International Journal of Clinical Pharmacy

, Volume 37, Issue 6, pp 1057–1067 | Cite as

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

  • Rebecca Venables
  • Heather Stirling
  • Hannah Batchelor
  • John Marriott
Research Article


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.


Healthcare professionals Adherence Medicines administration Pediatrics Prescribing 



We would like to thank all of the healthcare professionals for their participation in the focus groups. It should be noted that this study explored the reports of healthcare professionals, thus these may not be factually correct.


We would like to also acknowledge the West Midlands Medicines for Children Research Network (WM-MCRN) for funding this research.

Conflicts of interest

The authors declare that there are no conflicts of interest.


  1. 1.
    Staples B, Bravender T. Drug compliance in adolescents: assessing and managing modifiable risk factors. Pediatr Drugs. 2002;4(8):503–13.CrossRefGoogle Scholar
  2. 2.
    Winnick S, Lucas DO, Hartman AL, Toll D. How do you improve compliance? Pediatrics. 2005;115(6):e718–24.CrossRefPubMedGoogle Scholar
  3. 3.
    Burkhart P, Dunbar-Jacob J. Adherence research in the pediatric and adolescent populations: a decade in review. In: Hayman L, Mahon M, Turner J, editors. Chronic illness in children: an evidence-based approach. 1st ed. New York: Springer; 2002. p. 199–229.Google Scholar
  4. 4.
    Ernest TB, Elder DP, Martini LG, Roberts M, Ford JL. Developing paediatric medicines: identifying the needs and recognizing the challenges. J Pharm Pharmacol. 2007;59(8):1043–55.CrossRefPubMedGoogle Scholar
  5. 5.
    Conroy S, Choonara I, Impicciatore P, Mohn A, Arnell H, Rane A, et al. Survey of unlicensed and off label drug use in paediatric wards in European countries. BMJ. 2000;320(7227):79–82.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Nunn A. Making medicines that children can take. Arch Dis Child. 2003;88(5):369–71.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Skwierczynski C, Conroy S. How long does it take to administer oral medicines to children? Paediatr Perinat Drug Ther. 2008;8(4):145–9.CrossRefGoogle Scholar
  8. 8.
    Richey R, Donnell C, Shah U, Barker CE, Craig JV, Ford JL, et al. An investigation of drug manipulation for dose accuracy in paediatric practice: the modric study. Arch Dis Child. 2011;96(4):e1.CrossRefGoogle Scholar
  9. 9.
    Michaud P, Suris J, Viner R. The adolescent with a chronic condition. Part II: healthcare provision. Arch Dis Child. 2004;89(10):943–9.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    WHO. Adherence to long term therapies: evidence for action. Accessed 14 May 2010.
  11. 11.
    Brackis-Cott E, Mellins CA, Abrams E, Reval T, Dolezal C. Pediatric HIV medication adherence: the views of medical providers from two primary care programs. J Pediatr Health Care. 2003;17(5):252–60.CrossRefPubMedGoogle Scholar
  12. 12.
    Akram G, Mullen AB. Paediatric nurses’ knowledge and practice of mixing medication into foodstuff. IJPP. 2012;20(3):191–8.Google Scholar
  13. 13.
    Mukattash T, Hawwa AF, Trew K, McElnay JC. Healthcare professional experiences and attitudes on unlicensed/off-label paediatric prescribing and paediatric clinical trials. Eur J Clin Pharmacol. 2011;67(5):449–61.CrossRefPubMedGoogle Scholar
  14. 14.
    Mukattash TL, Wazaify M, Khuri-Boulos N, Jarab A, Hawwa AF, McElnay JC. Perceptions and attitudes of Jordanian paediatricians towards off-label paediatric prescribing. IJCP. 2011;33(6):964–73.PubMedGoogle Scholar
  15. 15.
    NPSA. Information sheets & consent forms. Guidance for researchers and reviewers. Version 3.5 May 2009. Accessed 13 May 2010.
