What nonpharmacologic measures should the nurse suggest when vomiting occurs?

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.  

Aim

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.

Definition of terms 

• Acute CINV- CINV occurring within 24 hours of chemotherapy administration; peak intensity often occurs 5 to 6 hours after 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 the sight of chemotherapy or when CVAD being accessed)
• BARF scale- Baxter Animated Retching Faces scale (validated pictorial nausea scale)  
• Breakthrough CINV - CINV occurring despite the use of preventative/prophylactic treatment; a failure to attain the goal of nil nausea and vomiting and a reasonable oral intake; often requires the use of other antiemetics; can be acute or delayed
  
• 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; commonly associated with anthracyclines or platinum agents such as cisplatin or carboplatin  
• 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
• NG- nasogastric
• Prophylaxis- prevention of
  
• Vomiting- ejecting part or all of the contents of the stomach through the mouth; emesis
• VAS- visual analogue scale

Assessment

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 (BARF) nausea scale

Visual Analogue Scale (VAS)

 

* Baxter Retching Faces Nausea Scale & Visual Analogue Scale- Baxter et al., 2011  

Each of the scales establishes a score from 0 to 10

• A score of 0 indicates no nausea
• A score of 10 indicates worst possible nausea

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.

Other indications of children experiencing CINV may include

• Food refusal
• Decreased fluid intake
• Decreased urine output
• Retching
• Less interaction with others
• Sweating

Management and principles of preventing and treating chemotherapy induced nausea and vomiting

Emetic potential of chemotherapy agents

Chemotherapy agents have different emetic potentials that are classified based on their risk of inducing nausea and vomiting

Low Emetogenic Potential

• 10 to <30% frequency of emesis in the absence of effective prophylaxis

Moderate Emetogenic Potential

• 30-90% frequency of emesis in the absence of effective prophylaxis

Highly Emetogenic Potential

• Greater than 90% frequency of emesis in the absence of effective prophylaxis

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.

Pharmacological prevention and management of CINV

In order for CINV prophylaxis to be effective;

• Antiemetics should be prescribed and released to the MAR from the treatment plan under the Oncology tab on EMR
  
• Antiemetics appropriate for the emetogenic class of the chemotherapy agent or regimen should be administered regularly, regardless of nausea or vomiting status (this is to ensure the prevention of breakthrough and delayed CINV)
  
• To minimise the risk of CINV, the first dose of antiemetics should be given prior to commencing chemotherapy as per the following;
  
  • Oral – 30 to 60 minutes prior to first dose of chemotherapy (optimal time is 60 minutes prior to commencing chemotherapy)
    
  • Intravenous – immediately before or up to 30 minutes prior to first dose of chemotherapy (optimal time is 30 minutes prior to commencing chemotherapy)
    

Antiemetic Prophylaxis guideline

Minimal emetic potentialLow emetic potential Moderate emetic potentialHigh emetic potential

•  Consider Ondansetron stat dose pre chemotherapy

• Aprepitant on day 1 of chemotherapy cycle
• Ondansetron 6/24
• Dexamethasone if appropriate (see table below)

Antiemetics should be continued throughout the period of administration of chemotherapy and for at least 24 hours following completion of chemotherapy.

Breakthrough CINV guideline 

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; 

Minimal emetic potential
Low emetic potential Moderate emetic potential High emetic potential

1. Ondansetron 6-8/24
2. Metoclopramide

1. Ondansetron 6-8/24
2. Metoclopramide
3. Dexamethasone if appropriate (see table below)

1. Metoclopramide
2. Dexamethasone if appropriate (see table below)
3. Aprepitant if appropriate (see table below)

1.  Metoclopramide
2. Cyclizine/ Chlorpromazine

Delayed CINV

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.

Antiemetic medications table

• The first dose of antiemetics should be given prior to commencing chemotherapy as per the following;
  • Oral – 30 to 60 minutes prior to first dose of chemotherapy (optimal time is 60 minutes prior to commencing chemotherapy)
    
  • Intravenous – immediately before or up to 30 minutes prior to first dose of chemotherapy (optimal time is 30 minutes prior to commencing chemotherapy)

Drug
Drug Class
RouteDose
Considerations

 Ondansetron

5HTз (serotonin) receptor antagonist.

