Managing Nausea and Vomiting with Complementary Therapies

• Introduction
• Who manages nausea and vomiting with complementary therapies?
• Types of nausea and vomiting
• Who can provide complementary therapies?
• How effective are complementary and alternative therapies?
• Dietary management of nausea and vomiting
  • Eating techniques
  • Foods to eat
  • Foods to avoid
  • Reintroducing food after a vomiting episode
  • Rehydration
  • Total food withdrawal
  • Following surgery
• Herbal remedies
  • Ginger
  • Aromatherapy
• Cognitive and behavioural approaches
  • Relaxation
  • Hypnosis
  • Imagery training
  • Music therapy
  • Meditation
  • Yoga
  • Diaries
• Touch therapies
  • Acupressure
  • Acupuncture
  • Electro-acupuncture and electro-acupressure
  • Massage
  • Therapeutic touch

Introduction

Nausea and vomiting are common complications that may occur as a side effect of medication use, because of illness or disease, following surgery, or as a symptom of pregnancy. Nausea refers to the urge to vomit and may be accompanied by other symptoms, including flushing, excessive salivation, sweating and rapid heartbeat. Vomiting is characterised by the forceful expulsion of the contents of the stomach via the mouth. It occurs in response to contractions of the abdominal muscles. Nausea and vomiting are reflexes that help protect the body by preventing the absorption of toxins in the gastrointestinal tract. They may also occur in response to certain stimuli such as stress.

For more information on the mechanism of nausea and vomiting, see Chemotherapy-Induced Nausea and Vomiting (CINV): What causes vomiting?

Due to the frequency with which they occur, nausea and vomiting are often considered minor and acceptable complications. However, they can be severely debilitating and may prolong recovery from illness or surgery. Persistent nausea and vomiting can lead to serious and potentially life-threatening health complications, including malnutrition, dehydration and disruption of surgical wounds (due to the forceful contractions of vomiting). In addition, they may cause an individual to stop their treatment, if the treatment is causing the nausea and vomiting. Nausea and vomiting can significantly affect an individual's psychological health.

Preventing nausea and vomiting when it is likely to occur, and treating these complications if they do arise, is therefore important. A group of medications known as anti-emetic drugs are accepted as the usual treatment for nausea and vomiting, and most individuals who experience nausea and vomiting will be prescribed these medications. However, many individuals are also interested in using complementary therapies (natural treatments used in addition to anti-emetic medications). Only in rare cases are alternative therapies (natural therapies used to replace medications) used in the management of nausea and vomiting. Complementary and alternative approaches include dietary modifications, herbal remedies, cognitive and behavioural approaches and touch therapies.

Who manages nausea and vomiting with complementary therapies?

Complementary therapies are now used to treat a wide range of health conditions. When used to relieve nausea and vomiting, complementary therapies are typically used by individuals who experience severe and/or persistent nausea and vomiting. This includes individuals:

• Being treated with chemotherapy;
• Who are pregnant, particularly in the first trimester; or
• Who have just undergone surgery.

Types of nausea and vomiting

Nausea and vomiting can be further classified into types, depending on the underlying cause and the time at which nausea and vomiting occurs in relation to the events that trigger it. In relation to medication-induced nausea and vomiting, classifications include:

• Acute: Refers to nausea and vomiting that occurs within 24 hours of taking the medication;
• Delayed: Refers to nausea and vomiting that occurs more than 24 hours after taking the medication;
• Anticipatory: Refers to nausea and vomiting that occurs in anticipation of treatment. It typically affects individuals who have experienced acute or delayed nausea and vomiting following several previous treatment sessions; or
• Chronic: Refers to persistent, long-term vomiting. It often affects individuals receiving palliative care (terminally ill individuals).