  16. 16.
    Krueger RA, Casey MA. Focus groups: a practical guide for applied research. 3rd ed. London: Sage; 2000.Google Scholar
  17. 17.
    Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Paediatric Formulary Committee. BNF for children (BNFC). London: Pharmaceutical Press; 2011–2012.Google Scholar
  19. 19.
    MHRA. Medicines that do not need a licence (Exemptions from licensing): the manufacture and supply of unlicensed relevant medicinal products for individual patients (‘specials’). Accessed 15 Feb 2012.
  20. 20.
    Baguley D, Lim E, Bevan A, Pallet A, Faust SN. Prescribing for children—taste and palatability affect adherence to antibiotics: a review. Arch Dis Child. 2012;97(3):293–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Chung T, Hoffer FA, Connor L, Zurakowski D, Burrows PE. The use of oral pentobarbital sodium (Nembutal) versus oral chloral hydrate in infants undergoing CT and MR imaging—a pilot study. Pediatr Radiol. 2000;30(5):332–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Lucas-Bouwman ME, Roorda RJ, Jansman FGA, Brand PLP. Crushed prednisolone tablets or oral solution for acute asthma? Arch Dis Child. 2001;84(4):347–8.PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003;39(4):299–304.CrossRefPubMedGoogle Scholar
  24. 24.
    Czyzewski D, Calles N, Runyan R, Lopez M. Teaching and maintaining pill swallowing in HIV-infected children. AIDS Reader-New York. 2000;10(2):88–95.Google Scholar
  25. 25.
    Garvie PA, Lensing S, Rai SN. Efficacy of a pill-swallowing training intervention to improve antiretroviral medication adherence in pediatric patients with HIV/AIDS. Pediatrics. 2007;119(4):e893–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Gibb DM, Goodall RL, Giacomet V, Mcgee L, Compagnucci A, Lyall H, et al. Adherence to prescribed antiretroviral therapy in human immunodeficiency virus-infected children in the PENTA 5 trial. Pediatr Infect Dis J. 2003;22(1):56–62.CrossRefPubMedGoogle Scholar
  27. 27.
    Marhefka S, Farley J, Rodrigue J, Sandrik L, Sleasman J, Tepper V. Clinical assessment of medication adherence among HIV-infected children: examination of the treatment interview protocol (TIP). AIDS Care. 2004;16(3):323–37.CrossRefPubMedGoogle Scholar
  28. 28.
    Paranthaman K, Kumarasamy N, Bella D, Webster P. Factors influencing adherence to anti-retroviral treatment in children with human immunodeficiency virus in South India—a qualitative study. AIDS Care. 2009;21(8):1025–31.CrossRefPubMedGoogle Scholar
  29. 29.
    Reddington C, Cohen J, Baldillo A, Toye M, Smith D, Kneut C, et al. Adherence to medication regimens among children with human immunodeficiency virus infection. Pediatr Infect Dis J. 2000;19(12):1148–53.CrossRefPubMedGoogle Scholar
  30. 30.
    Roberts KJ. Barriers to antiretroviral medication adherence in young HIV-infected children. Youth Soc. 2005;37(2):230–45.CrossRefGoogle Scholar
  31. 31.
    Ekins-Daukes S, Helms PJ, Taylor MW, McLay JS. Off-label prescribing to children: attitudes and experience of general practitioners. Br J Clin Pharmacol. 2005;60(2):145–9.PubMedCentralCrossRefPubMedGoogle Scholar
  32. 32.
    EMEA Reflection paper: formulations of choice for the paediatric population EMEA/CHMP/PEG/194810/2005 2006. London. Accessed 1 Oct 2011.
  33. 33.
    Bowles A, Keane J, Ernest T, Clapham D, Tuleu C. Specific aspects of gastro-intestinal transit in children for drug delivery design. Int J Pharm. 2010;395(1):37–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Nguyen TMU, Lau ET, Steadman KJ, Cichero JA, Dingle K, Nissen L. Pharmacist, general practitioner, and nurse perceptions, experiences, and knowledge of medication dosage form modification. Integr Pharm Res Pract. 2014;3:1–9.CrossRefGoogle Scholar
