access to more than 475 public and private patient assistance programsAs parents of sick children know, it is not always easy to measure out exact liquid medication doses. The younger the child, the harder it can be to give medicine and to judge if the medicine is helping. A number of potential problems can increase the difficulty of administering accurate doses of medicine to infants and children.
In this chapter I describe the best ways to give medications to infants and children, including medicine doses in tablet, capsule, and liquid form. I also explain how typical administration problems come about, and I suggest ways to avoid these problems. Common mistakes with medications may not always result in harm to a child, but significant adverse effects and harm from medication mistakes have been shown and are well known to have occurred. Researchers have evaluated many of these topics, and the results of their studies are discussed here.
Many published studies have shown that it is easy for parents to make mistakes when giving prescription and over-the-counter (OTC) medicines to their children. For example, in some studies parents were given a common pediatric medicine bottle, such as liquid antibiotics or liquid acetaminophen (Tylenol), and were asked to calculate a dose for their child. Study parents were given their child’s current weight and were also asked to measure the calculated dose with their choice of different dosing devices. (I’ll say more about these studies and their results in the following pages.)
All of the common parental mistakes discussed in this chapter can be easily avoided when parents know what the potential problems are. By following several simple rules caregivers can avoid these pitfalls. Common mistakes include:
• not reading the medication bottle instructions or label properly,
• not accurately measuring doses of liquid medicines,
• determining a child’s dose by age and not by weight,
• giving too many medicines at one time (over-medicating), and
• not finishing the full amount of a prescribed medicine.
Some of these medicine mistake “categories,” such as not reading the medicine label or instructions carefully, happen when adults give themselves medicine as well. It can be easy to inaccurately administer an OTC or prescription medication to your child if you do not read the label on the bottle and product packaging. Unfortunately, the ability to buy an OTC medication without speaking with a physician or pharmacist makes this too easy to do.
Let’s take these points one at a time.
As your child rapidly grows, his or her weight increases, meaning your child needs a higher dose than you may have previously administered. Weights of infants and children increase significantly in the first few years of life. As mentioned in chapter 1, the weight of a healthy infant can double at 6 months, triple at 12 months, and quadruple at 24 months of age. Another issue connected to weight is that medicines come in different concentrations. You might try a different liquid product that has a better flavor, and a different concentration, and consequently you give an incorrect dose based on your child’s weight.
Many OTC medication products list medication dose ranges for specific ages (for example, “for ages 4–6 years, give X mg”), and because parents don’t always know their child’s current weight, it is easy to rely on the age range on the product label. But your child’s weight may differ from the age range listed on the product. While it may seem straightforward to rely on your child’s age, determining a medication dose based specifically on your infant’s or child’s current weight is more accurate, and is most likely to help your child, without resulting in adverse effects.
This is probably the most common mistake parents make, and the mistake most closely studied by researchers. It is described in more detail in the following pages.
Healthy infants and children are frequently ill with colds and other common maladies, often more so than adults, and pharmaceutical manufacturers market many OTC products to treat these illnesses. Many of these products should not be used in children, as they have not been proven to be safe and effective in infants and children. Yet, it is tempting to try them, and as they are often not effective, it becomes easy to try giving more. In this case, more is not better!
The best example of this common mistake relates to antibiotics. Antibiotics typically begin to help within 72 hours, and by 5 days or so, your child often seems significantly improved. But generally antibiotics are prescribed for a course of 10 or more days. It becomes tempting to stop the antibiotic and save it for your child’s next fever or illness, even though this antibiotic was likely prescribed for longer.
Table 2.1 Information points to discuss with your child’s doctor and pharmacist about your child’s medicine
NAME OF THE MEDICINE*
Most drugs have two names—a trade name and a generic name (for example—Tylenol [trade] is acetaminophen [generic]).
Ask if the prescribed medicine is available in a generic form.
DOSE
• For liquid medicines
• What are the volume (mL) dose and the mg dose? (for example, amoxicillin liquid 5 mL usually is equivalent to 400 mg).
• For tablets and capsules
• How many mg are in one tablet or capsule?
• How many tablets or capsules should I give each day?
DOSING SCHEDULE
• How many times a day should I give the medicine?
• If dosing once a day, can I give the medicine at any time during the day?
• Can the medicine be given with meals?
• Is the medicine to be given as needed only, or scheduled every day?
DURATION
• How long should I give the medicine?
• Some pediatric medicines are given for short durations (for example, antibiotics).
• Other medicines (for example, those for a chronic condition like asthma) are taken for longer durations.
BENEFITS TO YOUR CHILD
• How will the medicine help my child?
• What should I look for to be sure it is helping?
• How long will it take until the medicine begins to help?
• If I miss a dose, what should I do?
ADVERSE EFFECTS
• What are the most common adverse effects of the medicine?
• What should I do if adverse effects occur?
• What can I do to decrease adverse effects?
• Are there any rare but serious adverse effects?
STORAGE
• For liquid medicine
• Should it be stored at room temperature, in the refrigerator, or does it not matter?
• Can the medicine be divided into different, but labeled, containers for use at school and home?
• It is best not to store medicine in nonpharmacy-labeled bottles. If it is misplaced or lost, whoever finds it may not know what medicine it is.
* Keep a list of your child’s medicines (name, dose, and schedule) in your cell phone “Notes” or on a piece of paper you carry.
When you are in the pediatrician’s office, or at the pharmacy picking up your child’s medicine, it is helpful to have in mind what information you should seek about your child’s new medicine. This information, listed in table 2.1, is important for all medications. Your child’s pediatrician and pharmacist will almost certainly talk with you about the specific medication dose and how often the dose should be given. Some of the other points—such as proper storage—may or may not be raised.
When I have senior pharmacy students with me in the pediatric clinic I attend, I give them an index card containing the discussion points listed in table 2.1 so they can use it as a guide when counseling patients on newly prescribed medicines. I have seen many instances of parents either not being given all of this information, or of not quite understanding how to use the information they received. Even with the best of intentions, parents sometimes forget what they have been told (it’s easy to do when you are concerned about a sick child). As a consequence of not having information, not understanding information, or forgetting information, a parent may not administer a medication correctly and it will not help as much as it would have if it had been given properly.