Works both centrally on the CTZ and peripherally on the vagus by blocking the 5HTз receptors

IV/PO/SL

0.15 mg/kg to a
maximum 8mg 8/24

Can be given 6/24 with highly emetogenic chemotherapy

Administer IV dosage immediately before or up to 30 minutes prior to dose of chemotherapy, or 30 - 60 minutes prior if oral dosage, then 6-8/24 as required

Efficacy is enhanced with Dexamethasone administration

 Metoclopramide

Dopamine receptor antagonist

Acts on dopaminergic receptors in the CTZ & on peripheral vagal receptors to accelerate gastric emptying

In high dose may act on 5HTз receptors in the CTZ

IV/PO

0.15mg/kg to a maximum of 10mg 8/24

Dystonic reactions including oculogyric crises are rare but caution is advised for first exposure to drug  

 Dexamethasone

Corticosteroid

Mechanism of action as an antiemetic is unclear 

IV/PO 

<0.6m² : 2mg 12/24 (pre chemotherapy loading dose 4mg)

0.6-1.5m² : 4mg 12/24 (pre chemotherapy loading dose 8mg)

>1.5m² : 6mg 12/24 (pre chemotherapy loading dose 12mg)

Can consider increasing to 8/24 if breakthrough vomiting occurs

Maximum of 12 doses per course of chemotherapy 

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)

 Cyclizine

Antihistamine

 IV/PO

0.5-1mg/kg to a maximum of 50mg 8/24Not for use in infants <1 year

Not a powerful antiemetic but may be used if vomiting persists despite recommended regimes

Rapid IV administration can cause drowsiness and dizziness

May antagonize the prokinetic effect of Metoclopramide

 Aprepitant

 Neurokinin-1

(NK-1) receptor antagonist

PO 

Single dose administered on day 1 of chemotherapy

Based on BSA;

0.5-0.8m²=55mg

0.8-1.2m²=110mg

>1.2m² BSA= 165mg

Potent antiemetic reserved for highly emetogenic chemotherapy regimens or where breakthrough vomiting has occurred in past courses

Course can be extended in some cases if required- discuss with fellow or consultant

Administer oral dose 1 hour prior to chemotherapy

Aprepitant increases steroid AUC; regimens including steroid medications, should have their dosages halved when also receiving Aprepitant (check with consultant)

 Lorazepam

Benzodiazepine

SL/PO 

12-16 kg=0.25mg BD

16-20 kg=0.5mg BD

20-30 kg=1mg BD

> 30 kg=2mg BD

Little efficacy as antiemetic alone; not to be administered without additional antiemetics

Useful for anticipatory nausea and vomiting

Should only be administered for short courses; usually charted PRN

 Domperidone

Dopamine antagonist

PO 

0.1-0.2mg/kg to

a maximum of 10mg QID 

Similar action to Metoclopramide but less of a central antiemetic effect

Consider use if nausea is associated with delayed gastric emptying

 Chlorpromazine

Phenothiazine antipsychotic.

Has antidopaminergic, antiadrenergic, antiserotonergic, anticholingeric and antihistaminergic effects

IV 

0.3-0.5mg/kg 6-8/24

Minimum infusion rate- 30 minutes

Can have sedative and extrapyramidal effects

Rapid administration can cause hypotension and dysphoria

Not for use in infants <1 year

Antiemetic guideline for common chemotherapy combinations

Antiemetic Traffic Light Regimen.

Further considerations

• Anticipatory CINV, is common in adolescents and rarely responds to standard antiemetic regimes. Benzodiazepines can be useful in this patient population but do not have direct antiemetic effects. The best treatment for anticipatory CINV is prevention- if patients do not associate chemotherapy with nausea or vomiting, anticipatory CINV may not develop
  
• Dexamethasone should be charted regular (not PRN) if included in antiemetic regimes as the efficacy is enhanced with prophylactic administration
  
• Delayed CINV is common after chemotherapy courses containing cisplatin. Antiemetics should be continued regularly for at least 48 hours after completing chemotherapy
  
• Ondansetron is as effective as granisetron and is the 5HTз (serotonin) antagonist of choice for CINV.
  