Nausea and vomiting can also be graded according to severity:

• Grade 1: Mild nausea that does not lead to altered eating, or mild vomiting (one episode per day);
• Grade 2: Nausea leading to reduced food intake but not weight loss, or 2–5 episodes of vomiting in a 24-hour period. May require treatment with intravenous fluids for < 24 hours to prevent dehydration;
• Grade 3: Nausea that leads to inadequate food and fluid intake, or ≥ 6 episodes of vomiting in a 24-hour period. May require treatment with IV fluids to prevent or reverse dehydration, and tube feeding (feeding via a tube placed in the gut) or total parenteral nutrition (IV feeding) for ≥ 24 hours to prevent or reverse malnutrition;
• Grade 4: Nausea or vomiting with life-threatening consequences;
• Grade 5: Fatal nausea and vomiting.

Who can provide complementary therapies?

The level of skill and expertise required to provide a complementary therapy varies considerably depending on the type of therapy. Some simple touch therapies can be provided by non-professionals and require minimal training. Other therapies (e.g. acupuncture) are considered safe only if conducted by highly trained professionals. Regardless of the type of complementary therapy, it is important to see a reputable complementary health professional and discuss the therapies you plan to use with your doctor before starting treatment.

How effective are complementary and alternative therapies?

While complementary and alternative therapies are popular, it is important to be aware that, with the exception of acupuncture, there is generally limited evidence regarding the effectiveness of any complementary therapy in the management of nausea and vomiting. Also bear in mind that most non-medical therapies for nausea and vomiting are designed for use in addition to medical therapies. They generally should not replace the medicines prescribed by your doctor. Always keep taking your prescribed medicines unless your doctor advises you to stop.

Be aware that some complementary medicines, particularly herbal remedies, have the potential to interfere with other aspects of your treatment. It is important to always take a holistic approach and discuss with your doctor any complementary therapies you are interested in using, in relation to the medical treatments you are already using. Always consult a certified practitioner for your complementary therapies.

Discussing complementary therapies with a doctor is particularly important if you have or have had cancer, as many complementary and alternative therapies are known to interact with drugs used in cancer treatment. There are also safety concerns regarding some therapies that could plausibly accelerate the growth of cancer. For example, it is unknown whether vitamin and mineral supplements are harmful or beneficial for individuals with cancer, and there are concerns that the use of phyto-oestrogens by menopausal women may increase their risk of cancer.

Your doctor may enquire about your use of complementary therapies during a consultation. This should not be interpreted to mean that your doctor disagrees with your use of complementary therapies. Rather, the doctor must assess the impact of the complementary therapies on your current medical treatment, and whether the combination of medicines creates any health risks for you. The doctor can also discuss the existing evidence base for the therapies you use. Always be honest with your doctor and report all the treatments you use, even if they do not seem harmful (e.g. ginger).

Dietary management of nausea and vomiting

Dietary management approaches involve modifying aspects of your diet, with the aim of eliminating foods that may cause or worsen nausea or vomiting. They may also be used to ensure that individuals with persistent nausea and vomiting, who are at risk of malnutrition and other disorders, maintain adequate nutrition despite their symptoms.

Eating techniques

Individuals with persistent nausea and vomiting may benefit not only from changing the types of food they eat, but also from changing the way they eat their food. In particular, it is important to not eat anything while you are vomiting or when you feel you may vomit if you eat. When eating, try to consume food slowly and eat frequent, small quantities.

The following points may also help you overcome nausea and vomiting:

• Take anti-emetic medications an hour before eating;
• Drink clear liquid about half an hour before eating. Do not drink during meals;
• Sip liquids slowly throughout the day. Use a straw if that makes it easier to consume the beverage;
• Eat in a place where you feel comfortable;
• Eat in a well-ventilated place that is free of strong cooking odours;
• Try eating your food at room temperature or cooler;
• Rest after eating;
• Eat something dry and bland (e.g. a cracker) before getting out of bed in the morning;
• If nausea and vomiting are related to treatment such as chemotherapy, try waiting until several hours after the treatment before eating.

You may also benefit from planning your meals in advance and arranging for someone to help you prepare their meals.

