Nausea and vomiting

Diagnostics of nausea and vomiting

DO	Look for possible causes and treat them. Weigh up how much a diagnosis is appropriate depending on the child's situation.

Create a calm environment.
Provide information about the possible cause, influencing factors and expected duration of the nausea and vomiting if it is intercurrent. When doing so, also point out the symptoms, consequences and risks of possible dehydration.
Provide information on the purpose, action, possible side effects and proper intake of antiemetics.
Indicate when the effect of treatment can be expected and the reason for adjusting treatment.
Check for anxiety, tension or other psychogenic factors.
Discuss with child and/or parents the role of nutrition in relation to life expectancy and its possible change.

Consider

In children with severe multiple disabilities, check for obstipation, urinary tract infection or nutrition-related discomfort, and consider causal treatment in combination with:
- Gastrointestinal venting,
- A lower intake rate and/or lower osmolality of tube feeding,
- Feeding via duodenum tube or a jejunostomy,
- Reducing total fluid and caloric intake, and/or
- Starting prokinetics.
In children with severe multiple disabilities, assess for autonomic dysfunction, visceral hyperalgesia and/or central neuropathy and consider drug treatment options such as gabapentin, pregabalin, Tricyclic Antidepressants and clonidine.

DO	Treat the cause of nausea and vomiting whenever possible.

Discuss with child and/or parents the role of nutrition and its possible change in relation to life expectancy.
Educate about various options when fluids and nutrition are not well tolerated:
- Administering smaller portions of oral fluids.
- Reduce total amount of nutrition.
- Possibly administer tube feeding or parenteral fluids.
Provide relaxation and distraction, especially in situations involving anxiety.

Consider

Consider providing nutritional counselling. Involve a dietitian, if necessary.
If the smell of food leads to symptoms, consider offering cold meals.
Consider having the child suck on ice cubes, crushed ice, or frozen piece of fruit.
In case of decreased gastric motility in children receiving tube feeding, consider, in consultation with an attending physician, a switch to semi-elemental nutrition or blended diet under the guidance of a dietitian.
Consider self-hypnosis for nausea and vomiting in children with cancer.

Consider

The use of medication for nausea and vomiting requires a rational approach. Base the choice of medication on the main (probable) cause and the pharmacological properties of the medication.

Consider

For nausea and vomiting without identifiable cause or with insufficient effect of causative treatment, consider administration of antiemetics according to the step-by-step plan below (and deviate from the order if necessary):
Step 1
Consider starting with:
1. A serotonin (5-HT3) antagonist, such as ondansetron; and/or
2. A dopamine (D2)-antagonist, such as domperidone or metoclopramide; and/or
3. An antihistamine such as cyclizine.
Step 2
Consider adding or substituting agents from the first step with:
1. Dexamethasone.
2. Granisetron (instead of ondansetron).
3. Haloperidol (instead of domperidone or metoclopramide).
4. Chlorpromazine or levomepromazine (instead of cyclizine)
Step 3
Consider adding:
1. Aprepitant.
2. A cannabis preparation containing dronabinol in consultation with an expert.

DO	Evaluate the effect and side effects of the treatment instituted at the appropriate time, and adjust treatment as needed. Involve child and family in this process.