FAMILIAL MEDICATION PRACTICES AND USE OF NON-PRESCRIBED DRUGS IN CHILDREN
Symposium Gatefossé 2009 : tackling current and future challenges
PAEDIATRIC DRUG PRESCRIPTION
André J. Fabre
Bulletin Technique Gattefosse n°102 2009 http://www.gattefosse.com/media/document/bt_2009.pdf
Faced with their child's illness, families react following three steps: evaluate their child's condition, get advice from their physician and/or go to their pharmacist. The pharmacist will help assessing the child's condition and provide, if needed, over-the-counter (OTc) drugs. Families expect clear instructions: "What is the drug and what is it for?" "Will there be a problem with other drugs my child is taking?", "What side effects does it have ?" all "Drugs cabinets" should be kept out of reach from children. Getting the right dose of drugs at the right time interval is of paramount importance. Drug administration to children is surrounded by potential hazards: drug overdose from multiple prescriptions, unintentional administration of adult medications, use of non child resistant drug packaging. migrants' and physicians' families are high risks groups. current outlooks: development of paediatric OTc drugs and availability of detailed information on the internet. Health professional agencies as seTe ( société d'education Thérapeutique européenne) face the increasing demand from families for a direct access to medications. implementation of school programs should help children become responsible and informed users of medicines. empowering patients to become active participants in their healthcare is a top priority for our times.
pharmacist, diagnostic, hospital, gp, side effects, poisoning.
PAEDIATRIC DRUG PRESCRIPTION
We all know that children can fall ill, any time, any place, any how!
This review is intended to describe medication practices in the domestic situation ie. the events that ensue when the child falls ill at home, the parents response in terms of seeking advice and the use of non-prescription drugs.
Six main points will be reviewed.
• When the child falls ill
• Getting help from the pharmacist
• The family drug cabinet
• administrating drugs to a sick child
• self-medication : hazards and dangers
• Family medication practices: future perspective.
when the child falls ill
Faced with an unexpected health problem with their child, most parents will react following a two-step process.
evaluating the child’s condition
Who will encounter the problem first?
a typical situation is when a mother receives an emergency call from the school or the nursery: her child is ill and she must come as soon as possible to take the child home.
During the day the father may be unreachable and, nowadays the occurrence of single parent families is much more common. sometimes, but increasingly rarely these days, the grandparents or a school nurse will be the first-in-line to take care of the sick child.
Main criteria for next-step decisions
In the case of a child with a chronic disease, the parents are often well aware of the ‘firstline’ medications to be administered and what to do if the situation deteriorates.
in most other cases the parents are required to make a prompt ‘diagnostic’ evaluation of the situation according to several criteria :
age of the child: if the child under 2 years of age an emergency call to the family doctor is mandatory.
When a high spiking fever is recorded, the family doctor (GP) should be called without delay. The high fever can be evaluated in the context of recent history, ie. if the child has been recently vaccinated, in which case the advice of the family doctor should be followed.
When the fever is moderate, antipyretics can be given however if this is ineffectual the GP should be consulted in order to evaluate the situation.
other frequent symptoms parents will encounter and evaluate are:
fever and vomiting - evaluation of the possible diagnoses: meningeal syndrome, appendicitis, gastroenteritis as well as simple upper respiratory infection (Uri).
fever and rash - classical diagnostic evaluation: scarlet fever, measles, roseola, erysipelas, among many others.
dysuria and fever suggesting the possibility of urinary tract infection and again the GP should be called.
parental decision making
Time is tickling and the evaluations and considerations described above are clearly better suited for the doctor than the parents. most parents find themselves having to make a quick decision ultimately based on three main factors :
• the age of the child
• the severity of symptoms
• and the parents ‘healthcare’ experience in such situations.
making the right decision
the parents decision process and ‘first-line’ consultation
The decision process of most parents was summarized by Michie in a recent issue of Lancet .in the case of very young children, less than 8 years old, parents will most often go to their pharmacist first (76%), although a large proportion will consult their GP or go straight to hospital (15%). Only 9% ask their friends or relatives.
For children over 8 years old, nearly all parents go to their pharmacist first (90%), but many will get advice from friends or their relatives (11%), very few will consult their GP or go to hospital (9%).
it is of interest to note that the highest proportion of families seeking advice from their GP or going to hospital (34%) are ‘young’ parents, under 24 years old, although within this sub-population 63% also seek advice from the pharmacist.
the final decision for parents
The final decision parents may take can be summarized as follows: during the day the standard decision is to call the family GP. Parents with more experience tend to seek advice from their pharmacist first.
