Development and validation of the pediatric nausea assessment tool for use in children receiving antineoplastic agents

CYP2D6 genotype and associated 5-HT3 receptor antagonist outcomes: A systematic review and meta-analysis

5-hydroxytryptamine-3 (5-HT3) receptor antagonists including ondansetron, tropisetron, dolasetron, palonosetron, granisetron, and ramosetron are commonly used to prevent and treat nausea and vomiting. Most of these medications are at least partially metabolized via the highly polymorphic CYP2D6 enzyme, resulting in variations of metabolism among individuals. Current (2017) international prescribing guidelines for ondansetron/tropisetron use according to genotype provide recommendations for CYP2D6 ultrarapid metabolizers but not intermediate or poor metabolizers. However, multiple studies have been conducted since this guideline was published. This review evaluated all available evidence of an association between CYP2D6 genotype and 5-HT3 receptor antagonist outcomes, including in patients who are CYP2D6 intermediate/poor metabolizers and pediatric-specific studies. In this review, we confirm that CYP2D6 genotype impacts ondansetron response in a postoperative nausea and vomiting setting, which was supported by a meta-analysis. We also highlight the heterogeneity and limitations of included studies as well as provide future directions for pharmacogenomics research.

Feasibility and face validity of two patient reported outcome measures for nausea: Preferences of children with cancer

PURPOSE

To optimize recognition and management of nausea in children with cancer using patient reported outcome measures (PROMs) and to identify preferences of children with cancer regarding two validated tools: the Baxter Retching Faces (BARF) scale and the Pediatric Nausea Assessment Tool (PeNAT).

DESIGN AND METHODS

This quantitative descriptive cross-sectional study (n = 34) used bespoke questionnaires to measure feasibility and face validity of the BARF and the PeNAT. Feasibility included the items: understanding, ease of use, and communication. Face validity was studied in terms of the degree in which the faces of both PROMs corresponded with children's feelings of nausea. A descriptive and comparative analysis of the data was performed.

RESULTS

Both the BARF and the PeNAT were rated by the children as feasible, and no significant differences were found. However, regarding the item communication, the PeNAT did not reach the cut-off value (≥80% of all children scored neutral, agree or totally agree on the Likert scale). Regarding face validity, only the BARF reached the cut-off value and corresponded significantly better with children's feelings of nausea than the PeNAT.

CONCLUSION

According to children with cancer, only the BARF is both feasible and meets criteria for face validity. Therefore, the BARF is recommended as a PROM for reporting nausea in children with cancer. However, possible differences between age groups should be taken into account for future research.

PRACTICE IMPLICATIONS

This study will help health care professionals in making a patient-centered and informed choice when using a PROM for measuring nausea in children with cancer.

Anti-Emetics in Children Receiving Chemotherapy for Solid Tumors and Leukemia: Pharmacology and Optimization of Therapy for Nausea and Vomiting

The management of chemotherapy-induced nausea and vomiting (CINV) in children remains challenging due to differences in the chemotherapy regimens, their relative emetogenicity compared to that in adults and differences in drug metabolism and the available formulations. The common four classes of anti-emetics used for the treatment and prophylaxis of CINV in children include dexamethasone, neurokinin-1 receptor antagonists, 5-hydroxytryptamine-3 receptor antagonists (5HT3RAs), and olanzapine. The appropriate dose of dexamethasone for CINV prophylaxis in children is unknown, with a significant variability in dosage ranging between 6 and 32 mg/m2/day. The dose of dexamethasone is decreased by 30% when this drug is combined with (fos)aprepitant in children, in contrast to a decrease of 50% required in adults. The use of aprepitant in younger children (<12 years) is often hampered by the non-availability of oral suspension formulations in many countries; alternatively, 80 mg capsules are administered for 1-3 days in certain institutes to children weighing between 15 and 40 kg. Among the different 5HT3RAs, palonosetron is comparatively metabolized faster in children than in adults, requiring a higher dosage for similar efficacy to that achieved in adults. Olanzapine is a newer agent, used in doses between 0.1 and 0.14 mg/kg/day in children, with good anti-emetic efficacy, but has sedation and hyperglycemia as concerning adverse effects. Drug interactions between anti-emetics and between anti-emetics and chemotherapy/supportive agents (azole antifungals, cyclosporine, arsenic trioxide), especially QTc prolongation, should be considered during prescription.

Pediatric oncology provider perspectives and patient/family perceptions of chemotherapy-induced nausea and vomiting management: Experiences at an academic medical center

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) is common in children undergoing cancer treatment, and significantly impacts quality of life. Clinical practice guidelines (CPGs) have been developed to guide CINV management, though many patients do not receive guideline-concordant care. Few studies have examined provider perspectives on CINV management or preferred improvement approaches, or pediatric patient perception of CINV control.

METHODS

A cross-sectional study of pediatric oncology providers was conducted at a large freestanding children's hospital. Providers completed an anonymous online survey about CINV control in patients admitted for scheduled chemotherapy, and their knowledge and utilization of CINV CPGs. A survey of English and Spanish-speaking pediatric oncology patients admitted for scheduled chemotherapy was conducted to assess CINV management, with key demographics used to understand association with perceptions and adherence to antiemetic guidelines.

RESULTS

For providers, 75% of respondents felt CINV management could be moderately or extremely improved, significantly more so by chemotherapy prescribers and pediatric medical residents than nurses. Over half of respondents did not have awareness of CINV CPGs, particularly pediatric medical residents. For patients, nausea was reported to be extremely well controlled in 44% of cases, and vomiting extremely well controlled in 50% of cases. There were no significant differences in patient-reported CINV across demographics, when considering emetogenicity of chemotherapy received, or concordance to guidelines.

CONCLUSIONS

Implementing education in this area may help to improve provider comfort, and ultimately, the patient experience. Future studies will expand upon this novel patient perception, and develop and evaluate CINV management interventions.

Translation and Psychometric Evaluation of the Hindi Language Version of the Pediatric Nausea Assessment Tool (PeNAT) in the Indian Population

OBJECTIVES

To translate the Pediatric Nausea Assessment Tool (PeNAT) into Hindi and validate it in Indian pediatric cancer patients and survivors.

METHODS

The PeNAT-Hindi was finalized by forward and backward translations, and pilot testing. The PeNAT-Hindi was administered to 200 Hindi-speaking pediatric (4-18 y) cancer patients/survivors, in three groups. These included pediatric cancer patients who had recently received chemotherapy (n = 150); who received no chemotherapy within 5 d (n = 25) and survivors (n = 25). Construct validity was tested by comparing scores among the three groups. Test-retest reliability and criterion validity were estimated by the correlation of the first PeNAT score with the second (taken 1 h later) PeNAT score and the number of vomiting/retching episodes, respectively. Convergent validity and discriminant validity were estimated by correlating PeNAT scores with parent-assessed nausea severity, and pain, respectively. The responsiveness was tested by comparing second PeNAT scores with subsequent divergent PeNAT scores among patients reporting subjective change (improvement and worsening, respectively) in nausea severity.

RESULTS

Test-retest reliability of PeNAT-Hindi was good (intraclass correlation = 0.791). The initial PeNAT score had moderate correlation with the number of vomiting/retching episodes (Spearman ρ = 0.401). Median PeNAT scores in group 1 versus groups 2 and 3 were significantly different (p < 0.001). Initial PeNAT scores showed a moderate correlation with parent-assessed nausea (Spearman ρ = 0.657) and a weak correlation with parent-assessed pain (Spearman ρ = 0.319). The responsiveness (standardized response mean) of PeNAT-Hindi to the change in nausea severity was -1.79 (improvement) and 2.19 (worsening), respectively.

CONCLUSION

PeNAT-Hindi showed good reliability and acceptable validity. It may be used among Hindi-speaking children for measuring nausea. The responsiveness of PeNAT-Hindi needs further evaluation.

Validation of co-Symptom Screening in Pediatrics Tool: a novel dyadic approach to symptom screening in pediatric patients receiving cancer treatment

BACKGROUND

Co-Symptom Screening in Pediatrics Tool (co-SSPedi) is a dyadic (child-guardian) approach to symptom assessment. Objectives were to evaluate the reliability and validity of co-SSPedi for pediatric patients receiving cancer treatments.

METHODS

This multicenter study included dyads of patients aged 4-18 years of age with cancer or undergoing hematopoietic cell transplant and their guardians. Two groups were enrolled. The more symptomatic group included those receiving active treatment for cancer or undergoing hematopoietic cell transplant where patients were in hospital or clinic for 4 consecutive days. The less symptomatic group included those receiving maintenance therapy for acute lymphoblastic leukemia or who had completed cancer treatments. At baseline, all dyads completed co-SSPedi, and guardians completed measures of mucositis, nausea, pain, quality of life, and overall symptoms. In the more symptomatic group, dyads completed co-SSPedi and a global symptom change scale on day 4.