  35. 35.
    Nissen LM, Haywood A, Steadman KJ. Solid medication dosage form modification at the bedside and in the pharmacy of Queensland hospitals. J Pharm Pract Res. 2009;39(2):129–34.CrossRefGoogle Scholar
  36. 36.
    Burridge N, Deidun D. Australian don’t rush to crush handbook. Therapeutic options for people unable to swallow solid oral medicines. 1st ed. Collingwood: The Society of Hospital Pharmacists of Australia; 2011.Google Scholar
  37. 37.
    Smyth J. NEWT guidelines 2012. Betsi Cadwaladr. Accessed 1 Jan 2013.
  38. 38.
    Manrique-Torres YJ, Lee DJ, Islam F, Nissen LM, Cichero JA, Stokes JR, Steadman KJ. Crushed tablets: does the administration of food vehicles and thickened fluids to aid medication swallowing alter drug release? J Pharm Pharm Sci. 2014;17(2):207–19.Google Scholar
  39. 39.
    Venables R, Stirling H, Marriott J. Poster 0073 Healthcare professionals’ understanding of children’s medicines. IJPP. 2012;20(Supplement 2):68–9.Google Scholar
  40. 40.
    Spomer N, Klingmann V, Stoltenberg I, Lerch C, Meissner T, Breitkreutz J. Acceptance of uncoated mini-tablets in young children: results from a prospective exploratory cross-over study. Arch Dis Child. 2012;97(3):283–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Thomson SA, Tuleu C, Wong IC, Keady S, Pitt KG, Sutcliffe AG. Minitablets: new modality to deliver medicines to preschool-aged children. Pediatrics. 2009;123(2):e235–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Gau SS, Shen H, Chou M, Tang C, Chiu Y, Gau C. Determinants of adherence to methylphenidate and the impact of poor adherence on maternal and family measures. J Child Adolesc Psychopharmacol. 2006;16(3):286–97.CrossRefPubMedGoogle Scholar
  43. 43.
    Mackner LM, Crandall WV. Oral medication adherence in pediatric inflammatory bowel disease. Inflamm Bowel Dis. 2005;11(11):1006–12.CrossRefPubMedGoogle Scholar
  44. 44.
    Mellins CA, Brackis-Cott E, Dolezal C, Abrams EJ. The role of psychosocial and family factors in adherence to antiretroviral treatment in human immunodeficiency virus-infected children. Pediatr Infect Dis J. 2004;23(11):1035–41.CrossRefPubMedGoogle Scholar
  45. 45.
    Shah CA. Adherence to high activity antiretroviral therapy (HAART) in pediatric patients infected with HIV: issues and interventions. Indian J Pediatr. 2007;74(1):55–60.CrossRefPubMedGoogle Scholar
  46. 46.
  47. 47.
    GRIP Webinar (online conference) GRIP Work Package 5 “Meet the Expert” on paediatric formulations 2013.Google Scholar
  48. 48.
    Glass BD, Haywood A. Stability considerations in liquid dosage forms extemporaneously prepared from commercially available products. J Pharm Pharmaceut Sci (www. 2015;9(3):398–426.Google Scholar
  49. 49.
    Haywood A, Glass BD. Liquid dosage forms extemporaneously prepared from commercially available products–considering new evidence on stability. J Pharm Pharm Sci. 2013;16(3):441–55.PubMedGoogle Scholar
  50. 50.
    McKenzie M. Administration of oral medications to infants and young children. US Pharmacist. 1981;6:55–67.Google Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  • Rebecca Venables
    • 1
    • 2
  • Heather Stirling
    • 3
  • Hannah Batchelor
    • 2
  • John Marriott
    • 2
  1. 1.School of PharmacyKeele UniversityKeeleUK
  2. 2.Pharmacy and Therapeutics Section, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences (CMDS), Medical School BuildingUniversity of BirminghamEdgbastonUK
  3. 3.Paediatric DepartmentUniversity Hospitals Coventry and WarwickshireCoventryUK

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