Kiddy pills, syrup, compliance and cost.

I was wandering through the Paeds journals looking for something relevant to EM recently (there wasn’t much) when I came across two articles in Archives of diease in childhood. The first by Baguley et al tells me that Kids are more likely to take medicines if they taste nice. Not exactly rocket science I agree, but what I did not know is that there is a scale of drugs which are known/not known to be taste nice, and interestingly Flucloxacillin, a drug widely used in emergency medicine is one of the least pleasant tasting. Augmentin on the other hand, for which the penalty for prescribing off protocol is crucifixion (not really but it feels like it) is apparently very tasty indeed. This may seem fairly benign and obvious but it’s really important for us as EPs as clearly there is no point in prescribing if the compliance is going to be poor.

Here’s a list from the paper ranking some of the more commonly prescribed antibiotics in Paeds ED practice from the paper.

  • ▶ Antibiotics children will normally swallow

    • ▶ Co-amoxiclav (×3/day) or Augmentin Duo (×2/day)

    • ▶ Cefaclor, cefalexin, Amoxil (branded) (all ×3/day)

    • ▶ Co-trimoxazole

  • Antibiotics children might swallow

    • ▶ Penicillin V (×4/day)

    • ▶ Amoxicillin (generic) (×3/day)

    • ▶ Clarythromycin (×2/day), azithromycin (×1/day)

  • Antibiotics children often spit out or grimace when taking

    • ▶ Erythromycin (×4/day)

    • ▶ Trimethoprim (×2/day)

  • ▶ Rarely tolerated with good adherence

    • ▶ Flucloxacillin (×4/day)

    • ▶ Clindamycin (×4/day)

So, is there a way round this rather than just continuing to prescribe and hope for the best? For patients there is some really good generic advice out there on loads of websites and your pharmacy may have advice as well, but what about us as EPs. Is this really a question for us at all or do we just prescribe and say get on with it. There are two suggestions in the journal that I thought were worth a ponder. One we can do right now and one for the future. In the same paper Baguley et al describe the concept of a ‘taste test’ to give the first dose of antibiotics before the child leaves to see if they will tolerate it. This seems perfectly sensible to me. We should probably do this for those drugs down the bottom end of the table, and arguably for all of them. I’m going to suggest and then wait for all the reasons why we can’t, and then I’ll suggest it again, and again…….

The future idea is another paper in Archives which challenges dogma, and I love a bit of dogma baiting! We all know that the only reason we are messing about with antibiotics in syrup form is because kids can’t take tablets. Or can they? Spomer et al have performed a rather nice (admittedly pilot) study looking at whether children aged 0.5-6 years can swallow tablets as compared to syrup….and the result is that they can. Not only that, but they can swallow tablets as well as they can take syrup, and, in children aged 6-12 months they do better with tablets. Ok, it’s a small paper, a pilot and we cannot infer from this that mini-pills are the future, but it does raise some interesting questions that I’d like to see answered over the next few years.

Compliance is a vital component of any successful theraputic intervention but one that we in Paeds EM perhaps do not take account of as much as we should. Better compliance has got to be better for patients, for countering microbiological resistance and ultimately for healthcare costs.

It’s certainly made me think about that next prescription for oral fluclox syrup. I wonder if it will get used in the way that I prescribe it?

Now, at this stage it would be great to tell you the results of my blind tasting of antibiotics in the department. This is of course unethical so I haven’t, but I’d love to hear from anyone who has. It does remind me of my time in Neonates (a long time ago when consultants could make juniors do this sort of thing) when the drug rep came round with all the different types of formula feeds designed from ultraprems right up to full term and beyond. It was possibly the weirdest, most unpleasant and arguably most bizarre taste test I’ve ever undertaken.

Simon C

7 responses to “Kiddy pills, syrup, compliance and cost.

  1. katherine potier

    What a good article in terms of making me think! It has made me wonder about the trimethoprim we give out for UTIs.

  2. This might be a dumb question, but over here in the states, do they use the same syrups for the antibiotics? Or does this list only apply to the motherland?

  3. This might be a dumb question, but are the syrups the same flavor over here in the states? Or does this list only apply to the motherland?

  4. Katherine – thanks, I agree. It’s really made me think about compliance as an issue in PEM.

    JSchonert/emchatter (I think you must be the same person) – That’s not a dumb question at all. I must admit that I’d not even thought about that and just presumed that they were.

    Great question. Sorry, don’t know the answer.

    S

  5. I always knew that the kids seemed to like augmentin better (i tasted it once as an SHO about 6 years ago.) but didn’t know fluclox was so awful. I imagine from a manufacturing point of view they could be made to taste nice fairly easily?

  6. I discovered this when I was a paediatric orthopaedic SHO a few years ago. Even though the guidelines for uncomplicated cellulitis here say flucloxacillin 12.5mg/kg po qid, after discussion with our local micro I switched to cefalexin 20mg/kg po tds – better strep coverage, similar staph coverage, better tasting, and fewer doses in a day.

    With the rise in MRSA, though, it’s hard to know what to add – I think some cotrimoxazole is what is recommended.

  7. Rachel Jenner

    I did know some of this, particularly about flucloxacillin being foul tasting, and did an n=1 study at home recently trying to give trimethoprim to my youngest (he was so traumatised that he refused to take any medicine, even the nice pink sugary kind for weeks). I still prescibe flucloxacillin to kids but a)encourage them to opt for tablets and b)warn the parents that it tastes bad and if they struggle with compliance to seek out an alternative

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