Consider these points when discussing your child’s medicine with your pediatrician or pharmacist.
For many medications, the time of day it is given, or the spacing of doses (how many hours pass between doses), is not critical. What’s important with these medications is that all of the daily doses are indeed given, and that the dosing schedule is the best fit for you and your child’s daily routine. For medications prescribed once daily, it may not matter if the medication is given in the morning, at noon, or at bedtime. For some medications, however, it does matter, so ask about this. Some medications may cause drowsiness or, alternatively, may be somewhat stimulating; these properties of the medication may affect what time of day you give the medicine (give at bedtime, or in the morning, respectively).
Morning is often a hectic time for many school-aged children or adolescents, so giving medicine in the afternoon or evening may work better with their schedules. When medications are prescribed to be given three times a day to school-aged children, ask if the medicine can be administered before school, after school, and in the evening, instead of at school, which may be difficult to arrange.
For medications prescribed “every 8 hours” or “every 12 hours,” and so on, the timing is usually not critically important. For example, if the second daily dose is given 9 to 10 hours, instead of 12 hours, after the first dose, this likely will not affect the medication’s benefit or have any adverse effects for your child. However, ask the doctor or pharmacist about how important the schedule is, to be sure. For some medications, such as those for treating seizure disorders, dose schedule timing may be more important. I’ve seen many families where medicine doses were missed because they could not strictly adhere to this type of schedule, and the families were concerned about giving doses too close or too far apart. It’s also important to be consistent—strive to give the medicine at approximately the same time each day, once you settle on a good schedule for you and your child.
Some medicines work quickly, within 1 hour, to help your child feel better. Good examples are medications for fever and pain, such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil). Other medicines may not begin to significantly help your child for 1 to 2 weeks, or longer. Examples include many antidepressant medications, such as fluoxetine (Prozac).
It is important to understand how you or your child will know if the medicine is helping. Don’t hesitate to ask your pediatrician or pharmacist, “How will I know if the medicine is helping my child? What should I look for?” I have spoken with adolescents who had been prescribed antidepressants but had stopped taking them because they did not know if they were making a difference. After we talked about how they might not recognize that the medication was helping them, they realized the medicine was beneficial.
Everyone, including me, forgets a dose of his or her medicine at times. What should you do once you realize that you missed a dose of your child’s medicine? This depends upon the specific medicine and how long it has been since the scheduled time of the dose. For many medications, even if several hours or more have passed since the scheduled time, it is better to give the missed dose instead of skipping it. This is not true for all medications, however, so ask what to do if a dose is missed. Many patients have told me over the years that they skipped doses completely because they missed their normal scheduled time. If this happens 2 or 3 days each week, which can be easy to do, the result may be that the medicine provides much less benefit.
One aspect of giving medicine to children that concerns many parents is a medicine’s adverse effects. This is certainly understandable. When you leave the pediatrician’s office or the pharmacy, you should have no lingering or unanswered concerns about your child’s medicine. All medications have potential to cause adverse effects. Adverse effects that nearly all oral medications may cause include nausea, vomiting, diarrhea, headache, or drowsiness/dizziness. Some of these effects may be minimized by, for example, giving some medications with meals (note, though, that some medications must not be taken with food).
A word of caution about the printed information you may receive at the pharmacy along with your child’s new medicine, or what you read online about a medicine. The adverse effects listed in the medication’s labeling (see chapter 1 for more on medication labeling) may not necessarily occur with your child. These listed adverse effects, which typically are many, occurred when the medication was studied and tested, and may or may not have directly resulted from the medication. As described in table 2.1, ask what adverse effects commonly occur with your child’s medicine and what you can to do minimize or prevent them. Ask what more serious adverse effects may occur and which adverse effects make it necessary to stop the medicine or return to your pediatrician’s office.
Some parents state that they are concerned about a medication’s “toxicities.” This is not the same as a medication’s adverse effects, or side effects. Adverse effects of a medication are unwanted and unintended effects of the medication. For example, antibiotics commonly produce nausea or loose stools—unwanted effects. Adverse effects can occur with just one dose of a medication—they can be mild or severe, common or uncommon, and predictable or unpredictable. Toxicity refers to the effects that occur from a medication dose that is greater than the normal therapeutic dosing range (the amount of medication normally given to treat a medical condition). Acetaminophen (Tylenol) is a very safe medication when given in normal doses to infants and children, and it has few adverse effects. However, if too much acetaminophen is given—if a toxic dose is given—acetaminophen can cause liver failure and be fatal.
It is also important to evaluate “benefit-to-risk” considerations for your child’s medicines. As with nearly everything in life, there are benefits and risks in what we do. The benefits, which should be greater than the risks, include things like reducing a fever, curing an infection, improving breathing difficulties from asthma, or preventing a seizure. The risks entail medication adverse effects, which often are not serious or are manageable. However, some can be serious. When the benefits to children of some medications or supplements are not proven, then the risks are greater than the benefits. Examples include OTC antidiarrheal medicines and many supplements (see chapter 3 for more information). This is a very important concept to understand and appreciate. Studies of pediatric medication adverse effects are described later in this chapter.
An important distinction to know about your child’s medicine is whether it should be given on a regular daily schedule or only as needed. Medicines for fever, such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil), are typically given as needed, when your child is uncomfortable or has a high body temperature. Other medicines should not be given only as needed, and are most effective when given daily, even if the child feels well and has no apparent symptoms from the illness. Examples of medications scheduled for every day administration are many asthma medicines, such as Flovent (fluticasone) or Singulair (montelukast), and many medicines for seizure disorders, such as Tegretol (carbamazepine) or Dilantin (phenytoin). It is easy to confuse some asthma medicines, such as some metered dose inhalers (Proair [albuterol] or Proventil [albuterol]), which are mostly given as needed when the child has difficulty breathing. Other metered dose inhalers, such as Flovent (fluticasone), should be used every day, whether or not the child has breathing difficulty, and are not effective when used only as needed.
