688638

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JPOXXX10.1177/1043454216688638Journal of Pediatric Oncology NursingMomani and Berry

Review
Journal of Pediatric Oncology Nursing

Integrative Therapeutic Approaches for

1­–12
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Hematology/Oncology Nurses
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in Children Undergoing Cancer DOI: 10.1177/1043454216688638

https://doi.org/10.1177/1043454216688638
journals.sagepub.com/home/jpo

Treatment: A Systematic Review of

Literature

Tha’er G. Momani, PhD, RN1,

and Donna L. Berry, PhD, RN, AOCN, FAAN1,2

Abstract
Chemotherapy-induced nausea and vomiting (CINV) continues to be a common symptom experienced by children
undergoing cancer treatment despite the use of contemporary antiemetics. Integrative therapeutic approaches in
addition to standard pharmacologic antiemetic regimes offer potential to control CINV. The purpose of this review
was to identify current evidence on integrative therapeutic approaches for the control of CINV in children with
cancer. Online search engines (PubMed, CINAHL, PsychINFO) were queried using MESH terms. Titles, abstracts,
and then full-text articles were reviewed for relevance to the review. The search resulted in 53 studies. Twenty-one
studies met our review criteria. Integrative therapies identified included acupuncture/acupressure, aromatherapy,
herbal supplements, hypnosis, and other cognitive behavioral interventions. Our review identified little information
on the effectiveness and safety of most integrative therapeutic approaches for the control and management of CINV
in children with cancer. However, evidence from adult cancer studies and some pediatric studies identify promising
interventions for further testing.

Keywords
chemotherapy-induced nausea and vomiting, integrative therapies, pediatric oncology

