Children's Medicines

Bell, Edward A.

Published by Johns Hopkins University Press

Bell, Edward A.
Children's Medicines: What Every Parent, Grandparent, and Teacher Needs to Know.
Johns Hopkins University Press, 2017.
Project MUSE., <a href=" https://muse.jhu.edu/.

For additional information about this book

https://muse.jhu.edu/book/72141

[ This content has been declared free to read by the pubisher during the COVID-19 pandemic. ]
 ❷
The Art and Practicality of
Giving Medicine to Children

As parents of sick children know, it is not always easy to measure out

exact liquid medication doses. The younger the child, the harder
it can be to give medicine and to judge if the medicine is helping.
A number of potential problems can increase the difficulty of ad-
ministering accurate doses of medicine to infants and children.
In this chapter I describe the best ways to give medications to
infants and children, including medicine doses in tablet, capsule,
and liquid form. I also explain how typical administration problems
come about, and I suggest ways to avoid these problems. Common
mistakes with medications may not always result in harm to a child,
but significant adverse effects and harm from medication mistakes
have been shown and are well known to have occurred. Researchers
have evaluated many of these topics, and the results of their studies
are discussed here.

Common Mistakes and Problems Parents

and Other Caregivers Face

Many published studies have shown that it is easy for parents to

make mistakes when giving prescription and over-the-counter
(OTC) medicines to their children. For example, in some studies
15
parents were given a common pediatric medicine bottle, such as liq-
uid antibiotics or liquid acetaminophen (Tylenol), and were asked
to calculate a dose for their child. Study parents were given their
child’s current weight and were also asked to measure the calculat-
ed dose with their choice of different dosing devices. (I’ll say more
about these studies and their results in the following pages.)
All of the common parental mistakes discussed in this chapter
can be easily avoided when parents know what the potential prob-
lems are. By following several simple rules caregivers can avoid these
pitfalls. Common mistakes include:
◆ not reading the medication bottle instructions or label
properly,
◆ not accurately measuring doses of liquid medicines,
◆ determining a child’s dose by age and not by weight,
◆ giving too many medicines at one time (over-medicating),
and
◆ not finishing the full amount of a prescribed medicine.
Some of these medicine mistake “categories,” such as not reading
the medicine label or instructions carefully, happen when adults
give themselves medicine as well. It can be easy to inaccurately ad-
minister an OTC or prescription medication to your child if you
do not read the label on the bottle and product packaging. Unfor-
tunately, the ability to buy an OTC medication without speaking
with a physician or pharmacist makes this too easy to do.
Let’s take these points one at a time.

Not Knowing Your Child’s Weight

As your child rapidly grows, his or her weight increases, mean-
ing your child needs a higher dose than you may have previously
administered. Weights of infants and children increase significantly
in the first few years of life. As mentioned in chapter 1, the weight
of a healthy infant can double at 6 months, triple at 12 months, and
quadruple at 24 months of age. Another issue connected to weight
is that medicines come in different concentrations. You might try
16  •  CHILDREN'S MEDICINES
a different liquid product that has a better flavor, and a different
concentration, and consequently you give an incorrect dose based
on your child’s weight.

Basing the Dose on Age Rather Than Weight

Many OTC medication products list medication dose ranges for
specific ages (for example, “for ages 4–6 years, give X mg”), and
because parents don’t always know their child’s current weight, it is
easy to rely on the age range on the product label. But your child’s
weight may differ from the age range listed on the product. While
it may seem straightforward to rely on your child’s age, determining
a medication dose based specifically on your infant’s or child’s cur-
rent weight is more accurate, and is most likely to help your child,
without resulting in adverse effects.

Inaccuracy in Determining and Measuring Doses

of Liquid Medicine
This is probably the most common mistake parents make, and
the mistake most closely studied by researchers. It is described in
more detail in the following pages.

Giving Too Many Medicines, or Over-Medicating, Your Child

Healthy infants and children are frequently ill with colds and
other common maladies, often more so than adults, and pharma-
ceutical manufacturers market many OTC products to treat these
illnesses. Many of these products should not be used in children,
as they have not been proven to be safe and effective in infants and
children. Yet, it is tempting to try them, and as they are often not
effective, it becomes easy to try giving more. In this case, more is
not better!

Not Administering All of the Medicine as Prescribed

The best example of this common mistake relates to antibiotics.
Antibiotics typically begin to help within 72 hours, and by 5 days
or so, your child often seems significantly improved. But generally
The Art and Practicality of Giving Medicine to Children  • 17
Table 2.1 Information points to discuss with your child’s doctor
and pharmacist about your child’s medicine

NAME OF THE MEDICINE*

Most drugs have two names—a trade name and a generic name
(for example—Tylenol [trade] is acetaminophen [generic]).
Ask if the prescribed medicine is available in a generic form.
DOSE
• For liquid medicines
• What are the volume (mL) dose and the mg dose?

(for example, amoxicillin liquid 5 mL usually is equivalent

to 400 mg).
• For tablets and capsules

• How many mg are in one tablet or capsule?

• How many tablets or capsules should I give each day?

DOSING SCHEDULE
• How many times a day should I give the medicine?
• If dosing once a day, can I give the medicine at any time
during the day?
• Can the medicine be given with meals?

• Is the medicine to be given as needed only, or scheduled

every day?
DURATION
• How long should I give the medicine?
• Some pediatric medicines are given for short durations

(for example, antibiotics).

• Other medicines (for example, those for a chronic

condition like asthma) are taken for longer durations.

BENEFITS TO YOUR CHILD
• How will the medicine help my child?
• What should I look for to be sure it is helping?
• How long will it take until the medicine begins to help?

18  •  CHILDREN'S MEDICINES

MISSED DOSES
• If I miss a dose, what should I do?
ADVERSE EFFECTS
• What are the most common adverse effects of the medicine?
• What should I do if adverse effects occur?
• What can I do to decrease adverse effects?

• Are there any rare but serious adverse effects?

STORAGE
• For liquid medicine
• Should it be stored at room temperature, in the

refrigerator, or does it not matter?

• Can the medicine be divided into different, but labeled,

containers for use at school and home?

• It is best not to store medicine in nonpharmacy-labeled

bottles. If it is misplaced or lost, whoever finds it may not

know what medicine it is.

* Keep a list of your child’s medicines (name, dose, and schedule) in your cell phone
“Notes” or on a piece of paper you carry.

antibiotics are prescribed for a course of 10 or more days. It becomes

tempting to stop the antibiotic and save it for your child’s next fe-
ver or illness, even though this antibiotic was likely prescribed for
longer.