All parents know the difficulties of giving medicine to infants and children. Beyond these relatively “simple” difficulties are potential problems that many parents may not be aware of, such as accurately measuring liquid doses. Most medicines given to infants and young children are liquids. Accurately measuring a dose of these liquid medicines is important and, as studies have shown, it can be quite difficult. Beyond accurately measuring a dose of liquid medicine comes the “art” of getting your infant or young child to take the medicine. Color, texture, smell, and, perhaps most important, taste of the liquid medicine all come into play. What can be done to entice your child to take his or her medicine?
I recall my mother giving me liquid medicine on a teaspoon when I was a young child. We have known for many years that this is not an accurate way to measure and give medicine. The pediatric medical community and professional medical organizations have recently published specific recommendations stating not to use kitchen teaspoons or tablespoons to give liquid medicine. Back in 1975 the Committee on Drugs of the American Academy of Pediatrics (AAP) stated in a report titled “Inaccuracies of Administering Liquid Medication” that “teaspoons are particularly poor measuring and administering devices.” This report also discussed how much the size of kitchen teaspoons varies, delivering between 50 percent and 156 percent of the amount medically considered to be a teaspoonful, which is 5 mL (milliliters). Other studies have found that teaspoons vary in their delivery of liquids by 60 percent to 180 percent.
In 2015, 40 years later, the AAP Committee on Drugs published a similar report again advising that kitchen or household teaspoons and tablespoons not be used to measure and deliver liquid medicines. This report also recommended that pediatricians and other prescribers stop writing prescriptions using teaspoon or tablespoon amounts. Unfortunately, some prescribers continue to write prescriptions this way. Several studies have documented that, when given the opportunity to choose a dosing device to measure liquid medicine, many parents choose a household teaspoon instead of other, more accurate, dosing devices. The 2015 AAP report included several important recommendations:
• Oral liquid medicine volumes should be expressed with metric system units, such as mL (milliliters), not with teaspoonsful or tablespoonsful.
• Pharmacy bottle labels should state volumes as mL and not teaspoon or tablespoon, for example, “Give 5 mL twice a day,” not “Give 1 teaspoonful twice a day.”
• Accurate dosing devices should be given to parents with all liquid medicines.
What are accurate measuring devices? Dosing devices evaluated in published studies include oral syringes, cylindrical spoons, droppers, and dosing cups. Several studies have demonstrated oral syringes to be the most accurate. Dosing cups, which are typically made of plastic and available with OTC liquid medication product packages, are often kept in homes and re-used by parents for giving different liquid medicines to their children. When comparing the accuracy of measuring 5 mL liquid volumes with dosing cups and oral syringes by parents, a study in 2008 and another in 2016 found dosing errors to be four times and five times more likely when dosing cups were used, as compared to when oral syringes were used. One of these studies also demonstrated that even though oral syringes were more accurate, only 67 percent of parents using them correctly measured an accurate dose, indicating that even oral syringes can be frequently used improperly or inaccurately.
Explanations of dosing technique given by parents enrolled in these studies is revealing. Some parents confused “teaspoonful” with “tablespoonful” (a tablespoonful is 15 mL, three times greater than a teaspoonful, 5 mL), and others believed a full dosing cup was the standard dose. In summary, practical recommendations from these studies include the following suggestions:
• Request an oral dosing syringe at the pharmacy for your child’s liquid medicine, and ask to be shown where on the syringe to measure your child’s dose (one published study demonstrated this as the most accurate method).
• Consider a smaller size oral syringe if you are administering liquid medicine to an infant. Smaller syringes are more accurate when measuring smaller liquid doses. Oral syringes can be especially useful when administering liquid medicine to your infant, as you can place the syringe just inside your infant’s mouth and he or she will naturally begin sucking the medicine out.
• Consider other dosing devices sold in pharmacies—droppers and dosing spoons, although they may not be as accurate or as easy to use as an oral syringe.
• Avoid using dosing cups, since they are not as accurate as measuring devices and it’s best not to use them to measure most liquid medicines; exceptions can include larger volumes of liquid for older children or adolescents.
• Use mL (milliliters) for measuring liquid medicines, not teaspoonsful or tablespoonsful, and ask your pediatrician and pharmacist to clarify your child’s medicine dose as mL.
• Take extra care when measuring and administering liquid medications. Studies of parents have shown it can be easy to make errors when giving liquid medicine to children.
The taste of liquid medicine is an important factor when administering medications to children. An effective medicine will not help your child if he or she refuses to take it, which can be frustrating. Pharmaceutical manufacturers strive to make their liquid medicine products appealing to children, focusing not just on taste but also considering the appearance or color, smell, texture, and viscosity. Fortunately, most liquid medicines given to children taste relatively good. Some medicines, however, are chemically bitter and this is hard to mask in a liquid medicine product. Several taste tests of liquid medicine products have been published, mostly focusing on antibiotics. Antibiotics that adults rated as tasting good in these taste tests include:
• amoxicillin
• amoxicillin-clavulanate acid (Augmentin)
• cefdinir (Omnicef)
• cefprozil (Cefzil)
• azithromycin (Zithromax)
Medications scoring less well on taste (that is, testers did not like their taste) include:
• cefpodoxime (Vantin)
• clarithromycin (Biaxin)
• penicillin
• clindamycin
• some prednisolone products (the product Orapred may taste better)
What can you do if your child’s pediatrician prescribes one of the medications above that does not taste good? Several methods may help your child successfully take the medicine. The following tips may be helpful:
• Ask your pharmacist to flavor the medicine.
Many pharmacies have standardized flavoring systems, such as FlavorRx, that utilize many different flavors to add to a liquid medication. They may charge an additional fee for this (usually about $3 extra). FlavorRx offers a variety of flavorings for liquid medication products that may be appealing to your child, such as chocolate, mango, orange, and watermelon. Your child can choose from bubblegum, grape, raspberry, or grape-bubblegum flavor enhancers to improve the taste of Vantin (cefpodoxime), an antibiotic commonly prescribed for children with ear infections. Ask if your pharmacy is able to do this.
• Offer your child a teaspoonful of sweet syrup before or after administering the medicine.
