antibiotics in children - using solid oral dosage form in place of oral suspensions

Last edited 12/2022 and last reviewed 02/2023

Using solid oral dosage form antibiotics in children (1)

Whole doses of solid oral dosage forms can be used 'off-label' in place of oral suspensions. This includes use for Group A streptococcal infections

Swallowing whole solid dose forms is preferred

Children should be encouraged to swallow oral solid dose forms (tablets and capsules), where possible:

  • Medicines for Children has useful guides on how to give medicines, including giving tablets and capsules.
  • KidzMed is an e-Learning resource from Health Education England for healthcare professionals teaching children to swallow pills

If a child is unable to swallow oral solid dose forms, the NHS Specialist Pharmacy Service have provided advice on how to give doses by dispersing or crushing tablets, or opening capsules below (1):

  • use in this way is outside the product license ('off-label')
Phenoxymethylpenicillin (Penicillin V) tablets

Phenoxymethylpenicillin tablets are available in a 250mg strength.

dispersing or crushing dispersing tablets masking the taste
  • are film-coated but can be dispersed in water, or crushed and mixed with liquid or soft food
  • crushing tablets should not be undertaken by anyone with a penicillin allergy
  • to disperse the tablet:
    • place the tablet in the barrel of a 10mL oral syringe
    • replace the plunger
    • draw up approximately 5mL of water and 2mL of air
    • shake well and allow to disperse (this may take up to 10 minutes)
    • ensure all contents of the syringe are given
  • alternatively, the tablet may be mixed with 5 to 10mL of water in small glass or medicine cup and stirred well
 the dispersed or crushed tablet will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the crushed tablet with food or drink, give it straight away

Phenoxymethylpenicillin would normally be given half an hour before food as food slightly decreases the peak plasma concentration of the drug; however, the manufacturer acknowledges food does not appear to affect the extent of absorption (1)

Clarithromycin tablets

Clarithromycin immediate-release tablets are available as 250mg and 500mg strengths

dispersing or crushing dispersing tablets masking the taste
  • the tablets are film-coated but can be crushed and mixed with liquid or soft food
  • crushing tablets should not be undertaken by anyone with a macrolide allergy
  • modified-release tablets must not be crushed
  • to disperse the tablet:
    • place the tablet in the barrel of a 10mL oral syringe
    • replace the plunger
    • draw up approximately 5mL of water and 2mL of air
    • shake well and allow to disperse (this may take up to 10 minutes)
    • ensure all contents of the syringe are given
  • alternatively, the tablet may be mixed with 5 to 10mL of water in small glass or medicine cup and stirred well
 the crushed tablet will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the crushed tablet with food or drink, give it straight away

Erythromycin tablets

Erythromycin tablets are available as 250mg and 500mg strengths. Some are film coated and some are enteric coated.

dispersing or crushing dispersing tablets masking the taste
  • film-coated tablets can be crushed and mixed with liquid or soft food
  • crushing tablets should not be undertaken by anyone with a macrolide allergy
  • enteric coated tablets should not be crushed

to disperse the tablet:

  • place the tablet in the barrel of a 10mL oral syringe
  • replace the plunger
  • draw up approximately 5mL of water and 2mL of air
  • shake well and allow to disperse (this may take up to 10 minutes)
  • ensure all contents of the syringe are given

crushed tablet will taste bitter

  • can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
    • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
    • it might be helpful to use an oral syringe for liquids
    • after mixing the crushed tablet with food or drink, give it straight away

 

Note that some generic products advise to give one hour before food, however this may not be necessary and is not practical in this situation.

Amoxicillin capsules

Amoxicillin capsules are available in 250mg and 500mg strengths.

opening and dispersing masking the taste
capsules can be opened and the contents tipped out and mixed with liquid or soft food
  • however, this should not be undertaken by anyone with a penicillin allergy
 the capsule contents will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the powder with food or drink, give it straight away
Azithromycin capsules

Azithromycin capsules are available in a 250mg strength

opening and dispersing masking the taste

capsules can be opened and the contents tipped out and mixed with liquid or soft food

  • however, this should not be performed by anyone with a macrolide allergy
 capsule contents will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the powder with food or drink, give it straight away

Absorption of azithromycin capsules (but not tablets or oral suspension) can be decreased by food; however, it is not clear whether absorption of opened capsules is affected.

Azithromycin tablets

Azithromycin tablets are available as 250mg and 500mg strengths.

dispersing or crushing dispersing tablets masking the taste
  • azithromycin tablets are film-coated but can be crushed and mixed with liquid or soft food
  • crushing tablets should not be undertaken by anyone with a macrolide allergy
  • to disperse the tablet:
    • place the tablet in the barrel of a 10mL oral syringe
    • replace the plunger
    • draw up approximately 5mL of water and 2mL of air
    • shake well and allow to disperse (this may take up to 10 minutes)
    • ensure all contents of the syringe are given
  • alternatively, the tablet may be mixed with 5 to 10mL of water in small glass or medicine cup and stirred well
 the crushed tablet will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the crushed tablet with food or drink, give it straight away

Cefalexin capsules

Cefalexin capsules are available as 250mg and 500mg strengths.

opening and dispersing masking the taste
cefalexin capsules can be opened and the contents tipped out and mixed with liquid or soft food
  • however, this should not be performed by anyone with penicillin or cephalosporin allergy
 capsule contents will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the powder with food or drink, give it straight away

Cefalexin tablets

Cefalexin tablets are available as 250mg and 500mg strengths.

dispersing or crushing dispersing tablets masking the taste
  • cefalexin tablets are film-coated but can be crushed and mixed with liquid or soft food
  • crushing tablets should not be undertaken by anyone with a penicillin or cephalosporin allergy
  • to disperse the tablet:
    • place the tablet in the barrel of a 10mL oral syringe
    • replace the plunger
    • draw up approximately 5mL of water and 2mL of air
    • shake well and allow to disperse (this may take up to 10 minutes)
    • ensure all contents of the syringe are given
  • alternatively, the tablet may be mixed with 5 to 10mL of water in small glass or medicine cup and stirred well
 the crushed tablet will taste bitter so it can be helpful to use a strongly flavoured drink (e.g. blackcurrant cordial) or food (e.g. jam, apple sauce, yoghurt) that the child likes:
  • use a small amount of food or drink (e.g. a teaspoonful) so you can be sure the child eats it all and swallows the whole dose
  • it might be helpful to use an oral syringe for liquids
  • after mixing the crushed tablet with food or drink, give it straight away
For further information then see Using solid oral dosage form antibiotics in children

Reference:

  1. NHS Specialist Pharmacy Service (December 2022). Using solid oral dosage form antibiotics in children

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