VOLUME 45 : NUMBER 6 : DECEMBER 2022
ARTICLE
Administration of medicines to children:
a practical guide
Lucinda Smith
Senior pharmacist1
SUMMARY
Catherine Leggett
Medicines information Getting children to take medicines can be difficult. There is no ‘one-size-fits-all’ approach.
manager1
When selecting medicines for children, it is important to consider the child’s age, swallowing
Corey Borg
Senior pharmacist1
ability, ease of administration and accessibility of the product.
Ask the child, parent or caregiver about their preference for formulations and flavours.
1
Medicines Information
Service, SA Pharmacy, There are different ways to alter the taste, aftertaste and mouth feel of medicines, which may help
Women’s and Children’s
improve palatability.
Hospital Campus, SA
Health, Adelaide Pharmacists or medicines information services can assist with advice on suitable formulations or
methods of administration.
Keywords
drug formulation, oral
administration, paediatrics, Introduction However, liquid formulations are not without risk and
palatability, patient safety,
Giving medicines to infants and children can be can result in over- or underdosing, particularly in the
taste following cases:
challenging. Children may refuse to take medicines
for many reasons, such as fear, taste, embarrassment • Small volumes are required to be measured.
Aust Prescr 2022;45:188–92 or inconvenience. Although smaller volumes may be preferable,
https://doi.org/10.18773/ the use of more concentrated liquids may
This problem is compounded by a lack of suitable
austprescr.2022.067 create an additional risk, particularly with drop
formulations for paediatrics, restricting prescribing
options and posing safety concerns. There is also formulations that are marketed for adult use, but
limited information for parents and caregivers may sometimes be given to children (e.g. tramadol
on how to give medicines to children, with 100 mg/mL).3 Their use can more easily result
most information coming from experience and in 10-fold dosing errors, such as measuring 1 mL
anecdotal reports. instead of 0.1 mL. This can be minimised by
providing carers with an oral syringe marked with
Choosing the right formulation the correct dose and appropriate counselling.4
There is a well-recognised lack of suitable paediatric
• Multiple formulations of the same active
formulations available,1 contributing to an increased
ingredient are available. For example, paracetamol
risk of dosing errors and difficulties in administration.
oral liquids are available in concentrations of
When selecting medicines for children, it is important
24 mg/mL, 48 mg/mL, 50 mg/mL and 100 mg/mL.
to consider factors such as the child’s age, swallowing
When discussing medicines for children, it is
ability, ease of administration and accessibility of
important for carers, clinicians and pharmacists
suitable formulations of the product. Understanding
to include instructions with the dose by weight
the characteristics of each formulation can assist
(e.g. mg or micrograms) and dose by volume.
with choosing the most appropriate medicine for
a child. Oral liquids may contain excipients such as colourings,
solvents and preservatives at concentrations that may
Oral liquids not be suitable for children.5 For example, furosemide
Oral liquids are the preferred formulation for younger (frusemide) oral solution contains 12.7% ethanol,
children as they are easier to swallow2 and allow for which is typically considered insignificant in adults.
flexible dosing based on the child’s age and weight. However, it exceeds the maximum allowed ethanol
Liquids may also be mixed with different flavours at content of 0.5% for children younger than six years
the time of administration to help mask the taste and of age, limiting the use of the proprietary furosemide
smell of a medicine. (frusemide) product in this age group.6
188 This article is peer-reviewed © 2022 NPS MedicineWise
VOLUME 45 : NUMBER 6 : DECEMBER 2022
ARTICLE
Oral liquids often contain sugars to help improve Most tablets are intended to be swallowed whole,
palatability. It is important to consider the effects of but some immediate-release preparations may be
sugar on teeth, particularly with chronic medicines. chewed, crushed, or halved or quartered using a tablet
To minimise dental cavities, consider sugar-free cutter.5 Caution should be taken when manipulating
formulations and encourage children to brush their tablets as this may result in a small portion of the
teeth after taking a dose.7 dose being lost. This is particularly significant when
giving medicines with a narrow therapeutic index.
Solid dosage forms Additionally, most tablets are not formulated to be
If an oral liquid is not available, alternative oral palatable, so crushing or dispersing them may impact
formulations may be suitable. If a solid dosage form a child’s willingness to take the medicine.
requires manipulation (chewing, crushing, dispersing,
halving or breaking) to facilitate administration, Modified-release tablets
particular drug properties should be considered: Modified-release tablets should be swallowed whole,
• palatability as chewing or crushing them may damage the
modified-release formulation, causing toxicity by
• physiochemical (e.g. acid labile or light sensitive)
releasing the total amount of medicine at once.11
• hazardous (e.g. irritant, cytotoxic)
• drug release kinetics (e.g. modified release, Capsules
enteric coating). Some children may find capsules easier to swallow
than tablets. However, capsules cannot be halved,
Tablets which limits their dose flexibility.