Try giving your child a teaspoonful of chocolate (or butterscotch, strawberry, or maple) syrup just before and after giving the liquid medicine. This may help “bribe” your child, as it tastes good, and the syrup can coat the tongue and help to mask the liquid medicine taste. You can also try honey, as it has a sweet flavor. A word of caution, though—do not give honey to infants younger than 1 year of age, as it may contain certain bacterial spores that can be dangerous to young infants. Some strong-tasting juices, such as grape juice (purple or white), can be similarly used, to give before and after the liquid medicine, to help mask its taste.
• Mix the liquid with applesauce, pudding, or jellies/jams.
If you try mixing a liquid with applesauce, pudding, or jellies, be sure to mix them well together. In addition, be careful not to use too much, as your child may not want to finish all of it, and consequently won’t get the full dose of medicine. Use enough, however, to mask the medicine taste.
• Give a popsicle or refrigerate the medicine.
Many liquids, such as orange juice, taste best when cold, and chilling your child’s medicine can also help it taste better. Ask your pharmacist if your child’s liquid medicine can be refrigerated. It is important to ask, because some liquid antibiotics, such as clarithromycin (Biaxin), should not be refrigerated (it can thicken up a lot when stored in a refrigerator). Giving a popsicle before the medicine can also be helpful, as a cold tongue may not detect the liquid medicine taste as much.
• Give a good tasting liquid or nutritional formula just after the medicine.
Give another liquid that your child likes, such as milk or juice, or your infant’s nutritional formula, just after the liquid medicine, as this can help flush the medicine taste out of the mouth.
• Give your child’s liquid medicine when he or she is likely to be hungry.
Your child is more likely to eat and drink when he or she is hungry. Check with your pharmacist to be sure that the medicine can be given with food or the drinks discussed above, as some medicines are best absorbed on an empty stomach (1 hour before or 2 hours after a meal).
• Try mixing your child’s medicine in with nutritional formula or expressed breast milk (in the same bottle) or in with a liquid that your child likes, such as chocolate milk.
Check with your pharmacist first to be sure that there are no problems with mixing the medicine this way (you want to avoid affecting the medication’s chemical stability). Don’t use too much formula or liquid since your child may not finish the full amount and consequently will not get all of the liquid medicine. For example, if your infant normally has 6 to 8 ounces of formula per feeding, try mixing about 3 ounces of formula with the medicine (when he or she is likely to be hungry), and then give the remaining amount of formula.
• Invest in a novel delivery device.
If you’re still having trouble getting your child to take the medicine, you can try some interesting and helpful devices available online (and perhaps in your pharmacy) that function by giving liquid medicines together with nutritional formula or other liquids, such as pumped breast milk. Some of these devices combine an oral dosing syringe within a bottle and nipple, so the formula or milk is taken together with the liquid medicine. Examples include Medibottle, Reliadose, and Munchkin. Another device, Pacidose, combines a pacifier directly with an oral dosing syringe, to encourage an infant or young child to take the liquid medicine. These devices seem reasonable to try.
This discussion of liquid medicine taste has centered on prescription liquid medicines. Your child may also not like the taste of some liquid OTC products, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Similar to some prescription medications, OTC medication products are available as trade products, such as Tylenol, and as generic products. Many retail pharmacy chains or pharmacies located in grocery store chains carry their own generic brand. Either the trade or generic product can be used, although generic products are likely to be less expensive. Their taste, however, may differ from the trade products, similar to trade and generic prescription medication products. I recall when my son was young and had a fever. We were out of Tylenol, so I went to the pharmacy to buy more (of course it was late at night). I noticed that a generic form of infant’s acetaminophen was much less expensive than the trade product, Tylenol, and I bought several boxes of the generic product. Well, my son must not have liked the taste because he wouldn’t take the generic product. Back to the pharmacy I went to buy the trade product Tylenol. He liked this better and took it easily. I tried the tastes of both, and I agreed that the trade product, Tylenol, tasted better than the generic product.
When giving an OTC liquid product to your child, use the dosing device that comes with the package, as this device should match the product package dosing instructions and you will be less likely to make an error when measuring an appropriate dose for your child’s weight.
Technique makes a difference when giving any liquid medicine. Use an oral dosing syringe and slowly administer the liquid toward the side of your child’s mouth, not directly on the tongue (where the taste buds are). In this way the medicine flows toward your child’s throat, is more easily swallowed, and bypasses the taste buds. Do not quickly squirt the liquid medicine into the back of your child’s mouth, as he or she may choke. Young children may want to help by holding the oral syringe or by sucking the medicine out of the syringe. If for some reason your child does not seem to be swallowing the medicine, you can try gently holding his or her cheeks together and then lightly stroking under the chin. When administering liquid medicine to infants, have another adult hold the infant, including his or her arms. Older infants or young children can be placed in an infant car seat or high chair used for eating. When you are done, rinse the oral syringe with water. Don’t let your child play with the dosing syringe, as he or she could potentially choke on it. Store it in a safe place.
A common question parents ask is, “When should my child be able to swallow a tablet or capsule?” There is no specific age when a child should be able to swallow a tablet or capsule. I’ve seen some 2-year-olds who can swallow tablets, and some adolescents who can’t. Several pediatric medicine textbooks state that by age 6 or 7 years, most children are able to swallow tablets, but this varies widely and is not a golden rule.
If your child is unable to swallow a tablet whole, don’t fret. There are several options you may try. Perhaps the easiest is to cut the tablet into two halves or even four quarters and let your child try swallowing these smaller pieces. Many medicine tablets are “scored”—they have a line in the middle of the tablet that can be used to more easily break the tablet into two pieces. You may be able to do this with your fingers, or you could use a tablet splitter (available at most pharmacies for a few dollars). Some tablet medications should not be broken or split (for example, coated tablets or slow-release tablets), so check with your pharmacist before doing this. You may ask your pharmacy to split all of your child’s tablets when you first pick up the prescription, or call in a refill. Some pharmacies will gladly do this, while others will not, but it is reasonable to ask.
