How to get kids to take . . . Pills!

The topic of kids and pills comes up frequently in the online discussion groups. There seem to be as many ways to get kids to take pills as there are kids! Here are a few suggestions from seasoned parents, parents of kids with cancer. These parents are the authors of this page, and they deserve a large round of applause. Feel free to email the editor with your own suggestions! Also see (off-site links):

Squirrel Tales site for more parents' suggestions
Baylor International Pediatric AIDS Initiative Educational Resources - an online video e-clinic on teaching children to swallow pills

Crush and Mix

There are many variations on this theme. Many of the references below are how to overcome prednisone aversions, as it seems to taste the worst of all the chemotherapy oral medications. Note, sometimes "prednisolone" can be substituted by the doctors, as it seems to work as well as prednisone but tastes better.

The basic strategy is to get the tablets, crush them, and place them in a small amount of food that your child likes (applesauce, juice, etc). Try not to choose a food that has a local significance to your area, like BBQ in the South, maple syrup in the Northeast and Canada, orange juice in Florida, because they can easily grow to hate this food in the future, and you don't want to make them a social outcast. Make sure that your child eats or drinks every bit of the food with which the medicine is mixed. Be prepared to try a different mixture if suddenly your child refuses to eat the latest successful concoction.

Note: Just a reminder . . . check with your pharmacist or doctor about crushing pills. Not all of them can be crushed.

Ice Cream and Chocolate

Crush the prednisone and put in vanilla ice cream.
Try sprinkling it on ice cream and covering it with chocolate syrup.
Crush it and mix it with Hersheys syrup. We found that it disguised the taste better than anything else: prednisone was our biggest challenge.

Candy and Sugar

Melt down starburst fruit chewies in the microwave just enough to soften and place the crumbled pill in it and made it into a little ball of candy.
We wrap everything in a fruit rollup.
First crush the pill, then take 1 1/2 teaspoon of powered sugar, about two match heads of your child's favorite powder koolaid, and a little bit of hot water and down it goes.
The way we were able to get pills down, to be specific we used this with the methotrexate tablets, my son could swallow pills but for his methotrexate dose he needed to swallow 7 1/2 of these MTX pills and that was a bit much for him. So we crushed the pills and mixed them in jelly. He could pick out his favorite kind of jelly, grape worked very well. This did not dissolve the crushed pills but covered any flavor and he was able to do this with just over a spoonful of jelly. This did get us through a tough time of oral meds.

Fruits and Juices

Crush the prednisone and mix it in a sweet fruit drink: fruit punch or Hawaiian Punch- the sweeter the better to mask the taste.
Try putting the predisone in some orange juice. My son was 18 months old and the predisone was the only med he refused to take, and a lot of times he would get so upset about having to take it that he threw it up and we had to start all over again.
For us, it was blackberries. Yep, blackberries. Like everyone else, we had a real tough time and tried all the usual tricks, even the child life specialist tried things. Nothing worked. Till one day about a month into treatment, we were eating blackberries. My daughter loves them. We were noticing how they are like little cups. Hmm, just the right size to hold a pill, in went a pill, and it worked like a charm. So for a few weeks I was always on the lookout for berries. When they became scarce, we moved on to applesauce and yogurt. No more problems!
We mixed the crushed pills with cranberry concentrate (no water added).
She could only take her pills if they were crushed and mixed with Diet Coke. Even hiding them in capsules didn't work.
- One of the tricks we started using for our BMT kids who hated all the pills we had to give them was to crush the meds. and mix them with a little water and syrup that is used to mix lattes and Italian ices. Works wonders!!
- Jello jigglers. I'd make a pan of them, slice a small square, then make a small slit & stuff the little pill inside. Totally eliminates the aftertaste, and actually made her LOOK FORWARD to taking prednisone. The jello would slide down her throat, the pill would stay inside, and mom & child would smile at having to take "jiggler pills" Only trouble is, the siblings would all want jigglers too, so I'd make it in bulk so we all could have our fill of jigglers....
- Our best disguise for pills is Motts Rugrats apple berry sauce.
- Another approach to large doses of liquid meds is to have a big glass of coca cola ready. The child gets to have a swallow of coke first, then can drink at will after each pulse fo the yucky stuff. Again, this enhances their feeling of control and coke serves as an excellent palate cleanser, partly because of its strong taste and because the carbonation helps to scour the medicine off their taste buds.

