Hiccups

The only symptom of hiccups is a slight tightening sensation in your chest, abdomen, or throat that causes the hiccup sound.

The hiccup reflex involves the synchronized action of the:

• Diaphragm: A large muscle located below the lungs that separates the chest from the abdomen. It contracts rhythmically and continually to aid in respiration.
• Muscles that open and close the windpipe.
• Nerves that act upon the diaphragm.

If any of the nerves involved in this cycle are triggered for any reason, the diaphragm may contract involuntarily, allowing air to be drawn into the lungs. As a result, the epiglottis (the top of the windpipe) closes, resulting in the distinctive cough-like ‘hic’ sound.

• Eating too quickly or too much
• Eating very hot or very cold foods
• Consuming spicy food
• Drinking alcohol and carbonated beverages
• Swallowing air with chewing gum or sucking on candy
• Indigestion
• Bad odor
• Inhaling toxic fumes
• Cigarette smoking
• Over-stretching the neck
• Sudden temperature changes
• Feeling nervous or excited

Causes of persistent and intractable hiccups:

1. Nerve damage or irritation: Conditions that may cause damage or irritation to the nerves controlling the diaphragm include Gastroesophageal Reflux Disease (GERD), sore throat, goiter, tumor, or cyst.
2. Medications: Certain medications can cause hiccups, such as:
   • Antibiotics like azithromycin
   • Psychiatric medications like aripiprazole
   • Anesthetic drugs like propofol
   • Steroids
   • Certain epilepsy medications
3. Instrumentation: Certain procedures requiring instruments can mechanically irritate the nerves controlling the diaphragm, inducing hiccups, e.g., abdominal or chest surgery.
4. Other medical conditions: Conditions that may prompt frequent or prolonged attacks of hiccups include:
   • Oesophagitis (inflammation of the food pipe)
   • An overactive thyroid gland
   • Pleurisy (inflammation of the membrane surrounding the lungs)
   • Pneumonia (inflammation of the lungs)
   • Tuberculosis
   • Influenza (flu)
   • Pericarditis (inflammation of the tissue surrounding the heart)
   • Diabetes
   • Malaria
   • Hernia
   • Uremia (increased levels of waste products in blood)
   • Hypocalcemia (deficiency of calcium)
   • Chronic kidney failure
   • Multiple sclerosis
   • Stroke
   • Cancer

Causes of hiccups in infants:

Hiccups are common in babies under 12 months. Newborns and infants may experience hiccups more frequently during or after feeding due to swallowing food too quickly or overfeeding. This can lead to stomach distension, pushing against the diaphragm, which causes it to contract and results in hiccups. Hiccups can indicate that an infant is full. Pediatricians typically recommend short feeds with burping breaks. Your baby will usually stop hiccupping within 5 to 10 minutes; however, if the hiccups persist for a couple of hours, it is advisable to consult a doctor. Generally, hiccups are a sign of healthy growth and development.

• Men are more prone to develop long-term hiccups compared to women.
• Anxiety, stress, and intense emotions.
• Patients who have received general anesthesia.
• Post-surgery, particularly after abdominal or chest surgery.
• Pregnancy.

No specific test is required in the diagnosis of hiccups, but in cases of persistent or intractable hiccups, it is important to detect any probable underlying illness.

1. History

A physician may ask for the history of the current illness, including the duration of the hiccups, any treatments used, and their relevance to a recent condition or operation. They may also inquire about your past medical history, including:

• Known gastrointestinal disorders
• Neurologic disorders
• Drug history, including alcohol use

2. Physical Examination

During the physical exam, the doctor may perform a neurological assessment to check:

• Balance and coordination
• Muscle strength and tone
• Reflexes
• Sight and sense of touch

3. Laboratory Testing

While no specific evaluation is required for acute hiccups, the following lab tests might be suggested for the diagnosis of long-term hiccups:

• Serum electrolytes
• Calcium test
• Blood urea nitrogen (BUN) test
• Creatinine test
• Lipase
• Liver function tests

4. Imaging Techniques

These tests may help identify abnormalities inside the chest, neurological changes, or lesions causing hiccups:

• ECG (Electrocardiogram)
• Chest radiograph
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI)

Hiccups are very common and usually resolve on their own. Try these tips to prevent hiccups by making some changes in your habits:

Do’s:

• Eating smaller meals
• A cold water shower
• Managing stress and anxiety effectively
• Self-protection from sudden changes in temperature

Don'ts:

• Eating too fast
• Consuming spicy food
• Drinking alcoholic, fizzy, or carbonated drinks
• Eating or drinking something very cold immediately after something hot
• Chewing gum
• Smoking
• Over-stretching your neck
• Inhaling toxic fumes

The doctor will want to know if your hiccups are caused by a medical condition or medication you are taking. If the underlying problem is treated or you switch medications, the hiccups should go away. The underlying cause determines the pharmacological treatment, which may include:

I. Medications Based on Specific Causes:

• For nasal symptoms: Nebulized 0.9% saline (2 mls over 5 minutes)
• To reduce gastric irritation: Proton pump inhibitors, including:
  • Omeprazole
  • Pantoprazole
  • Lansoprazole
• To reduce gastric distension (enlargement): Medications include:
  • Metoclopramide
  • Domperidone
  • Itopride
• Antiflatulent: These medications are used to treat or prevent excessive intestinal gas, including:
  • Simethicone
  • Peppermint water
  • Carminative agent

II. Medications for Intractable Hiccups:

• Dopamine antagonists: These medicines can relax the diaphragm muscle or its nerve supply and may stop persistent hiccups, including:
  • Haloperidol
  • Olanzapine
  • Chlorpromazine
  • Methylphenidate
• GABA agonist: Baclofen is the medication of choice as it helps relax muscles. Note: Caution is advised in the elderly and patients with kidney dysfunction.
• Local anesthetic: Low-dose lignocaine infusion or nebulization helps stop hiccups.
• Antiepileptic: These help relax the nerve supply to the diaphragm and relieve hiccups. The most commonly used drugs include:
  • Gabapentin
  • Sodium valproate
• Calcium channel blocker: These blockers, such as nifedipine, can help control hiccups.