Foods to eat

Try to eat foods that are easy to chew, swallow and digest. Such foods include:

• Dry foods like toast, crackers or pretzels;
• Crackers and cheese;
• Bland, soft, easy to digest food;
• Hard lollies such as peppermints or lemon drops;
• Soft cakes;
• Yoghurt;
• Porridge;
• Boiled starchy foods like rice and potatoes;
• Skinned chicken, boiled or baked but not fried;
• Cooked fruits or vegetables that are soft and bland; and
• Clear liquids, including carbonated beverages, broth, water, tea, plain gelatin, clear fruit juices such as apple and cranberry juice, and ice.

If you have persistent or severe nausea and vomiting, you are at risk of becoming malnourished and may need to increase your food intake. The following steps might help you do that:

• Eat small quantities of high-calorie foods every 2 hours;
• Add extra protein and calories to every meal;
• Seek foods that smell appealing; and
• Eat a large breakfast. Ideally, one third of your daily calorie and protein requirements should be consumed at breakfast.

Foods to avoid

If you are experiencing nausea and vomiting, avoid the following foods:

• Fatty or greasy foods;
• Very sweet foods;
• Spicy foods; and
• Foods with a strong odour.

Clean your teeth and mouth regularly. This may help prevent oral symptoms that can accompany nausea and vomiting (e.g. mucositis in individuals receiving cancer treatment) and reduce after-taste.

Reintroducing food after a vomiting episode

If you experience persistent nausea and vomiting, talk to your doctor for advice about ways to manage a vomiting episode. It is important not to eat anything until your vomiting is controlled. When you begin consuming food again, start by drinking very small amounts of clear liquid. Begin by drinking 1 teaspoon of liquid every 10 minutes, increasing to 1 tablespoon every 20 minutes and 2 tablespoons every 30 minutes. Soft or liquid foods such as jelly, milk, fruit juice and soup should then be reintroduced gradually.

Rehydration

Individuals who experience severe and persistent vomiting often become dehydrated as a result of the fluids lost from their body and lack of fluid intake. Dehydration must be treated promptly, or avoided where possible by maintaining fluid intake. Maintaining hydration is an important component of caring for yourself or someone else who is vomiting. Drink plenty of clear liquids such as water and fruit juice, particularly if you develop signs of dehydration such as thirst and dry mouth. An individual who has been admitted to hospital due to severe nausea and vomiting may require rehydration with intravenous fluids.

Total food withdrawal

Total food withdrawal and replacement with parenteral (IV feeding) or enteral (feeding via a tube placed in the gut) nutrition may be used to treat severe cases of nausea and vomiting when the person is admitted to hospital. These individuals typically also need IV fluids for rehydration. Enteral nutrition is the preferred option as it has similar efficacy, is more cost-effective and is associated with fewer complications. For example, the risk of infection at the site where the IV needle is placed for parenteral feeding does not arise with enteral feeding. Total parenteral feeding is generally only used as a last resort, when other treatments are ineffective.

Following surgery

The standard approach for preventing nausea and vomiting after surgery is by feeding via gastric tube until bowel movements resume. Thereafter individuals start a clear liquid diet and gradually introduce other foods as they are tolerated. Note, however, that there is no evidence regarding the effectiveness of this approach and one study found no difference in the incidence of nausea and vomiting in individuals who received a clear liquid meal or who received a regular meal after surgery.

Herbal remedies

There are a range of herbal remedies that are used or have been evaluated as nausea and vomiting treatments.

Ginger

A review of six studies examining the efficacy of ginger in relieving nausea and vomiting concluded that ginger appears to reduce these complications in individuals with sea-sickness, morning sickness or who were undergoing chemotherapy. There is insufficient evidence to determine whether or not ginger was effective in cases of post-operative vomiting.

There is some evidence that ginger may be effective in treating severe and persistent nausea and vomiting in pregnancy. Doses of up to 1 gram per day have not been shown to have any adverse effects on foetal development.

Aromatherapy

The safety and efficacy of aromatherapy have not been established in scientific studies. Using aromatherapy in the treatment of nausea and vomiting is therefore controversial, though a number of studies of aromatherapy for the relief of nausea and vomiting have produced promising results. For example, one study in which women smelt peppermint oil with high menthol content prior to gynaecological surgery reported slight reductions in nausea and need for anti-emetic medicines, as well as increased tolerance of anaesthesia in the peppermint oil treated group.

