Who should read this chapter? Parents who have children who are difficult medicine takers.

Summary: You can teach your child to be a good medicine taker or you can teach your child to become an uncooperative medicine taker. When children fuss and cry at medication time, they must learn that no matter how much they fuss and cry, they will still have to take their medication. By insisting on this, they become good medicine takers. If you give up on medication when they fuss and cry, you teach them that fussing and crying results in the "reward" of not having to take medication. They will be encouraged to fuss and cry with their next medication doses as well. In addition to training them to be good medicine takers using behavior methods, suppositories can sometimes be used, but these are only available for some medications. Insist on good tasting brands of medications if they are available. This can be discussed with your doctor.

I often see patients who have been prescribed medication by their doctors the day before and are now being brought to the emergency room because their child has not gotten better. The most common reason for this is that the child won't take his/her medication. When I ask why he/she has not taken the medication, these are the responses I hear:

1. He won't take his medicine.

2. She cries when I try to give her medicine.

3. She won't open her mouth when I try to give her medicine.

4. He gags and vomits after I give him his medicine.

These children have learned that; when I cry, or keep my mouth closed, or scream and kick, or gag or vomit, I won't have to take medicine. Most children do not like taking medicine. It is normal for them to fuss at medicine time, but they must still take their medication. Very young children do not understand the benefit of medication. They just know that it doesn't taste good. They LEARN that when they fuss or vomit, mom/dad gives up and they won't have to take medicine any more. Giving up on giving the medicine, REWARDS the child for fussing and vomiting.

Children can be good medicine takers. For this to happen, they must LEARN to be good medicine takers. They must learn that no matter how much they cry, scream, kick, or vomit, they will still have to take their medication. Their parents will never give up. After a while, children will learn that it is pointless to fuss because they will still have to take their medicine. They might as well take the medicine quickly so that they can get it over with and do other things. It doesn't matter if the medicine tastes good or bad. If your doctor feels that the medicine is important, then it should be given.

Some parents prefer to put the medicine in an infant bottle with milk or formula. This will often be successful in giving the medicine; however, this does not TEACH the child to be a good medicine taker. Eventually, the child will be old enough to tell that medicine has been put in the bottle or cup. He/She will then refuse to take it because it makes the drink taste different. Another problem with this method is the entire bottle or cup must be finished for the child to get the full dose of medicine. If the entire bottle or cup is not finished, only part of the medicine was given.

Always use a measuring cup or dosing syringe to properly measure liquid medicines. Even if the instructions are given in teaspoons, DO NOT use a spoon unless it is a cooking spoon made for accurate measurement. Many studies have shown that ordinary spoons do not measure medicines accurately. One teaspoon is equal to 5 cc (or 5 ml). One tablespoon is equal to three teaspoons or 15 cc (15ml). Note: cc's and ml's are the same thing.

Open their mouths and give them the medication slowly with a medicine cup, a dropper or a dosing syringe. Even if they are crying while you are doing this, you can still give them the medication slowly. Give small amounts at a time. In between crying breaths, they will usually swallow the medication in their mouth as they breathe in to continue crying. Take a firm approach to give them the message that taking medicine is important. In most cases, simple persistence will convince your child to become a good medicine taker.

In very difficult cases, you may need the extra-firm approach. This approach has worked well for my own children. You will often need two people to do this. One person holds the child steady, while the other administers the medicine. If you are by yourself, you can use a method similar to brushing their teeth. Lie your child on his/her back. Sit down on the floor so that your child's head is between your thighs. Your thighs should be over your child's shoulders to hold them down. By bringing your thighs together, you can steady the position of your child's head. Open his/her lips by squeezing the corners of his/her mouth together. Drip the medication in slowly into the side of the mouth until he/she has swallowed all of it. If they gag or vomit, you will have to let them turn their head to the side temporarily to prevent saliva, medicine, and vomit from being inhaled into the lungs (aspiration).

Some of our nurses (who are also parents) have special techniques used to give liquid medication to difficult patients. Here are some of their suggestions:

1) Using a syringe, slowly squirt the medicine inside their cheek. If they spit the medicine up, use your finger to sweep the medicine from their face back into their mouth.