III. Invasive Procedures:

More invasive options might be attempted only in extreme cases of hiccups. These include:

• Nasogastric intubation: Insertion of a tube into the stomach via the nose.
• Phrenic nerve block: The phrenic nerve, which supplies the diaphragm, can be blocked using anesthetic medication.
• Diaphragmatic pacemaker: A battery-powered device that can be implanted surgically to stimulate or pace the nerves supplying the diaphragm (the phrenic nerve or vagus nerve) and regulate breathing.

Hiccups usually resolve on their own. However, if the hiccups don't stop, here are some tips that can help. While not many studies evaluate the effectiveness of these hiccup remedies, they are supported by anecdotal evidence. Additionally, some of the most common remedies stimulate your vagus or phrenic nerves, which are connected to your diaphragm.

1. Posture and Breathing Tips:

• Pull your knees up to your chest and lean forward.
• Hold your breath for several seconds or longer.
• Breathe out against a closed mouth and nose.
• Breathe into a paper bag (do not put it over your head).

2. Pressure Points Tips:

• Pull hard on the tongue.
• Put pressure on your diaphragm (the diaphragm separates your abdomen from your lungs).
• Squeeze your nose closed while swallowing water.
• Use your thumb to apply pressure to the palm of your other hand.
• Give a gentle massage on your carotid artery on both sides of your neck.

3. Dietary Tips:

• Swallow a teaspoon of sugar.
• Slowly drink a glass of warm water without stopping to breathe.
• Sip ice-cold water or gargle with ice water.
• Bite on a lemon or taste vinegar.

4. Other Tips:

• Distract yourself with something engaging.
• Tapping or rubbing the back of your neck.

5. Home-Care Tips for Hiccups in Infants:

Here are some tips that can be helpful for toddler or infant hiccups.

Feeding Tips:

• Encourage your baby to burp as you switch from one breast to another or after feeding.
• After each feeding, keep the baby upright for 20 to 30 minutes.
• Resuming feeding can sometimes stop hiccups.
• If your baby is bottle-fed, make sure to tip the bottle while feeding to limit the amount of air the baby swallows.
• You can also use anti-colic bottles, which do not allow air passage during feeding.

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Other General Tips:

• Cold water can be given to the baby.
• Teas containing fennel, chamomile, or peppermint can be introduced into your infant's mouth using a dropper. This relieves the muscle spasms that cause hiccups.
• Rubbing the baby's back.
• Applying light downward pressure to the infant's upper stomach.
• Tickling can distract your toddler's attention from their hiccups.

It is always advisable to seek the child's pediatrician's consent before starting these tips.

What Not to Do:

• Never startle or scare the baby.
• Never try holding the baby's breath.

Frequent episodes of acute hiccups, as well as persistent and intractable hiccups, can significantly impact the quality of life and cause physical pain, humiliation, or psychological distress. The following complications are associated with them:

• Dehydration
• Malnutrition
• Tiredness
• Insomnia (lack of sleep)
• Weight loss
• Anxiety and depression
• Delayed healing of a scar (wound) after recent abdominal surgery, increasing the likelihood of wound complications.

Strong hiccups can also cause:

• Reduced heart rate
• Drop in blood pressure
• Collapse of the lung due to air or gas in the space between the lungs and the chest wall

1. Acupuncture

Acupuncture can be explored as an alternative treatment option for persistent and intractable hiccups. It stimulates the nerves responsible for hiccups. Some case studies indicate that acupuncture may effectively treat persistent hiccups, even when conventional treatments fail. Although there is insufficient evidence evaluating the safety and effectiveness of acupuncture in resolving hiccups, some individuals have successfully ceased their long-term hiccups with this therapy, making it a potential option worth considering.

2. Massage

A carotid sinus massage may be suggested to manage chronic hiccups. This technique involves rubbing the main carotid artery in the neck by a healthcare provider.

Hiccups are usually harmless and resolve themselves in a few minutes. Simple home remedies can help manage them.

However, chronic or prolonged hiccups can be highly stressful, annoying, and disrupt daily routines. They can make sleeping difficult or wake you up in the middle of the night. If the condition lasts for an extended period, the lack of sleep can lead to a loss of energy throughout the day, resulting in exhaustion. All these factors can negatively impact a person's quality of life.

To cope with the condition, consider the following:

• Get plenty of rest.
• Eat and drink small amounts regularly.
• Be aware of potential complications.

Additionally:

• Take prescribed medications on time.
• Keep yourself busy and distracted.
• Develop a hobby.
• Join support groups facing similar challenges.

Maintain regular contact with your doctor throughout treatment to avoid the recurrence of hiccups and complications associated with chronic hiccups.