Managed incorrectly, they can lead to physical problems such as anorexia, malnutrition, and dehydration, and cause significant emotional distress and psychological complications that in turn may lead to anticipatory nausea and vomiting (Phillips et al., 2020).
Teenagers and young adults (TYA) are more likely to report poor control of nausea and vomiting than younger children and are more prone to anticipatory nausea and vomiting (Slater et al., 2024).
Symptoms for children undergoing anti-cancer therapy are often found to occur in clusters, where interrelated physical and psychological symptoms emerge together, especially during chemotherapy. For example, nausea and vomiting commonly occurs with diarrhoea or constipation, taste alterations, loss of appetite and weight loss, which worsen other symptoms such as pain, fatigue and depression. An holistic approach to cluster symptom management is preferable to targeting specific symptoms. (Lopes-Junior et al. 2025).
Nausea and vomiting are reflexes, controlled by the vomiting centre in the brain, to expel toxic substances from the stomach and intestine (Navari, 2019). The vomiting centre is stimulated by drugs, smells, sights, foods, infections, and emotions and as well as individual triggers (CCLG, 2025).
Types of chemotherapy induced nausea and vomiting
- Acute: Occurs within 0-24 hours after first dose of chemotherapy usually peaks with first 5-6 hours following start of chemotherapy administration (Navari, 2019)
- Delayed: Occurs 24 hours after chemotherapy administration, lasting up to 5 days after the last dose of chemotherapy. Known drugs with this potential include cisplatin, carboplatin, doxorubicin, and cyclophosphamide (Navari, 2019)
NB: There are different causes for acute and delayed CINV and they need to be managed differently - Anticipatory: Occurs after the first cycle of chemotherapy and before subsequent ones. This generally occurs following an unpleasant experience during the first course of chemotherapy, where emesis was not well controlled. The child or young person starts to associate the clinical environment to the feeling of nausea and may start to feel sick or vomit before the administration of chemotherapy. This may cause weight loss, poor dietary intake, non-compliance with subsequent treatments or affect the patient’s quality of life (Slater et al., 2024; Phillips et al. 2020)
- Breakthrough: This is the reoccurrence of significant nausea or vomiting after a period of acceptable control.
- Refractory: This is the continuation of significant nausea or vomiting without a period of acceptable control.
NB: When breakthrough or refractory CINV occur, a ‘next level up’ approach to prophylaxis is required and should be considered for subsequent cycles of chemotherapy referring to the CCLG CINV guideline (CCLG, 2025) available from the child’s principal treatment centre (PTC) or shared care hospital (POSCU).
Risk factors
The severity of CINV is generally related to the emetogenic potential of the individual drugs however, certain risk factors may contribute to the patient’s experience (Navari, 2019).
- Patient specific - e.g. female, age > three years, anxiety, previous chemotherapy treatment, history of motion sickness, poor emesis control during previous chemotherapy treatment.
- Treatment specific - e.g. emetic potential of chemotherapy agent, regimen, dose, route, and administration rate of the chemotherapy.
Vomiting
The emetic reflex protects humans from poisoning. Chemotherapy is technically a poison which provokes this natural emetic response in humans (Slater et al., 2024). Stimulation of the vomiting centre in the brain results in the co-ordination of responses from the diaphragm, salivary glands, cranial nerves and gastro-intestinal muscles to produce the interruption of respiration and forced expulsion of stomach contents. 5HT3 inhibitors are the most effective anti-emetics, blocking one or more of the signals that cause nausea and vomiting.
Assessment of CINV
It is important to gain an accurate history of the degree of nausea and vomiting experienced by the child or young person to manage symptoms effectively.
The level of CINV experienced by the child or young person is determined through accurate assessment. To do this, it is vital to have an effective assessment tool which grades the severity of symptoms. On admission, before the administration of chemotherapy, the severity of nausea and vomiting experienced by the patient is assessed using the following scoring system.
Parents/carers, children and young people are advised that if they are concerned, they should contact their ward as soon as possible for help or advice.
Toxicity scoring criteria (CTCAE)
Common Terminology Criteria for Adverse Events (CTCAE) (National Cancer Institute 2025)
| Side effect | Grade 1 | Grade 2 | Grade 3 | Grade 4 | Grade 5 |
|---|---|---|---|---|---|
| Nausea – a queasy sensation +/- urge to vomit | Loss of appetite without alteration to eating habits | Oral intake decreased without significant weight loss, dehydration or malnutrition; IV intervention indicated | Inadequate oral caloric or fluid intake; tube feeding, total parenteral nutrition (TPN), or hospitalisation indicated | ||
| Vomiting - reflexive act of ejecting the contents of the stomach through the mouth | Intervention not indicated | Initiation of outpatient IV hydration; medical intervention indicated | Initiation of tube feeding, or TPN; hospitalisation indicated | Life threatening consequences | Death |
Management of CINV
Acute CINV prophylaxis
Pharmacological interventions
The provision of adequate preventative and responsive anti-nausea and vomiting therapies is key in all patients (CCLG, 2025). Medicines that act on different areas of the vomiting reflex are combined to provide optimal control. Caution must be taken to ensure that medicines do not interact or have cumulative side-effects. The full guideline for healthcare professionals can be found in CCLG Guideline for the Management of Chemotherapy-Induced Nausea and Vomiting (CINV).
