Understanding Directions for Childrens Medicine

By Claire McCarthy, MD, a primary care physician and the medical director of Children’s Hospital Boston’s Martha Eliot Health Center.

So you bought your child some cold medicine from the local pharmacy because he’s got a runny nose and cough. According to the directions on the box, the dose for his age is 2 teaspoons. You take out the little cup that came with it—but you don’t see 2 teaspoons marked anywhere on it. There’s a marking for 1 TSP, and something above it that says 1 DSSP—could that be short for Double Sized Spoon, or something? Is that 2 teaspoons? There are markings for various amounts of ML’s, CC’s, FL OZ’s and even DRAMS (what are drams?). But nowhere does it say 2 teaspoons.

This is an actual example in an article published last week in the Journal of the American Medical Association. They even have a picture of the cup. It’s just one example of what the authors nicely call “inconsistencies” between the package directions and measuring devices. The authors found that essentially all of the measuring devices provided with top-selling nonprescription medications for children had at least one problem, like missing markings, extra markings, or abbreviations that were undefined, unclear, or incorrect. It’s no wonder that studies show that 40 to 60 percent of parents make errors when giving medications to their children.

The blame for the “inconsistencies” clearly lies with the drug companies, who are apparently ignoring voluntary guidelines on measuring devices issued last year by the Food and Drug Administration. And the study lends more strength to the argument of the American Academy of Pediatrics that parents should stop buying over-the-counter cold medications for their kids. They don’t usually work very well anyway.

But if the patient doesn’t understand the treatment, or can’t measure the medicine, that excellent diagnosis and treatment won’t go very far.

But there’s a bigger point that we could easily miss if we just blame the drug companies and stop buying the medications. In the editorial that accompanies the article, Dr. Darren DeWalt wrote about what he called “the dismount”. In gymnastics, the dismount can be the most important part of a routine. In medicine, he said, the “dismount” is when the health care system hands the responsibility for care over to the patient—and it’s just as important. This hand-off could be at the end of a doctor’s visit, at a hospital discharge, or at the local drug store; it’s wherever and whenever the system steps out and the patient and family take over. In health care, Dr. DeWalt points out, we tend to pay the most attention to making the right diagnosis and picking the right treatment. But if the patient doesn’t understand the treatment, or can’t measure the medicine, that excellent diagnosis and treatment won’t go very far.

I see this all the time. I see the measurement errors the article talks about. I see parents who don’t understand when and how to give medications, only to have their child get sicker instead of better. I see families making themselves crazy trying to follow dosing schedules exactly, because nobody told them where they had leeway (or asked what dosing schedule they could manage with their life). I see children who got worse because their parents didn’t understand when to call us or return to the office. I see parents who don’t understand how to use an inhaler or other medical devices. It’s not that nobody explained anything—it’s just that the way it was explained didn’t make sense, didn’t get to the right person, didn’t sink in, or didn’t stick.

Doctors, pharmacies, drug companies and the whole health care system need to work on making the dismount stick. And actually, we are working on it. But families can do a lot to be sure their health care hand-offs go smoothly. Here are some suggestions:

  • Please, speak up if you don’t understand something! There’s no such thing as a stupid question when it comes to your child’s health and safety. Truly, we want to know if we’re not explaining things well enough. If questions come up after you leave, call!
  • Ask for instructions in writing. It’s easy to forget details, especially when you’re stressed or sleep-deprived (a child’s illness tends to cause both in parents)
  • If you have a child with asthma or another chronic disease, make sure you have a written plan for exactly what you should be doing both when your child is well and when the disease acts up (for asthma, we call these Asthma Action Plans.)
  • While you’re asking for written stuff, ask your doctor for patient education materials on your child’s condition—or recommendations for good web sites to help you learn more. The more educated you are, the better.
  • Don’t give any nonprescription medication without talking to the doctor first. Make sure it’s something your child really needs, and make sure you know how much to give.
  • Whenever possible, use oral medication syringes for giving liquid medications to your child, and ask for the dose in milliliters (mL). You’ll be able to measure more exactly that way. Avoid using medication cups, as they are less exact—and never use spoons out of the silverware drawer (measuring spoons are okay, but syringes are still better).

It’s all about partnerships. Doctors, nurses, parent, caregivers, drug companies, pharmacists…all of us need to work together. From diagnosis to dismount, we’re all important; we need each other to keep the patient—and all of us—healthy.

Used with permission from Children’s Hospital Boston.