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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.

“… 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 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 and 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!

References

Fuchs, J. The amount of liquid patients use to take tablets or capsules Pharm Pract (Granada). 2009 Jul-Sep; 7(3): 170–174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139049/

Mitchell JC, Counselman FL.  A taste comparison of three different liquid steroid preparations: prednisone, prednisolone, and dexamethasone. Acad Emerg Med. 2003 Apr;10(4):400-3. https://www.ncbi.nlm.nih.gov/pubmed/12670859

About the authors

  • A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons. @henrygoldstein | + Henry Goldstein | Henry's DFTB posts

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