During the night however, it is a different story and in many cases there is little choice other than to go to the nearest hospital emergency department.
getting assistance from the pharmacist
Pharmacists have a major role in family care as advisers on all health problems as well as being retailers of drug medications.
the role of the pharmacist
Generally speaking the pharmacist will have extensive knowledge in all fields of medication, and in particular paediatric drugs. He or she is the main adviser to parents on all health problems and he or she is also able to provide parents with over-the-counter (OTC) nonprescription drugs best tailored to meet their needs. The communication between the pharmacist and the family is a two-way dialogue: Familyto- Pharmacist and Pharmacist-to-Family.
Family to pharmacist
Parents ask their pharmacist a number of questions including :
• is the medicine suitable for children
• is it appropriate for my child’s age
• Will my child take it without fussing
• What does it taste like
• What time of day should the medicine be given and how often
• What to do if the child misses a dose.
pharmacist to Families
The pharmacist will explain to the family what the drug is and why it is given, the modalities of use and possible contra-indications. He or she will also ask questions about the general health of the child and the use of other medications and history of adverse reactions to medicines (possible side effects etc).
However when the local pharmacy is closed parents then turn to the family drug cabinet.
the family drug cabinet
use of the family drug cabinet
a survey by the British market research Bureau entitled ‘a consumer study of self medication in Great Britain’  showed that faced with an unexpected health problem, families will most often use a medication from their "Home Drug cabinet" (67% of cases) only 27% obtain the medication following a medical consultation or via an OTC purchase.
contents of the Family Drug cabinet
Besides first aid instruments and drugs, a 2007 study  confirms that the contents of the familiy drug cabinet cover three main health problems: 17% respiratory, 15% fever, 14% pain-control drugs (ibuprofen or paracetamol), in appropriate dosage form for each member of the family.
Other contents include paediatric cough medicine, oral rehydration solutions, paediatric antispasmodic drugs, antiemetic medicines and motion sickness drugs in paediatric dosage form.
Local medications are also tend to feature prominently: saline nose/eye drops, sore throat tablets (for the older children), bumps/bruises balms and insect bite ointments.
Maintenance of the drug cabinet
it is a mandatory rule that the drug cabinet should kept out of reach of children. it should be locked and placed vertically. Often it is kept in the parents’ bedroom.
To ensure optimal conservation of drugs, the cabinet should be placed away from light and moisture, in a cool place (between 15 and 22 °c) : this goes against common belief that the best place for the pharmacy cabinet is bathroom or kitchen.
maintaining the drug cabinet should be a constant objective. in a recent survey involving 130 households , maintenance was often inadequate. each family had an average of 8.8 prescribed medicines but more than half were beyond their expiry date or were not intended for ‘emergency’ use. There were also around 14.2 non-prescribed OTc drugs, giving an average total of 23 medications per household.
The conditions of storage and the use of drugs was ‘inadequate’ in more than half of cases.
However, it is worth noting that in 50% of the cases, families (irrespective of their age or social environment), changed their habits once they were informed of the risks associated with the state of their drug cabinet.
guidelines for families
medications should be kept in their original packaging, with their prescribing information and, if possible, a readable annotation on the acquisition date, the doses and times taken. They should be kept separate according to their mode of administration (internal or external), and organized by age group: all adult medications should be imperatively kept separate from children’s medication.
disposal of medicines
The drug cabinet should be periodically refreshed, its contents reviewed and cleaned at least once a year. it is important to ensure that the drug has not been opened, that expiry date has not passed and to replace the drugs already opened or obsolete. "leftovers" can be a problem as most people toss them in the garbage or flush them down the toilet. medicinal compounds filter into the groundwater and end up in rivers and lakes. in several countries, programs have been launched to collect discarded medications to reduce associated health risks and environmental pollution.
administering drugs to a sick child
Three golden rules apply :
• the right medication
• the right dose
• at the right time!
the right medication
This is essentially down to the correct identification of the drug and correct reading of the label. relevant information is, most often, directly available in the product label including drug identification number, brand name followed by the registered trademark symbol (™ or ®), formulation details on all active ingredients, suggestions for safe and effective dosing as well as the manufacturer's name and address to obtain further information about the product. in the future, electronic labelling systems are likely to be in use more frequently.