Introduction sufficient information from pediatric trials impedes the

Nausea is a common symptom experienced by children
undergoing cancer therapy. Emotional distress from nau-
sea can affect children’s compliance with treatment and
quality of life, cause emotional and physical distress, dis-
rupt the activities of daily living (Hockenberry &
Rodgers, 2015), and lead to further complications during
the course of chemotherapy (Dupuis & Nathan, 2010).
Despite significant improvements in the control of che-
motherapy-induced nausea and vomiting (CINV), many
children undergoing cancer chemotherapy continue to
experience nausea and vomiting (Miller, Jacob, &
Hockenberry, 2011). While vomiting is an objective
experience that can be observed, nausea is a subjective,
unpleasant sensation in the back of the throat and the epi-
gastrium that may or may not lead to vomiting (Rhodes,
Johnson, & McDaniel, 1995). Nausea, in particular, was
found to be the most troublesome symptom for children
with various cancer diagnoses during cancer treatment
(Momani, Gattuso, West, & Mandrell, 2015). The lack of
development of guidelines for the control of CINV in
pediatric oncology populations (Dupuis & Nathan, 2010).
Nursing care of children with cancer involves integrating
medical therapeutics, pharmacologic and nonpharmacologic
supportive interventions. A basic and important principle of
integrative nursing is to use the least invasive and most effec-
tive approaches first. This approach has gained wider appeal
within healthcare systems as a response to increased access
and knowledge of integrative interventions by patients and
their providers (Kreitzer & Koithan, 2014). Investigators
have identified and tested different integrative therapeutic
approaches to control nausea and vomiting associated with
1
Dana-Farber Cancer Institute, Boston, MA, USA
2
Harvard Medical School, Boston, MA, USA
Corresponding Author:
Tha’er G. Momani, Phyllis F. Cantor Center for Research in Nursing
and Patient Care Services, Dana-Farber Cancer Institute, 450
Brookline Avenue, LW 517, Boston, MA 02215, USA.
Email: thaer_almomani@dfci.harvard.edu
2 Journal of Pediatric Oncology Nursing 
cancer therapy (Dupuis & Nathan, 2003; J. Lee & Oh, 2013;
Stringer & Donald, 2011). In adults, reviews of integrative
approaches for controlling and managing nausea and vomit-
ing identified acupuncture and acupressure (Dupuis &
Nathan, 2010; Mustian et al., 2011), cognitive behavioral
interventions, aromatherapy, herbal supplements, and hypno-
sis (Mustian et al., 2011) as interventions with varying
degrees of effectiveness. However, little information is avail-
able on the effectiveness of such therapies in children with
cancer. In a 2007 review, Rheingans summarized 6 trials in
children with cancer in which behavioral therapy demon-
strated some benefit in preventing or managing nausea or
vomiting. Most of those trials were published in the 1980s.
Our literature review examines the state of science on the
definition, incidence, and pathophysiology of nausea and
vomiting in children undergoing cancer treatments and we
review integrative therapeutic trials to control the symptoms
in both adults and children with cancer.
Many nursing theories and frameworks address inte-
grative therapeutic approaches as part of a holistic care
approach to the health and well-being of patients. In par-
ticular, Roy’s adaptation model (Roy & Andrews, 1999)
allows nurses to identify focal, contextual, and residual
stimuli. The nurse assesses these stimuli and takes action
to promote the patient’s adaptation for physiologic needs,
self-concept, and role function (Frisch, 2001). The appli-
cation of effective integrative interventions allows the
nurse to support the patient’s adaptation responses.
Definition and Incidence
Prevalence estimates of nausea vary from 40% to 70% in
children treated for cancer (Hockenberry & Rodgers, 2015;
Miller et al., 2011). Nausea and vomiting is categorized
according to the time related to the administration of che-
motherapy when nausea occurs (Hockenberry & Rodgers,
2015). Acute CINV occurs 24 hours or less after chemo-
therapy. The best available antiemetic regimens can reduce
emesis up to 82% (Dupuis & Nathan, 2010). However, the
experience of nausea can be more frequent days after che-
motherapy. Delayed CINV occurs 24 hours after the che-
motherapy and during the 5- to 7-day period following
chemotherapy. The primary risk factor for delayed nausea
and vomiting is poor emetic control in the acute phase of
chemotherapy (Molassiotis et al., 2013). Anticipatory nau-
sea and vomiting occurs within 1 week before chemother-
apy is due to begin. It occurs almost exclusively in patients
who experienced poor emetic control during previous che-
motherapy cycles; likely a conditioned response (Bender
et al., 2002; Figueroa-Moseley et al., 2007).
Pathophysiology
Little information is available on the pathophysiology of
nausea in children with cancer, however, pathways of
action have been identified in adults. Physiologic path-
ways explain the experience of nausea and vomiting and
the potential effectiveness of integrative therapeutic
approaches.
The Activation of the Chemotherapy Trigger Zone (CTZ).  The
most common mechanisms by which chemotherapeutic
agents cause nausea and vomiting are complex and
thought to be through activation of the CTZ located in the
floor of the fourth ventricle. The CTZ is activated via
blood or cerebrospinal fluid and invokes the release of
various neurotransmitters, which stimulate the vomiting
center. Antiemetic therapy targets neuroreceptors located
in the peripheral and central nervous system that can acti-
vate this central processing area of the brain (Jordan,
Schaffrath, Jahn, Mueller-Tidow, & Jordan, 2014).
Stimulation of the Vagus Nerve.  The stimulation of gastroin-
testinal tract cells following exposure to cytotoxic materi-
als results in the activation of serotonin (5-HT) receptors in
the gut lining, and leads to the afferent stimulation of the
vagus nerve (cranial nerve X). This stimulation leads to the
activation of the respiratory, vasomotor, and salivary cen-
ters in the brain in addition to the abdominal muscles and