Your Child’s New Medicine: What to Discuss

with Your Pediatrician and Pharmacist

When you are in the pediatrician’s office, or at the pharmacy pick-

ing up your child’s medicine, it is helpful to have in mind what in-
formation you should seek about your child’s new medicine. This
The Art and Practicality of Giving Medicine to Children  • 19
information, listed in table 2.1, is important for all medications.
Your child’s pediatrician and pharmacist will almost certainly talk
with you about the specific medication dose and how often the dose
should be given. Some of the other points—such as proper stor-
age—may or may not be raised.
When I have senior pharmacy students with me in the pediatric
clinic I attend, I give them an index card containing the discussion
points listed in table 2.1 so they can use it as a guide when coun-
seling patients on newly prescribed medicines. I have seen many
instances of parents either not being given all of this information,
or of not quite understanding how to use the information they re-
ceived. Even with the best of intentions, parents sometimes forget
what they have been told (it’s easy to do when you are concerned
about a sick child). As a consequence of not having information,
not understanding information, or forgetting information, a parent
may not administer a medication correctly and it will not help as
much as it would have if it had been given properly.
Consider these points when discussing your child’s medicine
with your pediatrician or pharmacist.

Dosing Schedule
For many medications, the time of day it is given, or the spac-
ing of doses (how many hours pass between doses), is not critical.
What’s important with these medications is that all of the daily dos-
es are indeed given, and that the dosing schedule is the best fit for
you and your child’s daily routine. For medications prescribed once
daily, it may not matter if the medication is given in the morning,
at noon, or at bedtime. For some medications, however, it does mat-
ter, so ask about this. Some medications may cause drowsiness or,
alternatively, may be somewhat stimulating; these properties of the
medication may affect what time of day you give the medicine (give
at bedtime, or in the morning, respectively).
Morning is often a hectic time for many school-aged children
or adolescents, so giving medicine in the afternoon or evening may

20  •  CHILDREN'S MEDICINES

work better with their schedules. When medications are prescribed
to be given three times a day to school-aged children, ask if the med-
icine can be administered before school, after school, and in the
evening, instead of at school, which may be difficult to arrange.
For medications prescribed “every 8 hours” or “every 12 hours,”
and so on, the timing is usually not critically important. For ex-
ample, if the second daily dose is given 9 to 10 hours, instead of
12 hours, after the first dose, this likely will not affect the medica-
tion’s benefit or have any adverse effects for your child. However,
ask the doctor or pharmacist about how important the schedule
is, to be sure. For some medications, such as those for treating sei-
zure disorders, dose schedule timing may be more important. I’ve
seen many families where medicine doses were missed because they
could not strictly adhere to this type of schedule, and the families
were concerned about giving doses too close or too far apart. It’s also
important to be consistent—strive to give the medicine at approx-
imately the same time each day, once you settle on a good schedule
for you and your child.

Benefits to Your Child

Some medicines work quickly, within 1 hour, to help your child
feel better. Good examples are medications for fever and pain, such
as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil). Other
medicines may not begin to significantly help your child for 1 to
2 weeks, or longer. Examples include many antidepressant medica-
tions, such as fluoxetine (Prozac).
It is important to understand how you or your child will know if
the medicine is helping. Don’t hesitate to ask your pediatrician or
pharmacist, “How will I know if the medicine is helping my child?
What should I look for?” I have spoken with adolescents who had
been prescribed antidepressants but had stopped taking them be-
cause they did not know if they were making a difference. After we
talked about how they might not recognize that the medication was
helping them, they realized the medicine was beneficial.

The Art and Practicality of Giving Medicine to Children  • 21

 Missed Doses
Everyone, including me, forgets a dose of his or her medicine at
times. What should you do once you realize that you missed a dose
of your child’s medicine? This depends upon the specific medicine
and how long it has been since the scheduled time of the dose. For
many medications, even if several hours or more have passed since
the scheduled time, it is better to give the missed dose instead of
skipping it. This is not true for all medications, however, so ask what
to do if a dose is missed. Many patients have told me over the years
that they skipped doses completely because they missed their nor-
mal scheduled time. If this happens 2 or 3 days each week, which can
be easy to do, the result may be that the medicine provides much
less benefit.

Adverse Effects
One aspect of giving medicine to children that concerns many
parents is a medicine’s adverse effects. This is certainly understand-
able. When you leave the pediatrician’s office or the pharmacy, you
should have no lingering or unanswered concerns about your child’s
medicine. All medications have potential to cause adverse effects.
Adverse effects that nearly all oral medications may cause include
nausea, vomiting, diarrhea, headache, or drowsiness/dizziness.
Some of these effects may be minimized by, for example, giving
some medications with meals (note, though, that some medications
must not be taken with food).
A word of caution about the printed information you may re-
ceive at the pharmacy along with your child’s new medicine, or what
you read online about a medicine. The adverse effects listed in the
medication’s labeling (see chapter 1 for more on medication label-
ing) may not necessarily occur with your child. These listed adverse
effects, which typically are many, occurred when the medication
was studied and tested, and may or may not have directly resulted
from the medication. As described in table 2.1, ask what adverse
effects commonly occur with your child’s medicine and what you

22  •  CHILDREN'S MEDICINES

can to do minimize or prevent them. Ask what more serious adverse
effects may occur and which adverse effects make it necessary to
stop the medicine or return to your pediatrician’s office.
Some parents state that they are concerned about a medication’s
“toxicities.” This is not the same as a medication’s adverse effects, or
side effects. Adverse effects of a medication are unwanted and un-
intended effects of the medication. For example, antibiotics com-
monly produce nausea or loose stools—unwanted effects. Adverse
effects can occur with just one dose of a medication—they can be
mild or severe, common or uncommon, and predictable or unpre-
dictable. Toxicity refers to the effects that occur from a medication
dose that is greater than the normal therapeutic dosing range (the
amount of medication normally given to treat a medical condition).
Acetaminophen (Tylenol) is a very safe medication when given in
normal doses to infants and children, and it has few adverse effects.
However, if too much acetaminophen is given—if a toxic dose is
given—acetaminophen can cause liver failure and be fatal.
It is also important to evaluate “benefit-to-risk” considerations
for your child’s medicines. As with nearly everything in life, there
are benefits and risks in what we do. The benefits, which should be
greater than the risks, include things like reducing a fever, curing
an infection, improving breathing difficulties from asthma, or pre-
venting a seizure. The risks entail medication adverse effects, which
often are not serious or are manageable. However, some can be seri-
ous. When the benefits to children of some medications or supple-
ments are not proven, then the risks are greater than the benefits.
Examples include OTC antidiarrheal medicines and many supple-
ments (see chapter 3 for more information). This is a very important
concept to understand and appreciate. Studies of pediatric medica-
tion adverse effects are described later in this chapter.

As Needed, or Every Day?

An important distinction to know about your child’s medicine
is whether it should be given on a regular daily schedule or only

The Art and Practicality of Giving Medicine to Children  • 23

as needed. Medicines for fever, such as acetaminophen (Tylenol)
and ibuprofen (Motrin, Advil), are typically given as needed, when
your child is uncomfortable or has a high body temperature. Other
medicines should not be given only as needed, and are most effec-
tive when given daily, even if the child feels well and has no appar-
ent symptoms from the illness. Examples of medications scheduled
for every day administration are many asthma medicines, such as
Flovent (fluticasone) or Singulair (montelukast), and many med-
icines for seizure disorders, such as Tegretol (carbamazepine) or
Dilantin (phenytoin). It is easy to confuse some asthma medicines,
such as some metered dose inhalers (Proair [albuterol] or Proventil
[albuterol]), which are mostly given as needed when the child has
difficulty breathing. Other metered dose inhalers, such as Flovent
(fluticasone), should be used every day, whether or not the child has
breathing difficulty, and are not effective when used only as needed.

