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Just a spoonful of sugar ... kids and their medicines

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP Trainer
Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School
E:charles.broomhead@lineone.net

There is considerable evidence to show that as much as 50% of the medicines that we prescribe for chronic conditions are not taken in the way that is intended.(1) This lack of concordance represents a massive problem to both the individual patient and to society as a whole.(2) Many illnesses remain suboptimally treated and vast financial and healthcare resources are needlessly wasted. This state of affairs is usually better with acute medication, but it remains a significant barrier to the provision of best available treatments.
The reasons for poor concordance are complex. They are usually multifactorial and include issues such as whether the patient thinks they have a problem that needs treating and whether they understand the need for medication. Important considerations will be whether they believe that the medicine will do them more harm than good and whether they experience side-effects that they are prepared or able to tolerate. The form and a regimen of the treatment must be acceptable to them, and adequate dosing instructions must be provided to optimise adherence.

Concordance and children
Relatively few children need to take long-term medication. Young children generally associate taking medicines with being ill and, like many of their parents, may not understand that they need to continue to take them when they are well. How often do we tell a child that the medicine will "make them better", so why do they need to carry on taking it when it has done its job? A significant exception to this lack of understanding is in the treatment of asthma, where even small children are often responsible for the "routine" management of their condition.(3) This therapy area demonstrates the effectiveness of education and the importance of user involvement. Fundamental to the process is to allow the child a choice of inhaler. Provided they are able to use it correctly, this often pays dividends. From the prescriber's perspective, a metered-dose inhaler and spacer may appear to represent a cheap and efficient way of administering medication, but a turbohaler or accuhaler may actually be more likely to be used appropriately. If the inhaler does not have "street cred", it may not be used at all. Most importantly, it involves the child in decisions about their treatment and immediately generates active participation in their healthcare.
When the patient is a child an additional dimension is added to the consultation and prescribing process. A parent often makes decisions on the child's behalf. Many parents will be more cautious and questioning about their child's treatment than about their own - witness the anxiety generated by concerns about the safety or otherwise of the MMR vaccination. Few parents are likely to give their child a medicine that, for whatever reason, they believe to be inappropriate, harmful or ineffective. Learned patterns of behaviour and re-education are important here. The mother who believes that the antibiotic her child has been prescribed "never works", possibly because it has previously been prescribed inappropriately, may not only deprive them of vital treatment, but may also inadvertently educate them in the same belief system and perpetuate the problem.
In small children, this third party to the consultation will represent more of an influence than when the child is older and better able to express their opinions. Informed, interactive dialogue between doctor and patient is clearly desirable, but at what age do the child's views become more important than those of their parents? This issue can of course be as much of a problem for the parent as it is for the child or the doctor, and will undoubtedly vary from one consultation to another. It is certainly not a static situation but one where responsibility is gradually transferred from parent to patient. It can be facilitated by establishing a long-term, trusted therapeutic relationship between the prescriber, the child and the child's parents.
Children are naturally inquisitive and often want to know all about their medication. Their interest should be encouraged and information provided in a form that is appropriate to their age. This may be in written or pictorial form but should be accurate and consistent across the healthcare team. Conflicting advice will foster doubt and uncertainty and reduce the chances of it being taken correctly.

Practical solutions
As most of us know, especially those who have children of our own, getting a child to do anything against their will can be virtually impossible. Persuading a child to take medicine is no exception to this rule. In the short term, perhaps when a brief course of treatment is necessary for an acute condition, bribery may work! As a long-term strategy, however, this approach is doomed to failure. The novelty of a sweet or other treat that is given as a reward when medicine is administered will soon "wear thin". Inevitably, the child will learn to exploit the ­situation to its limits, to the frustration of parents.

Colour and taste
A better approach may be to use a medicine that the child likes to take or ideally one that they feel they have been involved in selecting. Factors such as the colour, smell or taste may be critical to this. For example, antibiotic mixtures tend to be coloured pink or yellow, and attempts are often made by manufacturers, usually in vain, to make them taste of bananas. This is not a flavour that is universally popular. Selecting a medicine that tastes of something that the child prefers, perhaps even asking them what flavour they would like, immediately improves the chance that they will take it. Of course, this isn't always possible for clinical reasons, and the range isn't limitless, but it is often possible to offer a choice of aniseed-, banana-, fruit-of-the-forest- or strawberry-flavoured medicine. To do this it may be necessary to prescribe by brand, and although in general I would advocate prescribing drugs generically, this may be a justifiable exception. Unfortunately, this isn't the end of the taste issue. A medicine that tastes reasonably good when freshly reconstituted may be much less palatable by the time it has spent a week in a refrigerator. Pharmaceutical manufacturers are well aware of these issues and make strenuous attempts to overcome the problems. In my experience, it seems to be the taste of macrolides such as erythromycin that deteriorates most.

Sugar-free
Sugar-free medicines are widely available, and many parents recognise their importance. Although children may find these less palatable, it seems sensible to encourage their use.

Frequency of dosing
The frequency of dosing is an essential consideration when treating small children, particularly if they are well enough to attend nursery or school. Many teachers are unwilling or are perhaps not permitted to give medicines to their pupils. This is a situation that makes a three- or four-times daily regimen very difficult to manage. A drug that can be given twice daily, before and after school, is far more likely to be taken correctly. Thus, trimethoprim may represent a better choice than amoxicillin, although in fact it is often acceptable to use a drug such as erythromycin or penicillin V twice daily.

The future
Considering this issue more widely, it may be possible to negotiate with educational authorities to allow drugs to be given by school staff. This process might include arranging simple education about the treatment of common conditions and the medicines that are used to manage them. Unnecessary anxiety about the possible dangers and harmful effects of medicines often lies at the root of the problem. Written protocols and perhaps a little training will often provide considerable reassurance and minimise the problem.

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References

  1. Haynes RB, McKibbon A, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996;348:383-6.
  2. Marinker M, Shaw J. Not to be taken as directed. BMJ 2003;326:348-9.
  3. Sanz EJ. Concordance and children's use of medicines. BMJ 2003;327:858-60.

Resources
Task Force on Medicines Partnership
W:www.medicinespartnership.org
NHS Direct
W:www.nhsdirect.nhs.uk