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Identifying strategies to overcome poor palatability of flucloxacillin

A summary of suggestions given by parents and carers who have experienced the struggle of administering the antibiotic flucloxacillin, which is known to taste bad, from a survey conducted by the University of Birmingham.

The antibiotic flucloxacillin has been a key part of cystic fibrosis (CF) care in the UK for several decades. During preparation for a national trial assessing the use of flucloxacillin in children with CF (CF START), the bad taste of flucloxacillin suspension was highlighted as a barrier to delivering this treatment. In order to more fully understand this problem a survey was conducted by the University of Birmingham asking parents and carers of children with CF about their experiences of using flucloxacillin and any strategies they used to make administration easier. This page presents a summary of the advice given by parent/carers, as well as further details about the study.

Advice from parents

It gets easier over time

Most parents are successful at getting their babies and toddlers to take flucloxacillin suspension, but this can initially be a challenge, particularly in small babies, because of the taste. It is recognised that this is a real challenge being so soon after diagnosis, and many parents/carers find it frustrating to have to battle to administer medicines. Other parents/carers told us that administration of flucloxacillin got easier with age and that once the baby is on solids the issues around dosing were halved. It is important to keep trying even though this may be difficult.  

The brand of flucloxacillin product can make a difference

Flucloxacillin is available in two different strengths (125mg in 5ml, and 250mg in 5ml) and brands; these products all taste different. Our results showed that some children preferred a particular brand, although it was not always the same brand. If you identify a brand that your child is more willing to accept, make sure you obtain this brand going forwards. You can ask the pharmacist for this brand but sometimes you may need to visit a different pharmacy that stocks your brand of choice.

Using a stronger suspension means a smaller volume is needed 

Some parents reported that using the stronger product (250mg/5mL) was better as the amount (volume) they had to administer was smaller, which made swallowing easier. You need to ask your doctor about using the stronger product as they need to prescribe this for you; they will also be able to confirm that this will be okay for the dose your child requires. 

Avoid mixing with food/drink if possible 

Flucloxacillin should be given on an empty stomach as administration with food can affect absorption and means that the drug may not work as well as expected. However, some parents and carers reported that mixing with food or a very small treat immediately afterwards did help their child to take the medicine. Try encouragement or non-food rewards where possible. If mixing with food is necessary, use the smallest volume possible to try to ensure the whole dose is taken or try a small treat immediately after the dose, often a jelly sweet is sufficient and should not affect absorption. Try to avoid acidic substances (eg orange juice).

Use a syringe rather than a spoon

Using a syringe to deliver the flucloxacillin suspension to the side or corner of the mouth may be very helpful as it avoids the taste buds on the tongue. If you or the child’s siblings will also take something that looks similar to the medicine (eg milkshake) from an oral syringe this can help to encourage the child to accept the medicine.

Be positive and use encouragement

Lots of parents/carers reported that lots of praise or clapping helped the child to take the flucloxacillin. If your baby/toddler is refusing the flucloxacillin, don’t draw attention to this as it may become a battle of wills (and toddlers rarely lose those battles!). Be positive and reward them when they take it, walk away when they refuse and get on with ordinary things. Try to stay calm and positive so that the baby/infant does not pick up on your stress surrounding the medicine. This is not always easy and parents often find it helpful to talk to their CF team about this and get reassurance that they are doing the right thing.

For ideas of rewards (typically not for each dose but for each week) consider inexpensive items (eg crafts or stationery); activities (eg picnic, bike ride) or special privileges (choosing meals, staying up late etc).

Consider switching to the capsules 

Parents/carers reported that moving from the liquid to capsules made it easier for the child (and the parents!). Switching to the capsules would need to be discussed with your doctor as they will need to be sure that the dose your child requires matches that of the capsules available. The age at which children are comfortable taking capsules varies. Most are able to try and succeed by six years of age, but some can take them as early as their third birthday. It is important that they are ready and are positively encouraged. Your CF team will be very experienced with this and able to provide you with support and tips.