2) Give the medicine slowly into their mouth using a medicine cup. You can use the medicine cup to scoop any medicine and saliva (drool) off their face and back into their mouth.

3) Pinch their nose so they open their mouth. Then squirt the medicine inside their cheek slowly until they swallow.

For most children, consistent administration of medication in this manner will teach them to be good medicine takers. Eventually (4 to 12 months depending on how often your child needs to take medicine), your child will become a good medicine taker. When it is time to take medication, they will open and swallow it without any fuss.

Some children are more difficult than others. Some children will vomit the medication. As noted earlier, if your child vomits or gags, you will have to let them turn their heads to the side or sit them up to prevent aspiration. Vomit is very upsetting. Vomit will demoralize most parents and at this point, they will give up on giving the medication. This rewards the child for vomiting and from now on, parents should expect that their child will vomit with all future attempts to give medicine.

For such children who vomit and gag during medication administration, may I suggest, that you give them their medication in the bathtub instead. Unfortunately, the bathtub is not as spacious so it might not be as easy to properly restrain your child to give the medication. If your child vomits, it is easier to clean up yourself and your child and you can simply rinse the vomit down the drain. If your bathtub is not large enough, then do this over a floor with an easily cleaned surface. You can use an old towel over the floor if you prefer. It would be unwise to do this over a carpeted floor or upholstery since we all know that carpet and fabric do not mix well with vomit.

If your child gags and vomits, he/she will quickly recover. You should continue giving the medicine. You must teach them that vomiting and gagging will not prevent you from giving the medicine. They must NOT learn that vomiting and gagging relieves them of the need to take medicine. In extreme cases, it may be necessary to give the medicine in little parts spread out over 20 to 30 minutes. This is helpful because, each tiny amount is so small, it is difficult for the child to vomit it out. For example, if the dose is one teaspoon, you can give 1/4 teaspoon, then wait 10 minutes. Then give another 1/4 teaspoon and wait for 10 minutes. Repeat this until the full one teaspoon is given.

If your child vomits the medication, how much more medicine should you give? It is impossible to measure exactly how much medicine came out with the vomit. Sometimes the child may vomit while the medicine is actually being given. Sometimes the child will vomit right after the medicine is given. Sometimes the child will vomit long after the medicine has been given. Parents can often estimate how much medicine came up by looking at the color intensity in the vomit and how much medicine was actually given. This is another good reason for giving the medicine in small amounts spread out over 20 to 30 minutes.

The same problem occurs if a child spits out the medication. This can be very frustrating and demoralizing. In these instances, a parent can be fairly certain that the amount of medicine spit out is very close to the amount of medicine that was just given. Such children must still learn that spitting the medicine out will result in another dose of the medicine. Do NOT give up since this will reward them for spitting, making the spitting behavior in the future much worse.

In general, if your child is normally healthy, it is usually safe to give back half the medicine amount which was given prior to vomiting. This depends on how much you estimate was vomited out. Since many medicines (especially antibiotics) require a certain duration (often 10 days), you may run out of medicine before the duration is completed. You will need to contact your doctor to explain why you need more. Your doctor should be able to call in a prescription to your local pharmacy to get more.

Some medicines require greater caution because they are more likely to cause overdose problems. In general, the following medicines can be given at twice the recommended dose without risk of overdose problems: Antibiotics (amoxicillin, erythromycin, sulfamethoxazole, cephalexin)
. . . . . Ibuprofen (Motrin, Advil)
. . . . . Corticosteroids (prednisone, prednisolone)

The following medicines have a greater risk of overdose potential, but are safe most of the time:
. . . . . Albuterol - Overdose may result in the heart beating fast, jitteriness, hyperactivity, and difficulty sleeping. This is likely to be temporary and not harmful.
. . . . . Acetaminophen (Tylenol, Tempra) - Overdose toxicity results in liver damage. The usual toxic dose of acetaminophen is 10 times the normally recommended dose. Thus, giving twice the normal dose is not likely to cause toxicity. However, giving twice the normal dose several times in a row raises the risk of toxicity. There are occasionally, patients who experience toxicity at lower doses of acetaminophen. These are generally patients with liver problems, but liver damage toxicity has been reported to occasionally occur in patients without liver disease.
. . . . . Cough, cold and allergy medicines - In children, these medicines are not very useful in the first place. These medicines have moderate overdose toxicity potential. Since their benefit is minimal and their overdose potential is moderate, I would recommend NOT giving these medications back if a child has vomited one of them.