The Us FDA has recently launched recently a Dailymed Program, for OTc as well as prescription drugs, labelling in multiple rolls, name, dates and times the patient should take the medicine.
paediatric use of OTC drugs
However one salient question often remains unanswered: is the drug safe for use in children ?
Presently, many, many OTC drugs as well as prescription drugs do not show any clear information on paediatric dosages in their labels. The Us FDa is now taking steps to increase the numbers of drugs being tested in children and it is working closely with the National institute of child Health and Human Development to conduct paediatric studies in such fields .
the right dose
a large variety of instruments can ensure a correct dosage of paediatric liquid medicines:
syringes: suitable for small children who are unable to drink from a cup. The medication is injected into the back of the mouth, where it is less likely to be spilled. such syringes are often provided with a cap which has to be kept far from of the child's reach.
droppers: safe and easy system with infants too young to drink from a cup.
dosing spoons: convenient for children who could drink from a cup but are likely to spill. They are generally ergonomically designed for children and for administration ease.
dosage cups: enable the measuring out of a liquid medicine with the cup at eye level on a flat surface.
getting a child to take medication
This can be a very challenging experience at times !
However some tips are known to help: prior to administration giving the child another food product with a distinct taste or texture that may help to mask the taste of the subsequent medicine. Giving a child crushed ice in a drink before the drug can help to ‘anesthetize’ the taste buds or a straw can be used to delivery fluid direct to the back of the mouth, behind the taste buds. Needless to say, over appealing drugs are not without their own
self-medication: hazards and dangers
review of child poisoning incidents
a review of all child poisoning incidents associated with admittance to Us Hospital emergency Departments during 2004 has been carried out by Franklin and rodgers .
Nearly 90,000 cases of unintentional child poisoning were reviewed: accidental poisoning remains the most common cause for emergency consultations in hospital with a total incidence of 429/100,000. 70% of all cases were in children less than 2 years of age and poisoning incidents were associated mainly with medicines (60%).
Poisoning with non-prescription drugs accounted for one third of all medication-related poisonings.
a paeditrician recalls
40 years of clinical experience points to the ‘evidence-based’ conclusion that the use of any drug in children is associated with potential hazards.
Unintentional poisoning, despite all admonitions, is still a major risk for children of all ages. Here are some snapshots from a clinicians experience.
adult ‘colds and cough’ medicines
There are many cases of the ‘I am a big boy’ syndrome: the child who wants to be like his elders and take the same medicine, unfortunately for him – it is pure codeine ! in addition, there are also too many cases of parents not being able to correctly read the drug label. as yet little evidence has been provided on the effectiveness of "colds and cough" medicines in children
Several recent publications have shown an equally efficient effect with honey . last year, the Us FDa took a stand by stating that ‘colds or cough’ medication were not recommended for use in children under two years old .
alcohol intoxication in children
Personally i can remember the story of the ‘young alcoholic’ - the child who took his parents "cough syrup" (formulated for adults and loaded with alcohol excipient). moreover, some children can be sensitive to the combination of antihistamines and alcohol, two common ingredients in adult ‘cold medications’. These days, alcohol-free ‘adult’ cough medicines are available in pharmacies as OTc drugs.
analgesic poisoning in children
salicylate intoxication can be seen as a thing of the past following the 1953 epidemic of Reye syndrome, which resulted in the identification of the link between this rare but potentially fatal disease and the use of salicylates in children and adolescents in the treatment of diverse viral illnesses. as a result aspirin no longer has a place in the family drug cabinet. in my personal experience, I can remember an unexpected Ibuprofen poisoning incident on a dehydrated child, causing leg cramps and renal failure. as for paracetamol, the incidence of paediatric poisonings have notably decreased since the application of child-resistant packaging.
cumulative prescriptions - when several gps are consulted
at times, summation of several prescriptions of the same product under several brand names can be a major risk of overdose. This is a very common incident among asthmatic children.
Drug abuse at 8 months old
an 8 month old boy and his 1 year old sister were living with their grandmother and mother. While the grandmother was caring for the toddler, he accidentally ingested drugs.
His mother returned home and noticed something was wrong with the boy and took him to the nearest hospital emergency department. lab tests revealed levels of amphetamine, caffeine, nicotine, dextromorphine along with anti-histamines!
