Preventing Medication Refusal

1. Approaching your child about medicine
   • When your child is sick, he may need to take some medicine. For liquid medicines, a plastic syringe or dropper is easier to use than a spoon (with infants or struggling children). If you have only a spoon, keep a towel handy for spills.
   • Approach your child in a matter-of-fact way with an expectation that he will take it without resistance. Some children respond better to an enthusiastic "Mary Poppins" approach.
   • Put your child in a sitting position and pour or drip the medicine onto the back of the tongue. Don't squirt it into the pouch inside the cheek. If your child is not cooperating, however, you must place the liquid beyond the teeth or gumline. Also, don't squirt it forcefully into the back of the throat, because of the danger of its going into the windpipe and causing choking. If you drip the medicine in slowly, you can avoid gagging or choking.
2. Medicines that taste bad - disguising the taste

   Bitter medicines often lead to refusal unless some of the following preventive steps are taken:

   • Have your child suck on a Popsicle beforehand to partially numb the mouth.
   • Serve the medicine cold to reduce the taste.
   • Mix it with a strong flavor (such as Kool-Aid powder, chocolate syrup, or pancake syrup) to hide the bad taste.
   • Dilute the medicine as much as possible (for example, one dose mixed in 2 glasses of cold apple juice), if you're certain your child can drink it all.
   • Mix crushed pills with one of your child's favorite foods that doesn't require any chewing. Consider ice cream toppings (especially chocolate), honey, maple syrup, applesauce, ice cream, sherbet, or yogurt. Before adding the medicine, have your child practice swallowing the food alone without chewing it (because chewing would bring out the bad taste of the medicine).
   • Have a glass of your child's favorite cold drink ready to rinse his mouth afterward - a sort of "chaser."
   • Praise and hug your child for all cooperation.
   • The older your child is, the more you can ask for his or her suggestions.
   • Some children respond to being given complete control of the spoon.

Overcoming Refusal of Liquid Medicines

Some children aged 1 to 4 years vigorously refuse to take medicines even after you have tried to hide the taste. If the medicine is not essential to recovery (such as most nonprescription medicines for coughs, colds, and fevers), stop giving it. If you are not sure of how important the medicine is, call your healthcare provider for advice. If the drug is essential (such as most antibiotics), use the following recommendations:

• Be honest and sympathetic ("I'm sorry it tastes bad. We can mix it with anything you like.").
• Be firm and give a reason ("You have to take it or you won't get well").
• Give your child a time-out in the corner to think about it. Every 5 minutes, ask him, "Are you ready yet?" If 15 minutes pass, take action.
• Immobilize your child. Two people are usually needed. Have someone position your child on the lap, holding the arms with one hand and the head with the other. You can use one hand to hold the medicine and the other to open your child's mouth. If you are alone, first wrap your child with a sheet. Ask the office nurse to show you how this is done.
• Be sure your child is not lying flat, to prevent choking.
• Open your child's mouth by pushing down the chin or running your finger inside the cheek and pushing down on the lower jaw.
• Insert the syringe between the teeth and drip the medicine onto the back of the tongue.
• Keep the mouth closed until your child swallows. Gravity can help if you have your child in an upright position. However, swallowing can't occur if the head is bent backward.
• Afterward, apologize and review the alternative: "I'm sorry we had to hold you. If you cooperate next time, we won't have to."
• Give your child a hug.
• Forcing your child in this way to take an important medicine will teach him you mean business and will eventually bring cooperation.
• Don't attack self-esteem (for instance, by saying, "You're acting like a baby").
• Don't punish, as with spanking or yelling.
• If your child vomits or spits out the medicine, estimate the amount lost and repeat it.

Overcoming Difficulties with Pills or Capsules

Some children have trouble swallowing pills and capsules.

• The easiest approach is to convert the medicine to a liquid form. Empty out the capsules or crush the pills. You can do this with any pills except slow-release or enteric-coated pills. (Check with your healthcare provider if you are uncertain what you can do.)
• Slow-release capsules can be emptied as long as the contents are swallowed without chewing. Since capsules usually contain medicines with a bitter taste, the contents need to be mixed with a sweet food.
• Pills are usually made as a convenient alternative to the liquid form, and they may not taste bad. Pills can be crushed between two spoons. Crushing is made easier by first moistening the pill with a few drops of water and letting it soften for 15 minutes.
• Place the pill or capsule far back on the tongue and have your child quickly drink water or Kool-Aid through a straw. If your child concentrates on swallowing (even gulping) the liquid, the pill will follow downstream without a hitch.
• If your child is over age 7 or 8 and unable to swallow pills, he should practice this skill when he's not sick or cranky. (Some children can't swallow pills until age 10, however.) Start with small pieces of candy or ice and progress to M&M's. Try to use substances that will melt quickly if they get stuck. If necessary, coat them with butter first. Use the liquid and straw technique. Once candy pellets are mastered, pills will usually be manageable. For extra confidence, split the pill into halves or quarters.

Call Your Child's Healthcare Provider If:

• Your child vomits the medicine more than once.
• You are unable to get your child to take an essential medicine.

The next time your healthcare provider prescribes a medicine, be sure to mention that your child has this common problem. Your provider may be able to prescribe a medicine that tastes better.