diaphragm resulting in vomiting (Horn, 2014).
The Inhibition of Serotonin and Endorphins and Other Recep-
tors.  The peripheral irritation to the gastrointestinal mucosa
by the chemotherapeutic agent results in the release of
multiple neurotransmitters that play a role in nausea and
vomiting. These include serotonin, substance P, histamine,
dopamine, acetylcholine, γ-aminobutyric acid (GABA),
and enkephalins (Hornby, 2001). The serotonin/5-HT3-
receptor pathway as well as the substance P/NK1 receptor
pathway play major roles in the modulation of nausea and
vomiting. Another potential receptor that may play a role
in nausea and vomiting is dopamine. Many effective anti-
emetics are dopamine antagonists.
Other Mechanisms. Other mechanisms that may be
involved in nausea and vomiting include direct or indirect
effects on the cerebral cortex, olfactory or gustatory stim-
uli, and the vestibular system (Hornby, 2001). Studies
have shown that nitrogen mustard partially causes emesis
via direct stimulation of the cerebral cortex (Cubeddu,
O’Connor, Hoffmann, & Parmer, 1995; Hesketh, 2005).
The importance of taste and odor perception in relation to
enhancement of gagging, nausea, and vomiting is well
appreciated, although the exact mechanism is unknown
(Coates et al., 1983). Patients with a history of motion
sickness or vertigo experience a greater severity, fre-
quency, and duration of nausea and vomiting from che-
motherapy than patients who do not experience motion
sickness or vertigo (Hornby, 2001).
Momani and Berry 3
53 articles identified in database search
30 full-text articles measuring integrative
therapies in cancer
3 articles added through citation
21 articles met inclusion criteria
Figure 1.  PRISMA flow diagram: integrative therapeutic approaches to control nausea in patients with cancer.
Method
To identify relevant literature regarding integrative thera-
peutic approaches to control nausea in patients with can-
cer, a PubMed, CINAHL, and PsychINFO search of
articles was performed using the combined MESH terms
nausea, cancer, integrative therapies, and alternative
therapies. Reference lists of final included studies were
checked to identify any additional eligible studies. Figure
1 presents the PRISMA flow diagram for the article selec-
tion process.
We applied the following inclusion criteria: (a) English
text, (b) full-text journals, (c) all ages, and (d) integrative
therapeutic addressing nausea and vomiting. We excluded
case studies, chart reviews, or any study in which the out-
comes were undefined or in which measurement of the
effectiveness of the intervention on the outcome was not
identified. For the purpose of identifying all relative inte-
grative interventions that addressed nausea and vomiting,
we did not set a year range for study inclusion. If multiple
systematic reviews were identified for the same interven-
tion, we included the most recent and comprehensive
review.
Results
Electronic and manual searches of the included databases
yielded 53 publications (Table 1). Of the studies identified,
a small number of studies focused on children and mainly
were observational studies. We selected the most recent
relevant systematic reviews and highlighted relevant stud-
ies that focused on children with cancer. Twenty-one stud-
ies that met the criteria were included in our review.
Of the 21 studies, only 4 randomized clinical trials
(RCTs) addressing nausea in children with cancer were
found. These studies assessed acupuncture (Reindl et al.,
2006), acupressure (Yeh et al., 2012), hypnosis (Zeltzer,
23 articles excluded on the basis of
abstract/full text as they did not meet
criteria
12 articles excluded as they did not provide
outcomes data or new information
Dolgin, LeBaron, & LeBaron, 1991), and inhalation aroma-
therapy (Ndao et al., 2012). The interventions were evalu-
ated in underpowered samples and revealed little
effectiveness; Ndao et al. (2012) reported a negative
response to aromatherapy in children with cancer. The other
17 publications are reviewed in order to present a more
comprehensive context of integrative interventions for con-
trol of nausea and/or vomiting in those with cancer.
Integrative Interventions
Acupuncture/Acupressure.  Acupuncture is one of the most
studied integrative interventions in adults with cancer.
Evidence from literature reviews and studies supports the
efficacy of acupuncture in control of chemotherapy-
related nausea and vomiting. Acupuncture strategies have
been found generally safe in adults and children (McKeon,
Smith, Hardy, & Chang, 2013). The most common side
effect in children has been reported as localized redness
at the acupuncture site (Mckeon et al., 2013). Reindl et al.
(2006), in the only study to assess the effectiveness of
acupuncture for chemotherapy-induced nausea in chil-
dren, were unable to recruit the planned sample, with
only 11 patients participating. Local pain from acupunc-
ture needles was the only reported side effect in this study
(Reindl et al., 2006).
Systematic reviews and trials have examined the effec-
tiveness of acupressure in decreasing the severity of nausea
in combination with antiemetics in adults (E. J. Lee &
Warden, 2013; McKeon et al., 2013; Molassiotis et al.,
2013; Molassiotis, Helin, Dabbour, & Hummerston, 2007),
and in children (Jones, Isom, Kemper, & McLean, 2008;
McKeon et al., 2013; Yeh et al., 2012). These studies have
found acupressure generally useful in reducing acute nau-
sea severity, but was not effective in reducing vomiting or
delayed symptoms. Small RCTs have demonstrated a sig-
nificant benefit of acupressure in addition to antiemetic
4
Table 1.  Literature Review of the Use of Integrative Therapies for Chemotherapy-Induced Nausea and Vomiting.
First Author, Year,
Country Design and Purpose
Acupuncture and acupressure
Mckeon, 2013, Systematic review and meta-
Australia analysis
Effectiveness of acupuncture and
acupressure in the management
of CINV
Reindl, 2006, Germany Crossover RCT
Evaluate acupuncture during highly Acupuncture was given at Day 1 of chemotherapy
emetogenic chemotherapy
Jones, 2008, USA 2-arm crossover RCT
Determine the feasibility and
effectiveness of acupressure
wrist bands in preventing CINV
in children with cancer
 
