Consider cause:

• Obstruction: Gastric outflow/ bowel
• Constipation
• Uraemia/ Deranged electrolytes/ Hypercalcaemia
• Raised intracranial pressure
• Upper gastrointestinal tract irritation
• Anxiety
• Cough
• Pain
• Drugs: opioids, chemotherapy, carbamazepine, NSAIDs
• Intercurrent illness: e.g. otitis media, gastroenteritis, urinary tract infection, epilepsy

Management

General measures

• Treat/remove underlying cause if possible
• Avoid strong food smells and perfumes which may antagonise nausea.
• Keep meals small and remove left over food quickly
• Nausea and vomiting can become associated with a wide range of situations that provoke anxiety, and non-drug interventions such as play therapy and psychotherapy may be helpful.

Give an appropriate antiemetic according to cause (see below), ± H₂ receptor antagonist/ proton pump inhibitor if gastric irritation is thought to be a contributory factor.

Stimulus	Area stimulated	Receptors	Anti-emetic choices
Drugs Chemotherapy Metabolic	Chemoreceptor trigger zone	Dopamine (D2) Serotonin(5HT)	Metoclopramide (D2 & 5HT) Ondansetron (5HT) Haloperidol (D2) Chlorpromazine (D2) Levomepromazine (D2 & 5HT)
Motion Position	Vestibular	Muscurinic (Ach)   Histamine (H1)	Cyclizine (H1 & Ach) Hyoscine  (Ach)
Visceral	Organs	Dopamine (D2)   Serotonin (5HT)	Metoclopramide  (D2& 5HT) Ondansetron(5HT) Haloperidol (D2) Levomepromazine (D2 & 5HT)
Raised Intracranial pressure (See also section on raised intracranial pressure)	Cerebral cortex	Histamine (H1)	Cyclizine  (H1) Levomepromazine (multireceptor) Dexamethasone
Non-specific	CNS	Cannabinoid	Nabilone

Cyclizine

Form

Tablet: 50mg
Injection: 50mg in 1mL
Suppositories: available as ‘specials’ 12.5mg, 25mg, 50mg, 100mg

Dose (Oral / i/v slow injection over 3-5 minutes)

1 month–6yr: 0.5–1mg/kg up to 3 times daily. (max. single dose 25mg)
6–12yr: 25mg up to 3 times daily.
12–18yr: 50mg up to 3 times daily.

Dose (Rectal)

2–6yr: 12.5mg up to 3 times daily.
6–12yr: 25mg up to 3 times daily
12-18yr: 50mg up to 3 times daily

Dose (SC / i/v continuous infusion)

1 month-5 years: 3mg/kg over 24 hours (maximum 50mg/24 hours),
6–12 years: 75mg over 24 hours,
12–18 years: 150mg over 24 hours.

• Care with subcutaneous or intravenous infusion – acidic pH and can cause injection site reactions
• For CSCI or IV infusion, dilute only with water for injection or 5% dextrose; incompatible with 0.9% saline and will precipitate.

Licence: Licensed in children >6yr

Domperidone

Form

Tablet: 10mg Suspension: 5mg in 5mL Dose (oral):

>1 month and body-weight ≤ 35 kg 250µg/kg 3 or 4 times daily if necessary to 500µg/kg 3 or 4 times daily. (max. 2.4mg/kg in 24 hours) Body-weight >35kg: 10–20mg 3 or 4 times daily, increasing if necessary to 20mg 3 or 4 times daily (max. 80mg daily)

Acute dystonic reactions less common than with metoclopramide. MHRA April 2014: Domperidone is associated with a small increased risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Use the minimum effective dose. Do not use in those with known cardiac problems or other risk factors.

Ondansetron

Form

Tablet: 4mg, 8mg
Tablet (melt): 4mg, 8mg
Oral solution: 4mg in 5mL
Injection: 2mg in 1mL, 2mL and 4mL ampoules.

Dose Oral or IV

Slow over 2-5 mins or 15 mins infusion

1 -18 years: 100-150µg/kg/dose three times daily (Max single dose 4mg) 4mg every 8 -12 hours for up to 5 days after chemotherapy.

Can cause constipation and headache.

Levomepromazine

Form

Tablet: 25mg, 6mg available as ‘special’
Injection: 25mg in 1mL, 1mL ampoule.

Dose (oral)

2–12 years: initial dose 50-100µg/kg given once or twice daily. This dose may be increased as necessary and as tolerated not to exceed 1mg/ kg/dose (or maximum of 25mg/dose) given once or twice daily.
12-18 years: initial dose 3mg once or twice daily. This dose may be increased as necessary and as tolerated to a maximum of 25mg once or twice daily.

Dose: (SC /  IV continuous infusion)

1 month–12yr: 100µg/kg /24hincrease to 400µg/kg/24hr (Max: 25mg/24hr).
12–18yr: initial dose of 5mg/24 hours increasing as necessary to a maximum of 25mg/24 hours.

Sedative.

Metoclopramide

Form

Tablet: 5mg, 10mg
Syrup/oral solution: 5mg in 5mL
Paediatric liquid: 1mg in 1mL
Injection: 5mg in 1mL, 2mL ampoule

Dose (oral / slow IV)

Neonate: 100migrogram/kg every 6-8hours
1 month –1 year and body-weight up to 10kg : 100µg/kg (max. 1mg/dose) b.d.
1–18yrs: 100-150µg/kg repeated up to 3 times daily. The maximum dose in 24 hours is 500µg/kg (maximum 10mg/dose).

To minimise the risk of neurological side effects associated with metoclopramide, the EMA in 2013 issued recommendations. However the use in palliative care setting was excluded from these recommendations Caution should be exercised nevertheless).

Use of metoclopramide is contraindicated in children younger than 1 year. If preferred the total daily may be administered as a continuous SC or IV 24hr infusion

Dystonic reactions can occur with any dose: reverse with benztropine or procyclidine.

Use with caution if intestinal obstruction suspected: if colic develops, reduce dose or stop altogether.

Licence: tablets only licensed in children >15yr.

Haloperidol

Form

Tablet: 0.5mg, 1.5mg, 5mg, 10mg, 20mg
Capsule: 500µg
Oral liquid: 1mg in 1mL, 2mg in 1mL
Injection: 5mg in 1mL, 1mL ampoules

Dose (oral)

1 month -12 yr: 50µg/kg b.d. (initial max. 3mg/24h, but can increase to 170µg/kg/24hr in divided doses)
>12 yr: 1.5mg once daily at night, increased to 1.5mg twice daily if necessary; max. 5mg twice daily

Dose (SC/ i/v continuous infusion)

1 month-12yr: 25-85µg/kg/24h
>12yr: 1.5-5mg/24h (higher doses under specialist guidance)

Licence: licensed for use in children

Dexamethasone

Form

Tablet: 500µg; 2mg.
Oral solution: 2mg in 5mL. Other strengths available as ‘special’
Injection: 4mg in 1mL can be given orally or 3.3mg in 1mL

Dose (oral/ IV)

1 month -1yr: 250µg t.d.s.(max: 1mg tds)
1-5yr: 1mg t.d.s.(max 2mg tds)
6-12yr: 2mg t.d.s.(max 4mg tds)
>12yr: 4mg t.d.s.

Co-prescribing: consider antacids and anti-thrush treatment. Use in short courses to limit unwanted side effects

Caution: renal disease or cardiac disease. Avoid in cardiac insufficiency.

See section on raised intracranial pressure