All posts tagged medication adherence

Caregivers often report difficulty administering medications to children. Up to one-quarter of children may refuse outright to take their medication, resulting in delayed treatment or the caregiver having to force the child to take their medication.(1) Willingness to take medication is particularly important in children with chronic illness. The following five tips may be helpful for pharmacists or caregivers to encourage children to take their medication:

1. Select the most appropriate formulation

The taste of oral medications may be a potential barrier to administering medications to children.(2) For non-oral medications, barriers may include dislike of using a mask or spacer and the time required to administer inhaled medications; fear of needles for injectable medications; and dislike of the texture of topical medications.(3,4)

Choose tablets or capsules for children who are able to swallow pills. It’s sometimes preferable to round a medication dose to a portion of a tablet (e.g., quarter or half) instead of providing a liquid that tastes unpleasant. Children as young as two years can learn to swallow pills using techniques such as shaping, modelling, head positioning and other behavioural techniques.(5-7) Shaping involves practising with increasingly larger sizes (e.g., using placebo capsules, small and large cake sprinkles, Tic Tac) before moving to the medication in question.(5,6)

Modelling involves demonstrating the technique to the child prior to their attempt.(5) Preferred head positions for swallowing pills include head at centre, chin tilted up, or head rotated 45⁰ to the left or right; chin down is generally not preferred by children.(6) It may be necessary to try more than one head position to find the child’s preferred position. Teaching pill swallowing is particularly helpful for children with chronic illnesses who will require daily medication.
Consider palatability if the child requires a liquid formulation. For example, cefuroxime liquid is often described as bitter, while cefprozil liquid is considered more palatable.

For inhaled medications, metered-dose inhalers with spacers and dry powder inhalers are generally preferred over nebulizers; they are quicker to administer and provide similar effectiveness.(8) For portability reasons, adolescents may prefer dry powder inhalers over metered-dose inhalers with spacers. For topical medications, creams and lotions may be better tolerated than ointments.(3) For injectables, choose the correct needle size to minimize injection pain. Suggestions for needle gauge (G) and length are available for the administration of vaccines.(9) Needle lengths of 25 mm (23G or 25G) lead to fewer local reactions than shorter needles for intramuscular vaccine administration in infants.(10) For subcutaneous injection of insulin, shorter needles (4–6 mm) are preferred to minimize the risk of intramuscular injection.(11)

2. Administer oral medications in the most palatable way

Some children have difficulty swallowing tablets (especially tablets that have a bitter taste if left on the tongue), but can tolerate capsules. In this case, tablets can be placed in empty gelatin capsules for easier administration. Some tablets or capsules can be crushed or opened and mixed in a small amount of sweet food (e.g., jam, chocolate sauce, pudding), provided there is no food interaction.(12) Mixing medication into essential foods is generally discouraged, as it may put the child off eating these foods.

Liquid medications can sometimes be made more palatable with specialized compounding. Liquids should be measured and administered using an oral syringe, particularly in young children and those who have difficulty cooperating. Administer the medication into the cheek, rather than directly onto the tongue.(13) If needed, give only a little at a time. Refrigerate liquid medications (if stable in the fridge), as they tend to taste better when cold.(12) Alternatively, numb the child’s taste buds by giving a cold treat (e.g., popsicle) before administering the medication. After administering a liquid or crushed tablet, the child’s favourite drink may be offered.

3. Approach medication administration with a positive attitude

Children can often pick up on a caregiver’s stress or anxiety regarding medication administration. Caregivers should remain calm and positive, and provide clear instructions to the child (e.g., “open your mouth,” “swallow the medicine”).(13) If a child resists, the caregiver should be firm, but gentle, and provide a reason for the medication to stress the importance of taking it. There should be no negotiation about whether or not the child takes the medication; however, caregivers may give the child choices where possible.(13)

For example, caregivers may ask the child how they would like to take the medication and can involve them in their medication schedule. Provide praise when the child takes the medication.

4. Talk to children about taking medication

Even young children can learn about their medication and have the right to receive age-appropriate information.(14) Caregivers should never refer to medication as candy; always refer to it as ‘medicine’ or, for older children, by the medication name. Children as young as seven years can understand that medication is used to ‘cure’ or ‘treat’ and can be taught the name of their medication.(15) Older children can be taught to describe their dosing schedule and how the medication works.(15) Caregivers should involve children in their medication use in a manner that’s age-appropriate. As the child gains knowledge and skills, give them more autonomy.(16) Young children should never be left alone with medication.