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Nausea and vomiting are common side effects of cancer and cancer treatments. Symptoms can vary from mild to severe and may occur before, during, or after treatment. Pediatric cancer patients and families often report that nausea is one of the side effects that bothers them most. If not managed, nausea and vomiting can have a negative effect on emotional well-being, hinder treatment compliance, interfere with daily activities, and lead to poor nutrition, weight loss and other health complications.
For most children with cancer, there are effective ways to reduce nausea and vomiting. These include nausea medicines, changes in diet, and coping strategies such as deep breathing and distraction. Complementary therapies such as acupuncture, aromatherapy, and hypnosis may also be effective.
Families may see or hear the term “emesis” during cancer care. Emesis is the clinical name for vomiting. Antiemetic drugs are medicines used to treat nausea and vomiting.
Nausea is the feeling of sickness or discomfort that a person associates with the urge to vomit. Nausea is subjective, meaning that it depends on the person’s own experience. Nausea usually involves unpleasant sensations in the throat, esophagus, or stomach. Other sensations a person may relate to nausea are dizziness, trouble swallowing, sweating, and feeling chilled or flushed.
Vomiting, or throwing up, occurs due to the action of the diaphragm and abdominal muscles. These muscles contract and push stomach contents up the esophagus and out the mouth. This is regulated by nerves that respond to certain triggers. Common triggers for nausea and vomiting are viruses and bacteria, motion, and physical or chemical signals. These activate nerve pathways that control the vomiting reflex.
Nausea and vomiting are related, but each may occur without the other.
Some care teams use a rating scale to help children talk about nausea. This scale, called the BARF scale, uses picture drawings of faces to assess a child’s level of nausea. Pictures are especially useful for younger children who might not know how to describe their symptoms. It can also be helpful to monitor nausea over time to see whether nausea gets better or worse.
Chemotherapy is a main cause of nausea in children with cancer. However, radiation therapy and other medicines can also trigger feelings of nausea. Some children have nausea due to the effects of cancer itself or because of other health problems. Children with brain tumors may have hydrocephalus, a build-up of fluid in the brain. The increased pressure can trigger nerves that cause vomiting.
Common causes of nausea and vomiting in children with cancer include:
Nausea and vomiting are caused by a complex interaction among several body systems including the autonomic nervous system, central nervous system, endocrine system, and digestive system. Thoughts and emotions also play an important role in nausea and vomiting.
Up to 70% of children who get chemotherapy will experience nausea at some point during treatment. Symptoms vary from mild stomach upset to severe vomiting. There are 3 types of nausea and vomiting (emesis) associated with chemotherapy:
Chemotherapy medicines can be classified by their risk or likelihood of causing nausea and vomiting:
These categories are based on the likelihood of symptoms if no anti-nausea medicines are given. Children receiving chemotherapy with high or moderate risk of vomiting are usually given medicines to prevent nausea and vomiting before symptoms occur.
|Chemotherapy with High Risk of Nausea and Vomiting||Chemotherapy with Moderate Risk of Nausea and Vomiting|
|Cyclophosphamide (high dose)||Cyclophosphamide (low dose)|
|Cytarabine (high dose)||Cytarabine (moderate dose)|
|Methotrexate (high dose)||Doxorubicin (low dose)|
|Doxorubicin (high dose)||Imatinib|
|Cytarabine + Etoposide or Teniposide||Intrathecal chemotherapy|
|Doxorubicin + Ifosfamide||Methotrexate (low dose)|
|Etoposide + Ifosfamide||Temozolomide|
|Cyclophosphamide + doxorubicin, epirubicin, or etoposide|
Nausea and vomiting with chemotherapy is not fully understood. However, chemotherapy may cause the release of certain neurotransmitters that regulate nausea and vomiting. Neurotransmitters including dopamine, serotonin, and substance P act as chemical signals in the areas of the brain that control nausea and vomiting. Some anti-nausea medicines act on these neurotransmitter systems to block the signals.
There are several ways to help manage nausea and vomiting during cancer treatment. It is important for families to work closely with the care team to make sure that children’s symptoms are managed.
Nausea medicines (antiemetics) may be used to prevent and treat nausea and vomiting. Common medicines used in pediatric cancer patients include:
Some patients will receive a combination of medicines. Many of the medicines used to reduce nausea and vomiting have other uses. Families should always talk with their doctor or pharmacist to know the purpose and dosing instructions for each drug their child is taking.
Doctors prescribe nausea medicines based on the chemotherapy plan, age of the child, type of cancer, and other patient factors. Some patients will be prescribed medicine before the start of chemotherapy. However, nausea medicines are also prescribed as needed. It is very important for families to discuss symptoms with the care team so that nausea and vomiting can be managed in the best way possible.
Certain foods and smells may make nausea worse. Many patients lose their appetite during cancer treatment. Children can be very different in what they are able eat when they don’t feel well. It may take some trial and error to find what works best. Some general tips are:
Nutrition professionals are important members of the care team, especially for children struggling with nausea and vomiting. A dietitian can help families find ways to address nutrition challenges. If children have severe nausea and vomiting, they might need to have a feeding tube (enteral nutrition) or receive IV nutrition (parenteral nutrition). These are important types of supportive care to encourage proper nutrition and hydration. Learn more about clinical nutrition in pediatric cancer care.
A variety of coping strategies and complementary therapies that have been shown to help with nausea and vomiting. These include:
Families should talk with their care team before trying any complementary therapy to make sure that it is safe. The care team can also help families figure out what combination of therapies works best to manage symptoms.
Together does not endorse any branded product mentioned in this article.
Reviewed: January 2019