Nausea And Vomiting - Paediatric Palliative Care
Description General and supportive measures Medication and treatment ICD-10 code: R11 DESCRIPTION Nausea is an unpleasant sensation vaguely referred to the epigastrium and abdomen that often but not always culminates in vomiting. Vomiting is the forcible expulsion of the contents of the stomach through the mouth. It should be distinguished from passive regurgitation and reflux.  
General and supportive measures
ICD-10 code: R11
DESCRIPTION
Nausea is an unpleasant sensation vaguely referred to the epigastrium and abdomen that often but not always culminates in vomiting. Vomiting is the forcible expulsion of the contents of the stomach through the mouth. It should be distinguished from passive regurgitation and reflux.
In acute illnesses, these presenting symptoms usually resolve with the treatment of the underlying disease and treatment is not indicated. In chronic conditions, especially where there is no cure (e.g. chronic renal failure), this symptom may persist and warrant targeted drug treatment. Untreated nausea and vomiting may contribute to anorexia and weight loss which can accelerate disease progression.
GENERAL AND SUPPORTIVE MEASURES
- Avoid foods/smells that aggravate nausea and vomiting, especially spicy, very sweet or fatty foods.
- Offer foods that are bland and dry until symptoms improve.
- Be careful of wearing strong-smelling perfumes around patients.
- Provide psychological support as anxiety and emotional distress can aggravate nausea and vomiting.
- Maintain hydration by giving small amounts or oral rehydration solution.
- Review medications that may be causing nausea and vomiting, discontinue or change where possible and/or space these out across the day if necessary.
- Nausea is a possible early side effect of opioids that can be managed with short-term anti-emetics. Tolerance usually develops to this side effect within 5–7 days.
MEDICATION AND TREATMENT
Targeted anti-emetic therapy is best to treat the specific underlying cause. Knowledge of the neuronal pathways, sites of action and receptors involved in nausea and vomiting as well as the sites of action of the anti-emetics are essential to provide targeted therapy.
Targeted anti-emetic therapy in palliative care patients:
| Cause | Site | Anti-emetic of choice |
| Anxiety, fear | Cortex | Lorazepam |
| Chemotherapy or medications (esp. opioids) or Metabolic (increased urea, calcium) |
Chemoreceptor trigger zone | Ondansetron Metoclopramide Haloperidol |
| Vomiting centre | Viscera (GIT obstruction) Raised intracranial pressure |
Hyoscine butylbromide Betamethasone |
| Obstruction, spasm | Gastric outlet | Metoclopramide |
| GI inflammation | Oesophagus: GORD Stomach: gastritis | Proton pump inhibitor: e.g.: omeprazole |
- Lorazepam, oral:
- Child < 2 years: 25 mcg/kg 8–12 hourly.
- Child 2–5 years: 500 mcg 8–12 hourly.
- Child 6–10 years: 750 mcg 8 hourly.
- Child 11–14 years: 1 mg 8 hourly.
- Child > 15 years: 1–2 mg 8 hourly.
- Ondansetron:
- Oral, 0.1–0.2 mg/kg 12 hourly.
If oral route cannot be used: - Ondansetron, IV, 0.1 mg/kg immediately and every 8–12 hours, thereafter, given over 2–5 minutes. Maximum: 4 mg/day.
- Oral, 0.1–0.2 mg/kg 12 hourly.
- Metoclopramide, oral or IV:
- Neonates: 100 mcg/kg 6–8 hourly.
- 1–11 months (up to 10 kg): 100 mcg/kg 12 hourly. Maximum: 1000 mcg/dose (1 mg/dose).
- 1–18 years: 100–150 mcg/kg 8 hourly. Maximum: 10 mg/dose.
Use with caution as extrapyramidal side effects may occur (especially at higher doses).
- Haloperidol, oral:
- 1 month to 11 years: 0.01–0.1 mg/kg 12–24 hourly.
- 12–17 years: 1.5 mg at night, increase to 1.5 mg 12 hourly. Maximum: 5 mg 12 hourly.
- Hyoscine butylbromide, oral, IM or IV:
- 1 month to 4 years: 300–500 mcg/kg 6–8 hourly. Maximum: 5000 mcg/dose (5 mg/dose).
- 5–11 years: 5–10 mg 6–8 hourly.
- 12–17 years: 10–20 mg 6–8 hourly.
- Betamethasone, oral:
- Child < 1 year: 250 mcg 8 hourly. Maximum: 1000 mcg (1 mg) 8 hourly.
- Child 1–5 years: 1 mg 8 hourly increased to a maximum of 2 mg 8 hourly.
- Child 6–11 years: 2 mg 8 hourly up to 4 mg 8 hourly.
- Child 12–17 years: 4 mg 8 hourly.
Better to give as intermittent short courses (5 days) rather than for protracted periods of time.
Need to wean if given for > 2 weeks, over a number of weeks.
Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter: 21. Palliative Care, 21.1 Symptom Control, 21.1.1 Gastro-intestinal Symptoms, 21.1.1.2 Nausea And Vomiting