Mayes SD, Zickgraf H Atypical eating behaviours in children and adolescents with autism, ADHD, other disorders, and typical development. Res Autism Spectrum Disorders. 2019; 64:76-83 https://doi.org/10.1016/j.rasd.2019.04.002
Specialty Doctor in Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery Department, Princess Alexandra Wing, Kingston Hospital, Surrey, KT2 7QB, UK
Many children struggle or refuse to take oral medications. The refusal of medication occurs for many reasons including learned and pre-existing anxiety, sensitivity to tastes and textures and sensory–motor/coordination difficulties (for tablet swallowing). Oral analgesics play a vital role in managing the odontogenic pain of children. This is especially true when they have limited access to appropriate dental care services, are pre-cooperative or lack the ability to be compliant for conventional dental treatment.
CPD/Clinical Relevance:
Practical advice around the facilitation of analgesic administration for odontogenic pain is lacking for parents of children who may not accept conventional preparations.
Article
Children with special needs (e.g. autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD)), may find taking analgesics challenging. Studies indicate that up to 62% of children with ASD display atypical eating behaviours and food selectivity.1 Preference for bland or beige food and limited food textures, may mean some cannot tolerate the fruity taste and gritty texture of age-appropriate analgesic solutions. Oro-sensory aversions can also develop in response to some medical conditions (e.g. gastro-oesophageal reflux, dysphasia) and trauma (e.g. choking, force feeding).
Many of these children will require referral for specialist input and access to sedation and/or general anaesthesia for their definitive dental treatment, for which there may be a significant wait. Furthermore, lack of chairside compliance may not allow for temporization/stabilization measures to be employed to ease symptoms in the interim.
Unmanaged long-standing and recurrent episodes of dental pain can cause dental anxiety and avoidance behaviours, with subsequent deterioration of the untreated dental problem.2 Therefore, the need for effective home administered odontogenic pain relief is paramount in this group of patients.
There is a dearth of practical advice for (often desperate) parents to effectively manage their child's dental pain at home.
This Technique Tip acts as a starting point for clinicians to provide more tailored pain relief advice for such patients.
Teaching children to take medication
Table 1 offers general advice that dentists can give to parents to facilitate the acceptance of oral analgesics in the potentially compliant child.
Communicate clearly what the medicine is for, and how it will help
Use visual aids
Ask what type of medicine they prefer, e.g. tablet, chewable, liquid
Create a solid routine, e.g. timing of medicine, location taken
Choose flavours they prefer
Have a ‘safe’ food or drink for the child to eat or drink straight after taking medicine
For children who have the potential to learn to take medication, the following behaviour management techniques may be of use to parents:
Shaping (gradual introduction): for example, practising swallowing on command, first with water, then with something like a small bean, then a tablet.
Desensitization: for example, show an empty oral suspension syringe, then practice holding the tip of empty syringe in mouth, then with water, then with diluted medicine, etc.
Modelling: demonstration of the task, for example by a parent, may help those whose learning is enhanced by seeing it performed with no harm coming about.
Positive reinforcement: by offering praise or reward for completion of the step/task.
Available over-the-counter analgesics
The Scottish Dental Clinical Effectiveness Programme (SDCEP) advises the use of non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol as the analgesia of choice for odontogenic pain.4 Ibuprofen is the most common NSAID appropriate for children because it is the safest on the stomach and is available in various doses to allow for age-appropriate adaptation.
Both medications are available in different forms, either over the counter or on prescription, which may be useful for special needs children who struggle to swallow traditional tablets. or are too young to take tablet doses. Specific details of these can be found in the British National Formulary for Children (BNFC).5,6
Parents must be advised to follow medication instructions to ensure age-appropriate dosing to prevent overdose. Clinicians should consult the BNFC when offering any advice to parents or carers, and be aware of medical contraindications to some medications, for example ibuprofen may be contraindicated for some asthmatics (risk of hypersensitivity), those with gastrointestinal bleeding and ulceration, and those with inherited bleeding disorders.