References

  • Hannah Batchelor, Oli Rayner, Jessica Nickless, Mandy Wan, Kevin Southern, Claudia Rose. Children with cystic fibrosis: understanding issues related to oral administration of liquid flucloxacillin. Arch Dis Child 2016;101:e2 doi:10.1136/archdischild-2016-311535.33
  • Claudia Rouse, Punam Mistry, Oli Rayner, Jess Nickless, Mandy Wan, Kevin W. Southern and Hannah K. Batchelor. A mixed methods study of the administration of flucloxacillin oral liquid; identifying strategies to overcome administration issues of medicines with poor palatability. Int J Pharm Pract. 2016 Sep 16. doi: 10.1111/ijpp.12308 

Find out more about CF START.

Background to the project

Read on for a summary of work conducted at the University of Birmingham under the supervision of Hannah Batchelor. This report is based on the final year dissertation project of Claudia Rouse and a paper published in International Journal of Pharmacy Practice (both available from Hannah Batchelor).

  • Hannah Batchelor, Oli Rayner, Jessica Nickless, Mandy Wan, Kevin Southern, Claudia Rose. Children with cystic fibrosis: understanding issues related to oral administration of liquid flucloxacillin. Arch Dis Child 2016;101:e2 doi:10.1136/archdischild-2016-311535.33
  • Claudia Rouse, Punam Mistry, Oli Rayner, Jess Nickless, Mandy Wan, Kevin W. Southern and Hannah K. Batchelor. A mixed methods study of the administration of flucloxacillin oral liquid; identifying strategies to overcome administration issues of medicines with poor palatability. Accepted for publication by 'International Journal of Pharmacy Practice'

Objective

The aim of this study was to assess views on the palatability of flucloxacillin suspension and identify factors associated with successful administration.

Design

A mixed methods study was undertaken which included a structured review of online forums and a survey of parent/carers of children with cystic fibrosis (CF).

Results

18 strategies to aid the administration of flucloxacillin suspension to children were identified on 10 different public online forums. 255 responses to the open online survey were received with 47% of respondents reporting that administration of flucloxacillin was more problematic compared to other medicines and 38% reporting the need to improve the palatability. 

The brand of flucloxacillin suspension significantly influenced the degree of difficulty associated with administration to children with cystic fibrosis. A significant relationship was also found between the concentration of flucloxacillin and the reported number of doses successfully administered.

Parent/carers of children with CF reported fewer issues with administration with increasing age.

Conclusion

Administration of flucloxacillin suspension is perceived as a challenge by parent/carers because of palatability. For long-term administration a more concentrated suspension is associated with better responses, and over time it would appear administration becomes less of an issue. This information and other evidence from this study will contribute to a parent support resource.

Key facts that are of value to parents of children with CF

  • 47% of parents/carers reported the administration of flucloxacillin was more problematic than other medicines. Of those who answered ‘more’ (n=119), the vast majority (73.1%) of parents/carers reported that it was the taste of flucloxacillin which made it more difficult to administer. 
  • The vast majority (89.3%) of parents/carers reported that they administer/administered ‘most doses’ or ‘all doses’ of flucloxacillin.
  • The most problematic age group for the administration of flucloxacillin was pre-weaned babies.
  • The oral syringe was almost unanimously the preferred administration device, with the most popular delivery being into the side of the mouth.
  • Parents/carers of pre-weaned babies found mixing with food/drink eased the administration of flucloxacillin. There appears to be an increase in finding mixing with food/drink useful from weaned babies up to 11 years of age, with parents/carers of children aged 12-17 years generally finding it less useful. As expected, in pre-weaned babies the only option was to mix with milk, with milk also being recommended for children up to five years old; in children aged 3-11, mixing with juice was popular, with hot chocolate also being recommended. Yoghurt was mentioned for all age groups that were weaned. 
  • The use of encouragement to aid the administration of flucloxacillin increased with age; the most commonly reported flucloxacillin were praise (16.3% of parents/carers), sweets (16.3% of parents/carers) and stickers (12.7% of parents/carers).

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