1. PALLIATIVE CARE OF CHILDREN
HYDRATION & NUTRITION
And
NAUSEA & VOMITING IN
PALLIATIVE CARE OF CHILDREN
Mike Harlos MD, CCFP
Medical Director, WRHA Palliative Care and St. Boniface General Hospital Palliative Care
Section Head, Palliative Care, University of Manitoba Dept. of Family Medicine

2. TREATMENT / INTERVENTION CONSIDERATIONS
What are the goals of the treatment?
Whose goals are they, and are they consistent with those of the patient?
Is it possible to achieve the goals?
What are the:
Positive effects vs. Side effects (clinical assessment by health care team)
Benefits vs. Burdens (experiential interpretation of positive and side effects by patient / family)
Is there enough reserve to tolerate the treatment?
Burdens include travel, financial, family

3. The “Path of Least Regret”
How will families look back on the decisions for care?
When family uncertain or ambivalent about “doing something” vs. “not doing something”, consider leaning toward “doing” if it is reasonable (eg. hydration)
Power imbalance between health care professionals and patient / family… be perceptive about when this might be influencing the dynamic of decision-making

4. Hydration in the Terminal Phase
Controversial topic; there is no consensus among the palliative care community
Morita T, Tei Y, Tsunoda J, Inoue S, Chihara S. Determinants of the sensation of thirst in terminally ill cancer patients. Support.Care Cancer 2001;9:177-86
Burge FI. Dehydration symptoms of palliative care cancer patients. J.Pain Symptom.Manage. 1993;8:
Conflicting literature regarding whether there is1 or is not2 a correlation between dehydration and thirst in the dying

5. Hydration ctd
There are specific circumstances where rehydration can be very helpful:
Opioid-induced neurotoxicity
Hypercalcemia
Reversible bowel obstruction
In severe hypoalbuminemia, may aggravate peripheral edema
No evidence for hydration causing ↑ terminal secretions
Each circumstance is approached individually with regards to goals

6. Hypodermoclysis
Effective, simple route for hydration when venous access compromised
In adults usually give ml/hr NS; there are reports of adding KCL
Adverse reactions include local edema, cellulitis, discomfort at insertion site
Use indwelling small gauge cathalon rather than butterfly needle
Very little literature regarding pediatrics:
Steffey JM Hypodermoclysis in infants and children. J Iowa State Med Soc Jul;53:393-6
Vyskocil JJ, Kruse JA, Wilson RF. Techniques for vascular access when venous entry is impossible. Route depends on urgency and the agent to be administered. J Crit Illn Apr;8(4):539-45

7. NUTRITION
IN THE
DYING CHILD

8. Proposed Nomenclature
Bechard L.J., et al Nutritional Supportive Care
Principles & Practice of Pediatric Oncology 4th Ed; Edited by Pizzo & Poplack
Wasting:
Involuntary weight loss
Seen in anorexia nervosa, cancer, HIV, and others
First see decline in body fat, then in body protein stores (fat-free mass; lean body mass)
Energy repletion usually successful in restoring nutritional status
Cachexia:
Involuntary loss of fat-free mass in the setting of minimal or no overall weight loss
Seen in cancer, critical illness, HIV, other metabolic stress
Patients may be of normal weight yet malnourished
Loss of lean body mass is associated with decreases in strength, immune function, pulmonary function, as well as increased disability and death
Nutritional support may not reverse catabolic effects of underlying condition

9. “The cancer anorexia-cachexia syndrome is extremely common in children with advanced cancer and is frequently associated with a patient’s decline and death. Its cause is multifactorial, and it is most often irreversible, even in the face of hyperalimentation or vigorous nutritional support”
Wolfe J., Grier H.E., Care of the Dying Child in Principles and Practice of Pediatric Oncology 4th Edition; Philip A. Pizzo and David G. Poplack, Editors

10. Feeding Options Oral May require soft diet if mucositis present
Caloric supplementation if required
“Normal”
Enteral (Tube)
Nasogastric or percutaneous gastrostomy
Demonstrated improved weight gain in newly Dx pediatric cancer patients and in BMT settings
Cost savings over TPN
Parenteral (TPN)
Of demonstrated benefit in BMT patients
Uncertain / unproven benefit in other cancer settings
Risks include infection, hepatic toxicity, metabolic abnormalities;
Careful patient selection and close monitoring required

11. Loss of Appetite Look for Reversible Causes
Pain
Anxiety
Nausea / Vomiting
Thrush in the mouth or esophagus
Constipation
Drugs
Depression

12. Goals of Nutrition and Fluid Management in the Dying Child
Alleviate any hunger and thirst
Reduce anxiety about intake
Preserve the social aspects of mealtimes

13. Strategies Around Feeding
Frequent small meals
Favourite foods, cravings
If not hungry, don’t force intake
Help find other ways than feeding for family to nurture

14. Management Of Nausea And Vomiting In Palliative Care Of Children

15. Symptoms At The End of Life in Children With Cancer
Hongo T. et al, Pediatrics International Feb p.60

16. Managing Nausea & Vomiting in Palliative Care
Some Differences in Children vs. Adults
Assessment, communication challenges
Higher risk of extrapyramidal reactions, akathisia, and somnolence with dopamine antagonists in children
Metoclopramide (Maxeran®)
Prochlorperazine (Stemetil®)
Haloperidol (Haldol®)
Chlorpromazine
If using dopamine antagonists, consider slow administration (45-60 min.), as well as concomitant use of diphenhydramine (Benadryl®) 0.5 – 1 mg/kg q4-6h po/IV continued for additional 24hrs after dopamine antagonist stopped.