The mother was a drug user and had not kept these drug products in a safe place and the toddler got hold of them.
grapefruit juice and medications: a dangerous mix
A known metabolic problem is the consumption of grapefruit juice and certain medications. The grapefruit juice keeps the liver busy and thereby blocking it from breaking down drugs such as Diazepam, erthromycin or methylprednisone.
Other similar problems include citrus juices, base ionizers, which prevent digestive absorption when added to anti-inflammatory drugs. milk can form complexes which block absorption of methotrexate, fluorine and iron salts. milk can also dissolve the coating of certain drugs such as tetracycline or cefalexin. even cola drinks have been occasionally found to present (minor) caffeine hazard to children.
Drug labels seldom show any details of possible interactions with food.
iron medication: under-rated as a harmful hazard!
Brightly coloured and sugar-coated iron tablets are fascinating but highly dangerous for toddlers. ingestion of 36 so-called prenatal vitamin tablets (60 mg of elemental iron in each) can be lethal for a 2-year-old child. a recent stand from the FDa recommends child resistant packaging for high dose iron medication.
Illiterate parents are unable to deliver the right amount of drugs or even read a drug labelcorrectly. This is both a historic and a current problem with many migrant families.
Dangerous drug samples
Doctors (and nurses) families should be classified as high-risk groups: in such families,children are often surrounded by lots of potentially harmful sample medications.
child-proof drug packaging
since the advent of child-resistant packaging, as reported by Franklin and Rodgers, poisoning incidents in children seems to have decreased .
among the examples of child-resistant packaging, an excellent and widely used mechanism is the safety cap system which requires two dissimilar forces at the same time: downward push and a turn (a process well beyond a young child's cognitive skills).
family self-medication: current outlook
some recent trends in familial use of medications; OTc drugs , e-mail pharmacies and health education.
current trends in OTC market
The OTC market is expanding everywhere throughout europe: austria, Belgium France and spain . However, there is growing concern surrounding OTc products sold outside the context of the pharmacy, in Germany, switzerland and more recently Poland and italy. There is great pressure from supermarkets to enter the OTc market. Further increase of OTc sales can be expected following the pan-european trend of Public authorities to drastically reduce the financial burden of prescription drugs. This situation has particular challenges.
OTC drugs in France
Historically in France there was what we refer to the ‘French paradox’: a huge contrast between the high consumption of drugs and the low share of OTc sales, the lowest in europe.
Only 25% of French Families were quoted to "often" purchase drugs without consulting a doctor, in fact, ‘rarely‘ or ’never‘ for nearly half the population . The explanation was that a large number of medications were subjected to a "retrospective" physician prescription. in simple terms the French saw their doctor for a prescription, when their neighbours went directly to their pharmacist .
However, drastic changes are coming: from a recent Government decree , more than 200 OTc drugs will be available in French pharmacies, in self-service areas. However, para-pharmacies and drugstores are still excluded from the OTc drugs market in France.
The latest report (2008) on OTc sales in France showed an increase of 2.7% in only one year, and now OTcs account for 14% of total sales in Pharmacies .
children and OTC drugs
There is currently no available data on the exact share of paediatric OTcs  thus making it impossible to assess the impact and risks associated with paediatric use. in addition,most OTcs are not specifically formulated for children and are sold without any specific information on content, age group or dosages.
as pointed recently by s. Gutschmidt , there is an urgent need for specific research in this field.
internet and Family Medicine
A vast amount of information on healthcare and drugs is available from various media: press, television and above all the internet. However; with few critical assessments of the quality of the content, the utility of an information-saturated society is questionable. Thus, there is need for a ‘Wikipedia’ type of internet information source compiled through collaborative, interdisciplinary and un-biased efforts. The medpedia Project  has been launched recently, aimed at providing a worldwide source of shared and advancing knowledge about health, medicine and diseases among medical professionals and families.
e-mail pharmacies and family medicine [19-20]
in November 2006, WHO  and IMPACT  published a program on legislation, law enforcement, regulation and communication about drugs. The program warns against buying medicines through dubious websites. Family use of OTc drugs and/or e-mail pharmacies are two major problems of our times and health education can be seen as a top priority in this field.
From health information to health education 
adults with limited education often have greater difficulties understanding health information and less knowledge about available health care services. low-income families are also at risk and are likely to have no health insurance, less frequent visits to a doctor, and less likely to report their health problems.