Some medications, such as amoxicillin and amoxicillin-clavulanate (Augmentin), are also available as chewable tablets or tablets that dissolve quickly in the mouth, and they typically taste good. Another option is to crush the tablet into many small pieces or a powder and give this. While this is commonly recommended, it can be hard to do and may not be accurate, since it can be difficult to gather up the entire crushed tablet pieces. If you try this, it is best to crush the tablet in a small bowl (or use a tablet crushing device sold in pharmacies) and then mix the small pieces together well with jelly or jam and give this to your child. When you mix medicines with food as described here and above with liquid medicines, always give the mixture to your child immediately after you prepare it, and do not save it for later or prepare doses ahead of time. Because of potential chemical instability, mixing medicines like this several hours in advance may affect the potency of the medication. In addition, check with your pharmacist to be sure that your child’s medicine can be given with food and is not supposed to be taken on an empty stomach.
Some medicine products are also available as capsules that can be easily opened up and sprinkled onto food and given this way. Your child’s pediatrician is likely familiar with these pediatric sprinkle capsule dosage forms, but you can ask if your child’s medicine is available as a sprinkle capsule. The type of food that many of these sprinkle capsule dosage forms are given with is important, so be sure to ask about this at the pharmacy. Most capsules are not specifically designed to be sprinkled onto food, although the contents of some capsules can be mixed with food. The powder contents are likely to taste bitter or bad, however, so mix it with a food that has a strong good taste, such as jelly or jam. Check with your pharmacist before doing this, to make sure there are no chemical stability problems.
If you want to help your older child swallow his or her tablets or capsules, several devices may be useful. A review of this subject published in 2014 found that certain head posture techniques, behavioral therapies, flavored throat sprays, and swallow tablet cups were effective. The head posture techniques and behavioral techniques are too complex to fully explain here, and are likely best demonstrated by and practiced with supervision by health care professionals at children’s hospitals located in large cities. A device that can help children (and adults) swallow tablets and capsules is Oralflo. This device looks like a children’s sippy cup and has a pocket inside to place the tablet or capsule. When the cup is filled with liquid, the medicine more easily slides out with the liquid, to be swallowed. Another aid that can be tried is Pill Glide, a lubricant sprayed into the mouth that reduces friction between the medicine and throat and mouth, helping the tablet or capsule slide and be swallowed more easily.
Once your child has swallowed his or her medicine, thanks in large part to your efforts in preparing the medicine and coaxing him or her, it’s always possible that soon after, he or she will vomit. What do you do then? Should you give another dose, or out of fear of giving too much medicine, let it be? This depends on several factors, including the specific medicine given and the time between giving the medicine and your child vomiting. Parents are often told if it has been less than 1 hour since giving a medication, another dose can be administered. This may not apply to all medicines, however. Liquid medicines are absorbed into the bloodstream faster than tablets or capsules. Most liquid medicines are absorbed in less than 1 hour, and if your child vomits 45 minutes after swallowing a liquid medicine, another dose is likely not necessary.
If the medication was a tablet, it can be helpful to look at your child’s vomit for visible pieces of the tablet. If you see some, much of the tablet probably was not absorbed. It is also important to consider the specific medication your child was given, and its potential for adverse effects. Some medications can cause significantly more adverse effects with only one or two doses above the current dose, while other medications, such as many antibiotics, are unlikely to cause more adverse effects with one or two extra doses. Check with your pediatrician before giving more medicine after your child has vomited.
Some medications are best given on an empty stomach, as food in the stomach delays or reduces how much of the medication is absorbed into the blood. An example is penicillin, the antibiotic of choice for strep throat infections. Penicillin is best absorbed with an empty stomach, although it can be given with food, if nausea occurs. Another antibiotic best given without food is tetracycline. Because dairy products bind with tetracycline in the stomach and reduce how much is absorbed, they should be especially avoided. Infants and children seem to be hungry nearly all of the time, and they can have food in their stomachs most hours of the day. If a medicine should be given on an empty stomach, which is typically described as 1 hour before a meal or 2 hours after a meal, the timing of giving the medicine with your child’s eating can be quite difficult.
Other medications are best given with food, as food increases the amount of medication absorbed, or more commonly, food reduces the likelihood of nausea or vomiting occurring. Amoxicillin-clavulanate (Augmentin), an antibiotic commonly used in pediatrics, is best given with food to decrease the potential for adverse effects of nausea, vomiting, or diarrhea. The antifungal medication griseofulvin is best given with food, since food increases the amount absorbed.
Whether to give some medicines with or without food can also depend on the dosage form of the medicine, and not the medicine per se. Fortunately, whether to give a medication with or without food is not significantly important for many medicines. Your pharmacy will counsel you on how your child’s medicine is best given, with or without food, or either. If you are not sure, ask your pharmacist.
Your child may need someone at school or daycare to administer his or her medicine. Schools and daycare establishments have widely varying policies about giving medicine to children, and it is best to contact your child’s school or daycare before you send medicine along with him or her. Your child’s school or daycare medicine should be sent in a regular pharmacy-labeled container, similar to what the pharmacy normally dispenses. Ask the pharmacy to place your child’s medicine into similar home and school or daycare bottles and vials with labels. The pharmacy will place various stickers on the vials as necessary, such as “Take with Food,” or “Store in the Refrigerator,” which will help ensure that the medicine is given properly.
Do not send your child to school with medicine in a baggie or other nonpharmacy containers, even if the medicine is an OTC medication such as ibuprofen (Motrin, Advil). Nursing offices at schools have bottles of these common OTC medications when a child is in need, such as for headache or other mild pain. The school nurse will likely call you for approval before giving any medicine, or you may be asked in advance to sign an authorization form.
All schools should allow your child to carry his or her asthma inhaler (such as albuterol), to be used as needed when your child has breathing difficulties. Your child may need access to this inhaler quickly when breathing difficulties begin. The school will probably require a signed consent note from you and your pediatrician allowing this use, and the school nurse may ask your child to demonstrate that he or she can properly use the inhaler. Inhalers are best sent properly labeled with a pharmacy label attached directly on the inhaler, and not just on the inhaler product box. Schools may also allow other medicines to be carried by a child, if this medicine is necessary for quick use by the child for a specific medical condition. Speak with your child’s pediatrician and school to determine this.
States have varying policies for allowing medicine to be given at daycare establishments. If your infant or young child attends daycare, speak with the daycare personnel before sending medicine. Just as in a school setting, you will need to sign a consent allowing the medicine to be given, and the medicine should be correctly labeled. The daycare workers should be properly trained to administer medicines. Ask about this. Your local or state health department can be a valuable information source about your state’s laws regulating daycare establishments.