Yeh, 2012, Taiwan 2-arm crossover RCT
Assess nausea and vomiting
control using AAP
Tas, 2014, Turkey Prospective single arm study
Investigate the efficacy of
acupuncture in controlling
nausea, vomiting, pain, poor
sleep quality and anxiety in adult
cancer patients
Sample and Methods Measures Major Outcomes
7 adult and pediatric acupuncture studies included Frequency of nausea/ Acupuncture reduced the frequency of acute vomiting
275 patients; 6 adult and pediatric acupressure vomiting; rescue and dose of rescue antiemetics compared with
trials included 1133 patients antiemetics antiemetics only in pediatric and adult studies
combined.
Acupressure plus medication decreased frequency of
nausea compared to antiemetics only group, but not
acute vomiting or delayed symptoms.
35 children/adolescents planned to be randomized Daily diary of vomiting Only 11 participants (6-18 years, mean age: 15.2 years)
to: (a) antiemetic medication plus acupuncture, episodes; completed one were enrolled before the study was closed due to
or (b) antiemetic medication alone MSAS nausea item after poor accrual.
every course
No significant differences between groups.
and on subsequent days
21 children randomized to sequences over 3 cycles Adapted MANE scale 18 patients completed all 3 treatments.
of chemotherapy infusions: (a) acupressure band, collected before and after
standard care, and placebo band. Or (b) placebo chemotherapy
band, standard care, acupressure band. Standard
care pharmacologic antiemetics provided before
all cycles in in each sequence
No significant difference in nausea or vomiting between
sequenced groups.
4 patients reported discomfort from tightness of both
acupressure and placebo bands.
17 children/adolescents randomized to: (a) MANE prior to, and for 7 10 participants completed the study. The AAP group
AAP or (b) acupressure using SAP. First cycle days following, each of 3 reported significantly lower occurrence and severity
chemotherapy data was considered a control rounds of chemotherapy of nausea and vomiting than patients in the control
condition condition.
There were no significant differences in between AAP
and SAP groups
45 patients with established nausea given Oral intake measures single Significant improvement in nausea scores from 24 hours
20-minute acupuncture sessions 1 day prior to, item with 5 responses after chemotherapy to the next day after acupuncture.
on the day of, and 1 day after chemotherapy ranging from “good oral
intake” to “continuous
nausea” as proxy for
nausea
Nausea assessed within 24  
hours after chemotherapy,
immediately after
acupuncture sessions on
chemotherapy day and the
next day
(continued)
 Table 1. (continued)