RESULTS

There were 501 dyads included: 301 in the more symptomatic group and 200 in the less symptomatic group. Median time to complete co-SSPedi was less than 3 minutes in both groups. Test-retest reliability intraclass correlation coefficient was 0.85 (95% confidence interval [CI] = 0.77 to 0.90). For internal consistency, total co-SSPedi Cronbach alpha was 0.81 (95% CI = 0.78 to 0.83). For known groups validation, mean difference in total co-SSPedi scores between the more symptomatic and less symptomatic groups was 7.8 (95% CI = 6.7 to 8.8; P < .0001). For convergent validation and responsiveness, all hypothesized relationships were demonstrated.

CONCLUSIONS

Co-SSPedi is a novel approach to dyadic symptom assessment that is reliable, valid, and responsive in pediatric patients aged 4-18 years.

Vomiting after intrathecal chemotherapy under anesthesia in pediatric patients with hematologic cancers: A cohort study

INTRODUCTION

Despite preventive strategies, vomiting is an adverse event affecting patients with cancer. However, literature on the incidence and risk factors for vomiting in pediatric patients with cancer are scarce.

AIM

To assess the incidence and risk factors for vomiting within 24 h and goodness of fit for the Eberhart score in pediatric patients with hematologic cancers after receiving intrathecal chemotherapy under deep sedation.

METHODS

This prospective cohort study included patients under 20 years of age with hematologic cancers who were scheduled to undergo intrathecal chemotherapy under anesthesia. The primary outcome was the occurrence of vomiting within 24 h after the end of anesthesia. Sociodemographic and procedure data and underlying diseases were collected. Patients were monitored during the procedure, in the postanesthesia care unit, and the day after (by phone call).

RESULTS

A total of 139 patients were included, and the incidence of vomiting was 30.9% within 24 h after intrathecal chemotherapy under anesthesia, with 90.7% of vomiting prior to 6 h. Prophylactic ondansetron was administered prior to the procedure to 45.3% of patients. Risk factors for vomiting were female gender (hazard ratio: 2.47, 95% confidence interval: 1.35-4.53, p: .003), consolidation phase of treatment (hazard ratio: 2.16, 95% confidence interval: 1.10-4.24, p: .025), and history of kinetosis (hazard ratio: 2.49, 95% confidence interval: 1.31-4.70, p: .005). Incidence of vomit was higher than estimated by the Eberhart score distribution (observed incidence in patients with a score of zero: 33.3%; with a score of one: 28.8%; with a score of two: 60%).

CONCLUSION

A high incidence of vomiting was observed within 24 h after intrathecal chemotherapy under propofol deep sedation. Risk factors for this outcome were established (being female, consolidation phase of treatment, and previous kinetosis), and evidence suggested that the Eberhart score was not suitable for the studied population.

Addition of aprepitant improves acute emesis control in children and adolescents receiving induction chemotherapy for acute myeloid leukaemia: a randomised, open-label trial

OBJECTIVES

More than 50% patients develop emesis during induction therapy for acute myeloid leukaemia (AML). The addition of aprepitant for emesis control in children receiving induction for AML have not been explored.

METHODS

A single-institutional randomised, open-label trial (NCT02979548) was conducted where children between 5 and 18 years with the diagnosis of AML being planned for 3+7 induction regimen were included. All study participants received ondansetron (0.15 mg/kg) every 8 hours for 8 days starting 30 min prior to chemotherapy. Children belonging to aprepitant group additionally received aprepitant capsules (15-40 kg=days 1-3, 80 mg; >40 kg=day 1, 125 mg and days 2-3, 80 mg) starting from 1 hour prior to chemotherapy. The proportion of patients with complete response (CR) in chemotherapy induced vomiting (CIV) in acute phase (day 1-8), delayed phase (day 9-13), overall and initial 96 hours were recorded along with severity of vomiting and adverse effects.

RESULTS

Total 78 children were randomised (Aprepitant group: 37 and control group: 41). The proportion of patients with CR in CIV was significantly higher in Aprepitant group in acute phase (p=0.007), overall phase (p=0.007) and in initial 96 hours (p<0.001) but it was not different in delayed phase (p=0.07). The first episode of vomiting was also significantly delayed in aprepitant group (p=0.02). Adverse effect profile was similar in two groups.

CONCLUSION

Aprepitant significantly improves emesis control in children receiving induction therapy for AML, especially in acute phase and should be routinely incorporated as part of antiemetic prophylaxis.

TRIAL REGISTRATION NUMBER

The study was registered at ClinicalTrials.gov (NCT02979548).

Risk factors associated with nausea and vomiting in children with cancer receiving chemotherapy

INTRODUCTION

Despite treatment with antiemetic medications, nausea remains uncontrolled for many children receiving chemotherapy. One reason is that risk factors for nausea in children remain poorly explored. The purpose of this study was to identify risk factors for chemotherapy-induced nausea (CIN) in children.

METHODS

Prospective, observational study including 101 children (median age 6.4 years, range 0.8-17.9) with cancer receiving moderately or highly emetogenic chemotherapy. Primary endpoints were complete control of acute and delayed CIN, defined as no nausea in the acute phase 0-24 h after chemotherapy and in the delayed phase starting after the acute phase and ending 5 days later. Multivariable analyses included age, sex, cancer type, susceptibility to motion sickness, chemotherapy duration, numbers of antiemetics, co-administration with opioids or tricyclic antidepressants, and previously uncontrolled nausea or vomiting.

RESULTS

Acute CIN was associated with susceptibility to motion sickness (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.36-33.7) and older age (OR 4.19, 95% CI 1.30-14.7), comparing age group 8-18 years with 0-3 years. Delayed CIN was associated with uncontrolled acute nausea or vomiting (OR 10.3, 95% CI 2.65-50.9), highly emetogenic chemotherapy (OR 8.26, 95% CI 1.17-76.8), and having a hematologic cancer type (OR 7.81, 95% CI 1.05-79.2).

CONCLUSIONS

Susceptibility to motion sickness and age can influence the risk of acute CIN. More research is needed on how best to integrate risk information in preventive antiemetic strategies. Sufficient acute nausea and vomiting control are crucial to prevent delayed CIN.

Pediatric Palliative Care: Insights into Assessment Tools andReview Instruments

The proper assessment of needs and outcomes in pediatric palliative care (PPC) is imperativeto ensure the best possible service to patients and families. However, given the multidimensionalnature of PPC, the low number of patients in this setting, the heterogeneity of diseases, the presenceof cognitive impairment in many patients, and the physiological development of children, outcomescan be complex and difficult to measure. Consequently, in this context, the use of standardizedand validated tools to assess the needs of children and families, to assess symptom severity, andto estimate the quality of PPC service represent a current need. Even if efforts have been made tostandardize approaches and tools for palliative care in adults, to our knowledge, a similar comprehensiveassessment of PPC has not yet been conducted to date. This narrative review provides anoverview and discusses the evaluation of tools currently applied in PPC, with an educational intentfor healthcare providers. We found that several instruments are available to assess different dimensionsof PPC. We proposed a classification into eligibility tools, patient and family needs assessmenttools, and care assessment tools. At present, two main eligibility tools exist, the PaPaS Scale and theACCAPED Scale questionnaire. Most of the tools for patient and family needs assessment have notbeen specifically validated in the PPC setting, and many may be more readily applied in researchsettings rather than in daily practice. Similar considerations can be made for tools assessing QoL,while tools assessing PPC service quality seem to be easily applied. Efforts to develop new specifictools and validate existing ones are undoubtedly advocated. However, in the patient's best interest,PPC healthcare providers should start using available tools, regardless of their validation status.

Addressing adherence to guidelines on prevention of acute chemotherapy-induced nausea and vomiting in pediatric patients

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) is a distressing adverse effect in children receiving cancer treatment. There are evidence-based pediatric clinical practice guidelines (CPG) on chemotherapy emetogenicity and acute CINV prevention, but adherence to these guidelines is low.

PROCEDURE

A quality improvement-based study was conducted at McMaster Children's Hospital. The SMART aim was to increase adherence to guidelines on prevention of acute CINV in hospitalized patients receiving high (HEC) and moderately emetogenic chemotherapy (MEC) from baseline 25% to more than 70% by June 2021. Barriers were identified by process mapping, and a series of interventions were implemented.

RESULTS

Guideline adherence was assessed in 270 inpatient chemotherapy administrations (HEC, MEC). Data were collected on 131 charts pre interventions and 139 charts post interventions. Interventions included education, addition of guideline-recommended anti-emetics to the inpatient formulary, and implementation of a standardized CPG tool. Initial rates of total CINV guideline adherence were 25%, which improved to 72% post intervention (p < .001). In subgroup analysis, guideline adherence in the MEC group improved from 13% to 34% (p = .015), and in the HEC group from 32% to 93% (p < .001). The most common reason for nonadherence in the HEC group was failure to use aprepitant as anti-emetic, and in MEC was option for ondansetron monotherapy prophylaxis.

