An Acquired Taste

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“Bad tasting medicines” date as far back as Asclepius and the Eye of Horus, and have a long and storied history through centuries of patent medicines, tonics and Cod Liver Oil. The idea that a bad tasting medicine is good for you has become pervasive in culture.

“… a person trained in pharmacy would have many tricks – sugar coating, encapsulation, or the addition of sickeningly sweet syrups to bitter liquids to make an elixir. For what adult, or especially a child, would take their medication for long if it were very bitter?” – Christopher Hobbs “Gentian – A Bitter Pill to Swallow”

One rationale for keeping medications tasting bad is that it reduces the chance of a child intentionally but unwittingly overdosing on a good-tasting medicine. Remember, KOOROC!

More recently, the flavours of particular preparations – including those we prescribe most often – have attained a marked distaste from our patients. Here are some of the more notable offenders;

Roxithromycin – flavoured dispersible tablets are ironically named, as the flavouring component disperses almost as rapidly as the tablet itself, leaving a nasty tasting liquid after about 45 seconds. Interestingly, this point of unpalatability can actually act as a decision point – does this child actually have an atypical bacterial pneumonia?

Augmentin – not the worst tasting medication we dish out, but certainly one of the more well known tasting medicines. The ‘banana’ flavouring is almost impossible to overpower, even with an entire dispensary’s worth of pharmaceutical flavouring (speaking from professional experience!)

Flucloxacillin is without a doubt the most offensive tasting antibiotic suspension I have sampled. The likelihood of convincing a child to take this stuff four times a day is bordering on impossible, and is a surefire way to put a heavy strain both medication compliance and the parent-child interaction.

Salbutamol – not traditionally renowned for its flavour, I use this question to check if a child is using a spacer – most poor coordinators will pump the inhaler all over their mouths and will recall the dry, bland but unique taste of salbutamol. In fact, it’s generally worth asking about the taste of inhalers – you might even identify a steroid-induced oral candidiasis on history!

Steroids are bitter tasting! In one study, eighty-six medical students compared the smell, taste, texture and aftertaste of dexamethasone, prednisolone and prednisone and found the latter to be the least palatable. The bitterness appears to be derived from the alkaloid (read: weak base) structure of corticosteroids, as well as their solubility agent – neither of which is masked easily.

Iron & pentavite – don’t underestimate the effect these common medications can have on an ex-premature neonate’s vomitus and stool. Not exactly palatability, but certainly an extension of it!

Also in the “not quite medicine” group of bad tasting “medicine” is the subset of elemental or metabolic formulas, such as elecare, neocate and the remainder of products on this list taste pretty weird. This group scores a mention because they are an entire diet for a reasonable number of infants you may see with poor feeding. For these kids, their food is medicine.

Most kids should be able to swallow by 10 years of age, and this process can often be hastened if clinically useful. I’ve seen kids as young as six – evidently medicalised – who would comfortably able to swallow tablets. Encourage children taking tablets to drink at least 60mL of water with each dose (Fuchs).

Finally, if you’re thinking of hiding the taste of medicine, the usual caveats apply. That is, if the child is old enough and capable of understanding, it’s best to be open and honest with them, to cede some element of control (cup vs syringe). Rather than asking, direct the child “it’s time to take your medication“. Practically speaking, be wary of crushing or chewing tablets lest the dose be compromised.

We’d love to hear some of your tips for helping dose bad tasting medicines in the comments below!

 

Quick Quiz:

  1. What is the Eye of Horus?
  2. Who was Asclepius?
  3. What does the abbreviation KOOROC stand for?
(answers below)
 

Quiz answers

  1. The Eye of Horus is an ancient Egyptian hieroglyph, one of the origins of the Rx notation used in prescribing. (wikipedia)
  2. Asclepius was the Greek God of Medicine, whose serpent entwined staff can probably be found on a medical logo near you.  Asclepius’ daughter was Hygieia, the Greek God of Cleanliness & sanitation [and mythological hand-hygiene champion] (wikipedia)
  3. Keep Out of Reach of Children! 
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About 

A Paediatric Trainee based in Queensland, Australia, Henry is passionate about Adolescent Medicine & General Paediatrics, with a strong interest in Medical Education & Clinical Teaching. An admitted nerd & ironman with a penchant for Rubik's Cubes & 'Dad jokes'.

@henrygoldstein | + Henry Goldstein | Henry's DFTB posts