April 2, 2018 -- For some people, it takes a lot more than a spoonful of sugar to help the medicine go down.
Lissa Smith’s toddler was one of them.
Six years ago, the 3-year-old boy from Stone Mountain, GA, was mauled by a dog, which left an infected, yellow, baseball-sized knot next to his eye. The boy’s eye was swollen shut, and the pediatrician would only know whether his sight was spared after the infection cleared.
And that meant taking antibiotics.
“He didn’t run and scream when the dog attacked him,” recalls Smith, who asked that his first name not be used to protect his privacy. “He sat still as a statue when the doctor stitched up the wound right next to his eye.”
“But when we had to give him this medicine, he’d gag on it and spit it up every time. He cried and begged us to stop.”
For 10 days, Smith and her husband had a twice-daily ritual: Strip the boy down, stand him in the bathtub, and drop the antibiotics into his mouth with an eyedropper. When he spit the offensive liquid down his chin, neck and bare chest, his dad would scoop it up with a spoon and put it back in his mouth again until it was all down. He had to have the medicine, or his infection could spread.
Eventually, it worked and the boy’s eyesight was fine.
Still, the bitter taste of some medications is an ongoing challenge in the health care of children and even some adults. If the medications taste too terrible, or if the consistency is hard to stomach, kids, and some adults, won’t take them. The risks of refusing medication are many. Smith’s son could have developed a more serious infection. But pharmacists and drugmakers face a number of challenges and limitations when tasked with making drugs more palatable for patients.
“This has always been an issue,” says Loyd Allen, PhD, a pharmacist and editor-in-chief of the International Journal of Compounding. “But it’s a balancing act.” Making a medication taste better can interfere with its basic chemistry and, sometimes, raise the concerns of parents and caregivers that it’s too attractive to children.
Why Does Medicine Taste So Bad?
By nature, medicine can’t be expected to taste good. The active ingredients, which include acids and bases that allow medications to do their job, are often bitter or even unbearably salty. In some cases, it’s the inactive ingredients, which give the drugs their texture and ensure their shelf life, that bring an offensive taste. If it’s not the taste that turns you off, the drug’s foul odor could be tough to swallow.
Some drugs are worse offenders than others, says Allen. “Antibiotics, especially penicillin-type antibiotics, have a distinct odor and bad taste. Antihistamines and decongestants taste bitter, too. It all goes back to their chemical structure.”
That bitter taste can be exaggerated by the dose, he adds. “If you have a really potent drug, where you only need 1 or 2 milligrams, that’s not going to be as disagreeable as a bad-tasting drug that you have to take 250 milligrams of, like an antibiotic.”
Researchers believe that your perception of that bitter taste helps protect you. Medicine can be toxic if you take too much. In fact, many potentially toxic substances taste bitter.
What’s more, children are more sensitive to bitter taste than adults. That’s a good thing when it keeps them from accidentally downing a bottle of drain cleaner, but it makes it hard to give them medicine.
What Can Be Done?
Solid pills and capsules, because of their coating, usually don’t have a bad taste. But kids up to about 6 or 8 years old often can’t -- or at least won’t -- swallow pills. Liquid medications are also easier to dose than cutting pills in half, since most dosages depend on the size of the patient. That means kids often have to deal with the taste of the medication as it slides down their tongue and into their throat.
Individual pharmacists or, if the demand is great enough, drugmakers, add flavors to medications to make them more agreeable for children and others who can’t swallow pills. But there’s only so much they can do. It’s very hard to mask a bitter taste. “Pharmacists can’t simply add a flavor and expect a bad-tasting drug to taste good,” Allen says.
Smith agrees. “We actually got the pharmacy to add a flavor in there, but it didn’t help,” she says, recalling her son’s ordeal. “It added a layer to it, but it didn’t do anything to alter just how gag-inducing this stuff was.”
Flavor chemists, or “flavorists,” add mixtures of five to 40 chemicals in order to get the desired flavor. “The flavorists are like perfumers in that they work with many different agents to achieve different notes and overtones,” says Allen. What they add to the drug, he says, “all depends on the drug itself, the concentration, and what you’re trying to do.”
For example, the best way to mask a bitter-tasting drug might be to blend in a complementary, more acceptable but still bitter flavor, such as chocolate, coffee, or maple. Acidic drugs blend well with the flavors of acidic fruits, such as orange or lemon. Sometimes flavorists opt to overpower the drug’s taste rather than blend a flavor into it. Wintergreen oil does that well. Chemists might also try to weaken or counteract an undesirable taste with its opposite. Adding salt, for example, can decrease sourness and increase sweetness. Often the goal is to make the drug more sour by adding acid to a bitter drug. Children, by nature, have a stronger preference for sour flavors than adults do.
Is It Safe?
Some ingredients added to medications raise concerns among parents and pediatricians from time to time, though “there are generally no risks or harms unless the patient is allergic to them,” Allen says.
Whether artificial colors, which are used in some liquid medications to make the color match the flavor, can contribute to ADHD and hyperactive behavior has been hotly debated for decades. But researchers haven’t reached a verdict on the topic.
Dextrose, a natural sweetener, can interfere with blood sugar control in kids who have diabetes. Research has connected both dextrose and sucrose to a higher chance of having cavities. But certain artificial sweeteners, used instead of natural sugars, raise concerns about cancer.
Flavorists use such small amounts of artificial flavors, research shows, that flavoring ingredients shouldn’t pose risks for kids unless they are allergic.
Parents who are concerned about ingredients should speak with their doctor or pharmacist. Compounding pharmacies can exclude sweeteners or dyes.
While Smith didn’t have to worry about her son’s medication tasting too good, some parents worry that the banana or bubble gum flavors will draw kids back to the medicine cabinet for more when no one is looking. “When it tastes too much like candy, pharmacists are criticized,” says Allen, “but parents have to assume a certain amount of responsibility for keeping the medications out of the reach of kids.”