CONCLUSION

Using quality improvement methodology, barriers to guideline adherence were identified and interventions implemented. Guideline adherence for prevention of CINV improved, particularly in the HEC group but less for the MEC group. Future steps will include sustainability of interventions and addressing adherence in the MEC group.

Pediatric Nurses' Person-Centered Approach to Nausea Management in Children With Cancer

Background: Nausea is a problematic side effect of childhood cancer treatment. However, it is not clear what interventions and assessments pediatric oncology nurses make when caring for a child with nausea. A person-centered approach can illuminate nausea management in pediatric care. The aim was to investigate how pediatric nurses retrieve the patient's narrative, establish partnership, and document nausea in hospitalized children with cancer. Methods: Individual interviews with nurses were conducted and analyzed using deductive content analysis with the framework of person-centered care. Results: The pediatric nurses described retrieving the patient's narrative regarding their nausea by listening to and observing the child. The pediatric nurses tried to establish a partnership with the child by allowing previous knowledge and the child's own preferences guide the interventions that focus on decreasing the child's nausea. The pediatric nurses also documented the effect of the given interventions and described the child's nausea using subjective words. When planning for the child's care it was rare for the nurses to have a documented care plan, but they did review documentation of previously administered interventions to plan for future care. Discussion: The results highlight the pediatric nurses' willingness to listen to the child, but also emphasize the need to further include the child and the parents in the partnership and documentation of nausea management. Collaboration with the child and the parents contributes to higher quality care and a partnership with trust.

The emerging role of olanzapine in paediatric CINV control: A review

Chemotherapy-induced nausea and vomiting (CINV) is a serious side effect of chemotherapy that negatively impacts the quality of life of oncological patients and is associated with the emetogenic risk specific to administered chemotherapy. Current practice guidelines on the use of antiemetics in CINV include the option of adding olanzapine to antiemetic regimens in the management of adult CINV. The use of olanzapine in pediatric CINV has been restricted to children with poor CINV control. Research on the use of olanzapine in pediatric CINV has been limited. The aim of this review was to evaluate current evidence on the effective and safe antiemetic use of olanzapine in pediatric CINV of any type following chemotherapy of any emetogenicity. Ovid MEDLINE, Embase, CENTRAL databases were searched for any literature on the use of olanzapine in pediatric CINV published from 2015 to 2022. Studies that reported on the olanzapine-containing antiemetic regimen in peadiatric CINV control specifically were included. Search restrictions were placed on research published in English. The search generated 43 records that were assessed for eligibility. Out of 10 identified eligible studies a third were RCT. Findings of this review suggest that adding olanzapine to antiemetic regimen in pediatric CINV control is a worthwhile consideration. Further research is needed to establish the efficacy and safety of antiemetic olanzapine use in pediatric CINV.

Longitudinal use of patient reported outcomes in pediatric leukemia and lymphoma reveals clinically relevant symptomatic adverse events

BACKGROUND

Leukemia and lymphoma (LL) are the most common cancer diagnoses of childhood with high survival rates, but not without impact on the child's functioning and quality of life. This study aimed to use patient-reported data to describe the symptomatic adverse event (AE) experiences among children with LL diagnoses.

METHODS

Two hundred and fifty seven children and adolescents aged 7-18 years with a first LL diagnosis completed the Pediatric Patient-Reported version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE) and Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric measures before starting a treatment course (T1) and after the treatment (T2).

RESULTS

Fatigue was the most severe AE (68.1% at T1; 67% at T2) and caused the most interference over time. Gastrointestinal AEs were also quite common (e.g., nausea 46.3% at T1 and 48.9% at T2; abdominal pain 42.4% at T1; 46.5% at T2). In general, symptoms were present both at T1 and T2 and did not change significantly in severity or interference. The prevalence of AEs varied by LL disease group (e.g., nausea was most common in acute lymphoblastic leukemia (ALL), fatigue was most severe in ALL and Hodgkin Lymphoma (HL), acute myeloid leukemia had the fewest AEs).

CONCLUSION

Despite current supportive care regimens, many children with LL continue to report fatigue, pain, insomnia, and gastrointestinal symptoms as the most frequent or severe symptoms during therapy.

[Antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: 2022: Guidelines from the supportive care committee of the French Society of Childhood Cancer (SFCE)]

Nausea and vomiting induced by cancer treatment (CINV) remain one of the most common and feared side effects in children despite the use of new drugs to prevent them. The existing recommendations for the prophylaxis and treatment of CINV are based on adult patients in Anglo-Saxon societies. Based on a recent review of the literature, we focused on specific pediatric issues in order to offer recommendations validated by the supportive care committee of the French society for childhood cancer.

Optimizing antiemetic therapy for children undergoing chemotherapy

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.

Reliability and validity of proxy-SSPedi and mini-SSPedi in pediatric patients 2-7 years receiving cancer treatments

Background

Symptom Screening in Pediatrics Tool (SSPedi) was developed for symptom screening by children 8-18 years. Objectives were to evaluate the reliability and validity of proxy-SSPedi and self-report mini-SSPedi for younger children.

Methods

This multi-center study enrolled guardians of children 2-7 years receiving cancer treatments (proxy-SSPedi) and their children 4-7 years (mini-SSPedi). The two populations were: (1) More symptomatic group where children were receiving active cancer treatment and were in hospital or clinic for four consecutive days; and (2) Less symptomatic group where children were receiving maintenance therapy for acute lymphoblastic leukemia or had completed cancer therapy. Proxy-SSPedi or mini-SSPedi were completed with measures of mucositis, nausea, pain, quality of life and overall symptoms. Respondents in the more symptomatic group repeated proxy-SSPedi/mini-SSPedi and a global symptom change scale 3 days later.

Results

There were 402 guardians and 326 children included in the analysis. Test re-test reliability of proxy-SSPedi showed intraclass correlation coefficient (ICC) 0.83 (95% confidence interval (CI) 0.72-0.90). Mean difference in proxy-SSPedi between more and less symptomatic groups was 9.7 (95% CI 8.3-11.1). Proxy-SSPedi was responsive to change and hypothesized relationships between measures were observed. With a priori threshold ≥0.6, inter-rater ICC among all dyads and those 6-7 years were 0.54 (95% CI 0.45-0.62) and 0.62 (95% CI 0.50-0.71) respectively. Among participating children, other hypothesized reliability and validity thresholds were generally met.

Conclusions

Proxy-SSPedi is reliable, valid and responsive in children 2-7 years old receiving cancer treatments. Mini-SSPedi can be used for children 6-7 years of age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09814-8.

A scoping review of nausea, vomiting and retching measurement methods in children with cancer

Evaluation of chemotherapy-induced nausea and vomiting (CINV) in the pediatric population is subject to diverse approaches. This scoping review summarizes the methods used in clinical studies that assessed nausea, vomiting or retching in children with cancer. We conducted a literature search of studies indexed in EMBASE and Ovid MEDLINE after 2000. Studies were included if they involved patients ≤18 years of age diagnosed with cancer, and had nausea, vomiting or retching as a primary study outcome. We excluded studies that reported only parent- or clinician-proxy measures without including the child's self-reported NVR, and those without specifying the NVR data collection process. The literature search identified twenty-four studies evaluating pediatric nausea, vomiting or retching. In the assessment of NVR, structured surveys were the most commonly used instrument for NVR assessment (75%) and the use of patient diaries (50%). Nine studies (38%) relied solely on self-reports from children as the outcome measure, while fifteen studies (62%) solicited input from parents/ caregivers and healthcare providers in addition to children's self-reports. Almost all the studies reported the frequency (n = 24) and/or severity (n = 23) of NVR symptoms and the use of antiemetic therapy (n = 19). Fewer studies evaluated distress caused by the symptoms (n = 2) and the effects of symptoms on activities of daily living (n = 4). Incorporating NVR measurement tools as part of standard of care for pediatric patients undergoing chemotherapy is strongly advocated. Based on the age group, we recommend the use of such tools comprising Likert scale, pictorial scales and structured scripts to assess various dimensions of a child's NVR experience.

Lack of Concordance in Symptomatic Adverse Event Reporting by Children, Clinicians, and Caregivers: Implications for Cancer Clinical Trials

PURPOSE

To examine concordance in symptomatic adverse event (AE) grading using the Common Terminology Criteria for Adverse Events (CTCAE 4.0) for clinicians and its patient-reported outcome (PRO) versions for children (Ped-PRO-CTCAE) and caregivers (Ped-PRO-CTCAE [Caregiver]).

METHODS

Children age 7-18 years with a first cancer diagnosis, their clinicians, and caregivers completed CTCAE-based measures before starting a treatment course (T1) and after the treatment (T2). Grades (0-3) were assigned by each reporter for 15 core AEs spanning physical and mental health. Mean grades were compared between reporters using two-sample t-tests; agreement was estimated using weighted kappa (κ) statistics. Multivariable mixed regression models were used to evaluate associations of clinical factors with AE reporting concordance. Significance was set at α = .05 (two-sided).

