudice E.
        • Crisanti A.F.
        • Strisciuglio C.
        • Romano A.
        • Staiano A.
        Functional gastrointestinal disorders in migrainous children: efficacy of flunarizine.
        Cephalalgia. 2006; 26: 1214-1219
        • Fortunato J.E.
        • Shaltout H.A.
        • Larkin M.M.
        • Rowe P.C.
        • Diz D.I.
        • Koch K.L.
        Fludrocortisone improves nausea in children with orthostatic intolerance.
        Clin Auton Res. 2011; 21: 419-423
        • Fortunato J.E.
        • Wagoner A.L.
        • Harbinson R.L.
        • D'Agostino Jr., R.B.
        • Shaltout H.A.
        • Diz D.I.
        Effect of fludrocortisone acetate on chronic unexplained nausea and abdominal pain in children with orthostatic intolerance.
        J Pediatr Gastroenterol Nutr. 2014; 59: 39-43
        • Tabbers M.M.
        • DiLorenzo C.
        • Berger M.Y.
        • Faure C.
        • Langendam M.W.
        • Nurko S.
        • et al.
        Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.
        J Pediatr Gastroenterol Nutr. 2014; 58: 258-274
        • Kearney R.
        • Edwards T.
        • Bradford M.
        • Klein E.
        Emergency provider use of plain radiographs in the evaluation of pediatric constipation.
        Pediatr Emerg Care. 2019; 35: 624-629
        • Wewer V.
        • Strandberg C.
        • Paerregaard A.
        • Krasilnikoff P.A.
        Abdominal ultrasonography in the diagnostic work-up in children with recurrent abdominal pain.
        Eur J Pediatr. 1997; 156: 787-788
        • Shrank W.H.
        • Rogstad T.L.
        • Parekh N.
        Waste in the US health care system: estimated costs and potential for savings.
        JAMA. 2019; 322: 1501-1509
        • Russell A.C.
        • Stone A.L.
        • Wang A.
        • Walker L.S.
        Development and validation of a nausea severity scale for assessment of nausea in children with abdominal pain-related functional gastrointestinal disorders.
        Children (Basel). 2018; 5: 68