The following medicines have a great risk of overdose toxic potential. These medications are generally given only to children with chronic medical problems. If your child vomits any of these medicines, you should contact your doctor for advice on how much more to give. In general, you should dose these medicines cautiously:
. . . . . Anti-seizure medicines (Tegretol, Dilantin, Depakene, phenobarbital, etc.)
. . . . . Heart medicines (propranolol, digoxin, procainamide, etc.)
. . . . . Blood pressure medicines (hydralazine, propranolol, etc.)
. . . . . Theophylline (an older medicine used in asthma)

Unless you are sure what to do, it would be best to check with your doctor.

Once your child becomes a good medicine taker, it will be easier to change them over to taking chewable tablets and eventually, regular tablets that they swallow. Chewable tablets often taste much better than the liquid forms. It is usually better to change over to chewable tablets as soon as possible.

Other tricks to giving medicines include the use of suppositories and knowing which brands of medicines taste better than others.

Suppositories: Some medicines come in suppository form. Suppositories are bullet-shaped and waxy. These are given in the anus into the rectum. The suppository melts and the medicine is absorbed into the bloodstream from the surface of the rectum. Acetaminophen (the generic name for Tylenol/Tempra) is the most common medication given by suppository. The dose is the same. Suppositories are useful if the child is vomiting since it is given in the rectum and it cannot be vomited out. If the child has excessive diarrhea, a suppository is usually not effective. Acetaminophen suppositories are OTC (over the counter). In other words, they do not require a prescription. Most parents don't know this, but if you ask your local pharmacist to point them out to you, you will see that acetaminophen suppositories are right on the counter with the other medicines you commonly buy. Tylenol and Tempra brands do not come in suppository. Generic acetaminophen suppositories are made by many companies. The most common brand name is Feverall. Giving acetaminophen by mouth or by suppository results in roughly the same degree of fever and pain control.

Suppositories should be kept in the refrigerator. They may not need refrigeration for preservation. Notice that they are often not refrigerated at the drug store. Refrigeration keeps the suppositories cold and "hard". At room temperature, the suppository will be too mushy to push into your child's rectum. A refrigerated suppository will be hard and slippery. Just push it in and within a few minutes, the suppository will melt inside the rectum.

The major problem with suppositories is that they do not TEACH the child to take medicine by mouth. Additionally, only a few medicines come in suppository form. Antibiotics, ibuprofen and albuterol do not come in suppository form.

Use better tasting medicines: When your doctor instructs you to give medications to your child, you should ask how the medicine tastes and find out if there is a better tasting form of the medication.

Most antibiotics taste fairly good, but the taste of this group of drugs is highly variable. You should ask your doctor for a good tasting antibiotic if possible. Don't be surprised to find that your doctor does not know the taste of all antibiotics. I try to taste most antibiotics myself, but there are many new antibiotics. Existing antibiotics have changed their tastes over the years (usually improved taste). Generic forms of antibiotics do not always mimic the original flavor of the drug. Often, the generic form tastes better, but once a generic medicine is used, your doctor may not be able to specify which one is used. It may be up to a pharmacist filling the prescription. I see nothing wrong with asking the pharmacist how their generic antibiotic tastes. Sometimes they will know and can give you advice about alternatives.

I have not been pleased with the taste of some of the chewable forms of antibiotic tablets (amoxicillin is the most common one available as chewable tabs). If there is some question about the taste of the chewable, I see nothing wrong with asking the pharmacist how it tastes. In general, I don't recommend chewable antibiotic tabs unless a patient already has had a positive experience with these and wants to use them again.

