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How Can Meds Be Made More Palatable for Kids?


Question:
What can I do to make oral medications taste better for children?
Response from Jessica C. Stovel, RPh
Adjunct Assistant Professor, Department of Psychiatry, Division of Child and Adolescent Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
Most children will need to take medications during childhood, whether it involves short-term treatment of an ear infection or long-term treatment of a chronic disease. Ensuring that the child gets the full dose can be a significant challenge for caregivers because most medications inherently have a bitter taste that can be very difficult to mask, even when pharmaceutical companies have developed a flavored liquid formulation. The texture of a commercially available liquid may also be problematic and unacceptable to a child (eg, it may be gritty).[1,2] An even greater challenge arises when no commercial liquid formulation is available and the child cannot swallow pills. In such scenarios, caregivers often have to find creative ways to make the medication palatable for their child.
Charles Darwin noted in 1877 that a child's taste preference differs from that of an adult,[3] and taste may also change throughout childhood as the number of taste buds decreases with maturity.[1-4] This means that what might have worked for masking the flavor of a medication when the child was 3 years old may not work now that the child is 8 years old, even for the same medication.
In addition to developmental changes, there can also be genetic differences with respect to sensitivity to specific tastes and flavors (eg, variations in the genotype of the gene TAS2R38).[3] To complicate matters even further, culture can influence taste.[3] For example, bubble-gum and grape flavors are popular in the United States, citrus and red berries in Europe, and licorice in Scandinavia.[3] Finally, smell may affect preferences.[5] Therefore, masking the flavor of a medication is not always straightforward and often requires careful thought and effective strategies.
Infants and children generally have a preference for sweet-tasting substances.[3] Caregivers can use several methods to help sweeten and mask the flavor of their child's medication. Before trying any of the following tips, advise caregivers to always check with their pharmacist to ensure that there will are no potential drug/food interactions; impact on stability, bioavailability, or efficacy[3]; or dietary issues (eg, limits for patient sugar or sweetener intake).[5]
Once safety has been confirmed, caregivers may wish to try one of the following suggestions:
  • Give a cold treat (eg, frozen slushy drink, ice pop, or ice chips) immediately before and after the medication in order to numb the taste buds and minimize the aftertaste of the medication;
  • Add such sweeteners as chocolate syrup, strawberry syrup, maple syrup, or sweetened soft-drink mix (eg, Kool-Aid®) to the child's dose of liquid medication;
  • Give the child a lollipop or other hard candy after taking medication to overpower the aftertaste;[1]
  • Add a flavoring agent, such as FLAVORx®, to the liquid medication when a prescription is filled.[6] FLAVORx flavoring options are available for many commonly used pediatric medications. The subsequent impact on the stability of the resultant product must be considered and communicated to caregivers; or
  • Add chocolate syrup or concentrated frozen orange juice to bitter or salty-tasting liquids (eg, promethazine, diphenhydramine).[7]
When counseling, pharmacists should inform caregivers that once medication is mixed with food or a flavoring agent, it should be administered immediately so that the effectiveness of the medication is not reduced.[7]

Working With Tablets and Capsules

For medications that are not commonly used in a pediatric population, a liquid formulation may not be available, or if such a formulation exists, it may not be available on the market owing to shortages one of 1 or more of the excipients used to make it. In such scenarios, the solid dosage form may be needed for some period.
A recent example is the shortage of sulfamethoxazole/trimethoprim liquid in Canada over the past several months. Given that this medication is used frequently to treat common pediatric infections and prevent Pneumocystis jiroveci pneumonia in patients with cancer and those receiving transplant, caregivers have been faced with the significant challenge of trying to mask the particularly bitter taste of the crushed tablets.
If only tablets are available, the tablet can be crushed into a fine powder using a pill crusher and mixed into a variety of foods or drinks, assuming that there are no pharmacokinetic or pharmacodynamic interactions. Pharmacists must emphasize to parents that the food or drink in which the medication is mixed should not be an item that is essential to the child's diet (eg, milk or formula) because the child may still taste the bitter medication and then develop an aversion to that food or drink, refusing it in the future.
Therefore, it is best to select a masking agent with a concentrated flavor that is not part of the child's usual diet. For example, the tablet powder could be mixed into a small volume of applesauce, pudding, yogurt, ice cream, jam, Gatorade®, Kool-Aid, frozen juice from concentrate, FLAVORx flavoring agent, or a concentrated syrup.[1,7]Pharmacists should remind caregivers that the entire volume containing the medication must to be consumed to ensure that the child gets the full dose.[1]
For medications that are only available as a capsule, the formulation must first be considered. If the capsule can be opened and its contents easily taken out of the capsule without interfering with the inherent drug-delivery system, then its contents may be sprinkled onto a variety of foods (eg, applesauce, ice cream, pudding, yogurt) or mixed into a drink -- again, assuming that there is no pharmacokinetic or pharmacodynamic interaction.[7]
For tablets or capsules with a drug-delivery system that does not allow for crushing or opening, the medication may need to be switched to an immediate-release formulation and administered more frequently throughout the day. Alternatively, caregivers can start to teach their child how to swallow pills or capsules using the newest method developed and tested by the University of Calgary.[8]

Conclusion

If a medication is unpalatable and unacceptable to the child, adherence and maximal efficacy will be compromised.[6,9-11] Moreover, poor-tasting medication can lead to daily struggle for caregivers. This may in turn have detrimental effects on the caregiver/child bond, undermine the trusting relationship between the caregiver and child, and potentially result in frustration for caregivers and anxiety for children. Consequently, if the child is old enough, having the child select the masking agent may be beneficial, as this empowers the child to take ownership of taking their medications

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