Liquid analgesics
Oral analgesic suspensions (e.g. Calpol, Calprofen) are commonplace in the medicine cabinets of many homes with children.
Parents should be encouraged explore the different flavours of these syrups available over the counter to find one to which their child can accept. Common flavours include strawberry and orange. Always recommend sugar-free for obvious reasons!
Dilution in a larger volume of a preferred drink could be considered if a parent can be sure the child will consume the full amount.
Alternatives to flavoured syrups include the use of effervescent (soluble) tablets that can be dissolved in either water or the child's preferred squash (e.g. for paracetamol, 500 mg effervescent tablets).
Tablet analgesics
There are recognized techniques to teach children how to swallow tablets, outlined in Table 2.
Practice in a quiet place without noise and distractions
Allow the child to choose between water, sugar-free juice or milk, and place into a bottle
Begin practising with the smallest tablet/sweet
Place tablet in the centre of the tongue
Take 3–4 big gulps from bottle without breaking in between gulps
Have a ‘safe’ food or drink for the child to eat or drink straight after taking medicine
Other non-liquid oral options
Tablet splitting can be used, if a tablet is scored in the centre, to reduced the size of pill to be swallowed. However, check instructions first.
Tablet crushing/capsule opening (and dissolving contents in water) is not advised because it can alter the rate of absorption into the bloodstream and lead to over or under dosing with subsequent ineffective analgesia.7
Chewable capsules could be useful; however, currently, only chewable ibuprofen is available on the market (Nurofen 100 mg chewable capsules).
Orodispersible (melt) tablets can be placed on the child's tongue and allowed to dissolve within their saliva (e.g. Calpol Six Plus Fastmelts, Nurofen Meltlets).
Modified-release capsules are only available for ibuprofen (e.g. Nurofen 300 mg long-lasting capsules).
Suppository analgesics
This could be considered for use following consultation with a pharmacist if a child is unable to take any alternative form. This may offer a practical solution for younger children, and medications administered this way are often very fast acting. Currently, paracetamol 125 mg and 250 mg suppository doses are available to buy over the counter. They are suitable for children from the age of 1 year at varying doses, depending on the child's weight.8,9 Ibuprofen suppositories are not available to buy in the UK, and are not included in the BNFC.
Discussion
Much in the same way that the success of providing dental treatment for children relies on mutual trust between dentist and child, so too does the administration of medicines between parent and child.
The authors acknowledge that, while hiding analgesics in food and drink that children like may allow for their acceptance, the following should be considered:
This may result in aversion of certain foods/drinks that the child previously liked, but which now taste different, which could be problematic if the child already has a limited diet.
Full administration of dose will only be guaranteed if all the food/drink the medicine is mixed into is consumed.
Often cariogenic foods/drink are used as the carrier to mask the taste, which is not ideal.
The authors also advocate the adjunctive use of practical actions by parents alongside analgesics to aid odontogenic pain reduction in children where possible:
Optimised oral hygiene;
Avoidance of precipitating stimuli, such as temperature extremes of food and drink;
Use of physical and environmental distraction from their symptoms, for example massage, music etc.
Conclusion
While use of analgesics is not a substitute for definitive dental treatment, it certainly has its place where compliance for pain relieving dental treatment is impossible, and waiting lists for specialist care and resources are lengthy.
It is hoped that this Technique Tip gives the reader some food for thought when considering how to tailor their odontogenic pain relief advice for the carers of paediatric (and indeed adult) special need patients.
To the authors' knowledge, the pharmaceutical industry has yet to develop a safe, effective, odourless, tasteless, colourless, non-cariogenic over-the-counter oral analgesic liquid preparation that is universally accepted by children and that is readily available to the public. This would be of great clinical relevance and value where conventional methods of teaching children to take medicines are likely to be ineffective or not possible.
