How Pharmacists Can Manage Metric Dosing of Children's Medications

In an effort to prevent accidental medication overdose in youth, the American Academy of Pediatrics (AAP) recommends that children’s liquid medications be prescribed and dispensed in metric units, rather than teaspoons and tablespoons.

While some may raise concerns that the American public is not generally familiar with metric units, Ian M. Paul, MD, MSc, lead author of the new AAP policy statement, told Pharmacy Times that those individuals are mistaken.

“Nearly all pills are (dosed) in mg—a metric unit,” Dr. Paul said in an email to Pharmacy Times. “Therefore, most people are already using metric units regularly.”

Although health care professionals may voice concern over increased dosing errors, the AAP asserted that minimal public education is needed to ensure safety, as evidenced from abroad.

To implement the new policy and counsel parents and caregivers on ml-based dosing, Dr. Paul recommends that pharmacists follow these steps:

• Dispense all liquid medications with appropriate volume syringes with clear metric markings.
• Ensure labels are clearly marked with metric units in ml, using only that abbreviation.
• Review the dose in ml with parents and caregivers.
• Consider adopting the use of flow restrictor technology for bottles and syringes, which can prevent unintentional, unsupervised ingestions by children and allow parents to turn the bottle upside down and withdraw medication. Dr. Paul noted that it is often quite difficult to get the last bunch of doses from a bottle using a syringe because of the shape of the bottle.

Additional recommendations from the AAP include clearly outlining the frequency of the medication and limiting the use of abbreviations (for example, daily instead of “qd,” which could be misinterpreted as “qid”); only dispensing medications with metric measurements from pharmacies, hospitals, and care centers; including dosing devices of appropriate sizes with the medications and counseling services to reduce overdose; and, in the future, examining caregiver health literacy on dosing precision to determine the best strategy to prevent overdose.

“Recent studies have demonstrated that syringes achieve more precise dosing than dosing cups or dosing spoons. Unfortunately, household spoons are still commonly used to administer liquid medications, particularly among those caregivers with low health literacy,” the AAP policy statement said. “Therefore, pediatricians should cease prescribing liquid medications to children that use teaspoon or tablespoon volumes and advocate for the use of oral syringes with metric markings.”