There are numerous reasons why children do not receive all of the medicine that is prescribed for them, including forgetting, concerns about adverse effects, cost of the medicine, belief that the medicine is no longer necessary once the child has begun to feel better, misunderstanding the directions, or a stigma associated with taking some medicines (such as antidepressants), among others. Forgetting doses is perhaps the most common reason, and it easily occurs, especially in a busy home or lifestyle. Nonadherence is the term used to describe not taking medicines as prescribed or recommended. Recognizing the potential for nonadherence with your child’s medicines is very important, and some relatively simple solutions can help you avoid many of the causes of reduced adherence.
The majority of children—63 percent—diagnosed with a chronic illness are prescribed at least one medicine. Unfortunately, studies have demonstrated that 50 to 88 percent of children who have a chronic illness, such as asthma or diabetes, do not take all of their prescribed medicine. Even though common sense suggests this, many studies have documented that medication adherence for asthma and diabetes, and other serious conditions, is beneficial, since children taking their medicine are less likely to be admitted to a hospital and are healthier. Numerous studies have been published in the medical literature about adherence to medication and other illness treatment recommendations given by physicians and health care professionals. Overall, these studies suggest that beneficial strategies can be used by parents to improve medication adherence and their child’s health. Strategies that parents can employ are described as behavioral and educational.
Behavioral strategies include instituting reminders to prevent missed doses because of forgetfulness, such as setting phone alarms, using pill boxes, or posting notes in your home. I frequently suggest to parents and adolescent patients that they link taking their medicine with a personal habit that is already established, such as teeth brushing. Place the medication vial next to your child’s toothbrush, as a visual reminder. Rewarding your young child when medicine is taken can also be helpful. Children and adolescents with a chronic disease such as asthma or diabetes can significantly benefit from involvement in local or national organizations representing the illness, as these organizations often have peer and parent support groups with local meetings where participants can hear from other parents about their success stories or frustrations with giving medicine to their children.
Educational strategies can also be helpful. These include being sure that you completely understand how your child’s medicine is appropriately given, including the information listed in table 2.1. This may seem rather simplistic, but it is important. I have spoken with many parents or adolescents who misunderstood how their medicine was supposed to be taken, and they mistakenly took the medicine only once daily instead of twice daily, as prescribed. It is easy to get confused, especially when you are given a lot of information in the pediatrician’s office and in the pharmacy when the medicine is initially prescribed. A common problem I hear from parents relates to missing doses. Nearly everyone likely misses occasional doses of his or her medicine, but if it happens frequently, the doses missed can significantly add up and decrease the medicine’s benefit. Be sure to ask your pharmacist and pediatrician what you should do if you miss a dose of your child’s medicine. For many medications, the missed dose can safely be given later.
Studies have shown the simpler the medication directions or regimen, the better—that is, the more likely that the medicine will be given. For example, adherence to a medicine that is dosed three times daily is likely to be less than to a medicine that is dosed twice daily. Discuss dosing schedules with your pediatrician, and ask your pharmacist how you can adapt your child’s medicine regimen to your daily home lifestyle. These discussions can be very helpful to you. Nonadherence with medication reaches a peak in the adolescent years—a time that can be very frustrating to parents. Being aware of this potential, and discussing it with your adolescent’s pediatrician, can be helpful.
It is important to be honest with your pediatrician and pharmacist when they ask about medication adherence. No one likes to be thought of as a “bad parent,” but if your child is not receiving all of his or her medicine, your doctor needs to know. Health care professionals understand the difficulties of giving medicines to children or adolescents. Sharing your difficulties and concerns about your child’s medicine will likely be very helpful, as your pharmacist and pediatrician will be able to suggest methods for improvement. I have heard from parents and adolescents about their concerns with a medicine’s adverse effects, and at times they have been reluctant to admit that their source was what they read on the Internet or what a neighbor may have told them about their child’s medicine (which often is misleading or false). Occasionally, cost and paying for medicines may be a concern, especially as medicine costs are rising and health insurance drug coverage is decreasing. If cost is a concern, pediatricians and pharmacists may well be able to help, by prescribing less expensive medicines or by utilizing pharmaceutical company rebates and discounts.
As discussed previously in this chapter, giving any medicine to your child involves certain benefits and risks. Benefits of giving medicine include helping your child feel better (reducing pain or fever), treating a chronic illness (such as asthma), or curing an infection (such as an ear infection). These benefits can be large and potentially life-saving. Risks and disadvantages of giving medicine involve medication adverse effects, allergic reactions, a potential for toxicity or poisoning, difficulties of giving the medicine, and cost, among others. The benefits should be greater than the risks; otherwise, the medicine is best not given.
In this section, I explore this principle more closely, and discuss the many studies that have evaluated medication adverse effects and other risks in large populations of children. One of the main points that this discussion will lead to is this: all medicines have a potential for risk. It is common in our society to treat nearly any symptom or any illness we have, even minor illnesses, with medicine. Children are not small adults, and the risks of using medicine in children can be greater than the benefits for some illnesses (these will be explained in more detail throughout this book). Thus, if a medication is unlikely to help your child, and as it may cause adverse effects or other risks, it is best not used. This is an important principle.
Several recently published studies have evaluated and documented medication risks in pediatrics. A study published in 2014 analyzed medication errors that occurred in settings outside of a hospital (at home or other areas) in children over an 11-year period. During this time, 696,937 children younger than 6 years of age experienced a medication error—this averaged to a medication error occurring every 8 minutes! The errors included accidentally giving a medicine twice and giving incorrect doses or measuring doses inaccurately, among others. In this study, the younger the child, the greater the likelihood of a medication error occurring—25 percent of all the errors occurred in infants younger than 1 year of age, and 25 children died as a result of these errors.
