The Bitter Taste of Medicine: The Importance of Palatability in Children’s Medication

Antibiotic adherence is an important issue in all patients, but specifically so in children. There are usually a number of factors influencing a doctor’s choice of antibiotic, however taste is not usually one of them. Research has indicated the importance of palatability when selecting drugs for paediatrics, so we are going to take a closer look at its influence, and what we can do to help.

Palatability

The tongue can distinguish five different components of taste: bitter, salty, sour, sweet and umami. Each of these excite a specific neural pathway and are processed along with other olfactory, visual and somatosensory inputs, as well as those from memory. It has been proposed that our ability to taste has evolved over time as a way to recognise foods that are helpful or harmful to us. For example being able to taste sweet helps us to recognise energy-rich foodstuffs, while bitter tastes may indicate substances that are unsuitable for consumption. Unfortunately it is fairly difficult to measure palatability in children, especially in those below 5 years.

Adherence and taste

As mentioned, our ability to taste bitter substances is believed to have evolved so we can recognise compounds that may be harmful to us. Unsurprisingly, it can therefore be quite difficult for parents to persuade their children to take bitter medicines. Studies undertaken in Japan, Saudi Arabia and Israel have all identified palatability as a significant contributor of noncompliance to an antibiotic prescription in children. Traditionally unpalatable drugs have been disguised with sugar, however regulatory agencies in both Europe and the USA have recommended avoidance of sugar in paediatric medicines. Artificial sweeteners are being used as a substitute, but these have their own adverse effects. Palatability should therefore be considered when doctors are prescribing antibiotics.

Improving adherence

The palatability of certain drugs is so poor that literature suggests that these drugs not be prescribed to children in suspension form at all, unless the child has been observed swallowing it prior to full prescription. For example flucloxacillin and clindamycin are rarely tolerated with good adherence, while Augmentin Duo, cefeclor, cefalexin and co-trimoxazole are usually well tolerated. Drug companies are certainly aware of the challenges in providing palatable drugs and are working on methods to improve tastes in children’s medication. Unfortunately the lack of stability in certain drugs such as erythromycin, a particularly grimace-inducing medicine, are limiting positive results. Health professionals however can play an active role in improving paediatric compliance to an antibiotic schedule through both taste testing and introducing a “pill school” to parents. In a hospital setting, the parent should be observed giving all doses of oral medication to the child prior to discharge. If it is possible for a repeat dose to be given should the medication be spat or vomited out, this should also be clearly explained. In a community setting, where the drug is available, the practice nurse should observe the dose being given prior to a prescription being written. “Pill school” is a method that parents can use to help children (older than six) practice swallowing medicines. Widely available confectionary is used, along with water or some diluted juice. Children can practice swallowing small pills (tic tacs), medium pills (Smarties) and even large pills (chocolate or yoghurt covered raisins). It is important to emphasise that this should be fun, and should not be a forced issue. Practicing a little bit each day can make a big difference for children when it comes to swallowing proper medication.

Palatability correlates so strongly with adherence to a paediatric drug regime that it is of absolute importance for doctors to consider it when prescribing medication. Where possible the child should be witnessed swallowing the medication before a full prescription is given. Nursing professionals can help through properly educating parents on the medicine and through teaching methods such as the “pill school” to aid with compliance.

Source

Baguley, D., Lim, E., Pallet, A. & Faust, S. (2011). Prescribing for children – taste and palatability affect adherence to antibiotics: a review. BMJ.