ORIGINAL ARTICLE The burden of chemotherapy-induced nausea and vomiting in children receiving hematopoietic stem cell transplantation conditioning: a prospective study J Flank 1,2 , J Sparavalo 1,2 , H Vol 1,2 , L Hagen 3 , R Stuhler 3 , D Chong 1 , S Courtney 4 , JJ Doyle 5,6 , A Gassas 7 , T Schechter 8 and LL Dupuis 1,2,9 This prospective study describes chemotherapy-induced nausea and vomiting (CINV) in children (4–18 years) receiving their first hematopoietic stem cell transplant. Emetic episodes, nausea severity (assessed using a validated, self-report nausea severity assessment tool) and antiemetic administration were documented from the start of conditioning until 24 h after the last conditioning agent was administered (acute) and for a further 7 days (delayed). Relationships between CINV control and parenteral nutrition (PN) use and acute gut GvHD (aGvHD) were explored. Fifty-nine children (4.6–17.4 years) were evaluable. Complete chemotherapy-induced vomiting (CIV; acute: 24%; delayed 22%) and chemotherapy-induced nausea (CIN; acute 7%; delayed 12%) control rates were low. Few children experienced complete CINV control (no vomiting/retching and no nausea) during the acute (5%) or delayed phases (12%). Children experiencing complete acute or delayed CIN control or complete delayed CIV control were more likely to have received: a lower proportion of their total energy requirement as PN at the end of the delayed phase (P o0.036) and PN for a shorter time (P o0.044). Low patient numbers did not permit evaluation of the association between gut aGvHD and CINV control. Effective and safe interventions aimed at improving CINV control in children are required. Bone Marrow Transplantation (2017) 52, 1294–1299; doi:10.1038/bmt.2017.112; published online 5 June 2017 INTRODUCTION Despite recent advances in the use of modern antiemetic agents, nausea and vomiting continue to be among the most common and distressing side effects associated with chemotherapy. Control of chemotherapy-induced nausea and vomiting (CINV) during hematopoietic stem cell transplant (HSCT) conditioning is recognized as particularly difficult since multiple, often highly emetogenic, chemotherapy agents are administered over several consecutive days to patients who may have experienced CINV during past chemotherapy cycles. 1,2 It is well-recognized that CINV impairs quality of life. Through its effect on enteral intake, CINV in the HSCT population may also increase mucositis severity, increase the risk of hepatobiliary toxicity and increase gut acute GvHD (aGvHD) severity. 3–6 We have previously shown that complete chemotherapy-induced vomiting (CIV) control in pediatric HSCT patients is seldom achieved. 7 Nausea control in pediatric HSCT patients has never been evaluated using a validated tool. The primary objective of this study was to describe the prevalence of acute and delayed phase CINV using the Pediatric Nausea Assessment Tool (PeNAT), 8 a validated, child self-report nausea severity assessment tool, in children aged 4–18 years receiving HSCT conditioning. We also explored the relationship between CINV control and the use of parenteral nutrition (PN) and, in children receiving allogeneic HSCT, the development of aGvHD. SUBJECTS AND METHODS This prospective, observational study was approved by the SickKids’ Research Ethics Board. Patients or their guardian provided informed consent to participate. When consent to participate was provided by a guardian, patients who were able to do so also provided assent. Patients Participants were: 4–18 years of age; English-speaking; without cognitive or physical impairments that would preclude the use of the PeNAT 8 and were planned to receive their first allogeneic or autologous HSCT at SickKids for an indication other than immunodeficiency. Children participated in this study once only. Definitions Vomiting was defined as the expulsion of any stomach contents through the mouth. Retching was defined as an attempt to vomit that was not productive of stomach contents. An emetic episode was defined as a vomit or a retch that was separated from another vomit or retch by at least 1 min. Chemotherapy emetogenicity was classified using a pediatric guideline. 9 The acute phase was defined as beginning with the first dose of HSCT conditioning and ending 24 h after the last dose of HSCT conditioning including TBI. Thus, the duration of the acute phase for each patient depended on the conditioning regimen. The delayed phase was defined as starting immediately after the acute phase and ended 7 days (168 h) later. 1 Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; 2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; 3 Department of Dietetics, The Hospital for Sick Children, Toronto, Ontario, Canada; 4 Department of Nursing, The Hospital for Sick Children, Toronto, Ontario, Canada; 5 Section of Pediatric Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada; 6 Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; 7 School of Clinical Sciences, University of Bristol and Bristol Royal Hospital for Children, Bristol, UK; 8 Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada and 9 Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada. Correspondence: Dr LL Dupuis, Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G1X8. E-mail: lee.dupuis@sickkids.ca Received 15 November 2016; revised 21 March 2017; accepted 2 May 2017; published online 5 June 2017 Bone Marrow Transplantation (2017) 52, 1294 – 1299 © 2017 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0268-3369/17 www.nature.com/bmt