In this section
Note: This guideline is currently under review.
Chemotherapy induced nausea and vomiting (CINV) is a common and extremely unpleasant side effect for children receiving chemotherapy. The goal of antiemetic therapy is to prevent vomiting and minimise nausea during and after the administration of chemotherapy. The severity of nausea and vomiting can, to some degree, be predicted by the chemotherapeutic agents being delivered but there is a degree of variation between patients. Antiemetic treatments should be initiated prior to the first dose of chemotherapy for best control of nausea and vomiting, as it can often become difficult to control nausea once the child is actually vomiting. Non-pharmacological measures are also an important consideration and should be implemented in conjunction with pharmacological regimes to allow for the effective management of CINV.
The aim of this guideline is to provide an overview of the prevention and management of chemotherapy induced nausea and vomiting in the paediatric oncology patient.
Acute CINV- CINV occurring within 24 hours of chemotherapy administration
ALL- acute lymphoblastic leukemia
AML- acute myeloid leukemia
AUC- area under the curve (pharmacokinetics)
Anticipatory CINV- CINV occurring within the 24 hour period prior to chemotherapy administration; often provoked by the environment or “thought” of chemotherapy (as example sight of chemotherapy, CVAD being accessed)
BARF scale- Baxter Animated Retching Faces scale (validated pictorial nausea scale)
BSA- body surface area
CINV- chemotherapy induced nausea and vomiting
CTZ- chemoreceptor trigger zone
Delayed CINV- CINV occurring 1-5 days after chemotherapy completion with a peak intensity 2-3 days post treatment completion
Emetogenicity- likelihood of chemotherapy agent inducing nausea, vomiting or retching
Haematopoietic stem cell transplant- transplantation of the blood forming components/cells of the body
Nausea- an unpleasant feeling in the throat or stomach that may or may not result in vomiting
Vomiting- ejecting part or all of the contents of the stomach through the mouth; emesis
VAS- visual analogue scale
All patients receiving chemotherapy for childhood cancer or as pre conditioning for a haemopoietic stem cell transplant (HSCT) require ongoing assessment of the incidence and severity of nausea and vomiting.It is the responsibility of nursing staff to regularly assess patients for signs and symptoms of CINV and decide on subsequent methods of management in consultation with the managing clinician. The following assessment tools can assist in determining the incidence and severity of CINV;
Suitable for children aged 0-7 years
Suitable for children > 7 years
* Baxter Retching Faces Nausea Scale & Visual Analogue Scale- Baxter et al., 2011
Each of the scales establishes a score from 0 to 10
The assessment tools should be utilised by health professionals to provide an overview of the child’s condition which will allow for an appropriate plan of care based on these findings.Results of the assessment should be clearly documented at least once per shift (more frequently if clinically indicated) in the medical record. The CINV score (0 to 10) and type of scale (BARF or VAS) utilized should be recorded.
Chemotherapy agents have different emetic potentials that are classified based on their risk of inducing nausea and vomiting
Often, combinations of moderately emetogenic agents can yield a course with high emetic potential; for example both ifosfamide and doxorubicin have moderate emetic potential yet when delivered together have high emetic potential. Other combinations of chemotherapy can, as a whole, have low emetic potential but with extra antiemetic cover required at certain times; for example high risk ALL induction is generally low emetic potential but antiemetics are usually required around daunorubicin doses.Anti emetic treatments should be decided based on the emetic potential of the prescribed course of chemotherapy, although there may be some instances where a specific child requires deviations from the guidelines. These decisions should be discussed with the child’s fellow or consultant. Once an effective antiemetic regimen has been determined for an individual child, this regimen should be used for future courses of chemotherapy as appropriate.
Full list of emetic potential of individual agents here.
Antiemetics should be continued throughout the period of administration of chemotherapy and for at least 24 hours following completion of chemotherapy.
Breakthrough nausea and vomiting (defined as a failure to attain the goal of nil nausea and vomiting and a reasonable oral intake) should be treated promptly. It is wise to have antiemetics charted on the prn chart so that nursing staff can initiate breakthrough medication promptly. A suggested order of escalation in the face of breakthrough nausea and vomiting is tabulated below but this should be adjusted for individual situations. Consideration should be given to the contribution of anticipatory nausea and vomiting which is likely to respond better to benzodiazepines and non-pharmacologic management.Recommended order of escalation for breakthrough nausea and vomiting;
This is defined as CINV occurring 1-5 days after chemotherapy and is most commonly seen after cisplatin. Regular antiemetics should be continued for at least 48 hours after completion of cisplatin and in any other course of chemotherapy where delayed CINV has occurred in the past. Consideration can be given to a second dose of aprepitant on day 3-4 of chemotherapy if this is appropriate. Ongoing dexamethasone and ondansetron may be sufficient.
Antiemetic Traffic Light Regimen.
Despite the advances in pharmacological management, standard pharmacological regimes may not fully alleviate symptoms of CINV in paediatric oncology patients. Investigating the adjuvant role of non-pharmacological interventions is an important consideration of antiemetic therapy. Non-pharmacological measures should be implemented in conjunction with pharmacological regimes to allow for the effective management of CINV. The use of non-pharmacological measures may not be appropriate for each patient, interventions should be implemented according to the individual patient’s needs and circumstances.Some suggested non- pharmacological interventions may include;
Music therapy and relaxation are beneficial interventions in managing CINV with minimal negative side effects. Music therapy may include a) active music engagement, and b) individual (recorded) music listening. These interventions are suitable for all ages, are cost effective and can be implemented in the inpatient, outpatient and home environments. The music therapist is available to assess and advise on the most suitable plan. Music listening/relaxation during chemotherapy:
For children aged under 7 years, active music engagement may be more effective than passive music listening. The music therapist can advise/ plan for this. See also section on Cognitive Distraction.
Encouraging patients to focus on thoughts and images they find pleasing and relaxing will divert attention from nausea and vomiting to desirable thoughts and images.
Cognitive distraction acts to counteract CINV by drawing a patient’s attention away from feelings of nausea and vomiting and focusing attention on more pleasant activities. Patients should be encouraged to participate in;
The Educational Play Therapy, Art Therapy and Music Therapy teams can assist in providing activities that promote cognitive distraction
Educating families to perform massage during periods of chemotherapy has a positive impact on reducing levels of stress, anxiety, nausea and vomiting.It is not recommended to use massage for the paediatric oncology patient with a low platelet count (platelets ≤ 20-30 x 10e9/L)
The acupressure technique involves the pressure applied to and then released from acupoints. Acupressure may be performed manually or with wrist pressure bands (also used for motion/travel sickness).
It is not recommended to use acupressure for the paediatric oncology patient with a low platelet count (platelets ≤ 20-30 x 10e9/L)
Refer to the acupressure points website under ‘useful links’ for a detailed description of acupressure points.
The following suggestions may be useful to help manage nausea and vomiting;
See attached document.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Andrew Dodgshun, Oncology Fellow and Lisa Barrow, Clinical Nurse Educator, of Children’s Cancer Centre, and approved by the Nursing Clinical Effectiveness Committee. First published December 2014.