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How likely a child's chemotherapy is to cause sickness decides which anti-sickness medicines they get, given before the chemotherapy, not after the child is sick. The strongest chemotherapy gets three medicines together. If a child is still sick, the team steps up the medicines straight away and for the next cycle, because sickness that is not controlled makes the next cycle worse.
Children's Oncology Group endorses four POGO guidelines (GRADE) and the ASCO 2020 antiemetics update. First classify the acute emetogenicity of the chemotherapy using the POGO 2019 paediatric classification (high, moderate, low, minimal; for example cisplatin 12 mg/m2 per dose or more is highly emetogenic). Acute prophylaxis: highly emetogenic, a 5-HT3 antagonist plus dexamethasone plus aprepitant or fosaprepitant (strong, high), with palonosetron-based alternatives where dexamethasone or the NK1 antagonist cannot be given, and olanzapine to be considered (conditional, moderate); moderately emetogenic, a 5-HT3 antagonist plus dexamethasone (strong, moderate); low, a 5-HT3 antagonist (strong, low); minimal, no routine prophylaxis (strong, very low). Delayed phase after highly emetogenic chemotherapy: oral aprepitant if started acutely (strong, high), dexamethasone after ondansetron or granisetron (strong, moderate), continue olanzapine, and no 5-HT3 antagonists (strong, low). Breakthrough nausea: escalate to the prophylaxis for the next emetogenic level (strong, low) or, on highly emetogenic regimens, consider switching to palonosetron and adding dexamethasone, an NK1 antagonist or olanzapine; next cycle, use what worked. Anticipatory nausea: control acute and delayed nausea from the start (strong, moderate); consider hypnosis, systematic desensitisation or relaxation and lorazepam; not ginger routinely; never clonidine.
Why: The level decides which anti-sickness medicines are needed, and the paediatric classification is built from studies in children.
“This information is critically important for the appropriate selection of antiemetic prophylaxis.”
Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2019 · Strong recommendation (very low to high quality evidence, by regimen)
Why: For the strongest chemotherapy this three-drug combination has the best evidence, rated high quality.
“a. Use a 5HT3RA + dexamethasone + (fos)aprepitant”
Children's Oncology Group 2024 · Strong recommendation, High quality evidence
Why: Some children cannot be given dexamethasone or an NK1 antagonist, and the guideline names palonosetron combinations for each of those cases.
Children's Oncology Group 2024 · Strong recommendation, Low to Moderate quality evidence (by combination)
Why: Olanzapine can add to the other medicines; the recommendation is conditional, so it is offered rather than required.
“e. Consider adding olanzapine to other CPG-consistent antiemetics”
Children's Oncology Group 2024 · Conditional recommendation, Moderate quality evidence
Why: Two medicines are enough for most children at this level.
“a. Use a 5HT3RA + dexamethasone”
Children's Oncology Group 2024 · Strong recommendation, Moderate quality evidence
Why: Children on mild chemotherapy are rarely sick, and extra medicines add side effects.
“a. Do not use prophylaxis routinely”
Children's Oncology Group 2024 · Strong recommendation, Very low quality evidence (minimal); Strong recommendation, Low quality evidence (low)
Why: Sickness can come on a day or more after chemotherapy, and these medicines cover that delayed phase.
Children's Oncology Group 2024 · Strong recommendation, High quality evidence (aprepitant); Strong recommendation, Moderate quality evidence (dexamethasone, olanzapine)
Why: They work for the first day's sickness, not for the delayed phase.
“g. Do not use 5HT3RAs in the delayed phase”
Children's Oncology Group 2024 · Strong recommendation, Low quality evidence
Why: Breakthrough sickness means the level of cover was too low.
“In patients with breakthrough CINV, escalation of antiemetic agents to those recommended for chemotherapy of the next higher level of emetogenic risk is strongly recommended.”
Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2023 · Strong recommendation, Low-quality evidence
Why: There is no higher level to step up to, so the team adds or swaps medicines instead.