First Author, Year,

Country Design and Purpose Sample and Methods Measures Major Outcomes

J. Lee, 2013, South Systematic review for the effect
Korea of acupressure on CINV and
incidence of side effects
 
Molassiotis, 2013, UK 3-arm RCT
Assess the effectiveness of self-
acupressure wristbands for
CINV
Molassiotis, 2007, UK 2-arm RCT
Assess the effectiveness of self-
acupressure wristbands for
CINV
Suh, 2012, South 4-arm RCT
Korea
Evaluate the effects of P6
acupressure wristband and
counseling on CINV in patients
with breast cancer
Aromatherapy
Ndao, 2012, USA 2-arm RCT
Evaluate the effect of bergamot
oil inhalation on anxiety, nausea,
and pain
 
 
Included 3 systematic reviews, 7 controlled, and 2
quasi-controlled adult studies
500 adult cancer patients randomized to (a)
acupressure wristbands, (b) sham bands, or (c)
standard care only, 7 days per chemotherapy
cycle over 4 cycles
36 adult breast cancer patients receiving
chemotherapy randomized to (a) acupressure
wristbands plus standard antiemetics, or (b)
antiemetics only for 5 days
120 adult women randomized to 4 arms: (a) P6
acupressure wristband, (b) sham acupressure on
joint of the little finger of both hands (SI3) (c)
P6 acupressure wristband and counseling, or (d)
counseling only
37 children, adolescents/young adults (ages 5-21
years) randomized to (a) bergamot oil inhalation on VAS
(intervention) or (b) placebo oils inhalation.
Both administered prior to infusion, on infusion
completion, and 1-hour postinfusion
NA Six of 7 clinical trials reviewed showed positive results of
acupressure on chemotherapy-induced nausea in 1341
patients with cancer.
Authors could not recommend acupressure as effective
for nausea due to poor quality of the studies.
Rhodes INVR FACT-G 361 patients completed study
Measures collected daily No statistically significant differences between the 3
for 8 days from before groups
chemotherapy till the end
of intervention over 4
cycles
Rhodes INVR collected Nausea and retching “experiences,” nausea, retching,
daily during 5 days of and vomiting “occurrences,” and nausea and vomiting
intervention “distress” were significantly less in intervention group.
Rhodes INVR measured daily 105 women completed study
over 5 days of intervention
Significant effect of acupressure and counseling on
delayed CINV at days 2-5 as compared with the sham
group
Nausea and pain measured All participants completed the study.
Anxiety measured with The intervention group reported significantly greater
State-Trait Anxiety nausea at the completion of infusion and 1-hour
Inventory for Children postinfusion.
(STAIC)
The treatment group reported higher anxiety at
completion and 1-hour postinfusion completion.
No significant differences in pain between 2 groups