Thus, there is a growing need for a public programme which could be referred to as "Health literacy", the goal of which is to improve knowledge and skills in health and wellbeing.
several associations of health professionals aim to help train families
in France there are several associations which play an important role within the overall healthcare system.
SETE (société européenne Therapeutic education) which aims to develop, disseminate and promote interdisciplinary research and education in therapeutic strategies to monitor
acute and chronic diseases.
AFIPA (association of the Pharmaceutical industry for self-mediaction).
AFSSAPS (agence Française de sécurité sanitaire des Produits de santé), which currently produces many individual information documents targeting patients.
in the United states BE MEDWISE is a non-profit organization which works with the National council on Patient information and education (NCPI). There are around 125 federal agencies/public health associations whose remit includes programs to ensure the safe use of OTC medicines. There is also the council for Family Health education (CFHE) non-profit educational organization whose goal is to provide family healthcare education.
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educating children for safe medication use
Health literacy can only be driven by general health education. schools and other care environments provide an ideal situation for the education of children, to give them basic knowledge about medications and their correct use. school health programs can provide children and adolescents with the basic skills which in the long-term helps develop responsible and well informed adults as regards the handling and use of medicine.
The times are changing and new types of medication practices within families are coming.
Every all health professional should be aware of an ever-increasing demand from families for direct access to medications.
Families have taken the primary responsibility of their own health. Therefore the top priority of our times is to help parents to become active and responsible participants in their children's care.
 michie ca, Jaffe a, Dixon m, Priori l, Harvey D.. Over-the-counter drugs for children. lancet 344, aug. 1994 p. 40
 British marker research Bureau. a consumer study of self medication in Great Britain. BmrB london 1987.
 Francis s. V. T. Pereira; Fábio Bucaretchi; celso stephan; ricardo cordeiro. selfmedication in children and adolescents. J. Pediatr. (rio J.) vol. 83 N°5, sept./Oct. 2007. 60 • Bul l e t in Te chnique Gat t e fos s é N° 102 - 2009
 G.P.l edwards. The family medicine cabinet. J r coll Gen Pract. 1982 November; 32(244): 681–683.
 Bazzano aT, mangione-smith r, schonlau m, suttorp mJ, Brook rH. acad Pediatr. 2009 mar-apr;9(2):81-8. epub 2009 Feb
 robert l. Franklin, ms and Gregory B. rodgers. Unintentional child Poisonings Treated in United states Hospital emergency Departments: National estimates of incident cases, Population-Based Poisoning rates, and Product involvement. Pediatrics Vol. 122 No. 6 December 2008, pp. 1244-1251.
 Pennstate live (University News source) (December 3, 2007)
 Public Health advisory January 17, 2008. Non prescription cough and cold medicine se in children. FDa recommends that Overthe- counter (OTc) cough and cold Products not be used for infants and children under 2 Years of age.
 Previously cited.
 robin e Ferner, keith Beard. Over the counter medicines: proceed with caution. BmJ 2008 ; 336:694-696 (29 march).
 according to James Dudley. european consumption of OTc drugs amounts 36% of the World market (OTc distribution in europe, exploring New Frontiers. J.D. intl 2007).
 source aFssaPs - see Ordre National des Pharmaciens.
 Hélène cHeValier, premier geste, aFiPa, 2 décembre 1999. Quoted from aFiPa est une association professionnelle qui regroupe les industriels du médicament d'automédication.
 Published in the June 28, 2008 issue of Journal official.
 le Quotidien du Pharmacien, 13 mai 2009.
 Oms/UNiceF Press release, January 21 2009.
 s. Gutschmidt. Gesellschaft für arzneimittelanwendungsforschung und arzneimittelepidemiologie e.V. (Gaa). Berlin, 02.- 03.11.2006.
 site internet http://www.medpedia.com/.
 Tillement J.P. et Delaveau P. automedicatiion et securité. Bull. acad. Natle med. 191, 8, 1517,1526, 2007.
 rapport de l'académie de Pharmacie sur l’évolution des pratiques professionnelles en pharmacie d’officine (Octobre 2005).
 counterfeited Drugs (WHO, Fact sheet revised, 14 November 2006).
 imPacT: international Task Force anti-counterfeiting of medical products (http:// www.who.int/impact/en/f).
 Guide Vidal familial, yearly publication intended to provide information to families on auto medication.
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Date de dernière mise à jour : 30/07/2013