Paediatric nurses' knowledge and practice of mixing medication into foodstuff

Nurses' knowledge and practice regarding mixing medications with food: a multicenter cross-sectional study from a developing country

BACKGROUND

Different pharmaceutical characteristics of the dosage form (DF) have a direct effect on how easily oral solid medicine is swallowed. The practice of crushing tablets or opening the capsule occurs daily in the hospital, and most nurses are unknowledgeable regarding these issues. Coadministration of medications with food can cause changes in drug absorption and lead to an alteration in gastrointestinal motility, which can cause an unexpected effect on the dissolution and absorption of the drug. Therefore, this study aimed to investigate nurses' knowledge and practices regarding the mixing of medications with food or drink in Palestine.

METHODS

From June 2019 to April 2020, a cross-sectional study was conducted, encompassing nurses working in government hospitals across various districts of Palestine. The data were collected through face-to-face interviews, using questionnaires that assessed nurses' understanding and implementation of mixing medications with food. The sampling method employed was convenience sampling. To analyze the gathered information, the Statistical Package for the Social Sciences version 21 (IBM-SPSS) was utilized.

RESULTS

A total of 200 nurses participated in the study. The data show a significant difference between the median knowledge scores according to the department of work (p < 0.001). The highest median [interquartile] knowledge score of 15 [12-15] was found for nurses working in the neonatal intensive care unit. In addition, nurses in the pediatric ward and the men's medical ward had high scores of 13 [11.5-15] and 13 [11-14], respectively. In general, the results show that 88% of nurses modified oral DF prior to administration to patients. Regarding the type of food used, mixing medicine into juice was the most common procedure performed by nurses (approximately 84%); 35% of nurses used orange juice to mix with medicine. The most common reason for crushing was to administer medications to patients with a nasogastric tube (41.5%). In regard to medications, aspirin was the most frequently used drug that was crushed by the nurses (44%); however, 35.5% of nurses did not feel sufficiently trained to carry out this practice. Concerning the sources of information, 58% of nurses usually asked pharmacists for information about medications.

CONCLUSIONS

The results of this study show that crushing and mixing medications with food is common among nurses, and most nurses are unaware of the dangerous effect of this practice on patient health. Pharmacists, as medication experts, should participate in sharing knowledge about unnecessary crushing situations or when crushing should be avoided and try to find an alternative, when available, to aid administration.

Practical and operational considerations related to paediatric oral drug formulation: an industry survey

For over 15 years, US and EU regulations ensure that medicines developed for children are explicitly authorised for such use with age-appropriate forms and formulations, implying dedicated research. To shed light on how these regulations have been adopted by pharmaceutical companies and how various aspects of paediatric oral drug formulation development are currently handled, an exploratory survey was conducted. Topics included: general company policy, regulatory aspects, dosage form selection, in-vitro, in-silico and (non-)clinical in-vivo methods, and food effects assessment. The survey results clearly underline the positive impact of the paediatric regulations and their overall uptake across the pharmaceutical industry. Even though significant improvements have been made in paediatric product development, major challenges remain. In this respect, dosage form selection faces a discrepancy between the youngest age groups (liquid products preference) and older subpopulations (adult formulation preference). Additionally, concerted research is needed in the development and validation of in-vitro tools and physiology based pharmacokinetic models tailored to the paediatric population, and in estimating the effect of non-standard and paediatric relevant foods. The current momentum in paediatric drug development and research should allow for an evolution in standardised methodology and guidance to develop paediatric formulations, which would benefit pharmaceutical industry and regulators.