5
(continued)
6
Table 1. (continued)
First Author, Year,
Country Design and Purpose
Lua, 2012, Malaysia Literature review
Identify the existing evidence on the
effectiveness of inhalation essential
oils on nausea and vomiting
Gonella, 2014, Italy 3-arm RCT
Assess the effectiveness of orange
aroma in ice lollies
  Prevent nausea and vomiting
related to cell reinfusion with
DMSO
Potter, 2011, USA 3-arm RCT
Assess feasibility and efficacy
of sliced oranges or orange
aromatherapy on nausea,
retching and tickle/cough
associated with stem cell
reinfusion with DMSO
Herbal supplements
J. Lee, 2013, South Systematic review and meta-
Korea analysis
Evaluate ginger for the control of
CINV
 
Sample and Methods Measures Major Outcomes
Review of studies on inhalation aromatherapy, 1 Nausea and vomiting Definitive conclusion could not be made due to
review and 4 clinical studies involving 328 adult underpowered sample sizes and design flaws
patients
 
69 adult bone marrow transplant receiving DMSO NRS of nausea intensity Deep breathing provided better nausea control than ice
patients randomized to (a) orange ice lollies, (0-100) lollies during first 48 hours of reinfusion
(b) noncitrus ice lollies, or (c) deep breathing
(control). All administered during reinfusion and
for 5 days following infusion
Number of vomiting  
episodes
Nausea intensity was  
reported every 4 hours and
averaged daily for 5 days
60 patients receiving at least 2 bags of reinfused stem Perceived intensity and Orange intervention group reported significantly
cells were randomized to (a) orange intervention relief for tickle/cough greater symptom relief. Patients weighing less than 90
(sniffing or tasting sliced oranges, (b) orange urge, nausea, and retching kilograms and using the orange intervention reported
aromatherapy, (c) or deep breathing (control) measured on a 0 to 10 NRS significantly lower tickle/cough and nausea intensity.
 
5 RCTs were included for the review. 4 RCTs for Incidence and severity of Ingesting ginger did not significantly affect the incidence
the meta-analysis with a total number of 872 acute and delayed CINV of acute nausea or acute vomiting.
patients
Effect of ginger on delayed nausea and vomiting was
hindered by heterogeneity of studies.
Ginger with antiemetics did not significantly affect the
severity of acute nausea
(continued)
 Table 1. (continued)
First Author, Year,
Country Design and Purpose
Ryan, 2012, USA 4-arm RCT
Determine if ingesting ginger was
more effective than placebo in
controlling acute CIN in cancer
patients receiving antiemetics
 
Tayarani-Najaran, 4-arm RCT
2013, Iran
Determine the efficacy of Mentha
spicata and Mentha × piperita in
preventing CINV
Wilkinson, 2007, UK 2-arm RCT
Hypnosis
Richardson, 2007, UK Literature review and meta-
analysis
Assess the effectiveness of
hypnosis in reducing nausea and
vomiting in children with cancer
Zeltzer, 1991, USA 3-arm RCT
Identify the effectiveness of
hypnosis and distraction for
CINV
7
Sample and Methods Measures Major Outcomes
744 adult cancer patients receiving antiemetics Severity of nausea on a 662 patients completed baseline measures; analysis was
over 3 cycles of chemotherapy, randomized 7-point NRS for 4 times conducted on 576.
to ingest: (a) placebo, (b) 0.5g ginger pills, (c) each day (over 3- to 4-day
1.0g ginger pills, (d) 1.5g ginger pills. Pills were periods; days 1-4) of each
administered twice daily for 6 days starting 3 cycle
days before chemotherapy
All doses of ginger significantly reduced acute nausea
severity compared with placebo on chemotherapy
Day 1.
The largest reduction in nausea intensity occurred with
0.5 g and 1.0 g of ginger.
200 adult patients randomized to (a) Mentha Nausea intensity on a NRS All randomized patients completed the study.
spicata, (b) Mentha piperta, (c) placebo, or (d) (0-100)
standard care (controls)
All agents ingested in capsules: 30 minutes before Number of vomiting Significant reduction in the intensity and number of
chemotherapy, 4 and 8 hours later episodes Reported by emetic events in the first 24 hours with M spicata
patients over 24-hour and M piperita treatment groups when compared to
period placebo.
288 adult patients randomized to (a) usual EORTC for nausea and No significant difference in nausea scores between the 2
supportive care, or (b) usual care plus vomiting, at randomization arms at 6 weeks and 10 weeks compared to baseline
aromatherapy message (4-week course of (baseline), 6 weeks, and 10
weekly, 1-hoursessions of aromatherapy weeks postrandomization
massage)
6 RCTs included in the review (5 in children), 4 Posttreatment means/ Significant reduction in anticipatory and CINV.
included in the meta-analysis standard deviations for
nausea and vomiting
Mean effect size for nausea
Meta-analysis revealed a large effect size of hypnotic
and vomiting treatment when compared with treatment as usual.
The effect was as large as that of cognitive–behavioral
therapy.
54 children/adolescents recruited, 19 randomized VAS for nausea severity at All randomized participants completed the study (5-17,
to (a) hypnosis, (b) distraction and relaxation, or baseline prior to treatment mean age: 11.67 years).
(c) casual conversations (control) and within 24 hours of
chemotherapy
Those in hypnosis and distraction groups had significantly
shorter nausea duration compared to conversation
group.
(continued)
8
Table 1. (continued)