17. Differences in Children vs. Adults ctd
N & V Management –
Differences in Children vs. Adults ctd
Route of administration
Oral may be compromised by developmental, psychological, or practical reasons (eg. too nauseated)
IV may be upsetting if no pre-existing line
Very limited data on SQ dosing
Tolerating SQ dosing?
Ongoing chemotherapy and feeding even in terminal phase
Available oral or transdermal doses may be inappropriately high

18. MECHANISM OF NAUSEA AND VOMITING
vomiting centre in reticular formation of medulla
activated by stimuli from:
Chemoreceptor Trigger Zone (CTZ)
area postrema, floor of the fourth ventricle
outside blood-brain barrier (fenestrated venules)
Upper GI tract & pharynx
Vestibular apparatus
Higher cortical centres

19. Cortex
CTZ GI
VOMITING
CENTRE
Vestibular

20. Chemoreceptor Trigger Zone
CAUSES OF NAUSEA & VOMITING
Chemoreceptor Trigger Zone
Vestibular
Cortical
Peripheral
drugs
opioids
chemoTx
etc...
biochemical
­ Ca++
renal failure
liver failure
sepsis
radiotherapy
tumor
anxiety
association
­ ICP
chemotherapy
GI irritation
inflammation
obstruction
paresis
compression

21. PRINCIPLES OF TREATING NAUSEA & VOMITING
Treat the cause, if possible and appropriate
Environmental measures
Antiemetic use:
anticipate need if possible (NB: Children do not usually require prophylactic antiemetics when opioids started Ref: Beardsmore et al 2002 Palliative Care in Paediatric Oncology; European J Cancer 38 p )
use adequate, regular doses
aim at presumed receptor involved
combinations if necessary
anticipate need for alternate routes

22. Chemoreceptor trigger zone
Stimulus
Area
Receptors
Drugs,
Metabolic
Chemoreceptor trigger zone
Motion,
Position
Vestibular
Visceral
Abdominal organs
↑ ICP
Cerebral cortex D 2
5HT M H1
5HT M H1
VOMITING
CENTRE D 2
5HT H1
Effector
Organs M D 2
5HT H1
Dopamine
Serotonin
Histamine
Muscarinic

23. Safety and Tolerability of 5HT3 Antagonists
Goodin S., Cunningham R. The Oncologist 2002 p
High specificity for 5HT3 receptors; extrapyramidal reactions unlikely
It has been suggested that the combination of a 5HT3 antagonist with dexamethasone should be the standard antiemetic prophylaxis in all pediatric patients
Granisetron well tolerated; fever and headache most common adverse events

24. Safety and Tolerability of 5HT3 Antagonists ctd
Goodin S., Cunningham R. The Oncologist 2002 p
May prolong QT interval
19% of patients given ondansetron in one study
Seems less with granisetron
risk of torsades de pointes
use with caution when high dose methadone used, or in patients with arrhythmias or on other meds that might prolong QT

25. Comparative Incidence of Adverse Effects:
Granisetron (n=542) vs. Ondansetron (n=543)
Perez et al; J Clin Oncol 1998;16:

26. RELATIVE ANTIEMETIC RECEPTOR AFFINITIES
1250

27. Antinauseants / Antiemetics
Drug
Class
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
Serotonin Antag.
Granisetron1 : ≥ 4 yo: mcg/kg/day divided once or twice daily single dose po/IV
Ondansetron2: 0.15 mg/kg /dose given tid
H1 Antag.
Dimenhydrinate (Gravol®): 5 mg/kg/day divided q6-8h, max 300 mg/day Children > 12 yo: 50 – 100 mg q 4-6h; max 400 mg/day
Anti-musc.: Transderm-V® (scopolamine patch) 3
2 – 3 yo
¼ Patch
3 – 9 yo
½ Patch
10+
1 Patch
1 Komada Y et al. A randomised dose-comparison trial of granisetron in preventing emesis in children with leukaemia receiving emetogenic chemotherapy. Eur J Cancer 1999; 35(7):
2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack
3 The Rainbows Children’s Hospice Guidelines 2002

28. Antinauseants / Antiemetics ctd.
Drug
Class
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
Dopamine
Antagonists *
Prochlorperazine1 (Stemetil®) for children >10kg
po/pr: 0.4 mg/kg/day in 3-4 divided doses
IM: 0.13 mg/kg/dose
IV: not recommended
Metoclopramide – 0.2 mg/kg/dose q6h prn **
Prokinetics *
Domperidone – 0.4 mg/kg/dose up to qid; max. 1.6 mg/kg/day
* Consider using prophylactic Benadryl® concomitantly ** Much lower than for established chemotherapy protocols
1 Pediatric Lexi-Drugs Sept. 2003
2 The Rainbows Children’s Hospice Guidelines 2002

29. Antinauseants / Antiemetics ctd.
Drug
Class
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
Cannabinoids
Dronabinol: has been effective in children with doses of 2.5 – 7.5 mg/m2 q2-4h prn up to 6 doses/day
Not first line; dysphoria common
Dexamethasone
limited data on dosing
One reference*: 10 mg/m2 to a maximum of 10 mg, given once/day
Misc.
Lorazepam**: mg/kg/dose, (max.1 or 2 mg/dose, depending on reference) po/IV q4-8h
* Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack
** Cancer Pain Relief and Palliative Care in Children, W.H.O. 1998