The Art of Giving Medicine to Children

All parents know the difficulties of giving medicine to infants and

children. Beyond these relatively “simple” difficulties are potential
problems that many parents may not be aware of, such as accurately
measuring liquid doses. Most medicines given to infants and young
children are liquids. Accurately measuring a dose of these liquid
medicines is important and, as studies have shown, it can be quite
difficult. Beyond accurately measuring a dose of liquid medicine
comes the “art” of getting your infant or young child to take the
medicine. Color, texture, smell, and, perhaps most important, taste
of the liquid medicine all come into play. What can be done to en-
tice your child to take his or her medicine?

Dosing Devices
I recall my mother giving me liquid medicine on a teaspoon
when I was a young child. We have known for many years that this
is not an accurate way to measure and give medicine. The pediatric

24  •  CHILDREN'S MEDICINES

medical community and professional medical organizations have
recently published specific recommendations stating not to use
kitchen teaspoons or tablespoons to give liquid medicine. Back in
1975 the Committee on Drugs of the American Academy of Pe-
diatrics (AAP) stated in a report titled “Inaccuracies of Adminis-
tering Liquid Medication” that “teaspoons are particularly poor
measuring and administering devices.” This report also discussed
how much the size of kitchen teaspoons varies, delivering between
50 percent and 156 percent of the amount medically considered to
be a teaspoonful, which is 5 mL (milliliters). Other studies have
found that teaspoons vary in their delivery of liquids by 60 percent
to 180 percent.
In 2015, 40 years later, the AAP Committee on Drugs published
a similar report again advising that kitchen or household teaspoons
and tablespoons not be used to measure and deliver liquid medi-
cines. This report also recommended that pediatricians and other
prescribers stop writing prescriptions using teaspoon or tablespoon
amounts. Unfortunately, some prescribers continue to write pre-
scriptions this way. Several studies have documented that, when
given the opportunity to choose a dosing device to measure liquid
medicine, many parents choose a household teaspoon instead of
other, more accurate, dosing devices. The 2015 AAP report included
several important recommendations:
◆ Oral liquid medicine volumes should be expressed with
metric system units, such as mL (milliliters), not with
teaspoonsful or tablespoonsful.
◆ Pharmacy bottle labels should state volumes as mL and not
teaspoon or tablespoon, for example, “Give 5 mL twice a day,”
not “Give 1 teaspoonful twice a day.”
◆ Accurate dosing devices should be given to parents with all
liquid medicines.
What are accurate measuring devices? Dosing devices evaluat-
ed in published studies include oral syringes, cylindrical spoons,

The Art and Practicality of Giving Medicine to Children  • 25

droppers, and dosing cups. Several studies have demonstrated oral
syringes to be the most accurate. Dosing cups, which are typically
made of plastic and available with OTC liquid medication product
packages, are often kept in homes and re-used by parents for giving
different liquid medicines to their children. When comparing the
accuracy of measuring 5 mL liquid volumes with dosing cups and
oral syringes by parents, a study in 2008 and another in 2016 found
dosing errors to be four times and five times more likely when dos-
ing cups were used, as compared to when oral syringes were used.
One of these studies also demonstrated that even though oral sy-
ringes were more accurate, only 67 percent of parents using them
correctly measured an accurate dose, indicating that even oral sy-
ringes can be frequently used improperly or inaccurately.
Explanations of dosing technique given by parents enrolled in
these studies is revealing. Some parents confused “teaspoonful”
with “tablespoonful” (a tablespoonful is 15 mL, three times greater
than a teaspoonful, 5 mL), and others believed a full dosing cup was
the standard dose. In summary, practical recommendations from
these studies include the following suggestions:
◆ Request an oral dosing syringe at the pharmacy for your
child’s liquid medicine, and ask to be shown where on the
syringe to measure your child’s dose (one published study
demonstrated this as the most accurate method).
◆ Consider a smaller size oral syringe if you are administering
liquid medicine to an infant. Smaller syringes are more
accurate when measuring smaller liquid doses. Oral syringes
can be especially useful when administering liquid medicine
to your infant, as you can place the syringe just inside your
infant’s mouth and he or she will naturally begin sucking the
medicine out.
◆ Consider other dosing devices sold in pharmacies—droppers
and dosing spoons, although they may not be as accurate or
as easy to use as an oral syringe.

26  •  CHILDREN'S MEDICINES

 ◆ Avoid using dosing cups, since they are not as accurate as
measuring devices and it’s best not to use them to measure
most liquid medicines; exceptions can include larger volumes
of liquid for older children or adolescents.
◆ Use mL (milliliters) for measuring liquid medicines, not
teaspoonsful or tablespoonsful, and ask your pediatrician and
pharmacist to clarify your child’s medicine dose as mL.
◆ Take extra care when measuring and administering liquid
medications. Studies of parents have shown it can be easy to
make errors when giving liquid medicine to children.

Taste of Liquid Medicines

The taste of liquid medicine is an important factor when admin-
istering medications to children. An effective medicine will not help
your child if he or she refuses to take it, which can be frustrating.
Pharmaceutical manufacturers strive to make their liquid medicine
products appealing to children, focusing not just on taste but also
considering the appearance or color, smell, texture, and viscosity.
Fortunately, most liquid medicines given to children taste relatively
good. Some medicines, however, are chemically bitter and this is
hard to mask in a liquid medicine product. Several taste tests of
liquid medicine products have been published, mostly focusing on
antibiotics. Antibiotics that adults rated as tasting good in these
taste tests include:
◆ amoxicillin
◆ amoxicillin-clavulanate acid (Augmentin)
◆ cefdinir (Omnicef )
◆ cefprozil (Cefzil)
◆ azithromycin (Zithromax)
Medications scoring less well on taste (that is, testers did not like
their taste) include:
◆ cefpodoxime (Vantin)

The Art and Practicality of Giving Medicine to Children  • 27

 ◆ cefuroxime (Ceftin)
◆ clarithromycin (Biaxin)
◆ penicillin
◆ clindamycin
◆ some prednisolone products (the product Orapred
may taste better)
What can you do if your child’s pediatrician prescribes one of
the medications above that does not taste good? Several methods
may help your child successfully take the medicine. The following
tips may be helpful:
• Ask your pharmacist to flavor the medicine.

Many pharmacies have standardized flavoring systems, such as

FlavorRx, that utilize many different flavors to add to a liquid med-
ication. They may charge an additional fee for this (usually about $3
extra). FlavorRx offers a variety of flavorings for liquid medication
products that may be appealing to your child, such as chocolate,
mango, orange, and watermelon. Your child can choose from bub-
blegum, grape, raspberry, or grape-bubblegum flavor enhancers to
improve the taste of Vantin (cefpodoxime), an antibiotic common-
ly prescribed for children with ear infections. Ask if your pharmacy
is able to do this.
• Offer your child a teaspoonful of sweet syrup before or after
administering the medicine.