In a study published in 2008 the researchers evaluated visits to hospital emergency departments because of adverse effects from antibiotic use in children and adults over a 3-year period. The majority, 79 percent, of the 6,614 cases identified were due to allergic reactions from the antibiotic. Children 14 years of age and younger accounted for 25 percent of all of the cases. The highest rate of antibiotic allergic reactions occurred in infants younger than 12 months of age. When these occurrence rates are extrapolated to all hospitals in the United States, 37,000 visits by children 14 years of age and younger to hospital emergency departments occur each year because of adverse effects from antibiotic use.
In an article published in 2013, the authors reviewed 11 published studies about medication-related emergency department visits and hospital admissions (described as adverse medication events in this study) in the pediatric population. The researchers found that adverse reactions, overdoses, and allergic reactions were the most common occurrences, with antibiotics the most common class of medication responsible. Perhaps most important, the researchers determined that 20 to 67 percent of the adverse medication events were preventable. Many additional published studies have shown that the most common medication error that occurs in infants and children involves errors with medication dosing.
What do these studies tell us? They reveal that medicine use in children, and especially in infants and younger children, can result in many unwanted and potentially serious—including death—adverse effects. It is best not to give medicine to your infant or child unless it will benefit them. Discuss benefits and risks with your pediatrician and pharmacist before a new medicine is begun and given to your child. Ask what the benefits and risks of the medicine are, and if the benefits will be greater than the risks. Ask what safer nonmedication treatments you may be able to use to help your child feel better.
Because young children are curious, active, and mobile (and have a tendency to put nearly anything in their mouths) they are at higher risk from accidental poisonings. More than 500,000 children 5 years of age and younger experience a poisoning exposure each year. This risk peaks at about age 2 years of age. There are many relatively simple changes you can make in your home, where most poisonings occur, to reduce the risk of your child experiencing an accidental poisoning. Several good Internet sites, including www.poisonprevention.org and www.healthychildren.org, list specific details of how to poison proof a home.
Medicines are a leading cause of accidental poisonings. Most homes contain several medicines that can be fatal to a young child if enough medicine is swallowed, including acetaminophen (Tylenol), aspirin, and iron (including vitamins containing iron). Many prescription medications commonly used by adults can be especially dangerous, including some antidepressants (such as amitriptyline), medications for heart problems and pain, and medications for high blood sugar. Just 1 or 2 tablets of some of these medications can be fatal to a 2-year-old child.
While young adult parents may not use these medications, they may be taken by grandparents and other older adults who frequently spend time with the children. A scenario that can easily occur involves young children visiting their grandparents, and while the adults congregate in the kitchen or family room, the young children somehow manage to find grandma’s or grandpa’s medicine bottles (more than 50 percent of grandparents have easy-open tops on their medicine bottles) and swallow several tablets. Other medicines that many may not consider dangerous include methyl salicylate and camphor. Methyl salicylate can be applied to skin (one example is Bengay) to reduce pain or it can be used as a food-flavoring agent, as oil of wintergreen. Camphor is an active ingredient in Vicks Vapo Rub (for treatment of cough in children) and if swallowed, just 20 mL (about 1 tablespoonful) can be fatal to a 2-year-old child. Less than 5 mL (less than 1 teaspoonful) of concentrated oil of wintergreen can be fatal to a 2-year-old child.
Pediatricians commonly include a discussion on home poison proofing with parents when infants are about 6 months of age, as they then begin to become more mobile by crawling. The information shared with you by your pediatrician and information from the Internet sites listed above can be very helpful, and it may potentially save your child’s life. It’s also important to know the national poison control center phone number—800-222-1222—and keep it in a handy place. By calling this phone number, you will be directed to your local poison control center, regardless of where you live in the United States. If your child is exposed to a potential poison, call this phone number before calling your pediatrician, as poison control centers employ health care professionals specifically trained in the treatment of poisonings. If your child is not breathing or is unconscious, call 911.
The short answer to this question is, yes. Generic medicines are equally safe and effective as the equivalent brand name medicine and are usually significantly less expensive than the brand name medicine. Generic medicines must be demonstrated to be bioequivalent to the same brand name medication (the amount of medication absorbed and distributed to the medication’s site of action) and to be as safe as the brand name medication. The FDA regulates generic medicines similarly to brand name medicines. The FDA ensures that generic medications have the same active ingredients, strength, purity, and quality as the brand name product.
About 80 percent of all prescriptions in the United States are generic medicines, and most generic medicines cost 80 to 85 percent less than the brand name medicine. When a brand name medication loses its patent or exclusivity (exclusive rights to market a medication product by a pharmaceutical manufacturer), the cost of the first available generic medication is usually not significantly lower. The medication’s price decreases only about 6 months later, when other generic companies begin producing additional generic versions of the medication. Most generic versions of a medication will appear different in color, size, or shape than the brand name product. However, when the same pharmaceutical manufacturer produces a generic version of its own brand product, to sell at a lower price, the generic medication may look very similar to the brand product.
All states allow generic medications to be dispensed, although these laws may differ among states. The FDA publishes a standardized book (the “Orange Book”) that pharmacies use to determine which generic medications are bioequivalent to brand name medications. I often hear parents express concerns that a generic medication is not the same, or will not work the same, as the brand name medication. While I certainly understand their concerns, I tell them that the generic medication should treat their child’s condition just as effectively and safely as the brand name product, as both are well regulated by the FDA for purity and content.
Some medications have a narrow therapeutic index, which implies that the difference between the medication’s efficacy and toxicity are narrower than most medications. When a medication with a narrow therapeutic index is used, either a blood level of the medication or another parameter in the blood is carefully measured and monitored to ensure that the medication concentration in the blood does not increase to a toxic amount. If a child is receiving a medication with a narrow therapeutic index and is doing well, it may not be wise to change from the manufacturer of this medication to a different generic or brand name manufacturer. Your pediatrician and pharmacist will discuss this with you. Examples of these medicines include some that treat seizure disorders, such as Dilantin (phenytoin) or Tegretol (carbamazepine).
If a medication prescribed for your child is expensive, ask your pediatrician and pharmacist if a generic version is available. If not, ask your pediatrician if a medication is available generically that will be just as effective and safe as the prescribed medication. The answer is often yes. For example, an older medicine in the same medication class may be just as effective as the new, more expensive medication.