Tablets are a suitable alternative to oral liquids, Most capsules are formulated to be swallowed whole.
particularly when medicines are unpalatable.8 Some hard capsules (filled with powder or coated
However, a child’s ability to swallow tablets must granules) may be opened and their contents mixed
be considered. There is no established age at which or sprinkled in food or drinks. Similarly, some soft
children are able to swallow tablets, as it is a skill that capsules (filled with liquids or semisolids) may be
must be learned.9 Several resources are available for chewed (e.g. colecalciferol).5
caregivers to assist with teaching children to swallow
tablets or capsules (see Box). Some children may be Oro-dispersible tablets
able to swallow tablets from a young age, although Oro-dispersible dosage forms, including tablets,
most children are usually at least 8–10 years of age wafers and films, are formulated to disperse rapidly
before they can routinely take tablets.10 If prescribing once placed on the tongue. Alternatively, they can
or dispensing for a child, the child or carer should be dispersed in a small volume of liquid before
always be asked if they would prefer tablets or administration. These preparations may be useful in
oral liquids. children, as they do not need to be swallowed whole
Tablets are more accessible with easier storage and or crushed.5
transport options than those for oral liquids. However, Oro-dispersible medicines are commonly formulated
tablets have limited dose flexibility, decreasing the with additive flavours to help mask the taste. Due
ability to prescribe weight-based doses.5 to their delicate composition, it may be difficult to
half or quarter these dosage forms, limiting their
dose flexibility.
Box Useful resources ‘Making the medicine go down’
There are some common ‘Dos & Don’ts’ for
Society of Hospital Pharmacists of Australia. Don’t rush administering medicines to children, which
to crush. 4th ed. [Booklet] depend on the type of formulation (Table 1). These
NPS MedicineWise. How to give medicines to children suggestions are also outlined in a consumer-friendly
Royal Children’s Hospital, Melbourne. How to give leaflet (see Fig.).12
medications to children. [Pamphlet]
Taste
Royal Children’s Hospital, Melbourne. Teaching children
how to swallow tablets and capsules Taste is a powerful deterrent for children and is
thought to have evolved as a safeguard against
Medicines for Children. Helping your child to swallow
tablets ingesting toxic substances.13 The unpleasant taste of
a medicine can be improved by mixing it with various
Full text free online at nps.org.au/australian-prescriber 189
VOLUME 45 : NUMBER 6 : DECEMBER 2022
ARTICLE Administration of medicines to children: a practical guide
flavoured syrups or cordials (Table 2).6,7 However, the Aftertaste
child’s taste preferences must be considered before The aftertaste of a medicine is a difficult issue to
mixing with flavours. Liquorice, peppermint and navigate, particularly if it prevents a child from
coconut flavours may taste reasonable to adults but accepting subsequent doses.13,14 When administering
may be disliked by children.14 a medicine, try and avoid the tongue, aiming oral
Mixing medicines with a small amount of food or liquids towards the back of the mouth against the
liquid is unlikely to cause drug–food interactions, cheek. Alternatively, consider swapping to a capsule
even with medicines recommended to be given on an or tablet formulation, which can be swallowed whole.
empty stomach (e.g. flucloxacillin). A small reduction Some children may find it more palatable to take a
in absorption of the medicine will pose less of a medicine via a straw or follow with a cold drink to
problem than that created by a child refusing to take lessen the aftertaste.
the medicine at all.
Mouth feel
The mouth feel of a medicine may also be a deterrent
Table 1 C
ommon recommendations and precautions for for some children. To improve the feel of oral liquids,
administering medicines to children consider diluting in water or a flavoured drink to
reduce their viscosity.13,14 To combat the grittiness of
Recommendations Precautions
crushed tablets or granules, try mixing with thick or
Oral liquids, suspensions and elixirs gelatinous foods such as jelly, custard or spreads.
