Nausea and Vomiting During Chemotherapy

Nausea and vomiting are common side effects of cancer and cancer treatments. These symptoms can vary from mild to severe. They may happen before, during, or after treatment. Childhood cancer patients and families often say that nausea is one of the side effects that bothers them most. 

If nausea and vomiting are not managed, they have a negative effect on your child’s quality of life. They can affect emotional well-being, treatment plans, and daily activities. These symptoms can also lead to poor nutrition, weight loss, and other health complications.

For most children with cancer, there are ways to reduce nausea and vomiting. These include medications, changes in diet, and coping strategies such as deep breathing and distraction. Complementary therapies such as acupuncture, aromatherapy, and hypnosis may also help.

Nausea

Nausea is the feeling of sickness or discomfort that a person feels with the urge to vomit. Nausea usually involves unpleasant sensations in the throat or stomach. Other sensations a person may relate to nausea are dizziness, trouble swallowing, sweating, and feeling chilled or flushed.

Vomiting

Vomiting, or throwing up, happens when muscles contract and push what is in the stomach up and out the mouth. Common causes of nausea and vomiting are illness, motion sickness, and medication side effects.

You may see or hear the term emesis during cancer care. Emesis is the clinical name for vomiting. Antiemetic drugs are medicines that treat nausea and vomiting.

Nausea and vomiting are related, but you may experience one without the other.

Causes of nausea and vomiting during cancer

Chemotherapy is a main cause of nausea in children with cancer. However, radiation therapy and other medications can also cause nausea. Some children have nausea because 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 in their head can press on nerves and cause vomiting.

Common causes of nausea and vomiting in children with cancer include:

• Chemotherapy
• Other medicines, including antibiotics, opioid medicines, and anti-seizure drugs
• Radiation therapy
• The cancer, especially if the tumor affects the brain or digestive system
• Disorders of the stomach and digestive tract
• Inner ear problems
• Hormones
• Fever and infection
• Stress and anxiety
• Pain
• Previous vomiting

Nausea and voming with chemotherapy

The connection between nausea and vomiting with chemotherapy is not fully understood. However, chemotherapy may cause the release of certain chemical messengers that control nausea and vomiting. Some anti-nausea medicines act on these chemical systems to block the signals.

Up to 70% of children who get chemotherapy have nausea at some point during treatment. Symptoms vary from mild stomach upset to severe vomiting. There are 3 types of nausea and vomiting related to chemotherapy:

• Acute. Symptoms happen during the first 24 hours after chemotherapy. It usually begins 1-2 hours after chemotherapy and starts to get better after 4-6 hours.
• Delayed. Symptoms start after 24 hours. Usually, delayed vomiting is most severe 48 to 72 hours after chemotherapy. Then it gets better over the next few days.
• Anticipatory. Symptoms can start before chemotherapy. Anticipatory nausea and vomiting is brought on by triggers that the person connects with chemotherapy. This is a learned response. It is most common in patients who had severe nausea and vomiting with past treatments.

Certain chemotherapy medicines are more likely to cause nausea and vomiting. These medicines can be grouped by how likely they are to cause symptoms:

• High risk of nausea and vomiting: more than 90% risk
• Moderate risk of nausea and vomiting: 30% to 90%
• Low risk of nausea and vomiting: 10% to 30% risk
• Minimal risk of nausea and vomiting: less than 10% risk

These groups 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.

Talk to your health care team about what category your child’s medicine is in. If it is in a higher risk group, talk about ways you can manage your child’s symptoms.

How to treat nausea and vomiting in children

There are several ways to help manage nausea and vomiting during cancer treatment. Work with your care team to make sure that your child’s symptoms are managed.

Medicines for nausea

Nausea medicines (antiemetics) may be used to prevent and treat nausea and vomiting. Common medicines used in pediatric cancer patients include:

• Ondansetron (Zofran®)
• Granisetron (Kytril®)
• Lorazepam (Ativan®)
• Diphenhydramine (Benadryl®)
• Dexamethasone (Decadron®, Dexamethasone Intensol®, Dexpak®)
• Aprepitant (Emend®)
• Metoclopramide (Reglan®)
• Olanzapine (Zyprexa®)
• Scopolamine (Transderm Scop®)

Some people get a combination of medicines. Many of the medicines used to reduce nausea and vomiting have other uses. Talk to your doctor or pharmacist to learn about the purpose and instructions for each medicine your child is taking.

Health care providers prescribe nausea medicines based on the chemotherapy plan, age of the child, type of cancer, and other factors. Some people will be prescribed medicine before the start of chemotherapy. However, nausea medicines are also prescribed as needed. It is very important that you discuss symptoms with your care team so any side effects can be managed in the best way possible.

Diet changes to help with nausea

Certain foods and smells may make nausea worse. Many people lose their appetite during cancer treatment. Your child’s appetite and food preferences may change. It may take some time to find what works best. Some general tips are:

• Eat small snacks and meals.
• Eat and drink slowly.
• Avoid having liquids with meals.
• Offer your child dry, bland foods such as crackers or toast.
• Avoid spicy, acidic, or rich foods.
• Eat in a place that does not have strong smells.
• Allow your child to choose when and what to eat.

Find more nutrition tips for patients with nausea and vomiting.

Dietitians are important members of the care team. They can help children struggling with nausea and vomiting. A dietitian can help you with nutrition challenges. If your child has severe nausea and vomiting, they might need to have a feeding tube (enteral nutrition) or to receive IV nutrition (parenteral nutrition). These are important to make sure your child has good nutrition and enough fluids. Learn more about nutrition in pediatric cancer care.

Other ways to manage nausea and vomiting

A variety of strategies and complementary therapies may help with nausea and vomiting. These include:

• Psychotherapy
• Biofeedback
• Deep breathing and relaxation techniques
• Hypnosis
• Acupuncture or acupressure
• Aromatherapy
• Herbal supplements, like ginger
• Distraction (playing video games, art, music)
• Exercise

Talk with your care team before trying any complementary therapy to make sure that it is safe. Your care team can also help you decide what treatments work best to manage symptoms.

Tips for families

Talk to your care team about nausea and vomiting. There are medicines and other strategies that can help.

Keep a record of symptoms. Write down when nausea occurs, what makes it worse, what makes it better. Note any other symptoms such as pain, loss of appetite, diarrhea, or constipation. This can help you and your care team understand your child’s symptoms and develop a plan.

• Tell your care team if your child is having problems eating or drinking. Nutrition support or IV fluids may be needed.
• Do not offer favorite foods when your child is nauseous. This food may become associated with feeling sick.
• Try chewing gum or sucking on hard candy, popsicles, or ice. 
• Avoid lying flat after meals.
• Make sure to rinse your child’s mouth after vomiting. Stomach acid can cause mouth irritation and tooth decay.
• Follow dosing instructions for nausea medicines. Make sure you refill the prescription before you run out.