This next section is very "medical". Reading this section is optional.

Ibuprofen (Motrin, Advil) liquid tastes very good. Chewable forms are available. These chewables taste good, but the liquids taste better to me.

Albuterol (Ventolin, Proventil) liquid tastes very good. Chewable tablets are not available. I have seen many overdoses of albuterol because it tastes so good. Keep this out of the reach of children.

The most commonly used bad tasting medicines are acetaminophen and corticosteroids (prednisone, prednisolone).

Acetaminophen comes in many brands (Tylenol, Tempra, etc.) and forms. The suppository form is given in the rectum so the taste is not important. Chewable acetaminophen tablets taste much better than the liquid forms of acetaminophen. Chewable tablets are available in cherry, grape, and bubble gum flavors. If possible, try to get your children to take the chewable tablets at as early an age as possible to take advantage of this.

Liquid forms of acetaminophen come as infant drops, suspension and elixir. The infant drops come in small bottles with a medicine dropper marked at 0.4ml (40mg) and 0.8 (80mg). The infant drops are more concentrated (100mg/ml). The elixir comes in a bigger bottle (4 oz.) and is usually given with a spoon or dosing syringe. The elixir is less concentrated (160mg per teaspoon, 32mg/ml). You will have to give a larger volume of elixir to give the same dose. For example, if your child's dose (based on weight) is 160 mg, you will have to give him/her 1.6ml of the infant drops or 5.0ml of the elixir.

Medication concentrations listed in this chapter apply to the USA only. Medications sold in other countries will often have different concentrations or different markings on their droppers.

Nearly all brands of both the infant drops and the elixir forms of acetaminophen taste bad. I know of only one form of the acetaminophen liquids that tastes good. This is the Tylenol brand "suspension". Note that Tylenol makes other liquid forms that taste as bad as the rest of them, but Tylenol's "suspension" liquid forms taste substantially better (by my taste test) than the other forms of liquid acetaminophen. Tylenol suspensions are thick and gooey. They are available in both the standard concentrations listed above. The Tylenol suspension is more expensive than the other liquid acetaminophens, but you will find the better taste worth the cost. By the time you read this, other companies may have put generic suspensions on the market. You should taste these medications yourself to taste what your child is tasting.

Corticosteroids are most commonly used in asthma. The generic names of these drugs are most commonly prednisone, prednisolone, and dexamethasone. The common brand names are Pediapred, Prelone, Deltasone and Decadron. Corticosteroids are commonly called "cortisone" by the public. Corticosteroids are very bad tasting. Taking corticosteroids as tablets are the best way to take these since this allows you to swallow it quickly without tasting it. For younger children who cannot swallow pills, the liquid forms must be used. With a few exceptions, most liquid preparations of corticosteroids taste very bitter.

Two brand names of liquid corticosteroids are favored by most pediatricians. As far as I know, Pediapred is the best tasting liquid corticosteroid. It's taste is surprisingly good compared to the terrible taste of the generic corticosteroids. Pediapred is concentrated at 1mg/ml of prednisolone. Most physicians dose prednisolone at 0.5 to 1mg per pound (1 to 2 mg/kg) per day. Thus the average 2-year old weighing 30 pounds (roughly 15 kg) must take about 20 mg per day. This amounts to 20 ml or 4 teaspoons of Pediapred per day. This amount can get rather large. Thus, the good taste of Pediapred is a tradeoff in concentration. The Prelone brand is concentrated at 3 mg/ml. Thus, the same 2-year old child dose would only be about 7.5ml or 1.5 teaspoons per day. The disadvantage of Prelone is its poor taste. My personal preference is to take Pediapred. Even if you have to take a larger volume of Pediapred, it tastes much better. If you have a preference for Pediapred or Prelone, you must ask your physician to write the brand name on the prescription with instructions for the pharmacist to "Do not substitute" a generic (which will taste very bad).

Your physician may know of other good tasting forms of corticosteroids. As usual, ask your physician to recommend a good tasting form of the medication that your child needs.