First Author, Year,

Country Design and Purpose Sample and Methods Measures Major Outcomes

  Children in the hypnosis and distraction groups

Cognitive behavioral therapies
Figueroa-Moseley, Literature review
2007, USA
Identify nonpharmacologic
interventions to control ANV in
adults and children with cancer
Redd, 1987, USA 2-arm pretest-posttest RCT
Investigate the use of cognitive/
attentional distraction (video
games) to control conditioned
nausea in pediatric cancer
patients receiving chemotherapy
Progressive muscle relaxation training (PMRT),
systematic desensitization, hypnosis, and
cognitive distraction.
Acupressure and acupuncture
26 children, adolescents/young adults randomized
to (a) playing video games, or (b) access to
toys, books, and TV (control), before or during
chemotherapy
reported the most reduction in anticipatory and
postchemotherapy nausea compared with the control
group
NA Identified behavioral interventions and acupressure/
acupuncture as effective interventions.
Focus on anticipatory nausea and vomiting.
10 cm visual analog scale for All participants completed the study (9-20 years, mean
nausea from 0 “no nausea” age: 14.0).
to 10 “nausea as bad is it
could be” measured before
and after the intervention
Nausea was significantly reduced in those playing
video games compared with control at the end of
intervention.

Abbreviations: AAP, auricular acupressure; CINV, chemotherapy-induced nausea and vomiting; DMSO, dimethyl sulfoxide; EORTC, European Organisation for Research and Treatment of Cancer; FACT-G, functional assessment
of cancer therapy–general; INVR, index of nausea, vomiting, and retching; MANE, Marrow Assessment of Nausea and Emesis; MSAS, Memorial Symptom Assessment Scale; NA, not applicable; NRS, numerical rating scale; RCT,
randomized clinical trial; SAP, sham acupressure; VAS, visual analog scale.
Momani and Berry 9
therapy versus antiemetic therapy (Molassiotis et al., 2007;
Suh, 2012), or sham acupressure (Suh, 2012) for decreas-
ing nausea and vomiting in adults with cancer. However,
the largest RCT to test the effectiveness of acupressure in
addition to the standard antiemetic therapies for control-
ling nausea and vomiting in a sample of 500 adult patients
receiving chemotherapy found no significant differences
between acupressure, sham acupressure, and standard care
only groups (Molassiotis et al., 2013). Taiwanese research-
ers (Yeh et al., 2012) investigated the efficacy of auricular
acupressure treatment versus sham auricular acupressure
(pressure in a location unrelated to stomach or digestion)
versus standard care to reduce delayed CINV in pediatric
and young adult patients with pediatric solid tumors. The
researchers reported significantly lower nausea and vomit-
ing severity and occurrence with true and sham interven-
tions compared to the standard care group. However, there
were no significant differences between the sham and true
acupressure groups. This suggests a strong placebo effect
for auricular acupressure. Acupressure has been found to
be generally safe in adults, with few adverse events that
included swelling, skin irritation, and sensitivity to the
wrist bands (E. J. Lee & Warden, 2013; Molassiotis et al.,
2013). Severity and duration of these symptoms was not
reported in any of the studies.
Aromatherapy.  Aromatherapy is the inhaled use of essen-
tial oils or natural scents for therapeutic or medical pur-
poses. Ginger (Zingiber officinale), spearmint (Mentha
spicata), and peppermint (Mentha piperita) have been
recommended for their antiemetic and antispasmodic
effects on the gastric lining and colon (Lua & Zakaria,
2012). Wilkinson et al. (2007) reported that aromatherapy
massage in adults resulted in no significant reduction of
nausea and vomiting. Orange iced lollies (popsicles),
taken for the purpose of inducing aroma, have signifi-
cantly reduced nausea intensity but not frequency in com-
parison to deep breathing in adult cancer patients receiving
stem cell infusions preserved with dimethylsufoxide
(DMSO). Patients on the orange ice popsicles group
reported the frequency of nausea was significantly less in
the orange popsicle group compared to the deep breathing
group (Gonella, Berchialla, Bruno, & Giulio, 2014). Pre-
venting nausea and retching associated with DMSO has
been tested in adults using strawberry lollipops (Ozdemir,
Akgedik, Akdogan, & Kansu, 2008) and scent and taste
from actual oranges and aroma from orange essential oil
(Potter, Eisenberg, Cain, & Berry, 2011). Ozdemir et al.
(2008) reported a statistically significant reduction in nau-
sea and vomiting. Potter et al. (2011) found that over 2
infused bags of stem cells, the actual orange intervention
resulted in significantly better symptom relief and the
investigators reported a more robust effect of the actual
orange scent in adults under 90 kg.
In a placebo-controlled pediatric trial of aromatherapy,
Ndao et al. (2012) tested the effectiveness of inhalation
aromatherapy using bergamot essential oil in 37 children
receiving stem cell infusions. Children in the aromather-
apy group reported significantly higher anxiety and nau-
sea levels than children in the placebo aromatherapy
group.
Herbal Supplements. Herbs have been assessed in the
management of cancer treatment symptoms in adults.
Ginger (Zingiber officinale) has been advocated as an
antiemetic herbal preparation for the management of
CINV. Systematic reviews of clinical trials in adults
found few adverse effects, but mixed evidence for effi-
cacy of ginger prevention or treatment of CINV (J. Lee &
Oh, 2013). However, the largest RCT to test the effective-
ness of ginger identified daily doses (0.5-1.0 g) to be
effective in significantly decreasing the severity of acute
chemotherapy-induced nausea in a sample of 576 adult
patients with cancer (Ryan et al., 2012). No RCTs have
been found to study the effect of herbal supplements in
children with cancer.
A study in Iran tested the effects of ingesting pills of
Mentha spicata and Mentha piperita in controlling nausea
and vomiting in adults receiving chemotherapy (Tayarani-
Najaran Talasaz-Firoozi, Nasiri, Jalali, & Hassanzadeh,
2013). The authors reported significant effects for both
types of supplements in controlling nausea frequency and
intensity, and vomiting frequency.
Hypnosis.  Richardson et al. (2007) evaluated 5 random-
ized trials that tested hypnosis for the control of CINV.
The reviewers concluded that hypnosis was effective to
treat CINV in children with cancer. The largest RCT to
study hypnosis to control CINV in children with cancer
(Zeltzer, Dolgin, LeBaron & LeBaron, 1991) found hyp-
nosis more effective than cognitive distraction/relaxation
or placebo in reducing anticipatory and postchemother-
apy nausea and vomiting.
Behavioral Interventions.  Systematic reviews identified 3
types of cognitive–behavioral therapy (CBT) interven-
tions for the management and control of anticipatory nau-
sea and vomiting in children with cancer may be effective:
progressive muscle relaxation training (PMRT), system-
atic desensitization (SD), and cognitive distraction
(Figueroa-Moseley et al., 2007). PMRT can allow patients
to exercise muscle relaxation as a response to certain nau-
sea and vomiting triggers, including chemotherapy. The
review found that adult breast cancer patients receiving
PMRT in addition to standard antiemetic therapy had sig-
nificantly shorter duration of nausea and vomiting in
comparison to the standard care only group. However, no
significant differences were identified in the frequency or
10 Journal of Pediatric Oncology Nursing 
intensity of nausea and vomiting between groups. SD is
commonly used to treat condition-response fears and
phobias and has been suggested for treating anticipatory