Cognitive and behavioural approaches

Relaxation

Relaxation therapies for nausea and vomiting are simple, low-cost therapies that can help relieve nausea and vomiting by encouraging relaxation. Various techniques can be used. For example, relaxation training may focus on teaching people to relax and decrease tension in different groups of muscles, or focus on breathing slowly and rhythmically to distract their focus from nausea and vomiting.

Muscle relaxation techniques may be particularly useful for individuals with post-operative nausea and vomiting as the muscle relaxation technique can also help overcome the after-effects of anaesthesia. This technique has been shown to reduce the duration and intensity of nausea and vomiting following chemotherapy. Relaxation techniques are considered important interventions for reducing anticipatory nausea and vomiting.

Hypnosis

Evidence suggests that hypnosis is effective in reducing the incidence of chemotherapy-induced and anticipatory nausea and vomiting, and post-surgical nausea and vomiting, in adults and children. There is particularly strong evidence for the role of hypnosis in reducing chemotherapy-induced and anticipatory nausea and vomiting in children. However, further research examining the effects of different types of hypnotherapy and the effects of this therapy in adults are warranted.

Imagery training

Relief of nausea and vomiting may be achieved through imagery training, which uses mental processes to increase relaxation. Individuals are encouraged to focus on pleasant memories and positive thoughts. This technique can be used alone or in conjunction with relaxation techniques.

Music therapy

Music therapy interventions involve listening to and/or creating music. An individual approach to developing interventions is required, based on the individual's relationship to and experience of music. Such interventions are designed by qualified music specialists, and there is some evidence that music therapy is an effective complementary treatment. For example, one study reported that listening to music helped relieve nausea and vomiting in individuals receiving cancer treatment who were also taking anti-emetic medications. However, studies of music therapy to date have been small and limited to special groups. It is unclear whether music therapy has a role to play in managing nausea and vomiting in the general population.

Meditation

Meditation is a relaxation technique through which people gain control and awareness of their emotions. Numerous meditation techniques exist and many have been applied to the relief of chemotherapy-related symptoms such as nausea and vomiting. However, there is currently no evidence that meditation is effective in relieving nausea and vomiting associated with chemotherapy.

Yoga

Yoga is a stretching exercise during which special attention is paid to breathing. There is some evidence that yoga may help individuals on cancer treatment relieve treatment-associated symptoms such as nausea and vomiting. For example, one study in India reported decreased frequency and intensity of nausea in women assigned to a yoga intervention. While further research on the therapeutic effects of yoga is warranted, there is currently insufficient evidence to recommend yoga as a complementary therapy for relief of nausea and vomiting.

Diaries

Some people may benefit from recording their experiences of nausea and vomiting in a diary. The information recorded in diaries might provide clues about the events triggering the nausea and vomiting.

Touch therapies

There are a range of touch therapies that may be used in the management of nausea and vomiting. Acupuncture and acupressure are traditional Chinese approaches that aim to relieve symptoms or complications by stimulating 'energy flow' through the body. Different points are targeted for the application of steady pressure using the fingers (acupressure) or the insertion of needles (acupuncture), through which energy flow through the body is apparently increased. There are many other therapies based on touch, including massage and reiki.

Touch therapies are generally safe and there is promising or strong evidence for a variety of treatments based on touch. Note that intense pressure therapies should not be applied near the site of cancerous tumours or enlarged lymph nodes, anatomical deformities including surgical wounds, or the site of a medical device (e.g. a catheter).

Acupressure

Acupressure is a simple technique that involves applying external pressure to acupuncture points. Unlike acupuncture, this therapy can be administered by non-trained providers. Applying acupressure to two points (the front of the lower leg about 10 cm below the knee, and the front of the forearm 3–5 cm above the wrist) has proven effective in reducing the intensity of nausea and vomiting in individuals using chemotherapy in some trials. A review of studies conducted to date concluded that current evidence suggests that acupressure is effective in reducing acute nausea, but not acute vomiting or delayed symptoms.