Non-pharmacological management of CINV

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 / relaxation

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:

• Where possible advise families to bring familiar music and music playing device for the first period of chemotherapy
  
• Involve a music therapist to assess the capability of children receiving chemotherapy to use music independently
  
• Encourage patients to listen to recorded music that is familiar and that they find comforting and relaxing during periods of chemotherapy. Familiar music is the best option
  
• For patients and families needing guidance the music therapist can make recommendations about styles of music that are effective in promoting relaxation for different age groups
  
• Commence music listening prior to chemotherapy administration or during experiences of anticipatory nausea and vomiting
  
• Contact Music Therapy, Educational Play Therapy or Comfort First Clinicians to assess if patient may benefit from focused breathing exercises to assist relaxation
  
• Encourage periods in a quiet environment
  
• Cluster medical and nursing care to allow for periods of rest
  

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. 

Guided imagery

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.

• Encourage patients to visualise images related to the external environment (nature, landscape images) prior to and during chemotherapy administration
• Place appealing images/paintings in patients’ rooms during chemotherapy administration
• Encourage patients to reside in areas where they are able to enjoy the outside view (e.g. by windows) during periods of nausea, vomiting and anxiety
• Implement music listening in combination with guided imagery for optimal management of nausea and vomiting

Cognitive distraction

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;

• Computer games
• Movies/Television
• Arts and crafts
• Developmental / Group play sessions
• Active Music Engagement 
• Education sessions (kinder and school)
• Socialisation with family, friends and other patients 
• Discussions about life outside of the hospital setting (pets, siblings, school, hobbies)
• Organising visits from volunteer services and ward grandparents available at the RCH

The Educational Play Therapy, Art Therapy and Music Therapy teams can assist in providing activities that promote cognitive refocussing to effectively manage CINV.

Massage

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)

• Caution should be taken in patients receiving radiation. Avoid massaging areas that have received treatment to reduce irritation of irradiated skin and/or skin breakdown
  
• Caution should be taken in patients with solid tumours. Avoid massaging directly over areas where tumour is present to reduce associated pain and anxiety
  
• The level of pressure applied to the patient should be adjusted in those at risk of peripheral neuropathy
  
• Care should be taken to minimise massage movements that create a rocking motion in patients with nausea and vomiting
  
• Use non scented oils to reduce nausea associated with oil scents
  
• Care should be taken in patients with accessed port-a-cath devices to avoid trauma
  

Acupressure

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)

• Acupressure wrist bands may be applied to children prior to and during chemotherapy administration where tolerated
  

Manual acupressure

• Perform daily during chemotherapy administration in the absence of acupressure wrist bands
  
• Pressure should be applied to acupoints for 1-3 minutes and then released
  
• Acupressure should commence prior to administration of chemotherapy and continue for the duration of the chemotherapy cycle
  
• Health professionals should familiarise themselves with the Pericardium 6 (P6) acupressure technique as this is the most successful point for targeting nausea and vomiting
  
• Encourage patients and families to familiarise themselves with the P6 acupressure point technique so they are able to independently perform this technique during treatment periods
  

Considerations

Dietary considerations 

The following suggestions may be useful to help manage nausea and vomiting;

• Offer bland, dry foods such as toast and dry biscuits
  
• Offer smaller serves of food more frequently
  
• Offer sips of fluid throughout the day, sucking on ice cubes, fizzy drinks such as soda water or dry ginger ale and jellies can assist with an upset stomach
  
• Offer cold foods that have little smell
  
• Eat meals in a well ventilated room to clear the smell of foods away
  
• Encourage oral intake during times when the child feels less nauseated
  
• Discuss with your doctor/medical team about optimising anti-emetics
  

Enteral nutrition (i.e. Nasogastric/PEG feeds)

• Consider reducing the rates of NG/PEG feeds during highly emetogenic chemotherapy
  
• If a child is vomiting during NG/PEG feeds, consider pausing the feeds for a short period (e.g. 1 hr) and restarting again at the last tolerated rate. If a child is on overnight NG/PEG feeds consider running total volume, prescribed by the dietitian, over 24 hours
  
• A dietitian can help to alter a child’s feeing regime if needed. Please contact your dietitian for advice.
  