Flavor-X

There is product is available at some pharmacies, called Flavor-X. The pharmacy can take the meds, crush them, make them into a suspension and flavor them with almost any flavor he chooses (pina colada, strawberry, cherry, fruit punch, chocolate, licorice etc) there are over 40 flavors. If you are interested, give them a call, they can tell you where to get it near you. My daughter picked Fruit Punch and Decadron the first time around and she did very well with it. The telephone number is 1-800-884-5771. Ask them for a name and phone number of a pharmacy near you. Or visit their web site: FlavorX.

SwallowAid

A reader sent the following comment: "a new product called SwallowAid is specifically formulated to help people of all ages to easily take oral medications. SwallowAid is in a gel format - you can stick the pill into in a spoon and place the cherry flavored gel and pill into the mouth and then take water. SwallowAid contains ingredients that stimulate saliva flow, lubricates the mouth and throat to prevent pills from overstaying in the oral cavity, flavorants that mask bad taste, fragants that mask bad smells, demulcents for lubrication, etc. Also the gel format of SwallowAid modifies the shape, form and texture of the pill which reduces the negative signals sent to the brain that something other than food has been placed in the mouth. My kids love the taste and smell of SwallowAid. The product comes in a tube which makes it portable and convenient to use. It really works."
Editor's Note: As of 3/01, I have not heard of a parents' personal experience with SwallowAid, so I can't say anything positive or negative about it. If you would like to try the product, it can be found at Meijer Drug stores, or order direct from National Consumer Products Inc. PO Box 791, Skokie, Il. 60076 Tel 847-673-8488. Price $8.00/tube including S&H.

Use a Syringe to Deliver Oral Meds

This is a variation on mixing with food and getting your child to eat or drink the pills. The pills are crushed and mixed with liquids, then placed in a syringe, a syringe without a needle on it. Then, you can quickly squirt the mixture into your child's mouth. A syringe is likely to be used with the younger kids.

I use special syringes for oral meds that are sturdier and have a different tip. Our pharmacy gives these to me.
We drop the pill in the syringe and then pour grape juice in and let the pill dissolve.
He is hopeless at swallowings pills, we dissolve his 6MP and Mtx in a syringe in blackcurrant juice.
My system is to put the pill in the syringe then crush it with the plunger then draw up apple juice, shake and give. For hard to crush pills like methotrexate and prednisone I crush it in a spoon first. 6MP crushes easily. Wash the syringe out well with hot water and let it air dry. I reuse syringes for oral medications only, never for IV meds or flushes.
As far as re-using the syringes for meds goes... Well, I did all the time. I always crushed his pills and added warm water and chocolate syrup. After I game him the med, I washed the syringe well and I put it in the silverware basket of my dishwasher. They don't last as long putting them in the dishwasher, but I felt that they were actually being sterilized. I think one syringe was good for 5 days.
My son taught himself at 2 1/2 years old to bring all pills right up. Well, here's what worked for us.... I crushed the pills in a plastic medicine cup. Then I added about 5 drops of water and a squirt of chocolate syrup. Then I mixed it really well with the straight end of a spoon, making sure that all the powder was mixed into the liquid. Then I pulled it up into a 5cc syringe and squirted it into my son's mouth. In the VERY beginning I had to use to lcc syringe and just jam it in. But he got used to the syringe pretty quickly. I crushed the Prednisone and Bactrim for the whole 3 years and it worked for us. The key was to not make too much. As long as I was able to get it all into a 5cc syringe it worked fine. With practice I learned exactly how much liquid to add.
If you must give large doses of bad-tasting liquid meds, it works much better to put the dose into several 1cc syringes rather than to put it in a large syringe. The small one will slide neatly down the outside of the teeth along the cheek and you can squirt it behind the molars where there are fewer taste buds. Also, this gives the child some control over the process: she gets to take a little rest between "pulses" and doesn't feel so overwhelmed. Also, if the kid is fighting, there is less waste. If the docs won't give you the slim syringes, you can often get them from home health. The family veterinarian is also a possible source.