Try giving your child a teaspoonful of chocolate (or butter-

scotch, strawberry, or maple) syrup just before and after giving the
liquid medicine. This may help “bribe” your child, as it tastes good,
and the syrup can coat the tongue and help to mask the liquid med-
icine taste. You can also try honey, as it has a sweet flavor. A word of
caution, though—do not give honey to infants younger than 1 year
of age, as it may contain certain bacterial spores that can be danger-
ous to young infants. Some strong-tasting juices, such as grape juice

28  •  CHILDREN'S MEDICINES

(purple or white), can be similarly used, to give before and after the
liquid medicine, to help mask its taste.
• Mix the liquid with applesauce, pudding, or jellies/jams.

If you try mixing a liquid with applesauce, pudding, or jellies, be

sure to mix them well together. In addition, be careful not to use
too much, as your child may not want to finish all of it, and conse-
quently won’t get the full dose of medicine. Use enough, however,
to mask the medicine taste.
• Give a popsicle or refrigerate the medicine.

Many liquids, such as orange juice, taste best when cold, and
chilling your child’s medicine can also help it taste better. Ask your
pharmacist if your child’s liquid medicine can be refrigerated. It is
important to ask, because some liquid antibiotics, such as clarithro-
mycin (Biaxin), should not be refrigerated (it can thicken up a lot
when stored in a refrigerator). Giving a popsicle before the medi-
cine can also be helpful, as a cold tongue may not detect the liquid
medicine taste as much.
• Give a good tasting liquid or nutritional formula just
after the medicine.

Give another liquid that your child likes, such as milk or juice, or
your infant’s nutritional formula, just after the liquid medicine, as
this can help flush the medicine taste out of the mouth.
• Give your child’s liquid medicine when he or she is
likely to be hungry.

Your child is more likely to eat and drink when he or she is hun-
gry. Check with your pharmacist to be sure that the medicine can
be given with food or the drinks discussed above, as some medicines
are best absorbed on an empty stomach (1 hour before or 2 hours
after a meal).

The Art and Practicality of Giving Medicine to Children  • 29

 • Try mixing your child’s medicine in with nutritional formula or
expressed breast milk (in the same bottle) or in with a liquid that
your child likes, such as chocolate milk.

Check with your pharmacist first to be sure that there are no

problems with mixing the medicine this way (you want to avoid
affecting the medication’s chemical stability). Don’t use too much
formula or liquid since your child may not finish the full amount
and consequently will not get all of the liquid medicine. For exam-
ple, if your infant normally has 6 to 8 ounces of formula per feeding,
try mixing about 3 ounces of formula with the medicine (when he
or she is likely to be hungry), and then give the remaining amount
of formula.
• Invest in a novel delivery device.

If you’re still having trouble getting your child to take the medi-
cine, you can try some interesting and helpful devices available on-
line (and perhaps in your pharmacy) that function by giving liquid
medicines together with nutritional formula or other liquids, such
as pumped breast milk. Some of these devices combine an oral dos-
ing syringe within a bottle and nipple, so the formula or milk is
taken together with the liquid medicine. Examples include Medi-
bottle, Reliadose, and Munchkin. Another device, Pacidose, com-
bines a pacifier directly with an oral dosing syringe, to encourage
an infant or young child to take the liquid medicine. These devices
seem reasonable to try.

This discussion of liquid medicine taste has centered on prescrip-

tion liquid medicines. Your child may also not like the taste of some
liquid OTC products, such as acetaminophen (Tylenol) or ibupro-
fen (Motrin, Advil). Similar to some prescription medications,
OTC medication products are available as trade products, such as
Tylenol, and as generic products. Many retail pharmacy chains or
pharmacies located in grocery store chains carry their own generic

30  •  CHILDREN'S MEDICINES

brand. Either the trade or generic product can be used, although
generic products are likely to be less expensive. Their taste, howev-
er, may differ from the trade products, similar to trade and generic
prescription medication products. I recall when my son was young
and had a fever. We were out of Tylenol, so I went to the pharmacy
to buy more (of course it was late at night). I noticed that a generic
form of infant’s acetaminophen was much less expensive than the
trade product, Tylenol, and I bought several boxes of the gener-
ic product. Well, my son must not have liked the taste because he
wouldn’t take the generic product. Back to the pharmacy I went
to buy the trade product Tylenol. He liked this better and took it
easily. I tried the tastes of both, and I agreed that the trade product,
Tylenol, tasted better than the generic product.
When giving an OTC liquid product to your child, use the dos-
ing device that comes with the package, as this device should match
the product package dosing instructions and you will be less like-
ly to make an error when measuring an appropriate dose for your
child’s weight.

Techniques for Giving Liquid Medicine

Technique makes a difference when giving any liquid medicine.
Use an oral dosing syringe and slowly administer the liquid toward
the side of your child’s mouth, not directly on the tongue (where
the taste buds are). In this way the medicine flows toward your
child’s throat, is more easily swallowed, and bypasses the taste buds.
Do not quickly squirt the liquid medicine into the back of your
child’s mouth, as he or she may choke. Young children may want to
help by holding the oral syringe or by sucking the medicine out of
the syringe. If for some reason your child does not seem to be swal-
lowing the medicine, you can try gently holding his or her cheeks
together and then lightly stroking under the chin. When adminis-
tering liquid medicine to infants, have another adult hold the in-
fant, including his or her arms. Older infants or young children can
be placed in an infant car seat or high chair used for eating. When

The Art and Practicality of Giving Medicine to Children  • 31

you are done, rinse the oral syringe with water. Don’t let your child
play with the dosing syringe, as he or she could potentially choke on
it. Store it in a safe place.

Giving Tablets and Capsules to Your Child

A common question parents ask is, “When should my child be
able to swallow a tablet or capsule?” There is no specific age when
a child should be able to swallow a tablet or capsule. I’ve seen some
2-year-olds who can swallow tablets, and some adolescents who
can’t. Several pediatric medicine textbooks state that by age 6 or
7 years, most children are able to swallow tablets, but this varies
widely and is not a golden rule.
If your child is unable to swallow a tablet whole, don’t fret. There
are several options you may try. Perhaps the easiest is to cut the tab-
let into two halves or even four quarters and let your child try swal-
lowing these smaller pieces. Many medicine tablets are “scored”—
they have a line in the middle of the tablet that can be used to more
easily break the tablet into two pieces. You may be able to do this
with your fingers, or you could use a tablet splitter (available at most
pharmacies for a few dollars). Some tablet medications should not
be broken or split (for example, coated tablets or slow-release tab-
lets), so check with your pharmacist before doing this. You may ask
your pharmacy to split all of your child’s tablets when you first pick
up the prescription, or call in a refill. Some pharmacies will gladly
do this, while others will not, but it is reasonable to ask.
Some medications, such as amoxicillin and amoxicillin-clavulanate
(Augmentin), are also available as chewable tablets or tablets that
dissolve quickly in the mouth, and they typically taste good. An-
other option is to crush the tablet into many small pieces or a pow-
der and give this. While this is commonly recommended, it can
be hard to do and may not be accurate, since it can be difficult to
gather up the entire crushed tablet pieces. If you try this, it is best
to crush the tablet in a small bowl (or use a tablet crushing device
sold in pharmacies) and then mix the small pieces together well

