HYDRATION & NUTRITION And NAUSEA & VOMITING IN PALLIATIVE CARE OF CHILDREN

1. 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?

3. 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 The “Path of Least Regret”

4. Conflicting literature regarding whether there is1 or is not2 a correlation between dehydration and thirst in the dying • 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;8:454-64. Hydration in the Terminal Phase • Controversial topic; there is no consensus among the palliative care community

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. Effective, simple route for hydration when venous access compromised In adults usually give 30 - 50 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. 1963 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. 1993 Apr;8(4):539-45 Hypodermoclysis

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

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 Childin Principles and Practice of Pediatric Oncology4th Edition; Philip A. Pizzo and David G. Poplack, Editors

10. Feeding Options

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

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

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

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 2003 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. 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. CAUSES OF NAUSEA & VOMITING

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 p1900-1907) • use adequate, regular doses • aim at presumed receptor involved • combinations if necessary • anticipate need for alternate routes

22. D D D 5HT 5HT 5HT 5HT 2 2 2 M M M VOMITING CENTRE H1 H1 H1 Effector Organs H1 Serotonin Histamine Dopamine Muscarinic

23. 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 Safety and Tolerability of 5HT3 Antagonists Goodin S., Cunningham R. The Oncologist 2002 p424-436

24. 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 Safety and Tolerability of 5HT3 Antagonists ctd Goodin S., Cunningham R. The Oncologist 2002 p424-436

25. Comparative Incidence of Adverse Effects: Granisetron (n=542) vs. Ondansetron (n=543) Perez et al; J Clin Oncol 1998;16:754-760

26. RELATIVE ANTIEMETIC RECEPTOR AFFINITIES 1250

27. Antinauseants / Antiemetics 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):1095-1101. 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. * 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. * Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack ** Cancer Pain Relief and Palliative Care in Children, W.H.O. 1998