Impact of Food and Drink Administration Vehicles on Paediatric Formulation Performance Part 2: Dissolution of Montelukast Sodium and Mesalazine Formulations

Paediatric medicines are not always age-appropriate, causing problems with dosing, acceptability and adherence. The use of food and drinks as vehicles for medicine co-administration is common practice, yet the impact on drug bioavailability, safety and efficacy remains unaddressed. The aim of this study was to use in vitro dissolution testing, under infant simulating conditions, to evaluate the effect of co-administration with vehicles on the dissolution performance of two poorly soluble paediatric drugs. Dissolution studies of mesalazine and montelukast formulations were conducted with mini-paddle apparatus on a two-stage approach: simulated gastric fluid followed by addition of simulated intestinal fluid. The testing scenarios were designed to reflect daily administration practices: direct administration of formulation; formulation co-administered with food and drinks, both immediately after mixing and 4 h after mixing. Drug dissolution was significantly affected by medicine co-administration with vehicles, compared to the direct administration of formulation. Furthermore, differences were observed on drug dissolution when the formulations were mixed with different vehicles of the same subtype. The time between preparation and testing of the drug-vehicle mixture also impacted dissolution behaviour. Drug dissolution was shown to be significantly affected by the physicochemical properties and composition of the vehicles, drug solubility in each vehicle and drug/formulation characteristics. Ultimately, in this study, we show the potential of age-appropriate in vitro dissolution testing as a useful biopharmaceutical tool for estimating drug dissolution in conditions relevant to the paediatric population. The setup developed has potential to evaluate the impact of medicine co-administration with vehicles on paediatric formulation performance.

Medicines Acceptability in Hospitalized Children: An Ongoing Need for Age-Appropriate Formulations

Although knowledge on medicine acceptability remains fragmented, this multi-faceted concept has emerged as a key factor for compliance in pediatrics. In order to investigate the acceptability of medicines used in the University Medical Centre Ibn Sina (CHIS) of Rabat, Morocco, an observational study was conducted. Using a multivariate approach integrating the many aspects of acceptability, standardized observer reports were collected for 570 medicine intakes in patients up to the age of 16, then analyzed on a reference framework. Tablets appeared to be well accepted in children greater than 6 years old, but were crushed/dissolved for 90% of the 40 children aged from 3 to 5, and 100% of the 38 patients younger than 3. Moreover, the prescribed dose was fully taken for only 52% and 16% of these younger children, respectively. Despite this, tablets represented 24% of evaluations in children from 3 to 5 and 20% in infants and toddlers. Oral liquid preparations appeared to be better accepted than tablets in preschoolers, but not for those under 3. Overall, these findings highlight the lack of suitable alternatives for the younger children, especially for formulations of antiepileptics, antithrombotic, and psycholeptic agents in the local context.

Impact of Food and Drink Administration Vehicles on Paediatric Formulation Performance: Part 1-Effects on Solubility of Poorly Soluble Drugs

Food and drinks are commonly used to facilitate administration of paediatric medicines to improve palatability and enhance patient compliance. However, the impact of this practice on drug solubility and on oral drug bioavailability is not usually studied. Based on recommended strategies for oral administration of paediatric medicines with food and drink vehicles, the aims of this study were (i) to measure the physicochemical properties of (soft) food and drink vehicles, commonly mixed with paediatric medicines prior to administration, and (ii) to assess the impact of the co-administered vehicles on the solubility of two poorly soluble paediatric drugs. Montelukast (sodium) and mesalazine were selected as the model compounds. Distinct differences were observed between the physicochemical properties (i.e. pH, surface tension, osmolality, viscosity and buffer capacity) and macronutrient composition (i.e. fat, sugar and protein content) of the different soft foods and drinks, not only among vehicle type but also within vehicles of the same subtype. Solubility studies of the two model compounds in selected drinks and soft foods resulted in considerably different drug solubility values in each vehicle. The solubility of the drugs was significantly affected by the vehicle physicochemical properties and macronutrient composition, with the solubility of montelukast being driven by the pH, fat and protein content of the vehicles and the solubility of mesalazine by vehicle osmolality, viscosity and sugar content. This vehicle-dependent impact on drug solubility could compromise its bioavailability, and ultimately affect the safety and/or efficacy of the drug and should be taken into consideration during paediatric product development.