Acupuncture

Acupuncture is a therapy, derived from traditional Chinese medicine, that applies needles or heat to pressure points on the body with the aim of stimulating the body's 'vital energy'. Scientific studies have not yet fully explained the mechanism through which acupuncture exerts its therapeutic effect (there is no scientific evidence to support the traditional hypothesis that acupuncture stimulates 'vital energy'). Current evidence suggests that acupuncture works by influencing the response of the central nervous system.

There is considerable evidence that acupuncture is an effective therapy for reducing nausea and vomiting. Several studies have reported reduced vomiting episodes in adults undergoing chemotherapy who received acupuncture as complementary therapy (they also used anti-emetic medications), compared to those who did not. There is also evidence that acupuncture is effective when used in children receiving cancer treatment. Acupuncture is strongly recommended as a complementary therapy for severe chemotherapy-induced nausea and vomiting. A review noted that while this therapy reduces the likelihood of acute vomiting by 26%, it does not reduce the incidence of acute nausea.

There is evidence that acupuncture is effective in reducing nausea and vomiting associated with pregnancy, motion sickness and surgery. However, because it can only be performed by qualified, certified practitioners, acupuncture may not be cost-effective for nausea and vomiting management in other settings such as critical care. In addition, acupuncture may not be suitable for individuals with a bleeding predisposition (e.g. those taking blood-thinning medications called anticoagulants).

Electro-acupuncture and electro-acupressure

Electro-acupuncture is a technique involving the application of electrical nerve stimulation to acupuncture pressure points. It may be applied using invasive (electro-acupuncture) or non-invasive (electro-acupressure) techniques. Electro-acupuncture is generally considered more effective than manual acupuncture using needles. Both therapies are more effective than acupressure.

A non-invasive wrist band, which applies electrical nerve stimulation through the skin to the acupressure point on the wrist, has been developed for the relief of nausea and vomiting and is approved for over-the-counter sale in the United States. In Australia, an acupressure wrist band was recently approved for the purpose of relieving nausea caused by various conditions including pregnancy, motion sickness, surgery or chemotherapy. 

Some studies have reported the wrist band effective in reducing nausea and vomiting of several origins. One study reported chemotherapy-induced nausea was reduced in individuals assigned to wear the wrist band during cancer treatment, compared to individuals who did not wear the wrist band. However, a review concluded that there is currently no evidence of sufficient quality to demonstrate the effectiveness of this or other non-invasive electro-acupressure techniques for the relief of chemotherapy-induced nausea and vomiting.

There is evidence that an acupressure wris tband is similarly effective in relieving post-operative nausea and vomiting, compared to the anti-emetic medication ondansetron (e.g. Zofran). A review concluded that current evidence is sufficient to support the use of such wrist bands as an alternative to anti-emetics in individuals who have just had surgery. Discuss the use of an electro-acupressure wrist band with your doctor before discontinuing your current anti-emetic medication.

Electro-stimulation may also involve the manual application of electrical nerve stimulation using invasive techniques. Current evidence shows that these treatments reduced the incidence of acute chemotherapy-induced vomiting by 24%. There is insufficient evidence to determine whether or not electro-acupuncture reduces the incidence of acute nausea or delayed symptoms in individuals using chemotherapy.

Massage

Studies of the effects of massage on nausea symptoms in individuals receiving cancer treatment have reported promising results, though evidence remains inconclusive. Tactile massage is recommended as adjunct therapy for severe pregnancy-induced nausea and vomiting.

Therapeutic touch

Therapeutic touch is a therapy that claims to manipulate human energy fields through touch. Scientific studies have produced no evidence that such energy fields exist and thus no scientific basis to support the use of this practice exists. However, touch may have therapeutic value in terms of comforting individuals experiencing nausea and vomiting.

More information

For more information about nausea and vomiting in cancer treatment, including ways to manage it, see Chemotherapy-Induced Nausea and Vomiting (CINV).

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Article Dates:

Modified: 27/7/2011

Created: 25/7/2011