Place in Gel Caps

Some of the oral meds have an awful taste, even if they are swallowed quickly. Many of us have found that they go down a lot easier if they are crushed and then put in gelatin capsules. These capsules are available at pharmacies for a nominal fee and come in several sizes, with the smaller numbers designating larger sizes. But to take even these, they still have to swallow them, which brings us to . . .

How to Teach Your Kid to Swallow Pills

This subject brings a little levity into the cancer parents' lives. At least it does when it's not your kid you are trying to teach. I'll start off with a couple long stories:

I decided to try teaching pill swallowing to my son (he had just turned 5 a few weeks earlier) during our initial hospitalization--after 5 days of forcing down the prednisone, I decided WE couldn't live like that for 3 years. The floor nurse told me the older kids usually took their prednisone in gel caps, as even the coating on prednisone tablets leaves a nasty aftertaste--we ordered up from the pharmacy a bunch of size 03 gel caps. They also manufacture 2 sizes smaller--I might have gotten smaller ones if they'd have been in stock but the O3s ended up working fine. Now he can take 00 and even bigger (pretty gigantic)--this is pretty impressive from a kid without the oral motor coordination to spit out toothpaste after brushing his teeth.
At first, I didn't tell him we were working on pill swallowing--I just bought a few kinds of candy he liked and also got some of those powder "Pixie Stix" which they happened to have in the hospital gift shop. After a bit of general candy play, I told him I had a game to play with him--he had to close his eyes, I would put a tiny touch of the Pixie Stix powder on his tongue, and he would try to guess what flavor it was without looking at the color. That was the end of lesson one--leave him having fun.
Several hours later, we played the candy game again. This time, after a while, I told him I had a way to trick him--I had filled a few of the gel caps in advance with his favorite Pixie Stix flavor. When he had his eyes closed, I gently dropped the pill on his tongue and told him to guess--when he couldn't taste it or anything, we talked about what a funny joke it was. I was careful not to suggest he might want to swallow it or that it was a pill or anything and he usually spit it out or occasionally opened it and poured it in his mouth. We did this a few more times, and end of lesson two for a while. Lesson 3 was similar, but at the end of this lesson, I told him to trick me with any color/flavor pixie stix gel cap he wanted (I had filled a few in advance). When he dropped one in my mouth, I very cheerfully swallowed it with a big drink of water and talked about how good it was and guessed all kinds of goofy flavors since I couldn't taste it. I bet him a dollar that he couldn't do that, too. After some gentle coaxing, he gave it a shot. He gagged a bit the first couple of times, but luckily the nurse came in about then and helped me challenge/encourage him to swallow a couple. (Again, we hadn't yet mentioned that this might be done with something other than candy). We made a huge deal of this, and had other nurses come in and view and applaud, etc.
Later that evening, the nurse dispensing meds suggested that since he hated the prednisone tablets smushed in juice so very very much, that she could put it in gel caps like the candy and he could swallow it without tasting it, just like the candy. It took a bit of coaxing, but he eventually agreed to try one if I would buy him a new Hot Wheels car. The rest is history . . . he found that even though he occasionally gagged, this was much much better than trying to take the prednisone other ways.
After a couple of months, we were able to gradually increase the gel cap size so that he didn't have to take so many pills every night. In the last month or so, I've been sneaking in the Bactrim, methotrexate, and the 6-TG without gel caps and he does fine. I still always put the prednisone in the gel cap, just in case.

