Patient Presentation
An 8-year-old male came to clinic for his well child care. His mother had no concerns and the patient was healthy. In the office, they were laughing because the boy had hiccups that were causing halting speech that was comical to them. The mother noted that he had intermittent hiccups that appeared to be associated with “fizzier” carbonated beverages such as some types of root beer or ginger ale. The physician inquired if they caused any problems or lasted a long time. The family said that they seemed to get better after a bit of time and never caused any problems. “He’s tried to hold his breath today, but I think all the laughing is making it worse. It’ll go away in a while after we all stop laughing,” chuckled the mother.

Discussion

Hiccups affect nearly everyone at sometime in their life but continue to be poorly understood and are usually considered a nuisance. The medical term for hiccups is singultus which comes from the Latin meaning “to be caught in the act of sobbing.” Hiccups are caused by a diaphragmatic spasm that causes a sudden inhalation that is interrupted by the spasmodic closure of the glottis that produces the characteristic hiccup sound. The ‘hic’ in hiccup occurs 4-60 times/minute and in adults has no physiological purpose, but in fetuses may help train inspiratory muscles for respiration after delivery.

A retrospective study of consecutive patients in a community hospital found 55 of 100,000 patients had hiccups. Of those, only 2 were under age 18, so it appears that although hiccups occur in the pediatric population, they are not often brought to the attention of medical personnel.

Hiccups are classified based on their duration. Acute hiccups last less than 48 hours, persistent hiccups last more than two days and intractable hiccups last more than one month. Hiccups that last more than 48 hours are more likely to be associated with an organic or anatomic problem.

Hiccups are caused by a reflex arc. The afferent component is from the vagus nerve, phrenic nerve and sympathetic nerves of the thoracic outflow tract. The central nerves are in the upper spinal cord, medulla near the respiratory center, hypothalamus and reticular formation. These areas seems to have numerous dopaminergic and GABA-ergic receptors involved. The efferent component is the phrenic nerve to the diaphragm (usually unilaterally) with intercostal muscles also being recruited. Glottis closure is through the recurrent laryngeal nerve branch of the vagus nerve.

Hiccups often seem to start and stop for no specific reason. Causes of hiccups are numerous but those affecting the gastrointestinal tract or central nervous system are common. Stomach distention and gastrointestinal/pulmonary irritants such as carbonated beverages, alcohol and smoking, or even hot chili peppers can cause hiccups. Anxiety and overbreathing or aerophagia can also cause hiccups. Central nervous system diseases that can have hiccups associated with them include epilepsy, meningitis, encephalitis and other brain injuries. Psychosomatic causes include anxiety and excitement, stress and fear. Drugs (benzodiazepines, steroids, and opiates) and also metabolic states (i.e. hyponatremia, hypokalemia, hypocapnia etc.) can cause hiccups.

Complications of hiccups include malnutrition, weight loss fatigue and insomnia.

Learning Point
Charles Mayo made the following comment, “The amount of knowledge on any subject such as hiccup can be considered as being in inverse proportion to the number of different treatments suggested for it.”

There are numerous purported treatments for hiccups. The best treatment for hiccups is directed toward underlying problems identified. Treatment for acute hiccups is usually physical maneuvers but no clinical trials have been conducted. Respiratory maneuvers such as breath-holding or rebreathing seems to help as acute hiccups seem to decrease with an increase in CO₂. Using valsalva maneuvers or CPAP-respiration may also be tried. Vagal stimulation such as cold compresses to the face, single-side carotid massage or gentle eyeball massage have also had some success. Induced fright or self-induced vomiting has also been tried. Nasopharyngeal stimulation using irritants such as smelling ammonia or vinegar, or drinking ice water to stimulate the oro-pharyngeal tissues has also been used.

Treatment for persistent or intractable hiccups often involves medications with baclofen and gabapentin being recommended in a recent systematic review. Other secondary and tertiary medications are recommended also in this publication. See To Learn More below.

Questions for Further Discussion
1. When should laboratory testing or radiological imaging be considered for hiccups?
2. If medications do not work, what are other alternative treatments which may be considered for hiccups?

Related Cases

Disease: Hiccups

Symptom/Presentation: Shortness of Breath | Respiratory Distress

Specialty: General Pediatrics | Gastroenterology | Neurology / Neurosurgery | Pharmacology / Toxicology | Medical History

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Hiccups.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Mayo CW. Hiccup. Sug Gynecol Obstet. 1932;55:700-8.

Amirjamshidi A, Abbassioun K, Parsa K. Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature. Surg Neurol. 2007 Apr;67(4):395-402.

Hao XT, Wang L, Yan B, Zhou HY. Intractable hiccup caused by spinal cord lesions in demyelination disease. J Spinal Cord Med. 2013 Nov;36(6):711-4.

Wallace AH, Manikkam N, Maxwell F. Seizures and a hiccup in the diagnosis. J Paediatr Child Health. 2004 Dec;40(12):707-8.

Cymet TC. Retrospective analysis of hiccups in patients at a community hospital from 1995-2000.
J Natl Med Assoc. 2002 Jun;94(6):480-3.

Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups.
Aliment Pharmacol Ther. 2015 Aug 25. (epub ahead of publication).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital