Aim Most paediatric formulations produced for children are generally liquids or powders for reconstitution. Palatability of liquid formulations is often cited as a barrier to medication adherence.¹ An alternative to liquid formulations is the conventional solid oral dosage forms, such as tablets or capsules. However, another barrier faced by paediatric patients is the inability to swallow tablets.² This presents a number of challenges for children with ALL, as treatment contains a phase of extended ‘maintenance’ therapy to prevent relapse. This involves taking oral chemotherapy daily, ± monthly chemotherapy injections, over 2 years for girls and 3 years for boys. Prior to 2014, paediatric oncology pharmacists would work with children refusing to take or struggling with their liquid medicines. It was a simple approach, where ‘tic-tacs®’ were used and swallowinSg these was practiced together. Through education sessions and informal discussions with nursing, medical and play therapists, a culture evolved in 2014 whereby medicine taking was not just the responsibility of pharmacy but of the wider team. Nursing and medical staff were actively involved identifying families that needed support with their medicines. Display boards were created advertising the option of tablets for different medicines and highlighting the different swallowing techniques. The play specialists became ‘Medicine Champions’ using novel approaches to provide children with the tools, confidence and ability to take tablets. Children who successfully mastered swallowing tablets were presented a ‘star award’ certificate for their achievement. Photographs of children with their certificates were displayed in the outpatient clinic.

Method Paediatric patients diagnosed with ALL between 2012 and 2017 were retrospectively identified using chemotherapy prescriptions, patient’s medical notes and electronic patient medical records. Data collected included age at diagnosis, formulation choice initiated on and whether patients switched formulations during the course of their treatment. Children were excluded for the following reasons: if they had a history of swallowing difficulties/choking, if the child had learning difficulties or if the child was deceased.

Results 172 patients were diagnosed with ALL between 1st January 2012 and 31st December 2017; 14 patients were excluded (13 deceased,1 learning difficulties). The percentage of children aged 3–12 years taking tablets in 2012 and 2013 was 41% (n=7) and 20% (n=2) respectively. This increased to 69% (n=11) in 2014, remained consistently above 60% in 2015/2016 and increased again to 76% (n=14) in 2017. Between 2014 and 2017, 100% of patient’s ≥ 6 years took their oral chemotherapy as tablets. Over 65% of all patients 0 – 18 years were taking liquids in 2012/2013. From 2014 to 2017 less than 50% of all patients each year were taking liquids. No patients were identified as switching back from tablets to liquid.

Conclusion This study supports an interdisciplinary approach to tablet taking. By bringing together different members of staff with the necessary knowledge, skills and experiences, we were able to provide families with the tools and confidence to support their child in mastering the technique of swallowing tablets, increasing the number of patients initiating on or transitioning to solid oral dosage forms by approximately 50%.

References

1. Baguley D, et al. Prescribing for children – taste and palatability affect adherence to antibiotics: a review. Arch Dis Childhood, 2012;97:293–7.

2. Polaha J. Dalton WT III, Lancaster BM. Parental report of medication acceptance among youth: implications for everyday practice. South Med J. 2008;101:1106–1112.