This probably sounds weird, but when my son was diagnosed at the age of 3 1/2, we too had a very hard time with the prednisone. We decided to have him swallow the pills instead of crush them. We started out with the baby-sized m&m candies, and him swallowing them whole, to get him used to swallowing things without chewing. Then we bought some empty gel-caps, found at most healthfood stores and can be ordered through pharmacies, and started putting the prednisone tablets in them. Whole, not crushed. We could fit 5 5mg tablets into one gel-cap. It worked great. But the trick was to teach him how to just "swallow" without chewing. It took quite a few m&m's (he didn't mind, and he thought it was fun), but he finally got the hang of it and started swallowing without the gag, or puke!

My son was dx just days after his 4th birthday. It took several weeks of choking down crushed up pills when he said "this is gross mom". I went out and got all the small kinds of candies I could find and he started practicing swallowing them. "Nerds" candies were the ones. He's been the master of pill swallowing ever since. He now shows off and can swallow several pills at one time. It has definitely made a huge difference in his attitude and compliance, and made life much easier for me!
My daughter was able to swallow pills at a very young age - little did we know how useful it would be. She 'swims' them down - a big swallow of whatever juice is handy and let the pill 'swim' down - and don't tilt head back, if anything tilt forward to open the throat.
We did the gel caps thing too. We went to the health food store and bought our gel caps there. It was much cheaper than the pharmacy. And we practiced with m & m candies. Swallowing them whole. I quit crushing the prednisone, and just dropped the pills into the gel cap. We can fit 6 methotrexate into one! The same for prednisone. When he was switched to decadron, we did not have the worry of the bitter taste anymore, so the empty gel caps were not needed, only a continence of not having to swallow so many pills.
My son (aged 5) hated Pred so much, we suggested he try swallowing tablets instead, and he agreed to try because the GIRL in the cubicle next door took hers like that, with 2 sisters, he hates being outdone by women! It was a historic moment!
My son learned to swallow his pills too. The trick is not to lean head back -- lean forward if anything. He hates any liquid meds, so we do everything in a #4 capsule.
The pill strategy (devised around taking prednisone).
1) crush pills
2) bury crushed pill, or a portion of it in an ice cream "capsule"
3) chant "just swallow, just swallow, just swallow it"
4) If this works, put crushed pill in a capsule (we used 2's)
5) coat capsule with ice cream
6) chant as per # 3
7) Discuss success, suggest that she probably really could just take a pill now.
8) Put crushed pill in capsule, offer juice, cross fingers and chant
The reason we buried the crushed prednisone was to avoid the taste (These home made ice cream capsules were about the size of a large - double strength - Bactrim.) Then we ended up burying capsules because sometimes he could still taste the prednisone. Then we tried the capsules alone because a nurse asked what we would do if there was no ice cream available at the hospital. The whole process took about 3 weeks - but we've never looked back and our 5 year old was involved in every step - always discussion before any new attempts.
I taught my daughter the first day to swallow gel caps (no 4's). Prednisone tastes vile with a nauseating metallic aftertaste. I would break the pills in half and stuff them into a gel cap. She got to choose her own drink (she always chose pop since it was a special treat in our house) to wash them down.
I have to second (or third or fourth) the suggestion to use gel caps. My five year old was having a real difficult time with prednisone (screaming, crying, gagging, vomiting--in that order usually). The nurse told me that the older kids took the prednisone in gel caps.
We bought some small ones (size 03) to begin with and I loaded them with sugar for several practice runs--I thought it might take a kid his age a while to learn this, but he had it down within 15 minutes and about 4 practice capsules. Now that he's got lots of other oral meds, he's learned to take a gargantuan-sized (00) gel cap. We smash and load up all his meds into one or two gel caps and he has to take many fewer pills (e.g, the 5.5 methotrexate tablets + septra + 6-TG can all be fit into 2 or 3 pills).

