Children refusing to take medications by mouth – how to prevent this from happening and how to manage it

Refusing to take medications – an precise combination of parental assertiveness and empathy starting at a young age

Before we start with the different techniques that we can try, let’s try to keep in mind that children and parental behavioural patterns are instilled at a young age.
In general, suspensions do not taste great, and so I really do understand why babies and children do not like taking in a liquid that at its best tastes okay. These meds are not pleasant.
But if the child learns, from a very young age, that if the parents have decided that they need to take certain meds by mouth they will have to take them, they will remember this also when they are 3 or 4 years old.
And if the child knows or feels that the parents may give in, then they will obviously resist. I personally know children that find it difficult to almost important to take antipyretics even at the age of 12.
So, I don’t think that things need to be done by force, but parental assertiveness is important. And it needs to be practiced by both parents together.
If you have decided that the medication is important, don’t give in to your child.
But before we give the meds, let’s ask ourselves a few questions.

Is the medication necessary?

It’s important to choose our battles in life.
If the child has a fever of 38.9 degrees Celsius, but is running around the living room, playing and well-appearing, then maybe it is not so important to give them the anti-pyretic. Afterall, fever is more than just a number. We have an important chapter on our website about “when is it necessary to reduce fever” and the answer to this is obviously associated with the concurrent symptoms and not only the degree of fever.
So, let’s start with thinking about whether the medication is necessary.

Is there an alternative to the medication? Is there a similar medication that tastes a bit better?

Most children do not completely refuse meds and will agree to one that tastes better. For example, Amoxicillin is produced by several different companies and can be found in multiple flavors. So, if you know your child prefers a specific flavor over the other, make sure you buy the flavor they like.
Another alternative to look for is a different medication that does the same job. For example, Ibuprofen is sold under several different brand names. Try to pick the brand name that produces it in a flavor that your child likes (orange/grapes/raisins/strawberries). Make sure you have the flavor they like at home so that if they spike a fever in the middle of the night you have the suspension that they like.
And consider using Acetaminophen instead, if your child prefers that medication.

Is there a way to administer the medication differently?

This is obviously related to anti-pyretics that can be given as suppositories/suspensions/powders and tablets that can be dissolved. Choose the formulation that best suits your child and their age.
In addition, I’ve seen children have to go to urgent care clinic for intravenous or intramuscular administration of antibiotics. Yes, that happens as well.

Why not give suppositories to anyone who isn’t willing to take a medication by mouth?

In general, most anti-pyretics are available as suppositories, however:
1. We are not only talking about anti-pyretics here. And antibiotics do not come in a suppository form.
2. At a certain age, I can’t tell when exactly, maybe around 3 or 4 years, it gets a bit awkward placing a suppository in a child. I see older children in the clinic that are only able to take anti-pyretics in suppository form. Again, I feel like when the child gets older it’s just not right.

Is there a different medication that is more concentrated?

It is certainly legitimate to discuss the right choice of antibiotic for different infections with your physician, and it is also acceptable to try and choose the antibiotic that best suits your child.
For example – group A streptococcus – a super sensitive bacteria to several different antibiotics. The choice of treatment, what is referred to as first line therapy, is Amoxicillin for 10 days, but Azithromycin can also work and only needs to be given for 5 days. In addition, the daily dose in millilitres that the child needs when given Amoxicillin is 4 times the volume of Azithromycin.
So, to be clear, I do not think that we need to make important medical conditions based on a fear that the child will refuse the medication. I strongly recommend Amoxicillin for strep throat infections rather than Azithromycin. But in exceptional situations, we can make exceptions to help with patient adherence.
I would rather a child take 5 days of Azithromycin for strep throat than 3 days of Amoxicillin.

Let us get to the action – how do you give suspensions to children?

Let us start with what should not be done when trying to give a child a medication.
Assertiveness is important but try to avoid using too much force – opening the mouth by force or pushing a syringe strongly into the child’s mouth can injure them or cause them to vomit.
Administering medication during sleep – this can lead to suffocation. I don’t think this is the right technique.
The parents fighting – this is never a good environment for the child.
One parent giving in – not so great. If you’ve decided the medication is important, take joint action.

What if the child continues to refuse?

a. Try to maintain a calm environment together with assertiveness
b. Give the medication while the child is sitting up, and not laying down
c. There is a preference for giving medications with a syringe, and not a spoon. Of course, if the child prefers the spoon, go for the spoon.
d. You can allow the child to hold the syringe and take the medication on their own.
e. If the child is still refusing, most of the time you will need two adults to deal with this. One of the adults will have the child in their lap. They will have to wrap one arm around the child and use the other hand to open their mouth. The second adult will place the syringe in the mouth.
f. Try to explain what is happening in a calm and pleasant way. “I’m sorry I had to hold you by force, dear. I hope that next time you will be able to take it without us having to hold you”
g. A hug is always helpful.
h. Stickers or surprises – in moderation. There is nothing wrong with giving your child a prize for taking their meds but don’t turn it into a habit, the prize will need to get bigger from one episode to the next and this is completely unnecessary.

How do you place the syringe in the child’s mouth and how fast should you push?

There are two ways to do this:
a. Place the syringe beyond the teeth/gums, in the midline. Not too deep so as not to elicit a gag reflex.
b. On the side of the mouth, in the area of the inner cheek.

Give the medication slowly – do not push in a large volume because the child will simply push it out. Give it at a rate that allows the child to swallow it. You can offer a sweet beverage between the doses.

What should you do if the child spits the medication up right away or vomits?

This is how I addressed this in the frequently asked questions about fever in children:
There is obviously a problem with giving an additional dose of a medication that has already been given because if the spit up/vomit were not immediate then some of the medication may have been absorbed.
And obviously, the implications of different antibiotics and anti-pyretics are not the same.
Nonetheless, if the medication that was given was immediately regurgitated (in front of your eyes), then it is acceptable to give the dose again as a one-time thing, making sure that:
• The spit-up/vomit happened immediately, and not after several minutes
• It is a one-time event and not something that happens several times a day
• It is not a special medication that is given for a chronic condition. If so, consult with your doctor before giving a second dose.

In summary, the mistakes we make with our third child are different to the ones we make with our first, fortunately. I think it is important to emphasize, already from a young age, that if a medication is important and the parents have decided the child must take it, then they must take it.
Easier said than done, I know.
Good luck.