Co-administration of Paediatric Medicines with Food and Drinks in the Context of Their Physicochemical Properties-a Global Perspective on Practices and Recommendations

Medicine co-administration with food or drink vehicles is a common administration practice in paediatrics. The aims of this review were (i) to describe the current recommended strategies for co-administration of paediatric medicines with food and drinks (vehicles); (ii) to compare current administration recommendations from different countries; and (iii) to obtain a global perspective on the rationale behind the choice of recommended vehicle, in the context of the physicochemical properties of the drug and formulation. This study used a defined search strategy on the practices of paediatric medicine co-administration with vehicles, recommended in a commonly used paediatric and neonatal handbook, in addition to the information previously gathered from UK formularies. Logistic regression analysis was performed to further understand the biopharmaceutical basis of the choice of recommended vehicle for medicine co-administration. Differences were identified in the type of vehicles globally recommended for medicine co-administration. Ultimately, a statistical model was developed which provided an understanding on which vehicle is recommended for use with drugs/formulations, with basis on their biopharmaceutical properties. Overall, this review highlights the areas where further information is needed to support standardised procedures and guide the recommendation of age-appropriate and acceptable vehicles for use in the co-administration of paediatric medicines. Unified requirements are needed for harmonisation of the practice of medicine co-administration with vehicles. In vitro and/or in silico tools should be developed to evaluate the potential clinical outcomes of this practice during paediatric drug development.

Making Medicines Baby Size: The Challenges in Bridging the Formulation Gap in Neonatal Medicine

The development of age-appropriate formulations should focus on dosage forms that can deliver variable yet accurate doses that are safe and acceptable to the child, are matched to his/her development and ability, and avoid medication errors. However, in the past decade, the medication needs of neonates have largely been neglected. The aim of this review is to expand on what differentiates the needs of preterm and term neonates from those of the older paediatric subsets, in terms of environment of care, ability to measure and administer the dose (from the perspective of the patient and carer, the routes of administration, the device and the product), neonatal biopharmaceutics and regulatory challenges. This review offers insight into those challenges posed by the formulation of medicinal products for neonatal patients in order to support the development of clinically relevant products.

Hydrocortisone Granules Are Bioequivalent When Sprinkled Onto Food or Given Directly on the Tongue

Background

Immediate-release hydrocortisone granules in capsules for opening in pediatric-appropriate doses have recently been licensed for children with adrenal insufficiency. This study evaluated the bioavailability of hydrocortisone granules administered as sprinkles onto soft food and yogurt compared with direct administration to the back of the tongue.

Methods

Randomized, 3-period crossover study in 18 dexamethasone-suppressed healthy men. In each period, the fasted participants received 5 mg hydrocortisone granules either directly to the back of the tongue or sprinkled onto soft food (applesauce), or yogurt, followed by 240 mL of water. Serum cortisol was measured by liquid chromatography tandem mass spectometry.

Results

The cortisol geometric mean maximum concentration (C_max) and area under the curve (AUC) for direct administration, sprinkles onto yogurt, and sprinkles onto soft food were: C_max 428, 426, 427 nmol/L and AUC_0-inf 859, 886, 844 h × nmol/L, and AUC_0-t 853, 882, 838 h × nmol/L respectively. The 90% CI for the ratios of C_max, AUC_0-inf and AUC_0-t for administration with soft food or yogurt to direct administration were well within the bioequivalent range, 80% to 125%. Median time to Cmax (T_max) was similar between methods of administration: 0.63 hours administered directly, 0.75 hours on soft food and 0.75 hours on yogurt. No adverse events occurred during the study.

Conclusions

Hydrocortisone granules administered as sprinkles onto soft food or yogurt but not mixed with these foods are bioequivalent to those administered directly to the back of the tongue. Carers, parents, or patients may choose to administer hydrocortisone granules either directly or sprinkled onto soft food or yogurt.