RESULTS

There were 438 child-clinician-caregiver triads with complete data at either T1 or T2. For children, the mean age was 13 years (standard deviation = 3.4), 53.7% were male, 32.6% non-White, and 56.4% had leukemia/lymphoma. At T1, clinician mean AE grades were significantly lower (ie, better) than children for all AEs and remained significantly lower at T2 except for constipation, nausea, anorexia, neuropathy, and anxiety. Caregiver mean AE grades were similar to children at T1 and significantly higher (ie, worse) at T2 for nausea, vomiting, anorexia, pain, fatigue, anxiety, and depression. Agreement for child-clinician grading was poor-to-fair at T1 (κ range, 0.08-0.34) and T2 (0.11-0.35), and for child-caregiver, was fair-to-good at T1 (0.34-0.65) and T2 (0.24-0.60). No factors were consistently associated with reporter concordance across AEs.

CONCLUSION

Compared with children, symptomatic AEs were consistently under-reported by clinicians with low agreement and over-reported by caregivers with low-moderate agreement. Direct reporting by children using Ped-PRO-CTCAE or similar measures should be routinely incorporated for toxicity assessment in clinical trials.

Validity and Reliability of the Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events

BACKGROUND

Patient-reported outcome (PRO) measurements linked to Common Terminology Criteria for Adverse Events (CTCAE) grading may improve symptom adverse event (AE) reporting in pediatric oncology trials. We evaluated construct validity, responsiveness, and test-retest reliability of the Ped-PRO-CTCAE measurement system for children and adolescents undergoing cancer care.

METHODS

A total of 482 children and adolescents (7-18 years, 41.5% not non-Hispanic white) newly diagnosed with cancer and their caregivers participated from nine pediatric oncology hospitals. Surveys were completed at 72 hours preceding treatment initiation (T1) and at follow-up (T2) approximately 7-17 days later for chemotherapy, and 4+ weeks for radiation. Psychometric analyses examined the relationship of Ped-PRO-CTCAE items (assessing 62 symptom AEs) with Patient-Reported Outcomes Measurement Information System, Memorial Symptom Assessment Scale, Lansky Play-Performance Scale, and medication use. A separate test-retest study included 46 children.

RESULTS

Ped-PRO-CTCAE and Memorial Symptom Assessment Scale were strongly correlated across age groups at T2: 7-12 years (r = 0.62-0.80), 13-15 years (r = 0.44-0.94), and 16-18 years (r = 0.65-0.98); and over time. The Ped-PRO-CTCAE was strongly correlated with Patient-Reported Outcomes Measurement Information System Pediatric measures at T2; for example, pain interference (r = 0.70, 95% confidence interval [CI] = 0.64 to 0.76), fatigue severity (r = 0.63, 95% CI = 0.56 to 0.69), and depression severity (r = 0.76, 95% CI = 0.71 to 0.81). Ped-PRO-CTCAE items differentiated children by Lansky Play-Performance Scale and by medication use. Test-retest agreement ranged from 54.3% to 93.5%.

CONCLUSIONS

This longitudinal study provided evidence for the construct validity and reliability of the core Ped-PRO-CTCAE symptom AE items relative to several established measures. Additional responsiveness data with clinical anchors are recommended. Incorporation of Ped-PRO-CTCAE in trials may lead to a better understanding of the cancer treatment experience.

Translation of the Pediatric Nausea Assessment Tool (PeNAT) Into Spanish and Evaluating Understandability Among Spanish-Speaking Hispanic American Children and Adolescents Receiving Chemotherapy

Introduction:

We aimed to create a Spanish-language version of the Pediatric Nausea Assessment Tool (PeNAT) and examine its understandability among Spanish-speaking, Hispanic American children.

Methods:

Translation: Forward and backward translations of the PeNAT documents were performed and verified by a bilingual panel. Four monolingual, Spanish-speaking dyads (child/parent) and four bilingual dyads piloted the Spanish-language PeNAT documents. Four additional bilingual dyads read both versions and completed the PeNAT using their preferred version. These were reviewed for errors due to misunderstanding.

Understandability:

Children aged 4–18 years about to receive chemotherapy who spoke Spanish at home and were without impairments precluding PeNAT use were eligible. Participants used the Spanish-language PeNAT during a chemotherapy block. Parents gave feedback on the PeNAT documents. Recruitment continued until 10 consecutive participants offered no substantive suggestions for revision.

Results:

Translation: All child/parent dyads completed the PeNAT without errors attributable to misunderstanding. The Spanish-language PeNAT was preferred by three of four bilingual dyads. Understandability: Ten cancer patients (mean age: 10.6 years) used the Spanish-language PeNAT. All parents felt their child understood the PeNAT; none felt the documents were hard or very hard to use.

Conclusion:

The Spanish-language PeNAT was understood by Spanish-speaking Hispanic American children. Further psychometric testing is warranted.

Data Quality of Chemotherapy-Induced Nausea and Vomiting Documentation

OBJECTIVE

The objective of the study was to characterize the completeness and concordance of the electronic health record (EHR) documentation of cancer symptoms among multidisciplinary health care professionals.

METHODS

We examined the EHRs of children, adolescents, and young adults who received highly emetogenic chemotherapy and characterized the completeness and concordance of chemotherapy-induced nausea and vomiting (CINV) documentation by clinician type and by the International Classification of Diseases 10th Revision (ICD-10) coding choice.

RESULTS

The EHRs of 127 patients, comprising 870 patient notes, were abstracted and reviewed. A CINV assessment was documented by prescribers in 75% of patients, and by nurses in 58% of patients. Of the 60 encounters where both prescribers and nurses documented, 72% agreed on the presence/absence of CINV.

CONCLUSION

Most patients receiving highly emetogenic chemotherapy had a documented assessment of CINV; however, many had incomplete or discordant documentation of CINV from different providers by role, implying the importance of incorporating pragmatic knowledge of EHR documentation patterns among multidisciplinary health professionals for EHR phenotyping and clinical decision support systems directed toward cancer-related symptom management.

Considerations to Support Use of Patient-Reported Outcomes Measurement Information System Pediatric Measures in Ambulatory Clinics

OBJECTIVE

To identify challenges to the use of Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric measures in the ambulatory pediatric setting and possible solutions to these challenges.

STUDY DESIGN

Eighteen semistructured telephone interviews of health system leaders, measurement implementers, and ambulatory pediatric clinicians were conducted. Five coders used applied thematic analysis to iteratively identify and refine themes in interview data.

RESULTS

Most interviewees had roles in leadership or the implementation of patient-centered outcomes; 39% were clinicians. Some had experience using PROMIS clinically (44%) and 6% were considering this use. Analyses yielded 6 themes: (1) selection of PROMIS measures, (2) method of administration, (3) use of PROMIS Parent Proxy measures, (4) privacy and confidentiality of PROMIS responses, (5) interpretation of PROMIS scores, and (6) using PROMIS scores clinically. Within the themes, interviewees illuminated specific unique considerations for using PROMIS with children, including care transitions and privacy.

CONCLUSIONS

Real-world challenges continue to hamper PROMIS use. Ongoing efforts to disseminate information about the integration of PROMIS measures in clinical care is critical to impacting the health of children.

Validation of the caregiver Pediatric Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events measure

BACKGROUND

Despite improvements in survival rates, cancer treatments have significant side effects that affect the quality of life of children and their families. When an ill child cannot self-report symptoms (eg, he or she is too ill), caregiver (parent) reporting becomes critical. This study evaluates the validity and reliability of the caregiver-reported Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE [Caregiver]) measure.

METHODS

A diverse sample of caregivers with children receiving treatment at 9 oncology centers completed the Ped-PRO-CTCAE [Caregiver] measure, the Patient-Reported Outcomes Measurement Information System^® (PROMIS^® ) Parent Proxy measures, the Lansky Play-Performance Scale (PPS), medication use questions, and Global Impressions of Change (GIC). Construct validity (including convergent, discriminant, and known groups validity and responsiveness over time) and reliability (stability) were examined.

RESULTS

A majority of the 473 caregivers were female (85%), non-Hispanic White (61%), and married (75%). Symptoms assessed with the Ped-PRO-CTCAE [Caregiver] and PROMIS Parent Proxy measures were strongly correlated (e.g., r for pain = 0.78; r for fatigue = 0.78; and r for depression = 0.83). Most of the Ped-PRO-CTCAE [Caregiver] item mean scores distinguished among PPS function levels and between children who did take medications for symptom control and children who did not. Changes in Ped-PRO-CTCAE [Caregiver] item mean scores were responsive to GIC over time. Test-retest evaluation found moderate to high agreement (57.8%-93.3%) over time.