Other considerations 

• A multidisciplinary approach to managing CINV will assist in providing appropriate supportive care and effective antiemetic regimes to the paediatric oncology patient
  
• Current literature supports the use of ginger supplementation to manage general nausea and vomiting, however ginger is not recommended for use in the paediatric oncology population due to unknown effects on coagulation
  
• Poorly controlled CINV can result in dehydration, electrolyte imbalance, anorexia and fatigue
  
• Antiemetic therapies should be routinely administered during chemotherapy administration known to induce nausea and vomiting, not just PRN when patients develop symptoms of nausea
  
• If a patient is being discharged with antiemetic medications, the patient and/or caregivers should be given instructions on the management of antiemetic regimes at home prior to discharge
  
• The use of various forms of non-pharmacological and complementary therapies has also found to reduce nausea, vomiting and fatigue intensity, however should be discussed with the medical team prior to use
  
• Rinse the mouth thoroughly after vomiting with water (stomach acid left in contact with the teeth and the mouth lining will cause tooth decay and irritate the mouth)
  

Companion documents

Information for parents

Information for Health Professionals

Evidence table

See attached document.

References

• Children’s Oncology Group, (2018) COG Supportive Care Endorsed Guidelines, Children’s Oncology Group (COG), Version date: August 22, 2018
  
• Dupuis, L.L., Boodhan, S., Holdsworth, M., Robinson, P.D., Hain, R., Portwine, C., O’Shaughnessy, E., & Sung L. (2012) Guideline for the Prevention of Acute Nausea and Vomiting due to Antineoplastic Medication in Pediatric Cancer Patients. Pediatric Oncology Group of Ontario; Toronto. 2012, Retrieved 12/02/2019
  
• Dupuis, LL, Boodhan, S., Sung, L., Portwine, C., Hain, R., McCarthy, P., & Holdsworth, M. (2010) Guideline for the Classification of the Acute Emetogenic Potential of Antineoplastic Medication in Pediatric Cancer Patients. Pediatric Oncology Group of Ontario; Toronto. 2010, Retrieved 12/02/2019
  
• Dupuis, L., Sung, L., Molassiotic, A., Orsey, A., & Tissing, W., & van de Wetering, M. (2017) 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children. Supportive Care in Cancer, 25(1), 323-331
  
• Flank, J., Robinson, P.D., Holdsworth, M., Phillips, R., Portwine, C., Gibson, P., Maan, C., Stefin, N., Sung, L., & Dupuis, L.L. (2016) Guideline for the treatment of breakthrough and the prevention of refractory chemotherapy induced nausea and vomiting in children with cancer. Pediatric Blood Cancer, 63, 1144-1151
  
• Grocke, D., & Wigram, T. (2007) Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators and students, Jessica Kingsley Publishers: London, Philadelphia.
  
• Grocke, D.  (2016). Receptive music therapy: In Edwards, J. (Ed.) The Oxford Handbook of Music Therapy: pp.684-708. Oxford, United Kingdom, Oxford University Press
  
• Momani, T.G. & Berry, D.L. (2017) Integrative Therapeutic Approaches for the Management and Control of Nausea in Children Undergoing Cancer Treatment: A Systematic Review. Journal of Pediatric Oncology Nursing, 34(3), 173-184
  
• Navari, R. M. (2018). Managing Nausea and Vomiting in Patients with Cancer: What works. Oncology, 32 (3), 121-136.
• Orrigo, K.M. (2015) The Impact of Interactive Music Therapy on the Pediatric Oncology Population. Senior Honors Projects, 2010-current, James Madison University, 1-34, Retrieved August 2018 https://commons.lib.jmu.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1125&context=honors201019
  
• Patel, P., Robinson, P.D., Thackray, J., Flank, J., Holdsworth, M.T., Gibson, P., Orsey, A., Portwine, C., Freedman, J., Madden, J. R., Phillips, R., Sung, L. & Dupuis, L.L. (2017) Guideline for the prevention of acute chemotherapy-induced nausea and vomiting in pediatric cancer patients: A focused update. Pediatric Blood Cancer, 64(10), e26542
  
• Phillips, R.S., Friend, A.J., Gibson, F., Houghton, E., Gopaul, S., Craig, S., Craig J.V. & Pizer, B. Antiemetic medication for prevention and treatment of chemotherapy-induced nausea and vomiting in childhood. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD007786. DOI: 10.1002/14651858.CD007786.pub3.

 Please remember to read the disclaimer. 

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.  

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