The effect of administration media on palatability and ease of swallowing of multiparticulate formulations

Multiparticulate formulations based on pellets, granules or beads, could be advantageous for paediatrics, geriatrics and patients with swallowing difficulties. However, these formulations may require suitable administration media to facilitate administration. The aim of this work was to investigate the effect of administration media properties on palatability and ease of swallowing of multiparticulates. A range of vehicles were developed using xanthan gum (XG) and carboxymethyl cellulose (CMC) as model hydrocolloids. Such vehicles were prepared at three consistency levels (Level 1 - 'syrup', Level 2 - 'custard' and Level 3 - 'pudding') to investigate the effect of viscosity on their performance as administration media. A randomised, single-blind sensory evaluation study was carried out in thirty healthy adult volunteers using microcrystalline cellulose pellets as model multiparticulates, dispersed in the hydrogels (and water as control) at a concentration of 250 mg in 5 ml. Samples were evaluated using 5-point scales. The use of hydrogels as administration media improved a range of sample attributes compared to water formulations, including appearance, taste, mouthfeel, ease of swallowing and residue in the mouth (all improved by ca. 0,5 points) and oral grittiness perception (improved by ca. 1 point). Polymeric hydrogels thickened to medium consistency (Level 2, XG 0.5% and CMC 1.0% w/v) demonstrated the best performance.

Biopharmaceutical considerations in paediatrics with a view to the evaluation of orally administered drug products - a PEARRL review

OBJECTIVES

In this review, the current biopharmaceutical approaches for evaluation of oral formulation performance in paediatrics are discussed.

KEY FINDINGS

The paediatric gastrointestinal (GI) tract undergoes numerous morphological and physiological changes throughout its development and growth. Some physiological parameters are yet to be investigated, limiting the use of the existing in vitro biopharmaceutical tools to predict the in vivo performance of paediatric formulations. Meals and frequencies of their administration evolve during childhood and affect oral drug absorption. Furthermore, the establishment of a paediatric Biopharmaceutics Classification System (pBCS), based on the adult Biopharmaceutics Classification System (BCS), requires criteria adjustments. The usefulness of computational simulation and modeling for extrapolation of adult data to paediatrics has been confirmed as a tool for predicting drug formulation performance. Despite the great number of successful physiologically based pharmacokinetic models to simulate drug disposition, the simulation of drug absorption from the GI tract is a complicating issue in paediatric populations.

SUMMARY

The biopharmaceutics tools for investigation of oral drug absorption in paediatrics need further development, refinement and validation. A combination of in vitro and in silico methods could compensate for the uncertainties accompanying each method on its own.

Knowledge and practice of healthcare professionals relating to oral medicine use in swallowing-impaired patients: a scoping review

Objectives

Swallowing impairment is a growing problem that affects 16% of the overall population and can significantly affect medicine-taking. However, little is known about the knowledge and practice of healthcare professionals (HCPs) relating to swallowing-impaired (SI) patients. The aim of this scoping review was to investigate the knowledge and practice of HCPs in supporting SI patients with their medicine-taking, to identify their reference sources, and to describe their training and information needs.

Method

Databases searched included Scopus, Web of Science, Medline and Google Scholar from inception to August 2017. Qualitative and quantitative studies describing knowledge and practice of HCPs relating to medicine use in SI patients were included.

Key findings

The nine included studies, from an initial 142, involved nurses (nine studies), pharmacists (one study) and doctors (two studies) in hospitals or aged-care facilities. A knowledge deficit linked to lack of training was revealed, particularly with identification of modified-release dosage forms, medication that can/cannot be crushed, vehicle for safe dispersion, consequences of inappropriate modification, drug stability and legal aspects. Written information sources were named, but not used in practice. Pharmacists were the primary experts for consultation, and were involved in nurse education, and were members of multidisciplinary teams.

Conclusions

Knowledge in nurses was inadequate, with practice indicating potentially serious medication-related errors. Additional training, either undergraduate or as continuing professional development, is recommended. Information to guide safe medicine modification practice should be accessible to all practitioners. Pharmacists could take the lead role in offering training to nurses.