Children's Oncology Group 2024 · Conditional recommendation, Low to Moderate quality evidence
Why: Sickness that was hard to control once is likely to happen again; preventing it is easier than treating it.
“A strong recommendation to use antiemetic agents that controlled breakthrough CINV for the prevention of refractory CINV is also made.”
Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2023 · Strong recommendation, Low-quality evidence
Why: Children who were sick in earlier cycles are the ones who later feel sick before treatment even starts.
Children's Oncology Group 2024 · Strong recommendation, Moderate-quality evidence
Why: The psychological methods carry little risk; lorazepam helped adults; ginger's results were inconsistent; clonidine has a poor safety record and no clear benefit.
“2.4 Do not use clonidine for secondary prevention of anticipatory CINV.”
Children's Oncology Group 2024 · Strong recommendation, Low-quality evidence (clonidine); Conditional recommendation (others)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The POGO paediatric guidelines endorsed together by the Children's Oncology Group (summary dated 15 January 2024) are the current standard for children: classify emetogenicity with the paediatric classification, then three-drug prophylaxis (5-HT3 antagonist, dexamethasone and an NK1 antagonist) for highly emetogenic chemotherapy, two drugs for moderate, one for low, none for minimal, with olanzapine considered; escalate for breakthrough sickness and carry the effective regimen into the next block. COG also endorses the adult ASCO 2020 antiemetics update for acute prevention; that guideline was not read here, so any difference between them is not stated. Where paediatric data for a regimen are lacking, the classification guideline says adult guidelines may be consulted.
Children's Oncology Group 2024 · Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2019 · Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2022 · Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2023 · Pediatric Oncology Group of Ontario, Pediatric Blood & Cancer 2021
Where it differs: Uses palonosetron rather than ondansetron or granisetron in the acute phase for children at high risk of delayed sickness, and may then add dexamethasone in the delayed phase rather than routinely.
Evidence: Strong recommendation, moderate quality evidence, for palonosetron in patients at high risk of delayed-phase CINV; conditional, moderate, for adding delayed dexamethasone after palonosetron.
Where it differs: Adds sickness-focused dietary counselling or yoga for a child who stays sick despite every suitable antiemetic.
Evidence: Conditional recommendation, low-quality evidence.
A cheap, old antipsychotic at a low dose is one of the best anti-sickness drugs for chemotherapy. Make sure every cancer unit in the world uses it.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| 5-HT3 antagonist, dexamethasone and (fos)aprepitant for highly emetogenic chemotherapy | Strong recommendation, High quality evidence | Children's Oncology Group 2024 |
| Olanzapine considered with highly emetogenic chemotherapy | Conditional recommendation, Moderate quality evidence | Children's Oncology Group 2024 |
| 5-HT3 antagonist with dexamethasone for moderately emetogenic chemotherapy | Strong recommendation, Moderate quality evidence | Children's Oncology Group 2024 |
| 5-HT3 antagonist for low emetogenic chemotherapy “a. Use a 5HT3RA” | Strong recommendation, Low quality evidence | Children's Oncology Group 2024 |
| No routine prophylaxis for minimally emetogenic chemotherapy | Strong recommendation, Very low quality evidence | Children's Oncology Group 2024 |
| Oral aprepitant in the delayed phase if started acutely (highly emetogenic) | Strong recommendation, High quality evidence | Children's Oncology Group 2024 |
| No 5-HT3 antagonists in the delayed phase | Strong recommendation, Low quality evidence | Children's Oncology Group 2024 |
| Escalate to the next level's prophylaxis for breakthrough sickness | Strong recommendation, Low-quality evidence | Children's Oncology Group 2024 |
| Lorazepam considered for secondary prevention of anticipatory sickness | Conditional recommendation, Very low-quality evidence | Children's Oncology Group 2024 |
| No clonidine for anticipatory sickness | Strong recommendation, Low-quality evidence | Children's Oncology Group 2024 |
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