32  •  CHILDREN'S MEDICINES

with jelly or jam and give this to your child. When you mix medi-
cines with food as described here and above with liquid medicines,
always give the mixture to your child immediately after you prepare
it, and do not save it for later or prepare doses ahead of time. Be-
cause of potential chemical instability, mixing medicines like this
several hours in advance may affect the potency of the medication.
In addition, check with your pharmacist to be sure that your child’s
medicine can be given with food and is not supposed to be taken
on an empty stomach.
Some medicine products are also available as capsules that can be
easily opened up and sprinkled onto food and given this way. Your
child’s pediatrician is likely familiar with these pediatric sprinkle
capsule dosage forms, but you can ask if your child’s medicine is
available as a sprinkle capsule. The type of food that many of these
sprinkle capsule dosage forms are given with is important, so be sure
to ask about this at the pharmacy. Most capsules are not specifically
designed to be sprinkled onto food, although the contents of some
capsules can be mixed with food. The powder contents are likely to
taste bitter or bad, however, so mix it with a food that has a strong
good taste, such as jelly or jam. Check with your pharmacist before
doing this, to make sure there are no chemical stability problems.
If you want to help your older child swallow his or her tablets or
capsules, several devices may be useful. A review of this subject pub-
lished in 2014 found that certain head posture techniques, behav-
ioral therapies, flavored throat sprays, and swallow tablet cups were
effective. The head posture techniques and behavioral techniques
are too complex to fully explain here, and are likely best demon-
strated by and practiced with supervision by health care profession-
als at children’s hospitals located in large cities. A device that can
help children (and adults) swallow tablets and capsules is Oralflo.
This device looks like a children’s sippy cup and has a pocket inside
to place the tablet or capsule. When the cup is filled with liquid, the
medicine more easily slides out with the liquid, to be swallowed.
Another aid that can be tried is Pill Glide, a lubricant sprayed into

The Art and Practicality of Giving Medicine to Children  • 33

the mouth that reduces friction between the medicine and throat
and mouth, helping the tablet or capsule slide and be swallowed
more easily.

Other Issues When Giving Medicine to Children

Your Child Vomits After Taking Medicine
Once your child has swallowed his or her medicine, thanks in large
part to your efforts in preparing the medicine and coaxing him or
her, it’s always possible that soon after, he or she will vomit. What
do you do then? Should you give another dose, or out of fear of
giving too much medicine, let it be? This depends on several factors,
including the specific medicine given and the time between giving
the medicine and your child vomiting. Parents are often told if it has
been less than 1 hour since giving a medication, another dose can be
administered. This may not apply to all medicines, however. Liquid
medicines are absorbed into the bloodstream faster than tablets or
capsules. Most liquid medicines are absorbed in less than 1 hour,
and if your child vomits 45 minutes after swallowing a liquid med-
icine, another dose is likely not necessary.
If the medication was a tablet, it can be helpful to look at your
child’s vomit for visible pieces of the tablet. If you see some, much
of the tablet probably was not absorbed. It is also important to con-
sider the specific medication your child was given, and its potential
for adverse effects. Some medications can cause significantly more
adverse effects with only one or two doses above the current dose,
while other medications, such as many antibiotics, are unlikely to
cause more adverse effects with one or two extra doses. Check with
your pediatrician before giving more medicine after your child has
vomited.

Giving Medicine with or without Food

Some medications are best given on an empty stomach, as food
in the stomach delays or reduces how much of the medication is

34  •  CHILDREN'S MEDICINES

absorbed into the blood. An example is penicillin, the antibiotic of
choice for strep throat infections. Penicillin is best absorbed with
an empty stomach, although it can be given with food, if nausea
occurs. Another antibiotic best given without food is tetracycline.
Because dairy products bind with tetracycline in the stomach and
reduce how much is absorbed, they should be especially avoided.
Infants and children seem to be hungry nearly all of the time, and
they can have food in their stomachs most hours of the day. If a
medicine should be given on an empty stomach, which is typically
described as 1 hour before a meal or 2 hours after a meal, the timing
of giving the medicine with your child’s eating can be quite difficult.
Other medications are best given with food, as food increases the
amount of medication absorbed, or more commonly, food reduces
the likelihood of nausea or vomiting occurring. Amoxicillin-clavu-
lanate (Augmentin), an antibiotic commonly used in pediatrics, is
best given with food to decrease the potential for adverse effects
of nausea, vomiting, or diarrhea. The antifungal medication gris-
eofulvin is best given with food, since food increases the amount
absorbed.
Whether to give some medicines with or without food can also
depend on the dosage form of the medicine, and not the medicine
per se. Fortunately, whether to give a medication with or without
food is not significantly important for many medicines. Your phar-
macy will counsel you on how your child’s medicine is best given,
with or without food, or either. If you are not sure, ask your phar-
macist.

Giving Medicine at School or Daycare

Your child may need someone at school or daycare to adminis-
ter his or her medicine. Schools and daycare establishments have
widely varying policies about giving medicine to children, and it is
best to contact your child’s school or daycare before you send med-
icine along with him or her. Your child’s school or daycare medicine
should be sent in a regular pharmacy-labeled container, similar to

The Art and Practicality of Giving Medicine to Children  • 35

what the pharmacy normally dispenses. Ask the pharmacy to place
your child’s medicine into similar home and school or daycare bot-
tles and vials with labels. The pharmacy will place various stickers
on the vials as necessary, such as “Take with Food,” or “Store in
the Refrigerator,” which will help ensure that the medicine is given
properly.
Do not send your child to school with medicine in a baggie or
other nonpharmacy containers, even if the medicine is an OTC
medication such as ibuprofen (Motrin, Advil). Nursing offices at
schools have bottles of these common OTC medications when a
child is in need, such as for headache or other mild pain. The school
nurse will likely call you for approval before giving any medicine, or
you may be asked in advance to sign an authorization form.
All schools should allow your child to carry his or her asthma
inhaler (such as albuterol), to be used as needed when your child
has breathing difficulties. Your child may need access to this inhaler
quickly when breathing difficulties begin. The school will probably
require a signed consent note from you and your pediatrician al-
lowing this use, and the school nurse may ask your child to demon-
strate that he or she can properly use the inhaler. Inhalers are best
sent properly labeled with a pharmacy label attached directly on the
inhaler, and not just on the inhaler product box. Schools may also
allow other medicines to be carried by a child, if this medicine is
necessary for quick use by the child for a specific medical condition.
Speak with your child’s pediatrician and school to determine this.
States have varying policies for allowing medicine to be given at
daycare establishments. If your infant or young child attends day-
care, speak with the daycare personnel before sending medicine. Just
as in a school setting, you will need to sign a consent allowing the
medicine to be given, and the medicine should be correctly labeled.
The daycare workers should be properly trained to administer med-
icines. Ask about this. Your local or state health department can
be a valuable information source about your state’s laws regulating
daycare establishments.

