A matter of taste: Results of antibiotic suspension tasting among paediatric doctors

Paediatric medication non-adherence is associated with increased morbidity.1 A major barrier to adherence in paediatrics is the inadequacy of available oral drug suspension formulations for children in terms of palatability, volume required, frequency of administration and the small number of proprietary products available.2 The combination of children's heightened bitterness to sensitivity and their aversion to the smell and texture of oral medication can reduce adherence.3 Antibiotics account for more than 60% of medicines prescribed to children in the hospital setting.4 An understanding of the palatability of antibiotics is an important component of informed prescribing. We assessed the impact of an antibiotic tasting session on perceptions of antibiotic palatability among new paediatric resident medical officers (RMOs). The most frequently prescribed antibiotic suspensions in our hospital were selected: cephalexin, ciprofloxacin, clindamycin, cotrimoxazole (trimethoprim with sulfamethoxazole) and flucloxacillin. Cephalexin, cotrimoxazole and flucloxacillin suspensions are proprietary products while ciprofloxacin and clindamycin are only available as tablet/capsule formulations in Australia and are compounded into suspensions with flavouring agents. RMOs were asked to rank antibiotic suspension palatability pre- and post-tasting and provide qualitative feedback. Of the 39 RMOs, 3 reported to have a beta-lactam allergy and did not participate. Of the 36 participating RMOs, 20 returned complete rankings pre- and post-tasting and 16 gave multiple antibiotics the same rank or provided incomplete rankings; these respondents were excluded from further analysis. Palatability ranking results are presented in Figure 1, which demonstrates broader variance in ranking of perceived palatability pre-tasting, and harmonisation of ranking post-tasting. Clindamycin and ciprofloxacin ranking after tasting firmly shifted towards ‘least palatable’ whilst flucloxacillin shifted to more palatable. The move towards ‘more palatable’ for flucloxacillin should be interpreted in light of the ranking being inherently relative. That is to say, participants did not necessarily find flucloxacillin more palatable than anticipated, but rather that they found ciprofloxacin and clindamycin to be less palatable than expected, and even less palatable than flucloxacillin, and ranked them accordingly, thus displacing flucloxacillin from its lowest ranked position. Kendallτ distance was used to quantify the difference between pre- and post-tasting palatability rankings for each of the 20 respondents. The mean Kendallτ distance was 0.42, where 0 represents no change and 1 represents the maximal change in rank order after taste testing. No respondents gave the same ranking before and after tasting, showing that this exercise produced some change in knowledge in all participants. This education session aimed to improve understanding of palatability through direct exposure. While most RMOs appreciated the palatability of cephalexin pre-tasting, there was limited awareness regarding the less palatable suspensions including ciprofloxacin and clindamycin. The movement and harmonisation of ranking reinforce the utility of this approach. Ranking may have been influenced by the sequential administration and order of exposure of antibiotic suspensions as the least palatable suspensions were offered last and bitter flavours may have accumulated. Furthermore, the degree of difference in palatability between the ranks may not be equal. This simple and practical intervention has the potential to increase adherence to prescribed antibiotic suspensions in children through palatability-informed prescribing. We recommend this hands-on educational approach be implemented for all new paediatric doctors to improve patient-centred prescribing to help maximise adherence. This was an investigator-initiated study carried out as part of our routine work.