Current opinions and recommendations of paediatric healthcare professionals - The importance of tablets: Emerging orally disintegrating versus traditional tablets

The appropriate prescribing of paediatric dosage forms is paramount in providing the desired therapeutic effect alongside successful medication adherence with the paediatric population. Often it is the opinion of the healthcare practitioner that dictates which type of dosage form would be most appropriate for the paediatric patient, with liquids being both the most commonly available and most commonly used. Orally disintegrating tablets (ODTs) are an emerging dosage form which provide many benefits over traditional dosage forms for paediatric patients, such as rapid disintegration within the oral cavity, and the reduction in the risk of choking. However the opinion and professional use of healthcare practitioners regarding ODT's is not known. This study was designed to assess the opinions of several types of healthcare professionals (n = 41) regarding ODTs, using a survey across two hospital sites. Results reaffirmed the popularity of liquids for prescribing in paediatrics, with 58.0% of participants preferring this dosage form. ODTs emerged as the second most popular dosage form (30.0%), with healthcare practitioners indicating an increasing popularity amongst patients in the hospital setting, belief with 63.0% of practitioners agreeing that many liquid formulations could be substituted with a suitable ODT. The desired properties of an ideal ODT were also identified by healthcare practitioners preferring a small, fast disintegrating tablet (90.2% and 95.1% respectively), with the taste, disintegration time and flavour being the three most important attributes identified (29.5%, 28.7% and 21.7% respectively). This study provided a pragmatic approach in assessing healthcare professional's opinions on ODTs, highlighting the ideas and thoughts of practitioners who are on the frontline of paediatric prescribing and treatment and gave an indication to their preference for ODT properties.

Age-appropriate and acceptable paediatric dosage forms: Insights into end-user perceptions, preferences and practices from the Children's Acceptability of Oral Formulations (CALF) Study

A lack of evidence to guide the design of age-appropriate and acceptable dosage forms has been a longstanding knowledge gap in paediatric formulation development. The Children's Acceptability of Oral Formulations (CALF) study captured end-user perceptions and practices with a focus on solid oral dosage forms, namely tablets, capsules, chewables, orodispersibles, multiparticulates (administered with food) and mini-tablets (administered directly into the mouth). A rigorous development and testing phase produced age-adapted questionnaires as measurement tools with strong evidence of validity and reliability. Overall, 590 school children and adolescents, and 428 adult caregivers were surveyed across hospitals and various community settings. Attitudes towards dosage forms primarily differed based on age and prior use. Positive attitudes to tablets and capsules increased with age until around 14 years. Preference was seen for chewable and orodispersible preparations across ages, while multiparticulates were seemingly less favourable. Overall, 59.6% of school children reported willingness to take 10mm diameter tablets, although only 32.1% of caregivers perceived this size to be suitable. While not to be taken as prescriptive guidance, the results of this study provide some evidence towards rational dosage form design, as well as methodological approaches to help design tools for further evaluation of acceptability within paediatric studies.

Suitability of E-tongue Sensors to Assess Taste-Masking of Pediatric Liquids by Different Beverages Considering Their Physico-chemical Properties

Manipulation of liquid oral drugs by mixing them into foodstuff is a common procedure for taste-masking of OTC pharmaceuticals when administered to children. However, the taste-masking capability of such application media is not systematically evaluated, and recommendations for suitable media are hardly published. In this study, a sensor array of commercially available and self-developed electronic tongue sensors was employed to assess the taste-masking efficiency of eight different beverages (tap water, apple juice, carrot juice, fennel tea, fruit tea, milk, cocoa, and Alete meal to drink) on the OTC pharmaceuticals Ambroxol-ratiopharm®, Cetirizin AL, and Laxoberal® by multivariate data analysis. The Euclidean distances between each pure application medium and its corresponding drug mixture were used as an indicator for the taste-masking efficiency and correlated to the physico-chemical properties of the beverages. Thus, the pH value, the viscosity, as well as the fat and sugar content of the beverages were included, whereas only the viscosity appeared to be insignificant in all cases. The sugar content as well as the fat content and pH value emerged to be a significant variable in taste-masking efficiency for some of the tested drug products. It was shown that the applied electronic tongue sensors were capable to demonstrate the impact of the physico-chemical properties of the application media on their taste-masking capacity regardless of their non-selectivity towards these characteristics.