36  •  CHILDREN'S MEDICINES

 Adherence: The Importance of Taking Medicine

There are numerous reasons why children do not receive all of the
medicine that is prescribed for them, including forgetting, concerns
about adverse effects, cost of the medicine, belief that the medi-
cine is no longer necessary once the child has begun to feel better,
misunderstanding the directions, or a stigma associated with taking
some medicines (such as antidepressants), among others. Forget-
ting doses is perhaps the most common reason, and it easily occurs,
especially in a busy home or lifestyle. Nonadherence is the term used
to describe not taking medicines as prescribed or recommended.
Recognizing the potential for nonadherence with your child’s med-
icines is very important, and some relatively simple solutions can
help you avoid many of the causes of reduced adherence.
The majority of children—63 percent—diagnosed with a chron-
ic illness are prescribed at least one medicine. Unfortunately, studies
have demonstrated that 50 to 88 percent of children who have a
chronic illness, such as asthma or diabetes, do not take all of their
prescribed medicine. Even though common sense suggests this,
many studies have documented that medication adherence for asth-
ma and diabetes, and other serious conditions, is beneficial, since
children taking their medicine are less likely to be admitted to a
hospital and are healthier. Numerous studies have been published
in the medical literature about adherence to medication and other
illness treatment recommendations given by physicians and health
care professionals. Overall, these studies suggest that beneficial
strategies can be used by parents to improve medication adherence
and their child’s health. Strategies that parents can employ are de-
scribed as behavioral and educational.
Behavioral strategies include instituting reminders to prevent
missed doses because of forgetfulness, such as setting phone alarms,
using pill boxes, or posting notes in your home. I frequently suggest
to parents and adolescent patients that they link taking their med-
icine with a personal habit that is already established, such as teeth

The Art and Practicality of Giving Medicine to Children  • 37

brushing. Place the medication vial next to your child’s toothbrush,
as a visual reminder. Rewarding your young child when medicine is
taken can also be helpful. Children and adolescents with a chron-
ic disease such as asthma or diabetes can significantly benefit from
involvement in local or national organizations representing the
illness, as these organizations often have peer and parent support
groups with local meetings where participants can hear from other
parents about their success stories or frustrations with giving med-
icine to their children.
Educational strategies can also be helpful. These include being
sure that you completely understand how your child’s medicine is
appropriately given, including the information listed in table 2.1.
This may seem rather simplistic, but it is important. I have spoken
with many parents or adolescents who misunderstood how their
medicine was supposed to be taken, and they mistakenly took the
medicine only once daily instead of twice daily, as prescribed. It is
easy to get confused, especially when you are given a lot of informa-
tion in the pediatrician’s office and in the pharmacy when the medi-
cine is initially prescribed. A common problem I hear from parents
relates to missing doses. Nearly everyone likely misses occasional
doses of his or her medicine, but if it happens frequently, the doses
missed can significantly add up and decrease the medicine’s benefit.
Be sure to ask your pharmacist and pediatrician what you should do
if you miss a dose of your child’s medicine. For many medications,
the missed dose can safely be given later.
Studies have shown the simpler the medication directions or
regimen, the better—that is, the more likely that the medicine will
be given. For example, adherence to a medicine that is dosed three
times daily is likely to be less than to a medicine that is dosed twice
daily. Discuss dosing schedules with your pediatrician, and ask your
pharmacist how you can adapt your child’s medicine regimen to
your daily home lifestyle. These discussions can be very helpful to
you. Nonadherence with medication reaches a peak in the adoles-
cent years—a time that can be very frustrating to parents. Being

38  •  CHILDREN'S MEDICINES

aware of this potential, and discussing it with your adolescent’s pe-
diatrician, can be helpful.
It is important to be honest with your pediatrician and phar-
macist when they ask about medication adherence. No one likes
to be thought of as a “bad parent,” but if your child is not receiving
all of his or her medicine, your doctor needs to know. Health care
professionals understand the difficulties of giving medicines to chil-
dren or adolescents. Sharing your difficulties and concerns about
your child’s medicine will likely be very helpful, as your pharmacist
and pediatrician will be able to suggest methods for improvement. I
have heard from parents and adolescents about their concerns with
a medicine’s adverse effects, and at times they have been reluctant
to admit that their source was what they read on the Internet or
what a neighbor may have told them about their child’s medicine
(which often is misleading or false). Occasionally, cost and paying
for medicines may be a concern, especially as medicine costs are
rising and health insurance drug coverage is decreasing. If cost is a
concern, pediatricians and pharmacists may well be able to help, by
prescribing less expensive medicines or by utilizing pharmaceutical
company rebates and discounts.

Benefits versus Risks of Medicine

As discussed previously in this chapter, giving any medicine to your

child involves certain benefits and risks. Benefits of giving medi-
cine include helping your child feel better (reducing pain or fever),
treating a chronic illness (such as asthma), or curing an infection
(such as an ear infection). These benefits can be large and poten-
tially life-saving. Risks and disadvantages of giving medicine involve
medication adverse effects, allergic reactions, a potential for toxicity
or poisoning, difficulties of giving the medicine, and cost, among
others. The benefits should be greater than the risks; otherwise, the
medicine is best not given.
In this section, I explore this principle more closely, and discuss

The Art and Practicality of Giving Medicine to Children  • 39

the many studies that have evaluated medication adverse effects and
other risks in large populations of children. One of the main points
that this discussion will lead to is this: all medicines have a potential
for risk. It is common in our society to treat nearly any symptom or
any illness we have, even minor illnesses, with medicine. Children
are not small adults, and the risks of using medicine in children
can be greater than the benefits for some illnesses (these will be ex-
plained in more detail throughout this book). Thus, if a medication
is unlikely to help your child, and as it may cause adverse effects or
other risks, it is best not used. This is an important principle.
Several recently published studies have evaluated and docu-
mented medication risks in pediatrics. A study published in 2014
analyzed medication errors that occurred in settings outside of a
hospital (at home or other areas) in children over an 11-year period.
During this time, 696,937 children younger than 6 years of age ex-
perienced a medication error—this averaged to a medication error
occurring every 8 minutes! The errors included accidentally giving
a medicine twice and giving incorrect doses or measuring doses in-
accurately, among others. In this study, the younger the child, the
greater the likelihood of a medication error occurring—25 percent
of all the errors occurred in infants younger than 1 year of age, and
25 children died as a result of these errors.
In a study published in 2008 the researchers evaluated visits to
hospital emergency departments because of adverse effects from
antibiotic use in children and adults over a 3-year period. The
majority, 79 percent, of the 6,614 cases identified were due to al-
lergic reactions from the antibiotic. Children 14 years of age and
younger accounted for 25 percent of all of the cases. The highest
rate of antibiotic allergic reactions occurred in infants younger than
12 months of age. When these occurrence rates are extrapolated to
all hospitals in the United States, 37,000 visits by children 14 years
of age and younger to hospital emergency departments occur each
year because of adverse effects from antibiotic use.
In an article published in 2013, the authors reviewed 11 published