NB: Dexamethasone should not be prescribed as an anti-emetic for patients with leukaemia or lymphoma, where steroids are prescribed as part of their chemotherapy treatment.
Delayed CINV prophylaxis
NB: Ondansetron is not effective in treating delayed emesis. Check the guidelines for more appropriate options.
Generally, for moderate emetogenic chemotherapy, anti-emetics are continued for three days following acute emesis prophylaxis.
Patients receiving drugs that have greater potential for delayed emesis (such as Carboplatin, Cisplatin, Cyclophosphamide and Doxorubicin) should be given up to five days anti-emetic treatment following acute emesis prophylaxis.
Anticipatory CINV
Effective prophylaxis for acute CINV would hopefully prevent anticipatory CINV. If it is already a problem, lorazepam can be given up to 24 hours before chemotherapy and has been beneficial, particularly in teenagers and young adults.
Please refer to CCLG CINV guideline for full management.
Non-pharmacological interventions
It is important to consider non-pharmacological interventions alongside pharmacological. This is a non-exhaustive list of non-pharmacological interventions
- Guided imagery – encourage patients to focus on a particular thought or image that they find joy, happiness or pleasing such as images related to nature or landscapes, a favourite place or person. This can be done prior to, during or after chemotherapy (Di Mattei et al., 2024)
- Distraction – cognitive distraction can be beneficial in counteracting CINV by taking the patient’s attention away from feelings of nausea and vomiting to focus on more pleasant activities such as playing computer games, group play sessions, education sessions, music activities, arts and crafts, films or television (Di Mattei et al., 2024). The play specialist can be helpful on these occasions.
- Dietary advice – chemotherapy effects the tastebuds, and this can contribute to altered sense of taste and increase nausea or vomiting (Gamper et al., 2010). Offer bland, dry foods, small portions but more frequently to prevent overeating. Continue to offer sips of fluid throughout the day or sucking on ice cubes. If eating highly fragranced food, have good ventilation to clear strong smells
- Ginger – has been shown in several studies to reduce the severity of acute and delayed CINV in conjunction with anti-emetic medication (Navari, 2019). Ginger is a herbal supplement that has been used to reduce the severity of motion sickness, pregnancy induced nausea and post-operative nausea and vomiting.
References
Di Mattei, V.E., Perego, G., Milano, F. and Gatti, F. (2024) The effectiveness of nonpharmacological interventions in the management of chemotherapy physical side effects: A systematic review. Healthcare, 12(18), p.1880. Available at: https://doi.org/10.3390/healthcare12181880
Gamper, E.M., Zabernigg, A., Wintner, L.M., Giesinger, J.M., Oberguggenberger, A., Kemmler, G. and Holzner, B. (2010) Taste alterations in cancer patients receiving chemotherapy: A neglected side effect? The Oncologist, 15(8), pp. 913–920. Available at: https://doi.org/10.1634/theoncologist.2009-0333
CCLG: The Children & Young People’s Cancer Association): Supportive Care SIG (2025) CCLG Guideline for the Management of Chemotherapy Induced Nausea and Vomiting (CINV) Available via CCLG Members in all UK Children & Young People’s Cancer Centres and Shared Care Units at: https://app.sheepcrm.com/cclg/treatment-guidelines/supportive-care/cinv/ (Last Accessed 24th July 2025)
Lopes-Júnior, L., Grassi, J., Freitas, M., Trigo, F., Aguilar, F., Nunes, K., de Vasconcelos, K., Lima, R. (2025). Cancer Symptom Clusters in Children and Adolescents with Cancer Undergoing Chemotherapy: A Systematic Review. Nursing Reports. 15 (163). Available from: DOI:10.3390/nursrep15050163 (Last accessed 24th July 2025)
Navari, R. (2019) Chemotherapy-Induced Nausea and Vomiting. In: De Mello, R., Mountzios, G., Tavares, A. (eds) International Manual of Oncology Practice. Springer: Switzerland
National Cancer Institute (2025) Common Terminology Criteria for Adverse Events (CTCAE) v6.0 (MedDRA 28.0). Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institutes of Health. Available at: https://dctd.cancer.gov/research/ctep-trials/for-sites/adverse-events/ctcae-v6.pdf (Accessed: 13th January 2026)
Priya, P. et al. (2022) Interventions for the prevention of acute phase chemotherapy-induced nausea and vomiting in adult and pediatric patients: a systematic review and meta-analysis Available at: https://pubmed.ncbi.nlm.nih.gov/35953731/ (Last Accessed 24th July 2025)
Phillips, B., Ffrench-Devitt, P., and Wellings, L. 2020. Prevalence of anticipatory nausea and vomiting in children undergoing cytotoxic chemotherapy for malignant disease - the SiCK2 (Sickness prior to Chemotherapy in Kids) study. medRxiv 2020. Available at: doi: https://doi.org/10.1101/2020.06.09.20126284 (Last Accessed 24th July 2025).
Slater, T., Tanna, N. & Soto, C. (2024). Chemotherapy Induced Nausea & Vomiting – What Do Teenagers & Young Adults with Cancer (TYAC) Want? University College London Hospitals NHS Foundation Trust. MASCC Conference Proceedings. Available at: https://simul-europe.com/2024/mascc/Files/1896.pdf [Accessed 17 Dec 2025]
Page last updated January 2026