Paediatric Drug Development and Formulation Design-a European Perspective

The availability of licensed paediatric drugs is lagging behind those for adults, and there is a lack of safe formulations in suitable doses that children are able and willing to take. As a consequence, children are commonly treated with off-label or unlicensed drugs. As off-label and unlicensed drug use are associated with a greater risk for harm than on-label drug use, a range of global initiatives have been developed to realize "better" medicines for children. This review describes the challenges and achievements of the European Union to realize this goal, with a focus on paediatric drug development and formulation design. In 2007, a European Paediatric Regulation was installed enforcing companies to consider children in the early development of drugs with a new drug substance, for a new indication or with a new route of administration. The Regulation, e.g. requires companies to develop a paediatric investigation plan discussing the proposed clinical trials in children of different ages and the formulations for future marketing. Since 2013, the pharmaceutical design of any newly marketed paediatric drug should comply with the "Guideline on the Pharmaceutical Development of Medicines for Paediatric Use." Companies should, e.g. justify the route of administration, dosage form, formulation characteristics, safety of excipients, dosing frequency, container closure system, administration device, patient acceptability and user information. In this review, the guideline's key aspects are discussed with a focus on novel formulations such as mini-tablets and orodispersible films, excipients with a potential risk for harm such as azo dyes and adequate user instructions.

A mixed methods study of the administration of flucloxacillin oral liquid; identifying strategies to overcome administration issues of medicines with poor palatability

BACKGROUND

The palatability of flucloxacillin oral liquid is poor. Parents/carers use strategies to aid the administration of poorly palatable medicines.

AIM

To assess views on the palatability of flucloxacillin oral liquid and identify factors associated with successful administration.

METHODS

A mixed methods study which included a structured review of online forums and a survey of parent/carers of children with cystic fibrosis (CF) to obtain parent/carer views on the administration of flucloxacillin oral liquid.

RESULTS

A total of 18 strategies to aid the administration of flucloxacillin suspension to children were identified on 10 different public online forums. A total of 255 responses to the open online survey were received with 47% of respondents reporting that administration of flucloxacillin was more problematic compared to other medicines and 38% reporting the need to improve the palatability. The brand of flucloxacillin oral liquid significantly influenced the degree of difficulty associated with administration to children. A significant relationship was found between the concentration of flucloxacillin and the reported number of doses successfully administered. The use of food and drink to aid administration was more commonly stated in online forums (44%) compared to the survey data of parents/carers of children with CF (15.9%).

CONCLUSION

The administration of flucloxacillin oral liquid is perceived as a challenge by parent/carers because of palatability. For chronic use, a more concentrated oral liquid and certain brands are likely to improve acceptability.

Oral dosage form administration practice in children under 6 years of age: A survey study of paediatric nurses

The purpose of this study was to interview paediatric nurses on administration issues using extemporaneous capsules and marketed capsules and tablets in children younger than 6 years old, based on most frequently administered drugs in six participating wards. The 59 responding nurses estimated respectively at 7.7±1.7 and 7.3±1.8years the age from which children would properly swallow extemporaneous capsules and marketed solids, with 33% and 37% of nurses considering that children under 6 would not get their prescribed treatment using these dosage forms. Refusal of the child to take the solid was the first reason to explain administration failure (85% of nurses for extemporaneous capsules, 89% for marketed solids). Although type of formulation and requirement of chewing were factors influencing the age at which children would take solid from nurses' experience, size of conventional tablets was not among these factors. All respondents use to crush tablets in children unable to swallow whole solids; 37% of nurses systematically split the tablets to ease the swallowing in children able to swallow. Only 11 nurses had an information tool at their disposal to guide manipulation of solids, with 7 of them using it in their daily practice. Providing specific-ward questionnaires, this study gives factual information on administration practices, perceptions and issues faced by paediatric nurses.