CONCLUSIONS

This study found strong evidence for the convergent and discriminant validity, known groups validity, responsiveness, and stability of the Ped-PRO-CTCAE [Caregiver] measure in a large and diverse sample of caregivers. The caregiver perspective provides a valuable and unique insight into the experiences of children and adolescents undergoing cancer treatment.

LAY SUMMARY

Despite advances in cancer treatments, children and adolescents continue to suffer from treatment side effects, including pain, nausea, fatigue, and emotional distress, that can adversely affect quality of life for children and their families. Although it is best for children to report how they are feeling, there are times when a child may be too young or too ill to self-report. This study provides critical evidence for a new type of questionnaire that allows the caregiver or parent to report accurately what the child is experiencing. This measure can be used to improve adverse event reporting and child cancer care.

Chemotherapy-Induced Nausea and Vomiting: Pathogenesis, Recommendations, and New Trends

The significant physical and emotional effects of chemotherapy-induced nausea and vomiting (CINV) are experienced by cancer patients. Severe symptoms decrease the patient's quality of life and potentially deters further treatment. The five main forms of CINV (i.e., acute, delayed, anticipatory, breakthrough, and refractory) require different treatment regimens, which often include 5-HT3 receptor antagonists, NK1 receptor antagonists, and corticosteroids. Despite a significant amount of research and development of antiemetic agents, management of CINV remains a great challenge with many needs waiting to be adequately addressed, such as controlling non-acute CINV, developing appropriate CINV treatment protocols for multiple-day chemotherapy patients, and providing options for those prone to CINV despite treatment. Further research is required to optimize CINV management for these patients.

Olanzapine for Prevention of Vomiting in Children and Adolescents Receiving Highly Emetogenic Chemotherapy: Investigator-Initiated, Randomized, Open-Label Trial

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) is a significant toxicity of chemotherapy. Olanzapine is recommended in adult patients for the prevention of CINV but has not been prospectively investigated in children.

METHODS

This investigator-initiated, randomized, open-label trial evaluated olanzapine in children (ages 5-18 years) scheduled to receive the first cycle of highly emetogenic chemotherapy (HEC). All participants received aprepitant, ondansetron, and dexamethasone during and 2 days after chemotherapy. Participants in the study group additionally received oral olanzapine 0.14 mg/kg/day (rounded to the nearest 2.5 mg; maximum, 10 mg) during the chemotherapy block and 3 days postchemotherapy. The primary objective was to compare complete response (CR) rates (no vomiting and no rescue medication) between the groups in the acute, delayed, and overall periods. Nausea comparison and safety evaluation were secondary and additional objectives, respectively. The collection of outcomes and adverse events was performed daily until the completion of the overall period.

RESULTS

A total of 240 patients underwent randomization. We performed a modified intention-to-treat analysis on 231 patients (116 in the control group and 115 in the study group). A higher proportion of patients in the olanzapine group achieved CR in the acute period (78% v 59%; P = .001), delayed period (74% v 47%; P < .001) and overall period (64% v 38%; P < .001) than in the control group. The proportion of patients with no nausea was significantly higher in the olanzapine group in the acute period (74% v 52%; P < .001), delayed period (74% v 47%; P < .001), and overall period (64% v 37%; P < .001). Grade 1/2 somnolence was greater in the olanzapine group (35% v 11%; P < .001). There was no grade 3/4 somnolence reported.

CONCLUSION

Olanzapine significantly improved CR rates for vomiting in children receiving the first cycle of HEC.

Antiemetic Prophylaxis with Fosaprepitant and 5-HT3-Receptor Antagonists in Pediatric Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation

Background

High-dose myeloablative conditioning prior to autologous hematopoietic stem cell transplantation (autoHSCT) in pediatric patients is usually highly emetogenic. The antiemetic neurokinin-1 receptor antagonist fosaprepitant was safe and effective in children receiving highly emetogenic chemotherapy. Data on fosaprepitant during autoHSCT in children are currently not available.

Methods

A total of 35 consecutive pediatric patients, who received an antiemetic prophylaxis with fosaprepitant (4 mg/kg; single dose, max. 1 x 150 mg/kg BW) and ondansetron (24-hours continuous infusion; 8–32 mg/24h) or granisetron (2 x 40 µg/kg∙d⁻¹) during highly emetogenic conditioning chemotherapy before autoHSCT were retrospectively analyzed, and their results were compared with a control group comprising 35 consecutive pediatric patients, who received granisetron or ondansetron only. The antiemetic efficacy and the safety of the two prophylaxis regimens were compared with respect to three time periods after the first chemotherapy administration (0–24h, >24–120h, >120–240h).

Results

Clinical adverse events and clinically relevant increases/decreases of laboratory markers were similarly low and did not significantly differ between the two study groups (p>0.05). The registered number of vomiting events was significantly higher in the control group in the time periods of 0–24h (64 vs 22 events; p<0.01), >24–120h (135 vs 78 events; p<0.0001), >120–240h (268 vs 105 events; p<0.0001), and the whole observation period 0–240h (467 vs 205 events; p<0.0001). The percentage of patients experiencing vomiting was higher in the control group during the time period of >24–120h (100% vs 74.3%) but not the other analyzed time periods (p>0.05).

Conclusion

The fosaprepitant-based antiemetic prophylaxis was safe, well tolerated and significantly reduced vomiting in children undergoing highly emetogenic chemotherapy prior to autoHSCT. Prospective randomized trials are necessary to confirm these results.

Olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced vomiting in children: An open-label, randomized phase 3 trial

BACKGROUND

Breakthrough chemotherapy-induced vomiting (CIV) is defined as CIV occurring after adequate antiemetic prophylaxis. Olanzapine and metoclopramide are two drugs recommended for the treatment of breakthrough CIV in children, without adequate evidence. We conducted an open-label, single-center, phase 3 randomized controlled trial comparing the safety and efficacy of olanzapine and metoclopramide for treating breakthrough CIV.

PROCEDURE

Children aged 5-18 years who developed breakthrough CIV after receiving highly emetogenic chemotherapy or moderately emetogenic chemotherapy were randomly assigned to the metoclopramide or olanzapine arm. The primary objective of the study was to compare the complete response (CR) rates between patients receiving olanzapine or metoclopramide for treating breakthrough CIV during 72 hours after the administration of the study drug. Secondary objectives were to compare CR rates for nausea and toxicities between the two arms.

RESULTS

Eighty patients were analyzed (39 in the olanzapine arm and 41 in the metoclopramide arm). CR rates were significantly higher in the olanzapine arm compared with the metoclopramide arm for vomiting (72% vs 39%, P = 0.003) and nausea (59% vs 34%, P = 0.026). Seven patients in the metoclopramide arm crossed over to the olanzapine arm and none crossed over in the olanzapine arm (P < 0.001). The mean nausea score in the olanzapine arm was significantly lower than the metoclopramide arm after the initiation of the rescue antiemetic (P = 0.01). Hyperglycemia and drowsiness were more commonly seen in the olanzapine arm.

CONCLUSION

Olanzapine is superior to metoclopramide for the treatment of breakthrough CIV in children. Drowsiness and hyperglycemia need to be monitored closely in children receiving olanzapine for breakthrough CIV.

Creation of a chemotherapy-induced nausea/vomiting dashboard to improve outcomes for pediatric cancer patients

PURPOSE

Two of the most common acute side effects of chemotherapy are nausea and vomiting. Nausea and vomiting impact quality of life, nutritional status, and ability to tolerate further chemotherapy. Parents of pediatric oncology patients rank nausea as one of the most bothersome treatment-related symptoms.

METHODS

Utilizing Quality Improvement methodology, we developed a dashboard interface to facilitate extraction of data from the electronic medical record (EMR), which is presented via a visual display that summarizes the type of chemotherapy and antiemetic medications, use of as needed medications, and number of episodes of emesis.

RESULTS

This dashboard interface allows for rapid and efficient identification of patients whose antiemetic regimen is mismatched for the emetogenicity of ordered chemotherapy, thus providing a timely opportunity to modify the antiemetic regimen based on published guidelines before administration of chemotherapy drugs. It also allows measurement of the effectiveness of the antiemetic regimen in terms of the number of break through emesis and the need for as needed medications.

CONCLUSIONS

A novel CINV dashboard was created, which visually conveys complex information about antiemetics, chemotherapy emetogenicity, as needed medications, and breakthrough vomiting for inpatient pediatric oncology patients.

Smartphone App to Self-Monitor Nausea During Pediatric Chemotherapy Treatment: User-Centered Design Process

Background

Nausea and vomiting are common and distressing side effects for children receiving chemotherapy. Limited evidence is available to guide antiemetic recommendations; therefore, prospective and reliable evaluation of antiemetic efficacy is needed. Smartphone apps can be used to effortlessly and precisely collect patient-reported outcomes in real time.