40  •  CHILDREN'S MEDICINES

studies about medication-related emergency department visits and
hospital admissions (described as adverse medication events in
this study) in the pediatric population. The researchers found that
adverse reactions, overdoses, and allergic reactions were the most
common occurrences, with antibiotics the most common class of
medication responsible. Perhaps most important, the researchers
determined that 20 to 67 percent of the adverse medication events
were preventable. Many additional published studies have shown
that the most common medication error that occurs in infants and
children involves errors with medication dosing.
What do these studies tell us? They reveal that medicine use
in children, and especially in infants and younger children, can
result in many unwanted and potentially serious—including
death—adverse effects. It is best not to give medicine to your in-
fant or child unless it will benefit them. Discuss benefits and risks
with your pediatrician and pharmacist before a new medicine is
begun and given to your child. Ask what the benefits and risks of
the medicine are, and if the benefits will be greater than the risks.
Ask what safer nonmedication treatments you may be able to use
to help your child feel better.

Protecting Your Child from Medicine Poisonings

Because young children are curious, active, and mobile (and have a
tendency to put nearly anything in their mouths) they are at high-
er risk from accidental poisonings. More than 500,000 children
5 years of age and younger experience a poisoning exposure each
year. This risk peaks at about age 2 years of age. There are many
relatively simple changes you can make in your home, where most
poisonings occur, to reduce the risk of your child experiencing an
accidental poisoning. Several good Internet sites, including www
.poisonprevention.org and www.healthychildren.org, list specific
details of how to poison proof a home.
Medicines are a leading cause of accidental poisonings. Most

The Art and Practicality of Giving Medicine to Children  • 41

homes contain several medicines that can be fatal to a young child
if enough medicine is swallowed, including acetaminophen (Tyle-
nol), aspirin, and iron (including vitamins containing iron). Many
prescription medications commonly used by adults can be especial-
ly dangerous, including some antidepressants (such as amitripty-
line), medications for heart problems and pain, and medications for
high blood sugar. Just 1 or 2 tablets of some of these medications can
be fatal to a 2-year-old child.
While young adult parents may not use these medications, they
may be taken by grandparents and other older adults who frequent-
ly spend time with the children. A scenario that can easily occur
involves young children visiting their grandparents, and while the
adults congregate in the kitchen or family room, the young children
somehow manage to find grandma’s or grandpa’s medicine bottles
(more than 50 percent of grandparents have easy-open tops on their
medicine bottles) and swallow several tablets. Other medicines that
many may not consider dangerous include methyl salicylate and
camphor. Methyl salicylate can be applied to skin (one example is
Bengay) to reduce pain or it can be used as a food-flavoring agent,
as oil of wintergreen. Camphor is an active ingredient in Vicks Vapo
Rub (for treatment of cough in children) and if swallowed, just 20
mL (about 1 tablespoonful) can be fatal to a 2-year-old child. Less
than 5 mL (less than 1 teaspoonful) of concentrated oil of winter-
green can be fatal to a 2-year-old child.
Pediatricians commonly include a discussion on home poison
proofing with parents when infants are about 6 months of age, as
they then begin to become more mobile by crawling. The informa-
tion shared with you by your pediatrician and information from the
Internet sites listed above can be very helpful, and it may potentially
save your child’s life. It’s also important to know the national poi-
son control center phone number—800-222-1222—and keep it in
a handy place. By calling this phone number, you will be directed
to your local poison control center, regardless of where you live in
the United States. If your child is exposed to a potential poison,

42  •  CHILDREN'S MEDICINES

call this phone number before calling your pediatrician, as poison
control centers employ health care professionals specifically trained
in the treatment of poisonings. If your child is not breathing or is
unconscious, call 911.

Generic Medicines: Are They Safe and Effective?

The short answer to this question is, yes. Generic medicines are
equally safe and effective as the equivalent brand name medicine
and are usually significantly less expensive than the brand name
medicine. Generic medicines must be demonstrated to be bioequiv-
alent to the same brand name medication (the amount of medica-
tion absorbed and distributed to the medication’s site of action)
and to be as safe as the brand name medication. The FDA regulates
generic medicines similarly to brand name medicines. The FDA
ensures that generic medications have the same active ingredients,
strength, purity, and quality as the brand name product.
About 80 percent of all prescriptions in the United States are
generic medicines, and most generic medicines cost 80 to 85 per-
cent less than the brand name medicine. When a brand name med-
ication loses its patent or exclusivity (exclusive rights to market a
medication product by a pharmaceutical manufacturer), the cost
of the first available generic medication is usually not significantly
lower. The medication’s price decreases only about 6 months later,
when other generic companies begin producing additional generic
versions of the medication. Most generic versions of a medication
will appear different in color, size, or shape than the brand name
product. However, when the same pharmaceutical manufacturer
produces a generic version of its own brand product, to sell at a
lower price, the generic medication may look very similar to the
brand product.
All states allow generic medications to be dispensed, although
these laws may differ among states. The FDA publishes a standard-
ized book (the “Orange Book”) that pharmacies use to determine

The Art and Practicality of Giving Medicine to Children  • 43

which generic medications are bioequivalent to brand name med-
ications. I often hear parents express concerns that a generic med-
ication is not the same, or will not work the same, as the brand
name medication. While I certainly understand their concerns, I
tell them that the generic medication should treat their child’s con-
dition just as effectively and safely as the brand name product, as
both are well regulated by the FDA for purity and content.
Some medications have a narrow therapeutic index, which
implies that the difference between the medication’s efficacy and
toxicity are narrower than most medications. When a medication
with a narrow therapeutic index is used, either a blood level of the
medication or another parameter in the blood is carefully measured
and monitored to ensure that the medication concentration in the
blood does not increase to a toxic amount. If a child is receiving a
medication with a narrow therapeutic index and is doing well, it
may not be wise to change from the manufacturer of this medica-
tion to a different generic or brand name manufacturer. Your pe-
diatrician and pharmacist will discuss this with you. Examples of
these medicines include some that treat seizure disorders, such as
Dilantin (phenytoin) or Tegretol (carbamazepine).
If a medication prescribed for your child is expensive, ask your
pediatrician and pharmacist if a generic version is available. If not,
ask your pediatrician if a medication is available generically that will
be just as effective and safe as the prescribed medication. The answer
is often yes. For example, an older medicine in the same medication
class may be just as effective as the new, more expensive medication.

