When children fall ill, getting them to take their medicine is even harder than getting them to see the doctor. The child cries, the parent gets angry, pandemonium ensues, and the child ends up throwing up more medicine than she ingests. This scene is played out again and again in families with young children, but few people stop to ask why it is so difficult to get children to take their medicine. Isn't there a solution to this problem?

Did you know that the mortal enmity between children and medicine is avoidable? The simple solution is for clinics and hospitals to prescribe sweet, non-bitter pediatric medications in syrup, liquid, chewable tablet, or suspension (soluble) form. Yet because of an adult-centric outlook and cost considerations, Taiwanese hospitals rarely consider this issue from the standpoint of children.

Because pediatric drugs are not widely imported into Taiwan, for a long time medications intended for adult use have been ground into smaller doses and then given to children. Whenever a pharmacist sees a doctor's prescription that reads "1/6 of a pill" or even "1/8 of a pill" he does not know whether to laugh or cry.

"Accurately splitting a pill in eight is a very difficult thing to do," says Wu Lin Fe-lin, director of National Taiwan University's Graduate Institute of Clinical Pharmacy.

Although not every pharmaceutical drug has a pediatric version, respiratory tract and gastrointestinal drugs for pediatric use were developed a long time ago. But due to cost considerations and restrictions on the types of medications that are covered by the National Health Insurance program, very few Taiwanese hospitals actually use pediatric drugs. In recent years, Wu Lin Fe-lin has managed to persuade National Taiwan University Hospital to import more than a dozen different pediatric drugs. Even so, compared to Japan, where 60% of medications prescribed to children are pediatric drugs, Taiwan lags far behind with its pediatric drug use rate of only 0.2%.

In Taiwan, only 0.2% of medications prescribed to children are pediatric drugs. Much work remains to be done in this area.

If it's bitter, it must be healthy?

For many years, Taiwanese pharmacists have been grinding pharmaceutical tablets into smaller doses for children. Most parents think that this is simply a matter of convenience and don't realize that this sort of ad-hoc medication is very dangerous.

Grinding tablets into powder and breaking capsules apart to make smaller doses can lead to all sorts of problems. The Taiwan Health Reform Foundation has catalogued a number of shocking cases of negligent administration of medication to children in recent years.

Four years ago, a six-year-old girl suddenly started menstruating after taking several days' worth of cold medicine. It turned out that the medicine she took had been ground in a medicine grinder that had previously been used to grind a female hormone drug, some of which had evidently been left in the grinder.

Two years ago, a doctor mistakenly wrote "5" instead of "0.5" on a tablet prescription for a five-year-old boy. The dosage was multiplied by ten and caused serious liver damage.

Grinding medicine into smaller doses is not only dangerous because it is easy to contaminate it or get the dosage wrong, but also because it may alter its pharmaceutical properties. Wu Lin Fe-lin points out that when tablets are ground into smaller doses, it is extremely difficult to make sure that each dose is the same, and even a tiny difference in dosage can alter the drug's efficacy or effect on a child. Mixing different medicine powders can lead to drug interactions or reduce their efficacy. Some drugs that are specially designed to provide a steady stream of medication over an extended period of time--such as enteric coated tablets and long-release and slow-release tablets--lose their efficacy when they are ground into powder.

Because children's metabolic capacity is different from adults', body weight is an important factor in determining dosage.

Putting children in adult shoes

Children also differ from adults in how they absorb and respond positively or negatively to certain drugs.

Because the pediatric drug market is small, pediatric drugs have a short shelf life, and cost is the bottom line, even in the United States 75% of drugs prescribed for children have not been clinically tested for children. In other words, there is no way to know whether these drugs may have harmful effects on children.

Even more shocking is the fact that for more than a decade, only the active ingredients but not the inactive ingredients have had to be listed on pharmaceutical drug labels in Taiwan.

"Some drug components can be harmful to children, but there is no way to tell if they are present by reading the medicine labels currently in use," says Lin. For example, preservatives can harm a child's developing nervous system and may trigger epilepsy. Not only may no medication containing preservatives be given to newborns, but it is also strictly forbidden to inject drugs containing preservatives to children under 18--yet labels give no indication as to whether the drug contains preservatives. "Even phoning the drug importer won't get you a straight answer," sighs Lin. Dispensing medicine to children is evidently a risky proposition.

There is also plenty of room for improvement in doctors' prescriptions.

"Prescriptions ought to indicate the child's weight to enable the pharmacist to check whether the dosage makes sense," notes Lin. During the neonatal and infancy stages, digestion and bowel movements are slow and ingested drugs tend to remain in the intestine for a relatively long period. Because young children's kidney function is immature, some drugs can have a toxic effect on them. On the other hand, once their metabolic functions mature, children's metabolic capacity exceeds that of adults per pound of body weight, which means that in some cases they may need an even higher drug dosage than adults. The upshot is that pediatric dosages have to be calculated with extreme care.

Taiwan's medical community would like to introduce reforms to stop the practice of giving adult drugs to children and put an end to the dangers it entails. Lin Tzou-yien, president of the Taiwan Pediatric Association and director of Chang Gung Children's Hospital, says that in the near future he will make every effort to promote the safe administration of drugs to children and to introduce an evaluation program for medical centers. But he acknowledges that because of the costs involved, it will be very difficult to get primary care clinics onboard.

Unfortunately, primary care clinics are the front-line healthcare providers that most often come into contact with children, and Taiwan's pediatric drug reform will not be achieved in a day. Who will speak up for children's right to be given medicine that is made just for them?