Objective

Our objective was to develop a smartphone app to monitor nausea and vomiting episodes in pediatric cancer patients aged 0 to 18 years and to test its usability and adherence to its use.

Methods

We used a user-centered design process and the evolutionary prototype model to develop and evaluate the app. Multidisciplinary group discussions and several rounds of patient feedback and modification were conducted. We translated the validated Pediatric Nausea Assessment Tool to assess nausea severity in children aged 4 to 18 years. The child’s own term for nausea was interactively incorporated in the nausea severity question, with response options expressed as 4 illustrative faces. Parent-reported outcomes were used for children aged 0 to 3 years. Reminders were sent using push notifications in order to ensure high response rates. Children aged 0 to 18 years who were undergoing chemotherapy were recruited from the Department of Pediatric Oncology at Copenhagen University Hospital Rigshospitalet to evaluate the app.

Results

The app’s most important function was to record nausea severity in children. After assistance from a researcher, children aged 4 to 18 years were able to report their symptoms in the app, and parents were able to report symptoms for their children aged 0 to 3 years. Children (n=20, aged 2.0-17.5 years) and their parents evaluated the app prospectively during a collective total of 60 chemotherapy cycles. They expressed that the app was user-friendly, intuitive, and that the time spent on data entry was fair. The response rates were on average 92%, 93%, and 80% for the day before, the first day of, and the next 3 days after chemotherapy, respectively. Researchers and clinicians were able to obtain an overview of the patient’s chemotherapy dates and responses through a secure and encrypted web-based administrative portal. Data could be downloaded for further analysis.

Conclusions

The user-friendly app could be used to facilitate future pediatric antiemetic trials and to refine antiemetic treatment during chemotherapy.

[Prevention and treatment of antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: An update]

Antineoplastic drug induced nausea and vomiting are common adverse events in cancer care of paediatric patients ; therefore, prevention and management of these adverse events is a major concern for healthcare professionals. There are common features between paediatric and adult patients in terms of the emetogenic level depending on antineoplastic agents or about available medicines. However, there are also specificities for paediatric population including individual risk factors of emesis or nausea assessment for example. Knowledge relative to available medicines is also limited in the paediatric population, especially for recent medicines. This review aims to provide a comprehensive overview about antiemetics in paediatric oncology to clinicians and other healthcare professionals involved in paediatric cancer care. First of all, we describe physiopathological paediatric specificity, risk factors and clinical assessment of antineoplastic drug induced nausea and vomiting. Secondly, we focus on available medicines and also address the issue of complementary and alternative medicines.

Association between multiple symptoms and quality of life of paediatric patients with cancer in Brazil: a cross-sectional study

OBJECTIVES

To identify the association of multiple symptoms and clinical characteristics on quality of life (QoL) of paediatric patients with cancer.

DESIGN

A descriptive, cross-sectional study.

SETTING

South American Children's Hospital for Cancer Treatment (Barretos, São Paulo, Brazil).

PARTICIPANTS

A total of 157 participants, 116 paediatric patients, diagnosed with cancer, undergoing chemotherapy treatment, between 7 and 18 years of age and 41 proxies for patients between 2 and 6 years of age.

PRIMARY OUTCOME MEASURES

The severity and prevalence ofsymptoms were identified through the use of a culturally adapted multi-symptomscreening tool, and the influence these symptoms, in association with clinicalcharacteristics, had on the QOL of Brazilian pediatric cancer patients wasassessed.

RESULTS

Prevalent symptoms identified by all participants were 'feeling tired' (98, 62.4%), 'feeling more or less hungry (do not feel like eating) than you usually do' (96, 61.1%), 'changes in taste (flavour of the food)' (89, 56.7%), 'throwing up or feeling like you may throw up' (77, 49%) and 'changes in how your body (visually) or face looks' (72, 45.9%). The multivariate analysis for symptom severity as reported by proxies showed that surgery (OR 0.20, 95% CI 0.04 to 0.98, p=0.047) and time of diagnosis (OR 0.14, 95% CI 0.03 to 0.66, p=0.012) were associated with a decreased OR of high severity symptoms.An analysis of the clinical characteristics associated with Pediatric Quality of Life Inventory (PedsQL) demonstrated no significant effect on QoL in any of the domains evaluated. The association between Symptom Screening in Pediatrics Tool and PedsQL in the self-report version demonstrated a significant negative influence of all symptoms on the QoL.

CONCLUSIONS

The prevalence of symptoms experienced among pediatric patients during treatment was high and significantly influenced all aspects of quality of life,especially in the emotional domain.

Integration of a nausea and vomiting assessment tool into antineoplastic management of pediatric oncology patients

BACKGROUND

Antineoplastic-induced nausea and vomiting (AINV) is a treatment-related issue that can have significant negative influences on the cancer patient's quality of life. Assessment of nausea is challenging in children as few studies include the perception of nausea as an outcome, and the severity is rarely evaluated with the use of a validated instrument. We describe our experience of integrating an AINV tool into patient care at the Alberta Children's Hospital.Procedure: The Pediatric Nausea Assessment Tool (PeNAT) was adapted to create a standardized tool that could be used by the clinical pharmacists for AINV assessment. From February to August 2017, 74 patients receiving 217 cycles of highly or moderately emetogenic chemotherapy (HEC or MEC) were eligible to use the AINV tool. Patients that completed the AINV tool were contacted to complete a satisfaction survey.

RESULTS

AINV tool uptake was low: 47 (22%) eligible chemotherapy cycles utilized the tool (24 (32%) and 23 (16%) cycles of HEC and MEC, respectively, (p < 0.01)). Ifosfamide-containing cycles received the highest nausea ratings, with nausea severity correlated with agent emetogenicity. Mean nausea rating was 2.07 versus 1.76 for patients receiving HEC or MEC, respectively. Clinical pharmacists performed 1.24 AINV interventions per day. Patient satisfaction with AINV care overall was high; however, 51% of patients indicated that the tool led to no changes in nausea symptoms.

CONCLUSIONS

AINV tool uptake was low with limited value in improving outcomes. Incorporation of nausea assessment into the electronic health record and potential use of a mobile application may improve uptake.

Safety and Efficacy of Low-dose Domperidone for Treating Nausea and Vomiting Due to Acute Gastroenteritis in Children

BACKGROUND

This study was conducted based on a request from the European Medicines Agency to generate robust data on domperidone efficacy in children in the relief of symptoms of nausea and vomiting by assessing the effect of a low-dose and short treatment duration.

METHODS

In this randomized, double-blind, phase 3 study, children ages 6 months to 12 years with acute gastroenteritis randomly (1:1) received oral domperidone 0.25 mg/kg with oral rehydration therapy (ORT) or matching placebo thrice daily for 2 to 7 days. The proportion of patients with no vomiting episodes (primary endpoint) and patients ages ≥4 years with no nausea episodes (key secondary endpoint) within 48 hours of first treatment administration were evaluated.

RESULTS

The study was terminated early following futility analysis. At early termination, 292 patients randomly received domperidone (n = 147) or placebo (n = 145). The proportion of patients with no vomiting episodes within 48-hours of first treatment administration was similar between domperidone (32.0%) and placebo groups (33.8%). Similarly, there was no significant difference in proportion of patients ages ≥4 years with no nausea episodes within 48 hours of first treatment administration between domperidone (35.7%) and placebo (38.6%). Total 13 patients (domperidone, 3.4% [5/147] vs placebo, 5.5% [8/145]) reported ≥1 treatment-emergent adverse events. No deaths or adverse events of special interest (extrapyramidal symptoms and QT prolongation) were reported.

CONCLUSIONS

Low-dose of domperidone with ORT did not significantly differ from placebo in reducing vomiting and nausea episodes in pediatric patients with acute gastroenteritis (AG), and the safety profile was similar between both groups.

Mapping child and adolescent self-reported symptom data to clinician-reported adverse event grading to improve pediatric oncology care and research

BACKGROUND

Clinicians are the standard source for adverse event (AE) reporting in oncology trials, despite the subjective nature of symptomatic AEs. The authors designed a pediatric patient-reported outcome (PRO) instrument for symptomatic AEs to support the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) (the Pediatric PRO-CTCAE). The current study developed a standardized algorithm that maps all possible Pediatric PRO-CTCAE response patterns to recommended CTCAE grades to improve the accuracy of AE reporting in pediatric oncology trials.

METHODS

Two rounds of surveys were administered to experienced cancer clinicians across 9 pediatric hospitals. In round 1, pediatric oncologists assigned CTCAE grades to all 101 possible Pediatric PRO-CTCAE response patterns. The authors evaluated clinician agreement of CTCAE grades across response patterns and categorized each response pattern as having high or low agreement. In round 2, a survey was sent to a larger clinician group to examine clinician agreement among a select set of Pediatric PRO-CTCAE response patterns, and the authors examined how clinical context influenced grade assignment.