The rising cost of medicine became a top news story in 2015, and it continues to be a headline on televised national news programs and in newspapers. How pharmaceutical manufacturers determine medication prices is quite complex. As with other commodities that we consume, a lack of competition for specific medications drives prices up, since a pharmaceutical manufacturer can charge exorbitant prices when it is the only supplier of a product. This has occurred with several medicines recently, resulting in price increases of up to 6,000 percent when competition for a medicine dwindles.
Many factors determine what you pay at the pharmacy, including competition (multiple pharmaceutical manufacturers producing the same medication), health insurance coverage (copay and deductible amounts), and availability of a generic form, among others. When a medication is available in more than one generic form, it is likely to be significantly less expensive. When a new medication is manufactured and is not available generically, it is likely to be expensive. All medications can be placed into categories or medication classes, according to what they are used to treat (this is called their “indication”) and their pharmacology (their mechanism of action or how they function). When new medications are introduced, quite often older medications within the same class that function similarly continue to be available and are often less expensive. New medications are not always better, and their high prices may not be justified. Medications within the same class can differ to some extent, such as one may be given once daily, as compared to others in the same class given twice or three times daily. This can be an important characteristic, and may justify a medication’s higher cost.
Insurance companies often dictate to a large extent what price you will pay at the pharmacy. For example, an insurance company may decide not to pay for a new, expensive medication when it is prescribed for its insured members. If your child were prescribed this medication by your pediatrician, you would be charged a high price for it. The insurance company would likely pay for similar, less expensive, medicines within the same medication class, and thus your price at the pharmacy would be lower. Insurance companies maintain drug formularies, a listing of prescription drugs within a class or category, including the amount of the drug cost they will cover, and how much you will pay. Your pediatrician may be able to prescribe a medication for your child that is preferred by the insurance company, saving you money.
What can you do to avoid paying higher costs for your child’s medicines? When a medication is prescribed for your child, discuss the cost of the medication with your pediatrician. If it is expensive, ask if a less expensive medication can be used that will be just as likely to help your child. Ask if a generic form of the medication is available and can be prescribed. Your pediatrician’s office staff may be able to check your insurance company’s Internet site for specific medications covered under your plan, or you can call your insurance company and ask for this information. Many OTC medications are also available as generic, less expensive, products. Ask your pharmacist to help you choose one that is best for your child. Many patient assistance programs are available that you may qualify for, allowing you to save money on prescription drug costs. These programs can be viewed on several Internet sites:
• Partnership for Prescription Assistance, www.pparx.org
access to more than 475 public and private patient assistance programs
• RxAssist, www.rxassist.org
listing of numerous patient assistance programs
• NeedyMeds, www.needymeds.org
listing of numerous patient assistance programs
It is best not to use an expired medicine. However, the convenience of choosing to use a medication in your home which has a recent expiration date (say, several months ago) versus driving to a pharmacy late at night or in bad weather is also important to consider. In many circumstances, using the expired medicine until you are able to buy new medicine is likely a reasonable and safe option.
The pharmaceutical manufacturer’s expiration date is usually stamped in print on the bottom or side of the bottle or box for OTC medications, and may appear as something like EXP 10/16. Products that contain medications that are applied to the skin, such as lotions or skin protectants may not have an expiration date on the box or product. For prescription medications obtained at your pharmacy, the expiration date will likely be one year from the date it is dispensed, even when the original product bottle the pharmacy used had an expiration date of more than one year. A one-year expiration date will be placed on your bottle because how you store the medicine cannot be guaranteed to be appropriate. Storage conditions, such as temperature, humidity, and light, can greatly affect a product’s expiration date. The most appropriate conditions to store most medicines are a cool, dry place, with low humidity. Unfortunately, most medicines are likely stored in our bathrooms—not a good place because of the high humidity. A better place to store many medicines is in a clothing drawer, where it is cool, dry, and dark.
Use of a medication with an expiration date long since passed may result in the medicine not functioning as well, due to loss of strength or potency. Consumers may be concerned that an expired medication may somehow morph or change into a toxic or dangerous substance, but this is unfounded.
Several published studies have evaluated medication expiration dates and tested medication potency at times significantly longer than the product’s expiration date. These studies found that when stored in the medication’s original, sealed container at room temperature, many medications retain their original potency for many years beyond the manufacturer’s labeled expiration dates. However, it is also important to consider that nearly all medications given to your child are not in their original container and are not stored under ideal conditions. How you store medicine—away from humidity, light, and high or low temperatures, and with the vial or bottle top tightly in place—can significantly affect the expiration time and potency of the medicine.
The intended use of a medication is an additional important consideration. Medications that may greatly affect your child’s health with each dose, such as insulin or epinephrine auto injectors for severe allergies, should not be used past their indicated expiration date, even when they are stored under good conditions. If your child uses one of these medications, or a medication for a similar purpose, it is best to be aware of the medication’s expiration date and obtain a refill at the pharmacy or a new prescription from your pediatrician well ahead of the expiration date. It may be reasonable and safe to use other medication products, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil), with recent past expiration dates, when giving one or two doses is not as critical to your child’s health, and when you are realistically unable to obtain more medicine immediately.
• Dosing errors are the most common drug error in pediatrics. Determine an accurate dose for all OTC drugs given to your infant or child. Ask your pharmacist to help you if need be.
• Use an accurate dosing device to measure your child’s liquid medicine. Do not use teaspoons or tablespoons. As many parents easily make mistakes measuring liquid medicine, don’t hesitate to ask your pharmacist to show you how best to measure your child’s dose.
• Your child may not like the taste of a liquid medicine and may refuse to take it. Your pharmacy may be able to flavor your child’s medicine and improve the taste.
• Before giving any new prescription or OTC drug to your child, consider if, and how, the drug will help your child, and what adverse effects it may cause. All drugs have potential to result in adverse effects, and some may be severe. The benefit of any drug given to your child should be greater than the adverse effects.
• It can be easy to make mistakes when giving medicine to your child, such as missing doses. Discuss how to appropriately give a new medicine to your child with your pediatrician and pharmacist, and know what questions to ask.
• Some medicines can be very expensive. Less expensive medicines are often just as likely to help your child. Know what questions to ask your pediatrician and pharmacist about the cost of your child’s medicine.