Crushing oral solid drugs: Assessment of nursing practices in health-care facilities in Auvergne, France

Iatrogenic harm from crushing oral drugs, a common but hazardous practice, can be largely avoided by following recommendations for good practice. The aims of this study were to evaluate the frequency of tablet crushing and opening capsules in hospitals and to compare the nursing practices with national recommendations. From 46 health facilities in Auvergne, 1110 nurses answered an anonymous self-completed questionnaire between September and November 2014 regarding general medication issues, prescription, preparation and administration of crushed medications. Crushing tablets or opening capsules was reported as a daily practice for 28% (increasing to 67% in geriatric units). While most best practice recommendations were followed by most nurses, scope for improvement remained: pharmacists were rarely contacted, rationales for change of medication formulation were seldom recorded in patients' files and medications were often crushed and administered together, risking drug interactions. Study data were used to inform recommendations for practice improvement. As findings bear similarities to those from other countries, this may be a widespread issue and study recommendations may be widely relevant. Practice will be reviewed again once practice improvement has been completed.

Problems with oral formulations prescribed to children: a focus group study of healthcare professionals

BACKGROUND

There is evidence to suggest that adherence with prescribed medication is lower amongst adolescents and children than in adults. Medication adherence rates between 11 and 93 % in paediatric patients have been reported. More research needs to be carried out in order to understand why medicines adherence is low and how adherence can be improved in children with long-term conditions. Personal communication with paediatricians in secondary care has highlighted that problems are most likely to be encountered by parents, carers, nurses and children themselves when administering medicines for prevalent long-term childhood conditions.

OBJECTIVE

To explore problems with oral medicines prescribed to paediatric patients from the perspectives of medical practitioners, pharmacists and nurses. Setting Two NHS trusts in the West Midlands, UK.

METHODS

Four focus groups (FG) were conducted. Five nurses, eight medical practitioners and six pharmacists participated in focus groups. The themes explored were problems experienced when prescribing, dispensing and administering oral medicines for children. Main outcome measure Themes evolving from Healthcare professionals reports on problems with administering medicines to paediatric patients.

RESULTS

Two main themes: sensory and non-sensory emerged from the data. Included within these were taste, texture, colour, smell, size, swallowing, quantity, volume and manipulation with food. Taste was the most commonly reported barrier to medicines administration. Texture was reported to be a significant problem for the learning disability population. Medicines manipulation techniques were revealed across the groups, yet there was limited knowledge regarding the evidence base for such activity. Problems surrounding the supply of Specials medicines were discussed in-depth by the pharmacists.

CONCLUSION

Organoleptic and physical properties of medicines are key barriers to medicines administration. A robust scientific evidence-based approach is warranted to inform standardised protocols guiding healthcare professionals to support safe and effective medicines manipulation across all settings. Pharmacists' knowledge of Specials medicines needs to be recognised as a valuable resource for doctors. Findings of this study should help to optimise paediatric prescribing and direct future formulation work.

Methods of administering oral formulations and child acceptability

INTRODUCTION

Children may be unable or unwilling to swallow medicines. In order to avoid or accommodate any such problems, parents may decide to administer medicines other than intended. The aim of this study was to investigate how parents administered four oral placebo formulations to infants and preschool children and how the applied methods correlated with child acceptability.

METHODS

Parents were asked to administer a 4 mm mini-tablet, powder, suspension and syrup to their child twice on one day and to report the child characteristics and administration details in a participant diary.

RESULTS

A 151 children were included. The tablet, syrup and suspension were mostly given on their own, whereas the powder was commonly given with food or drink. Generally, the higher the child acceptability (VAS-score) of the first administration of a specific formulation, the less frequently its method of administration was changed. A change in the method of administration of the same formulation involving (a larger quantity of) food or drink generally resulted in a higher VAS-score.