RESULTS

A total of 10 pediatric oncologists participated in round 1. Of the 101 possible patterns, 89 (88%) had high agreement. The Light weighted kappa was averaged across the 10 oncologists (Light kappa = 0.73; 95% CI, 0.66-0.81). A total of 139 clinicians participated in round 2. High clinician agreement remained for the majority of generic response patterns and the clinical context did not typically change grades but rather improved agreement.

CONCLUSIONS

The current study provides a framework for integrating child self-reported symptom data directly into mandated AE reporting in oncology trials. Translating Pediatric PRO-CTCAE responses into clinically meaningful metrics will guide future cancer care and toxicity grading.

Latest Update on Prevention of Acute Chemotherapy-Induced Nausea and Vomiting in Pediatric Cancer Patients

PURPOSE OF REVIEW

Chemotherapy-induced nausea and vomiting (CINV) is a common cause of acute morbidity that impacts quality of life in children receiving cancer treatment. Here, we review the evolution of CINV prophylaxis guidelines in children, with an emphasis on the literature published in the last 5 years, to bring the reader up to date.

RECENT FINDINGS

Recent studies have led to the adoption of the "triple therapy" regimen of antiemetic prophylaxis (a 5-HT3 antagonist, dexamethasone, and a neurokinin-1 antagonist) as the backbone of recommendations for the prevention of CINV in children. Areas of new data include the addition of aprepitant and inclusion of palonosetron as a non-inferior 5-HT3 antagonist. In addition, there are emerging pediatric data informing patient-derived risk factors associated with CINV risk and classification of antineoplastic drugs based on emetogenicity. Several recent pediatric studies have shaped published guidelines for CINV prophylaxis in children.

Acupressure to Reduce Treatment-Related Symptoms for Children With Cancer and Recipients of Hematopoietic Stem Cell Transplant: Protocol for a Randomized Controlled Trial

BACKGROUND

We describe the study design and protocol of a pragmatic randomized controlled trial (RCT) Acupressure for Children in Treatment for a Childhood Cancer (ACT-CC).

OBJECTIVE

To describe the feasibility and effectiveness of an acupressure intervention to decrease treatment-related symptoms in children in treatment for cancer or recipients of a chemotherapy-based hematopoietic stem cell transplant (HSCT).

DESIGN

Two-armed RCTs with enrollment of 5 to 30 study days.

SETTING

Two pediatric teaching hospitals.

PATIENTS

Eighty-five children receiving cancer treatment or a chemotherapy-based HSCT each with 1 parent or caregiver.

INTERVENTION

Patients are randomized 1:1 to receive either usual care plus daily professional acupressure and caregiver delivered acupressure versus usual care alone for symptom management. Participants receive up to 20 professional treatments.

MAIN OUTCOME

A composite nausea/vomiting measure for the child.

SECONDARY OUTCOMES

Child's nausea, vomiting, pain, fatigue, depression, anxiety, and positive affect.

PARENT OUTCOMES

Depression, anxiety, posttraumatic stress symptoms, caregiver self-efficacy, and positive affect. Feasibility of delivering the semistandardized intervention will be described. Linear mixed models will be used to compare outcomes between arms in children and parents, allowing for variability in diagnosis, treatment, and age.

DISCUSSION

Trial results could help childhood cancer and HSCT treatment centers decide about the regular inclusion of trained acupressure providers to support symptom management.

Symptom screening in paediatrics tool for screening multiple symptoms in Brazilian patients with cancer: a cross-sectional validation study

OBJECTIVE

The objective of this study was to translate, culturally adapt and validate the Symptom Screening in Paediatrics Tool (SSPedi) into the Brazilian Portuguese language to be used by paediatric oncology patients in Brazil.

DESIGN

A descriptive, cross-sectional study that follows an established methodology for translation and cultural adaptation, developed in two phases: phase I, linguistic translation and cultural adaptation of the SSPedi scale and phase II, psychometric properties evaluation.

SETTING

Children's Hospital for Cancer Treatment in Latin America.

PARTICIPANTS

Paediatric patients between 7 and 18 years of age and proxies of patients between 2 and 6 years of age, diagnosed with cancer and undergoing chemotherapy treatment. Patients and proxies with significant neuropsychiatric disorders and/or visual impairment that prevented the ability to read were excluded.

PRIMARY OUTCOME MEASURES

Construct validation of SSPedi using convergent validity and contrasted groups. Reliability was evaluated using Cronbach's alpha test and assessing the retest using the intraclass correlation coefficient (ICC).

RESULTS

The psychometric properties of the symptom screening tool were evaluated using 157 participants, of which 116 were patients and 41 were proxies. Convergent validity and hypothesised correlations (Spearman's r>0.4) were confirmed for both self- and proxy-reported versions of the assessment tool. No significant differences found between the two contrasting groups. Assessment of SSPedi resulted in an internal consistency of reliability of α=0.77 (95% CI 0.70 to 0.82) for the self and α=0.81 (95% CI 0.71 to 0.88) for the proxy and overall reproducibility ICC values of (95% CI), 0.54 (0.15 to 0.77) and 0.77 (0.64 to 0.86).

CONCLUSION

SSPedi was found to be culturally and linguistically adaptable and considered valid and reliable for use by paediatric oncology patients in Brazil. The new translated and adapted version was named SSPedi-BR.

Symptom screening in paediatrics tool for screening multiple symptoms in Brazilian patients with cancer: a cross-sectional validation study

OBJECTIVE

The objective of this study was to translate, culturally adapt and validate the Symptom Screening in Paediatrics Tool (SSPedi) into the Brazilian Portuguese language to be used by paediatric oncology patients in Brazil.

DESIGN

A descriptive, cross-sectional study that follows an established methodology for translation and cultural adaptation, developed in two phases: phase I, linguistic translation and cultural adaptation of the SSPedi scale and phase II, psychometric properties evaluation.

SETTING

Children's Hospital for Cancer Treatment in Latin America.

PARTICIPANTS

Paediatric patients between 7 and 18 years of age and proxies of patients between 2 and 6 years of age, diagnosed with cancer and undergoing chemotherapy treatment. Patients and proxies with significant neuropsychiatric disorders and/or visual impairment that prevented the ability to read were excluded.

PRIMARY OUTCOME MEASURES

Construct validation of SSPedi using convergent validity and contrasted groups. Reliability was evaluated using Cronbach's alpha test and assessing the retest using the intraclass correlation coefficient (ICC).

RESULTS

The psychometric properties of the symptom screening tool were evaluated using 157 participants, of which 116 were patients and 41 were proxies. Convergent validity and hypothesised correlations (Spearman's r>0.4) were confirmed for both self- and proxy-reported versions of the assessment tool. No significant differences found between the two contrasting groups. Assessment of SSPedi resulted in an internal consistency of reliability of α=0.77 (95% CI 0.70 to 0.82) for the self and α=0.81 (95% CI 0.71 to 0.88) for the proxy and overall reproducibility ICC values of (95% CI), 0.54 (0.15 to 0.77) and 0.77 (0.64 to 0.86).

CONCLUSION

SSPedi was found to be culturally and linguistically adaptable and considered valid and reliable for use by paediatric oncology patients in Brazil. The new translated and adapted version was named SSPedi-BR.

Symptom Experience of Children With Cancer Younger Than Eight Years of Age: An Integrative Review

CONTEXT

Children with cancer endure multiple symptoms during treatment. However, there remains a lack of systematic approaches to capture the whole picture of the symptom experience of children with cancer younger than eight years of age.

OBJECTIVE

The purpose of this study was to conduct an integrative review to explore symptom experience of children with cancer younger than eight years of age.

METHODS

A literature search of PubMed, CINAHL, Web of Science, PsycINFO, Cochrane databases, and four Chinese databases was performed to identify empirical studies, followed by an evaluation of empirical quality and data extraction and synthesis.

RESULTS

Twelve articles covering 11 symptoms met the inclusion criteria. Children with cancer under the age of eight years experienced multiple intense symptoms, especially pain, worry, and anxiety. PedsQL™ Cancer Module (for age five to seven years) was the most commonly used instruments. There were limited data on these children's symptom quality, timing, and distress. Discordance between a child's age and symptom intensity was noted. Inconsistent concordance existed between children and their proxy symptom reports.

CONCLUSION

Children with cancer younger than eight years of age experience multiple symptoms. There is a need to investigate the full symptom profiles of these young children in consideration of their developmental nuances; to examine the concordance among different symptom reporters; and to conduct more qualitative studies to explore their symptom experience.

Symptoms and Self-Management Strategies Identified by Children With Cancer Using Draw-and-Tell Interviews

PURPOSE

This cross-sectional study described how school-aged children with cancer represent their symptoms and associated characteristics using draw-and-tell interviews.

PARTICIPANTS & SETTING

27 children aged 6-12 years receiving treatment for cancer at the Cancer Transplant Center at Primary Children's Hospital, a tertiary pediatric hospital in Salt Lake City, Utah.