The Rising Cost of Medicines

The rising cost of medicine became a top news story in 2015, and
it continues to be a headline on televised national news programs
and in newspapers. How pharmaceutical manufacturers determine
medication prices is quite complex. As with other commodities
that we consume, a lack of competition for specific medications

44  •  CHILDREN'S MEDICINES

drives prices up, since a pharmaceutical manufacturer can charge
exorbitant prices when it is the only supplier of a product. This has
occurred with several medicines recently, resulting in price increases
of up to 6,000 percent when competition for a medicine dwindles.
Many factors determine what you pay at the pharmacy, includ-
ing competition (multiple pharmaceutical manufacturers produc-
ing the same medication), health insurance coverage (copay and
deductible amounts), and availability of a generic form, among
others. When a medication is available in more than one generic
form, it is likely to be significantly less expensive. When a new med-
ication is manufactured and is not available generically, it is likely
to be expensive. All medications can be placed into categories or
medication classes, according to what they are used to treat (this
is called their “indication”) and their pharmacology (their mech-
anism of action or how they function). When new medications
are introduced, quite often older medications within the same class
that function similarly continue to be available and are often less
expensive. New medications are not always better, and their high
prices may not be justified. Medications within the same class can
differ to some extent, such as one may be given once daily, as com-
pared to others in the same class given twice or three times daily.
This can be an important characteristic, and may justify a medica-
tion’s higher cost.
Insurance companies often dictate to a large extent what price
you will pay at the pharmacy. For example, an insurance company
may decide not to pay for a new, expensive medication when it is
prescribed for its insured members. If your child were prescribed
this medication by your pediatrician, you would be charged a high
price for it. The insurance company would likely pay for similar, less
expensive, medicines within the same medication class, and thus
your price at the pharmacy would be lower. Insurance companies
maintain drug formularies, a listing of prescription drugs within a
class or category, including the amount of the drug cost they will
cover, and how much you will pay. Your pediatrician may be able to

The Art and Practicality of Giving Medicine to Children  • 45

prescribe a medication for your child that is preferred by the insur-
ance company, saving you money.
What can you do to avoid paying higher costs for your child’s
medicines? When a medication is prescribed for your child, discuss
the cost of the medication with your pediatrician. If it is expensive,
ask if a less expensive medication can be used that will be just as
likely to help your child. Ask if a generic form of the medication is
available and can be prescribed. Your pediatrician’s office staff may
be able to check your insurance company’s Internet site for specific
medications covered under your plan, or you can call your insurance
company and ask for this information. Many OTC medications are
also available as generic, less expensive, products. Ask your pharma-
cist to help you choose one that is best for your child. Many patient
assistance programs are available that you may qualify for, allowing
you to save money on prescription drug costs. These programs can
be viewed on several Internet sites:
◆ Partnership for Prescription Assistance, www.pparx.org
access to more than 475 public and private patient
assistance programs
◆ RxAssist, www.rxassist.org
listing of numerous patient assistance programs
◆ NeedyMeds, www.needymeds.org
listing of numerous patient assistance programs

Expired Medications

It is best not to use an expired medicine. However, the convenience

of choosing to use a medication in your home which has a recent ex-
piration date (say, several months ago) versus driving to a pharmacy
late at night or in bad weather is also important to consider. In many
circumstances, using the expired medicine until you are able to buy
new medicine is likely a reasonable and safe option.
The pharmaceutical manufacturer’s expiration date is usually

46  •  CHILDREN'S MEDICINES

stamped in print on the bottom or side of the bottle or box for
OTC medications, and may appear as something like EXP 10/16.
Products that contain medications that are applied to the skin, such
as lotions or skin protectants may not have an expiration date on
the box or product. For prescription medications obtained at your
pharmacy, the expiration date will likely be one year from the date
it is dispensed, even when the original product bottle the pharma-
cy used had an expiration date of more than one year. A one-year
expiration date will be placed on your bottle because how you store
the medicine cannot be guaranteed to be appropriate. Storage con-
ditions, such as temperature, humidity, and light, can greatly affect a
product’s expiration date. The most appropriate conditions to store
most medicines are a cool, dry place, with low humidity. Unfor-
tunately, most medicines are likely stored in our bathrooms—not
a good place because of the high humidity. A better place to store
many medicines is in a clothing drawer, where it is cool, dry, and
dark.
Use of a medication with an expiration date long since passed
may result in the medicine not functioning as well, due to loss of
strength or potency. Consumers may be concerned that an expired
medication may somehow morph or change into a toxic or danger-
ous substance, but this is unfounded.
Several published studies have evaluated medication expiration
dates and tested medication potency at times significantly longer
than the product’s expiration date. These studies found that when
stored in the medication’s original, sealed container at room tem-
perature, many medications retain their original potency for many
years beyond the manufacturer’s labeled expiration dates. However,
it is also important to consider that nearly all medications given
to your child are not in their original container and are not stored
under ideal conditions. How you store medicine—away from hu-
midity, light, and high or low temperatures, and with the vial or
bottle top tightly in place—can significantly affect the expiration
time and potency of the medicine.

The Art and Practicality of Giving Medicine to Children  • 47

 The intended use of a medication is an additional important
consideration. Medications that may greatly affect your child’s
health with each dose, such as insulin or epinephrine auto injectors
for severe allergies, should not be used past their indicated expira-
tion date, even when they are stored under good conditions. If your
child uses one of these medications, or a medication for a similar
purpose, it is best to be aware of the medication’s expiration date
and obtain a refill at the pharmacy or a new prescription from your
pediatrician well ahead of the expiration date. It may be reasonable
and safe to use other medication products, such as acetaminophen
(Tylenol) or ibuprofen (Motrin, Advil), with recent past expiration
dates, when giving one or two doses is not as critical to your child’s
health, and when you are realistically unable to obtain more med-
icine immediately.

Summary Points for Parents

◆ Dosing errors are the most common drug error in pediatrics.

Determine an accurate dose for all OTC drugs given to your
infant or child. Ask your pharmacist to help you if need be.
◆ Use an accurate dosing device to measure your child’s liquid
medicine. Do not use teaspoons or tablespoons. As many parents
easily make mistakes measuring liquid medicine, don’t hesitate to
ask your pharmacist to show you how best to measure your child’s
dose.
◆ Your child may not like the taste of a liquid medicine and may
refuse to take it. Your pharmacy may be able to flavor your child’s
medicine and improve the taste.
◆ Before giving any new prescription or OTC drug to your child,
consider if, and how, the drug will help your child, and what
adverse effects it may cause. All drugs have potential to result in

48  •  CHILDREN'S MEDICINES

 adverse effects, and some may be severe. The benefit of any drug
given to your child should be greater than the adverse effects.
◆ It can be easy to make mistakes when giving medicine to your
child, such as missing doses. Discuss how to appropriately
give a new medicine to your child with your pediatrician and
pharmacist, and know what questions to ask.
◆ Some medicines can be very expensive. Less expensive medicines
are often just as likely to help your child. Know what questions
to ask your pediatrician and pharmacist about the cost of your
child’s medicine.

The Art and Practicality of Giving Medicine to Children  • 49