nausea and vomiting. Anticipatory nausea and vomiting
may develop through conditioning at previous chemo-
therapy infusions. SD involves using counter-condition-
ing measures, such as PMRT, to reduce or eliminate the
anticipated nausea and vomiting. Cognitive distraction
may promote muscle relaxation and assist in decreasing
nausea and vomiting in adults and children undergoing
cancer treatment. This benefit was achieved by distract-
ing adult cancer patients from the nausea or triggers of
nausea using video games. In a nonrandomized, pre-post,
repeated measures study, video game distraction was
found to result in significant reduction of conditioned
nausea in a small sample of children with cancer (Redd,
Montgomery, & DuHamel, 2001).
Discussion
Relief of cancer treatment-related nausea is an important
component of supportive care for children with cancer as
nausea is a side effect with much relevance to quality of
life and the cancer treatment experience. Complementary
and integrative therapies, both alone and as adjuvants to
pharmacologic antiemetics, have sometimes helped
reduce symptoms in adults without any or minimal side
effects. Several relatively small clinical trials of varying
quality have been conducted with these integrative thera-
pies in pediatric oncology. The lack of evidence precludes
confidence in the effectiveness for many of these inter-
ventions for children with cancer.
The evidence in the area of hypnosis research supports
the premise that interventions which have not been effec-
tive in adults may prove effective in children with cancer
to control nausea and vomiting. Children may respond to
novel interventions or may be more willing to accept such
interventions to control nausea. Other interventions
including acupressure and ginger have offered varying
degrees of effectiveness in adults, but also provide
approaches that may be more feasible within the limited
time frame in which pediatric nurses intervene for nausea
and vomiting. However, children may be less receptive to
a potentially beneficial therapy if the intervention
involves discomfort as the children cannot balance per-
ceived initial discomfort with potential benefit (eg, Reindl
et al., 2006).
Studies on CBT and hypnosis offered beginning evi-
dence for such interventions to control nausea and vomit-
ing in children with cancer. However, hypnosis has not
been adopted widely in clinical practice and no recent
studies have been conducted. Since the 1980s, the advent
of more effective antiemetic drugs may have diminished
the perceived need for a time-intensive intervention
requiring special expertise not typically found in a pedi-
atric clinic setting. Other CBT interventions, including
video game distraction, offer promising, though prelimi-
nary results and will require further testing and research
with the advent of better access to technology and self-
use of electronics by children and parents.
Aromatherapy with bergamot resulted in negative
effects in children with cancer receiving cell infusions
with DMSO. Any further testing of other aromatherapy
essential oils in children receiving emetogenic chemo-
therapy could be conducted with careful safety
assessments.
Implications for Practice
Counseling pediatric patients and family members on the
safety and efficacy of integrative therapies is a challenge
to healthcare providers, as there is a paucity of data from
well-designed research trials. Guidelines for assessing
the safety and efficacy of integrative therapies in adult
cancer patients have been previously published and are of
limited use with children. Health care providers should
initiate open, nonjudgmental discussions with patients
and parents regarding integrative therapies use. It is
important to assess and document the child’s use of any
self-administered integrative therapies, critically evaluate
the evidence or lack of evidence, balance the potential
risks with possible benefits, and assist the family in their
choices and decisions regarding use of integrative thera-
pies for their child with cancer.
The high prevalence of nausea, coupled with patient
and family access to multiple sources of both reputable
and questionable information and active involvement in
care decisions, may drive families of children to seek
integrative therapies. Nurses should have the knowledge
necessary to inform patients’ and families’ decisions
regarding effective integrative therapies to control nau-
sea. Despite the lack of evidence on the effect of many of
integrative interventions in children, nurses could encour-
age families and children with uncontrolled nausea and
vomiting to explore low risk, nonpharmacologic meth-
ods, such as distraction, to help alleviate the experience.
Future Research
Future research in integrative therapy approaches for
children with cancer should aim to identify effective and
feasible interventions that are readily accepted by chil-
dren and their families. Our review has identified critical
areas where further research is warranted. Our review has
identified differences in responses between the adult and
pediatric cancer population to the various integrative
interventions. This finding implies the need to identify
the acceptability and practicality of different integrative
Momani and Berry 11
intervention in the pediatric oncology population before
relying on information from adult cancer studies. Thus, it
is imperative that any integrative therapy found effica-
cious in adults should pass through pilot and safety test-
ing to identify potential issues in children.
Another finding from this review was the lack of more
recent studies on nonpharmacologic, cognitive behavioral
interventions found effective in controlling nausea and
vomiting in children with cancer. In particular, research on
hypnosis had been conducted in the late 1980s and early
1990s. This gap in knowledge and practice of such inter-
ventions in pediatric oncology settings may be due to the
development of more powerful antiemetics and clinician
beliefs that the problem is best addressed with these
agents. However, the continued empiric findings of
uncontrolled nausea and vomiting in large proportions of
pediatric oncology populations call for reexamining the
effectiveness of nonpharmacologic therapies.
Of particular interest is research related to the effec-
tiveness of video game distraction in controlling nausea
and vomiting in children with cancer. Such video game
apps have been more available with the current advantage
of access to portable technology including smart phones
and tablets. This technology was not available at the time
of the previous distraction studies. Further research is
warranted.
Conclusion
Integrative therapies tested in adults have not been ade-
quately evaluated with regard to controlling cancer ther-
apy-associated nausea or vomiting in children with cancer.
Likely candidates for future work include cognitive dis-
traction, hypnosis, and acupressure. However, further test-
ing of the feasibility and efficacy of these interventions
should be performed to support dissemination into clinical
settings. Nurses should be aware of the existing evidence,
and lack thereof, of these therapies to guide and counsel
patients and their families toward better control of nausea
and vomiting during cancer treatment.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Tha’er G. Momani, PhD, RN, is a postdoctoral research fellow at
the Phyllis F. Cantor Center for Research in Nursing and Patient
Care Services, at Dana-Farber Cancer Institute in Boston, MA.
Donna L. Berry, PhD, RN, AOCN, FAAN, is an associate pro-
fessor of medicine at Harvard Medical School, and director of
the Phyllis F. Cantor Center for Research in Nursing and Patient
Care Services at Dana-Farber Cancer Institute in Boston, MA.