METHODOLOGIC APPROACH

Children participated in draw-and-tell interviews while completing drawings depicting days when they felt well and days when they felt sick. Children's drawings and accompanying explanations were analyzed qualitatively.

FINDINGS

Children's drawings related symptoms and the strategies children used to self-manage those symptoms. Nausea, fatigue, pain, and sadness were the most frequently reported symptoms. Strategies to manage symptoms most often included physical and psychosocial care strategies.

IMPLICATIONS FOR NURSING

Children with cancer were able to relate detailed descriptions of their symptoms and symptom self-management strategies when presented with developmentally sensitive approaches. Healthcare providers are well positioned to integrate arts-based approaches to symptom assessment and to support children in implementing their preferred strategies to alleviate symptoms.

Chemotherapy-induced nausea and vomiting control in pediatric patients receiving ifosfamide plus etoposide: a prospective, observational study

PURPOSE

Little evidence exists regarding the emetogenicity of chemotherapy in pediatric patients. This study describes the prevalence of chemotherapy-induced nausea and vomiting (CINV) in pediatric patients receiving etoposide plus ifosfamide over 5 days, a common pediatric regimen.

METHODS

English-speaking, non-chemotherapy-naïve patients aged 4 to 18 years about to receive etoposide 100 mg/m²/day plus ifosfamide 1800 mg/m²/day over 5 days participated. Antiemetic prophylaxis was determined by each patient's care team. Emetic episodes were recorded and nausea severity was assessed by patients beginning with the first chemotherapy dose, continuing until 24 h after the last chemotherapy dose (acute phase) and ending 7 days later (delayed phase). The proportion of patients experiencing complete acute CINV control (no nausea, no vomiting, and no retching), the primary study endpoint, was described. The prevalence of complete chemotherapy-induced vomiting (CIV) and chemotherapy-induced nausea (CIN) during the acute, delayed, and overall (acute plus delayed) phases; complete delayed and overall CINV control; and anticipatory CINV were also determined.

RESULTS

Twenty-four patients participated; acute CINV was evaluable in 22. Most (75%; 18/24) received a 5-HT3 antagonist plus dexamethasone for antiemetic prophylaxis. Few (23%; 5/22) experienced complete acute CINV control. Complete acute CIV and CIN control were experienced by 57% (13/23) and 27% (6/22) of patients, respectively. Complete delayed CINV, CIV, and CIN control rates were 42% (8/19), 70% (14/20), and 42% (8/19), respectively.

CONCLUSIONS

Our findings support the classification of etoposide 100 mg/m²/day plus ifosfamide 1800 mg/m²/day IV over 5 days as highly emetogenic. This information will optimize antiemetic prophylaxis selection and CINV control in pediatric patients.

Observational Study of Pediatric Inpatient Pain, Nausea/Vomiting and Anxiety

Background: The prevalence and severity of pain, nausea/vomiting, and anxiety (PNVA) among hospitalized children is not well established. We describe the prevalence and severity of PNVA among hospitalized patients from oncology, general pediatrics, and cardiology services in a tertiary care center. Methods: Patients were recruited on admission and enrolled if their caregiver consented, spoke English, and were anticipated to stay 2-30 days. Symptoms were measured weekdays using age-validated tools. PNVA symptoms were described and compared. Results: We enrolled 496 (49.4%) patients of 1005 admitted. Patients were predominantly Caucasian (57.9%) on their first admission (53.6%). The average (SD) age was 8.6 years (5.9) in oncology, 4.2 (5.3) in general pediatrics and 2.6 (4.0) in cardiology. 325 (65.6%) patients reported anxiety, 275 (55.4%) reported nausea and 256 (52.0%) reported pain. Mean (SD) severity out of 10 was 3.7 (2.5) for anxiety, 3.2 (2.1) for nausea and 3.0 (1.5) for pain. Prevalence of PNVA was no different between clinical programs, but pain (p = 0.008) and nausea (p = 0.006) severity were. PNVA symptom co-occurrence was positively correlated (p < 0.001). Conclusions: Anxiety was the most common and severe symptom for hospitalized children. Patients in oncology demonstrated the least severe pain and nausea with no difference in anxiety between services.

Risk factors for chemotherapy-induced nausea in pediatric patients receiving highly emetogenic chemotherapy

BACKGROUND

Little is known regarding risk factors for chemotherapy-induced nausea (CIN) in pediatric patients.

PROCEDURE

A secondary analysis was conducted of a previously published multicenter, prospective, randomized, single-blind, sham-controlled trial assessing the efficacy of acupressure in preventing CIN in pediatric patients receiving highly emetogenic chemotherapy. The primary outcome was nausea severity, self-reported using the Pediatric Nausea Assessment Tool. The relationships between acute and delayed nausea severity and patient- (sex, race, age, and cancer diagnosis) and treatment-related (chemotherapy, antiemetic prophylaxis, CIN, and vomiting control) factors were analyzed by a proportional odds generalized estimating equation approach. The acute phase started with administration of the first and continued for 24 hours after the last chemotherapy dose. The delayed phase started at the end of the acute phase and continued until the next chemotherapy block (maximum seven days).

RESULTS

In the acute and delayed phases, 165 and 144 patients provided data for analysis, respectively. Nonwhite race was significantly associated with higher acute phase nausea severity (OR, 1.7; 95% CI, 1.1-2.6). Poor CIN control in the acute phase (OR, 16; 95% CI, 4.0-64.6), diagnosis of a cancer other than a central nervous system (CNS) tumor (OR, 2.5; 95% CI, 1.2-5.3), and cisplatin administration (OR, 3.7; 95% CI, 2.1-6.0) were significantly associated with higher delayed phase nausea severity.

CONCLUSION

Acute phase CIN was associated with nonwhite race. Delayed phase CIN was associated with poor acute phase CIN control, diagnosis of non-CNS cancer, and receipt of cisplatin. These findings will inform future antiemetic trial design.

Systematic Symptom Reporting by Pediatric Palliative Care Patients with Cancer: A Preliminary Report

Background: Systematic symptom assessment is not a standard of care in children with cancer. Many well-known symptom assessment tools are lengthy or difficult to integrate into a daily pediatric palliative care practice. We created a series of brief and simple questions to be systematically given to children and their caregivers. Objective: The primary objective was to determine the percentage of eligible children and caregivers exposed to the questions that were able to complete the assessment. Secondary objectives included documenting the symptom burden at the time of consultation, evaluating the level of agreement in symptom reporting between children and caregivers, as well as between children/caregivers and the referring medical team. Design: A series of systematic questions were presented to all caregivers (if present) and children who were seven years of age or older at the time of initial consultation with pediatric palliative care. Results: One hundred twenty-two consecutive children/caregiver dyads were given the survey. One hundred seven of 108 (99%) eligible caregivers and 83 of 97 (86%) eligible children completed the survey. Lack of appetite (child-72/83, 87%; caregiver-89/107, 83%) and pain (child-71/83, 86%; caregiver-86/107, 80%) were the most commonly reported symptoms. Caregivers reported irritability (p = 0.005) and nervousness (p < 0.001) more frequently than children. Referring medical teams significantly underdiagnosed psychological and other less clinically evident symptoms such as lack of appetite, fatigue, and sleep disturbance (p < 0.001). Conclusions: Our series of questions is easy to complete by children and caregivers. Systematic symptom assessment of children with cancer referred to palliative care should become a true standard of care.

The association of age, literacy, and race on completing patient-reported outcome measures in pediatric oncology

PURPOSE

Age is often used to determine when children can begin completing patient-reported outcome (PRO) instruments or transition to adult instruments. This study's purpose was to determine relationships between literacy, age, and race and their influence on a child's ability to understand and complete a PRO instrument.

METHODS

The Wide Range Achievement Test was used to evaluate literacy in children and young adults with cancer, participating in a cognitive interview for the Pediatric PRO-CTCAE instrument. 140 participants (7-20 years) were recruited from 8 sites. Logistic regression and multivariable liner regression were used to examine relationships among key variables.

RESULTS

Higher literacy scores were significantly associated with fewer PRO-CTCAE items being identified as "hard to understand" (p = 0.017). Literacy scores increased with age, but older participants were more likely to fall behind expected reading levels compared with US norms. A 1-year increase in age was associated with a 19% increase in the likelihood for being below the expected WRAT word reading score (OR 1.19; 95% CI 1.06-1.33, p = 0.003). No associations were found between race and literacy.

CONCLUSIONS

Wide variations in literacy were noted across age groups. All participants were able to complete the Pediatric PRO-CTCAE, although most 7 year olds (63%) required reading assistance. Those with lower literacy skills were able to understand items suggesting that multiple factors may be involved in comprehension (developmental stage, concentration, vocabulary, or prior health experiences). Risk for falling below expected literacy levels increased with age implying a need for literacy consideration for cancer patients.