Use metric measures, such as a medicine Do NOT use everyday utensils, such as Advice for prescribers
syringe or cup teaspoons or tablespoons
When prescribing medicines for children, some
Count oral drops on a spoon before Do NOT administer drops directly from practical considerations include:
administering the bottle into the child’s mouth
• minimising the dosing frequency where appropriate
Mix oral liquids with a small amount of Do NOT mix the medicine in large volumes (e.g. prescribing cefalexin 12-hourly (twice a day)
water or juice
rather than six-hourly (four times a day))
If the medicine is available in multiple Do NOT mix the medicine with a child’s
• avoiding medicines that are known to be less
flavours, ask the child for their preference essential foods (e.g. milk or formula),
palatable (e.g. flucloxacillin is known to be bitter,
as the altered taste may cause future
aversion to the essential foods so using cefalexin as an alternative)
• using alternative routes of administration,
Tablets, capsules and solid dosage formulations
especially for children who cannot tolerate oral
Place the tablet in the middle of the Do NOT mix with honey in children fluids (e.g. using a rectal paracetamol formulation
tongue and follow with a large volume younger than one year of age due to the rather than an oral formulation).
of liquid potential risk of infant botulism
Try drinking a small amount of liquid from Do NOT give large volumes (i.e. aim for
Conclusion
a bottle or using a straw one mouthful)
Try halving or quartering tablets Do NOT break modified-release, cytotoxic There are several techniques and strategies that can
or hazardous medicines
be used to improve the palatability and acceptance
Crush tablets between two spoons and Do NOT crush modified-release, cytotoxic of medicines by children. Often, there is no single
mix with a small amount of soft food or hazardous medicines solution, and instead, there are many strategies that
such as yoghurt, cold custard, fruit puree may be implemented by the parent or caregiver.
or jam
Further guidance may be obtained from the local
Try dispersing the tablet in a small pharmacist or medicines information service.
volume of liquid (water or juice)
Acknowledgements: Sean Turner (Director of
Check with a pharmacist if the tablets
can be crushed or the capsules opened
Pharmacy), David Ellis (Senior specialist pharmacist
(Manufacturing and Psychiatry)) and Lynn Costi
Encourage parents and caregivers to
(Senior pharmacist, Medicines Information Service),
teach children how to swallow tablets.
SA Pharmacy, Women’s and Children’s Hospital Campus,
There are several resources to assist with
teaching children to swallow solid dosage SA Health.
forms (see Box)
Conflicts of interest: none declared
190 Full text free online at nps.org.au/australian-prescriber
VOLUME 45 : NUMBER 6 : DECEMBER 2022
ARTICLE
Fig. Suggestions for administering medicines to children12
General
Try cold treats like an ice cream or Try mixing with fatty foods like peanut butter Have the child’s favourite drink
ice blocks to numb the tastebuds or chocolate to coat the tastebuds ready to follow the medicine
Tablets/capsules Liquids
Try cutting the tablet in halves Try using an oral syringe, aiming towards the
before swallowing it* back of the mouth against the inner cheek
Avoid the tongue
Try crushing the tablet or opening the capsule and sprinkling Try mixing the medicine into a small amount
the contents on foods such as yoghurt or custard* of fruit juice before drinking†
Try crushing the tablet or opening the capsule and sprinkling Try pouring the medicine in a small cup
the contents in a small amount of fruit juice* and drinking with a straw
* Not all tablets and capsules can be altered. Confirm with your local pharmacist.
† The entire drink must be consumed to ensure the full dose has been taken.
Adapted from reference 12
Table 2 T
astes and masking flavours
Taste of the medicine Examples* Flavour to mask the taste of the medicine
Sour Multivitamins (e.g. vitamin C) Cherry, lemon, lime, mandarin, orange, strawberry, raspberry, pineapple
Bitter Antibiotics Cherry, chocolate, liquorice, strawberry, peach, coffee, mint, lemon, lime, raspberry,
Paracetamol tutti-frutti, orange, cinnamon
Corticosteroids
Sweet Lactulose Caramel, lemon, orange, vanilla, bubble-gum
Sorbitol
Salty Iron supplements Banana, caramel, cream, chocolate, grape, vanilla, raspberry, orange, cinnamon, nut,
Antihistamines butter, butterscotch, maple
Macrogol laxatives
Oral rehydration solutions
Any Spreadable yeast extract, peanut butter, jam, honey, apple sauce, custard, ice cream
* Common examples are based on patient reports, although any drug may be considered ‘bad’ tasting depending on subjective taste preferences.
Full text free online at nps.org.au/australian-prescriber 191
VOLUME 45 : NUMBER 6 : DECEMBER 2022
ARTICLE Administration of medicines to children: a practical guide
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