In this section
Chemotherapy induced nausea and vomiting (CINV) is a common and extremely unpleasant side effect for children receiving chemotherapy. CINV can lead to complications of treatment and also cause significant emotional and physical distress, disruptions to activities of daily living and influence the quality of life of the patient. The goal of antiemetic therapy is to prevent vomiting and minimise nausea both 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.
All patients receiving chemotherapy for childhood cancer or as pre conditioning for a haematopoietic 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 medical team.
The following assessment tools can assist in determining the incidence and severity of CINV. Results of the assessment tools should be clearly documented once per shift (more frequently if indicated) in the Electronic Medical Record. The CINV score (0 to 10) and type of scale (BARF or VAS) utilized should be recorded under the Nausea Scale assessment in the Observation flowsheet.
* 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.
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.
Antiemetic 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.
In order for CINV prophylaxis to be effective;
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 should be treated promptly. It is advised to have further antiemetics charted on the treatment plan under the Oncology tab on EMR to enable nurses to initiate breakthrough medication as required. 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 associated with anthracyclines or platinum agents such as cisplatin or carboplatin. 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 may 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.
Works both centrally on the CTZ and peripherally on the vagus by blocking the 5HTз receptors
Dystonic reactions including oculogyric crises are rare but caution is advised for first exposure to drug
Mechanism of action as an antiemetic is unclear
Caution in patients with AML- increases risk of infection (consultant approval required)
Not for use in patients where corticosteroids are part of their chemotherapy regime (B & T Cell ALL, NHL)
Not for use in children having chemotherapy for CNS tumours without direct fellow or consultant approval- may impair CNS penetration of chemotherapy
If using Aprepitant, halve the dose of Dexamethasone (Aprepitant doubles the AUC of Dexamethasone)
(NK-1) receptor antagonist
a maximum of 10mg QID
Consider use if nausea is associated with delayed gastric emptying
Has antidopaminergic, antiadrenergic, antiserotonergic, anticholingeric and antihistaminergic effects
Antiemetic guideline for common chemotherapy combinations
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) live and active music engagement, and b) individual (recorded) music listening for refocusing and/or relaxation. 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 for each patient.
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 refocussing to effectively manage CINV.
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)
The following suggestions may be useful to help manage nausea and vomiting;
See attached document.
Please remember to read the
The development of this nursing guideline was coordinated by Lisa Barrow, CNE, and Chantelle Di Gregorio, CNS, of Kookaburra, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2019.