Treatment of Hiccups in Pediatric Patients
For acute hiccups in children, start with five firm back blows to the middle of the back while holding the child prone with the head lower than the chest, followed by five chest thrusts if needed, repeating this cycle until hiccups resolve. 1, 2
First-Line Physical Maneuvers
Position the child prone (face down) along your forearm for infants or across your thighs while kneeling for older children, ensuring the head is always lower than the chest throughout the procedure. 3, 1, 2
Deliver five sharp, firm back blows to the middle of the back using the base of your hand. 1, 2 These create an artificial cough mechanism that may terminate the hiccup reflex. 1
If back blows alone are insufficient, turn the child supine (face up) with head still lower than trunk and deliver five chest thrusts to the sternum. 2 For infants, use two fingers positioned one finger-width below the nipple line, compressing approximately 3 cm depth (one-third of chest diameter). 2
The chest thrusts should be more vigorous and rapid than standard CPR compressions, at approximately 20 per minute. 3, 2
After each cycle of back blows and chest thrusts, check the mouth and remove only visible foreign bodies—never perform blind finger sweeps as these can worsen the situation. 3, 4, 2
Critical Safety Warnings
Never use abdominal thrusts (Heimlich maneuver) in children for hiccup treatment, as they may cause abdominal organ rupture. 3, 1, 2
Never perform blind finger sweeps of the pharynx, as these can push material further into the airway. 3, 4, 2
When Physical Maneuvers Fail: Pharmacologic Options
If hiccups persist beyond 2-3 days despite physical maneuvers, pharmacotherapy becomes necessary. 5, 6
Chlorpromazine (FDA-Approved for Intractable Hiccups)
For intractable hiccups in children over 6 months, chlorpromazine 25-50 mg three to four times daily is the FDA-approved treatment. 5 This represents the only medication with formal FDA approval for hiccup treatment. 5
Chlorpromazine should generally not be used in children under 6 months except in potentially life-saving situations. 5
If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated. 5
Chlorpromazine and metoclopramide are the two most widely employed agents for intractable hiccups based on clinical experience. 6
Alternative Pharmacologic Agents
While chlorpromazine has FDA approval, other medications have shown efficacy in case reports and clinical experience:
Gabapentin and baclofen are commonly used alternatives for persistent hiccups, particularly when central nervous system involvement is suspected. 7, 8
Metoclopramide (a prokinetic agent) may be beneficial when gastroesophageal reflux is the underlying cause. 7
Identifying the Underlying Cause
Most acute hiccups in children result from gastric overdistension, followed by gastroesophageal reflux and gastritis. 9
Look for recent large meals, carbonated beverage consumption, or rapid eating patterns. 9
Assess for symptoms of reflux including regurgitation, feeding difficulties, or respiratory symptoms. 9
Hiccups persisting beyond 48 hours warrant investigation for serious underlying pathology including neurological, cardiovascular, pulmonary, infectious, or gastrointestinal disorders. 9
When to Seek Emergency Evaluation
Medical evaluation is mandatory if the child develops difficulty breathing, signs of respiratory distress, or if hiccups persist beyond 48 hours. 1, 9
Even if a child appears asymptomatic after a choking episode with hiccups, foreign body aspiration must be excluded—clinical history takes precedence over normal imaging. 4
Treatment Algorithm Summary
Start with physical maneuvers: 5 back blows (prone position, head down) → 5 chest thrusts (supine position, head down) → repeat cycle. 1, 2
If hiccups persist but child is stable, continue physical maneuvers and address underlying causes (reduce gastric distension, treat reflux). 9
If hiccups persist 2-3 days, initiate chlorpromazine 25-50 mg three to four times daily (for children >6 months). 5
If no response or contraindications exist, consider gabapentin or baclofen as alternatives. 7, 8
Persistent hiccups beyond 48 hours require diagnostic workup to identify underlying pathology. 9
Common Pitfalls to Avoid
Do not dismiss persistent hiccups as benign—they can herald serious medical conditions requiring investigation. 9, 8
Do not use abdominal thrusts in any pediatric patient for hiccup treatment. 3, 2
Do not assume normal chest radiograph excludes pathology if clinical history suggests foreign body aspiration or other serious cause. 4
Most acute hiccup episodes resolve spontaneously within minutes and rarely require medical intervention. 9 However, the distinction between benign self-limited hiccups and those requiring treatment depends on duration, severity, and impact on the child's comfort and feeding ability.