Elsevier

Journal of Pediatric Nursing

Volume 66, September–October 2022, Pages 136-142
Journal of Pediatric Nursing

Optimizing antiemetic therapy for children undergoing chemotherapy

https://doi.org/10.1016/j.pedn.2022.06.006Get rights and content

Highlights

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    Chemotherapy-induced nausea and vomiting (CINV) impacts quality of life.

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    Reviews pediatric-specific recommendations for monitoring and pharmacotherapy for CINV.

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    Shares antiemetic algorithm and experience from our institution.

Abstract

Chemotherapy-induced nausea and vomiting (CINV) is a common side effect of most chemotherapy agents. Suboptimal management of CINV impacts quality of life, nutrition, gastrointestinal (GI) integrity, and adherence to chemotherapy treatment plans. This article reviews the principles of CINV management, planning and implementation of antiemetic regimens, and pharmacology of the antiemetics currently available in the United States appropriate for pediatric use. With the advent of more targeted therapies, increased use of immunotherapy, and the effects of radiotherapy to the brain, spine, and abdomen, treatment of CINV now has a broader application than just for chemotherapeutics alone.

Section snippets

Background

If you ask any patient who has undergone chemotherapy, they will tell you that one of the most undesirable side effects of treatment is nausea and vomiting. It is something parents and children most fear when starting treatment for a new diagnosis of cancer (Dupuis et al., 2018; Hematology/Oncology Pharmacy Association, 2015; Sherani et al., 2019; Sommariva et al., 2016). Management of chemotherapy-induced nausea and vomiting (CINV) requires a thoughtful, evidence-based approach to assessment,

Pathophysiology of CINV

Two areas of the brain involved in CINV are the vomiting center (VC), a network of neurons distributed throughout the medulla oblongata, and the chemotherapy trigger zone (CTZ) located in the area postrema on the dorsal surface of the fourth ventricle. The CTZ is outside of the blood-brain barrier and thus is exposed to both blood and cerebrospinal fluid. This location makes it highly sensitive for detecting noxious substances. Nausea and vomiting involve stimulation of the vomiting center via

Assessment

Emesis is an objective symptom and can be quantified. Nausea is a subjective sensation of gastrointestinal distress that may precede emesis. Like pain, nausea is what the patient says it is when they say it is. There are two validated tools for nausea assessment currently available. The Pediatric Nausea Assessment Tool (PeNAT) was validated in children 4 years and older and has been used clinically in pediatric CINV studies (Dupuis et al., 2006; McKinnon & Jupp, 2020). The Baxter Retching Faces

Implementation

Preparing the family and patient for CINV management is a crucial step. Reassurance that the goal is CINV control and that the care team will continually assess, intervene, and reassess the patient's response to the antiemetics can go a long way in alleviating anxiety. Often the first chemotherapy experience is the most emetogenic, likely due to multifactorial influences from a larger tumor burden and a higher anxiety level related to a new and unknown experience (Dranitsaris et al., 2017).

Treatment and re-assessment

The goals of therapy are to prevent nausea, to prevent emesis, and to overall improve the patient's quality of life. Antiemetic therapy is initially selected based on the chemotherapy's emetic risk and can be tailored to patient's preference and past history for subsequent cycles. It is important to categorize what type of CINV the patient experienced in the past (acute, delayed, anticipatory, breakthrough, or refractory) as this can be a helpful guide to modifications (Barbour, 2017; Paw Cho

5HT3 receptor antagonists

5HT3 receptor antagonists work by selectively blocking serotonin both peripherally on the vagal nerve terminals and centrally in the CTZ. This class of antiemetics has revolutionized the management of CINV in pediatric and adult patients and is considered the backbone of antiemetic prophylaxis. Agents in this class are ondansetron, granisetron, and palonosetron. Dolasetron is no longer used due to its increased risk of QTc prolongation. 5HT3 receptor antagonists best prevent CINV in the acute

Implications for pediatric hematology/oncology nursing

Nurses have the most sustained contact with their patients during chemotherapy. They are in a prime position to monitor and help improve emetic control in their patients. Nursing assessments and subsequent reassessment after interventions are crucial in determining what works and what doesn't for their patient as they strive together for the goal of emetic control. Ongoing communication between provider, patient, parents, and nursing together is crucial to success. Nurses have a key role in

Conclusion

Appropriate and effective antiemetic management can decrease patient and parent distress, offers improved quality of life, and encourages adherence to chemotherapy regimens. A sound knowledge of antiemetic principles and currently available interventions enables nurses to provide optimal care for their patients and families.

Credit authorship contribution statement

Mya Merrow: Methodology, Visualization, Validation, Writing – original draft, Writing – review & editing, Project administration. Nancy King: Conceptualization, Writing – original draft, Writing – review & editing, Project administration, Supervision.

Declaration of Competing Interest

The authors have no conflicts of interest and did not receive any funding for this work.

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