CONCLUSIONS

The joint administration of medicines with food or drink is an effective strategy to ensure swallowing. This study supports earlier findings that 4mm mini-tablets are a suitable dosage form from infant age.

Influence of Food on Paediatric Gastrointestinal Drug Absorption Following Oral Administration: A Review

The objective of this paper was to review existing information regarding food effects on drug absorption within paediatric populations. Mechanisms that underpin food-drug interactions were examined to consider potential differences between adult and paediatric populations, to provide insights into how this may alter the pharmacokinetic profile in a child. Relevant literature was searched to retrieve information on food-drug interaction studies undertaken on: (i) paediatric oral drug formulations; and (ii) within paediatric populations. The applicability of existing methodology to predict food effects in adult populations was evaluated with respect to paediatric populations where clinical data was available. Several differences in physiology, anatomy and the composition of food consumed within a paediatric population are likely to lead to food-drug interactions that cannot be predicted based on adult studies. Existing methods to predict food effects cannot be directly extrapolated to allow predictions within paediatric populations. Development of systematic methods and guidelines is needed to address the general lack of information on examining food-drug interactions within paediatric populations.

Determination of formulation factors that affect oral medicines acceptability in a domiciliary paediatric population

Acceptability of medicines for children is a challenge, yet critical to ensure adherence to treatment. There is very little literature on formulation factors that influence acceptability of medicines, particularly in the domiciliary environment. This pragmatic study was conducted at University Hospital Coventry and Warwickshire (UHCW) with the aim of identifying the prevalence and nature of oral formulation-related barriers to medicines administration in children suffering from long-term conditions. This study used semi-structured face-to-face interviews with 221 parents/carers of children (0-18 years) and 57 young people (12-18 years).

RESULT

showed significant medicines refusal and manipulation in the domiciliary environment. Nearly one-third (71/232) of respondents reported medicines refusal. This was associated significantly with the age of child (p=0.016), socioeconomic status (IMD 2010 score) (p=0.002), taste (p<0.001), texture (p=0.017), and volume (of liquid/powder) or quantity (of solid dosage form) (p<0.001). 29% (74/252) of respondents reported manipulating medicines. P-values are based on multivariable statistical analysis models. This study has indicated that formulations prescribed to children with chronic conditions are not meeting the needs of a significant number of patients based on self-report. Age-appropriate medicines are required to provide suitable dose units with an acceptable taste for children. This study should aid pharmaceutical companies to prioritise paediatric formulation work.

Difficulties experienced during preparation and administration of oral drugs

AIM

It was aimed to determine the difficulties experienced by pediatric nurses working in the wards of a university hospital during preparation and administration of drugs and to determine solution recommendations.

MATERIAL AND METHODS

One hundred and eight nurses who accepted to participate in the study constituted the sample of the study. Open-ended questions were asked in order to obtain detailed information about the attitudes and views of the participants and face to face interview was used. The problems experienced during preparation and administration of drugs were collected using the data collection form prepared by the investigators. Institution approval, ethics committee approval (HEK12/193) and written informed consent from the nurses who wished to participate in the study were obtained to conduct the study. The data obtained were expressed as figures and percentages.

RESULTS

The most commonly reported problems in preparation of drugs included incomplete dissolution of tablets or non-homogeneous distribution in fluids (54.6%) and difficulty in breaking tablets in appropriate doses (45.3%). The most commonly reported problem experienced during administration of drugs was rejection of drugs which tasted bad by babies/children or spitting out the drug (75.9%). In our study, the nurses also mentioned the problems related with drug administration equipment. These problems included fear of injectors (25.9%), escape of the drugs into the respiratory way (15.7%) and lack of appropriate equipment for administering the drugs (7.4%).

CONCLUSIONS

In our study, it was found that all nurses experienced difficulty in preparing and administering drugs. The problems experienced by the nurses and solution recommendations for these problems were reported to the hospital administration.