Anecdotes

So, you think you have it bad??

I wanted to weigh in on the pills topic, as we also have experienced difficulty with prednisone. [My son] is now just 2 years old, and when he was first prescribed prednisone would vomit upon swallowing. Of course, this didn't stop the doctors/ nurses trying to give it to him - but after 5 doses in one try, they switched us to prednisolone. Well, that lasted until he got onto maintenance, and then our staff doctor wanted him switched back to prednisone. When my wife (who does all the hospital stuff as I'm at work) pointed out he was either going to a) vomit, or b) spit it out, our doctor demonstrated the famous "give a cat a pill" technique - pinion him, plug his nose and jam the stuff down his throat, hold his nose until he swallows. Fair enough - it worked.

So then we started into the 5 days per month regime - dreading the whole thing. (I've noticed in several of the e-mails I have already received mention of how prednisone affects the personality of the patient - I don't know about how my son feels - he is just starting to talk - but we sure notice the change!) Any rate - my wife would give his dose 3 times a day -- wrestle him down, plug his nose and feed it to him. I should mention that we always mixed the prednisone with maple syrup.

One night, I was home, giving Deb the night off, and had to give him his dose. So I prepped the pill - ground it up, mixed it with syrup, sucked it up into a syringe (no needle, of course) and then found my son.

He knew what was coming, started to cry; I grabbed him, pinioned his legs between mine, held down his hands with one hand, and got the syringe to give him his steroid. And looked at him. It was funny. I could see in his eyes he was ready to talk about this. So I let him go, stood him up and said, "Buddy, it's yucky medicine time. I know how awful it tastes but you have to take it. Tell you what I'll do - you take the medicine, don't spit it out, and I won't hold you down." And then I had a brain wave - I went to the kitchen and got some chocolate chips. I looked at him and said, "Look, I'm going to give you a chocolate chip now, it'll make your mouth taste all good." He ate the chip. The I said, "OK, here comes the yucky medicine, swallow it fast, and you can have some more chips." my son took the prednisone, whole syringe, swallowed it, no spitting it out, no fuss, and filled his mouth with chocolate chips."

Since then, all we do is tell him "yucky medicine", he looks for chocolate chips, takes about 3 in his mouth, takes his prednisone, more chips, end of story.

If it makes you feel any better, my daughter never accomplished swallowing pills. She was 7 1/2 at dx, finished at 10 and 2 1/2 months, will be 11 in a couple of weeks and still CANNOT swallow a pill to save her life!! Believe it or not, she chewed her pills up. This terrified her drs- What will happen to her teeth? Well, she still has no cavities, no plaque problems. The only problem she has is receding gum lines and horrible tooth alignment- neither of which could be from chewing pills.

Once we switched to Bactrim pills, my daughter decided she didn't want those either. So we threatened to call the hospital to prepare a "pokey". When she called our bluff on that one, I called my fax machine number and "talked" to the fax about preparing the "pokey". That worked for a while until she figured out that Beaumont was a zone call (needed the area code prior to the number) and my fax number wasn't. After that every with every pill I would call my mother in Kentucky and pretend she was Beaumont. My mother was very confused at first but hers was the only long distance number I had memorized (other than Beaumont's).

At one stage we had to take him to hospital every night for his orals, we could not get it down at home anymore, he vomited it straight out every night. We spoke to his doc who suggested we give his orals at hospital until he gets used to taking them, as he can probably feel our tension and takes advantage of the situation. He still vomited quite often at hospital too though, but at least they were the "bad guys" (and cleaners) and not us! When we got tired of driving to hospital every night, they threatened him with a gastric nasal tube, and that's when he decided to have his pills at home. It still takes a long time every night, but with lots of fizzy drinks in between he gets it down.