Category: 1. Medication Safety

Medical treatments can affect the way children digest and absorb food. By the same token, what children eat can influence the effects that medications have on the body. For example, griseofulvin, an antifungal medication, needs to be taken with a fatty meal to be absorbed properly. Iron supplements for anemia are best taken with a mild acid like orange juice; if taken with milk they may not be well absorbed. Medications affect nutrition in 4 main areas—they can stimulate or suppress the appetite; they can alter the amount of nutrients absorbed and the rate of absorption; they affect the way the body breaks down and uses up nutrients; and finally, they can slow down or speed up the rate at which food passes through the digestive tract.

Always ask your pediatrician, pharmacist, and other specialists involved in your child’s medical care to explain whether medication should be taken with meals or on an empty stomach. Several antibiotics can cause stomach pain or upset unless taken with food. Also find out whether taking medication with a specific food, such as a glass of milk or grapefruit juice, can make the treatment more or less effective, and ask what foods, if any, should be avoided during treatment.

There are thousands of possible drug-food interactions. The following list represents commonly used medications and foods, and guidelines for preventing such interactions or keeping the effects to a minimum. Be sure to check every prescription with the pharmacist and read the package insert.

Commonly Used Medications and Foods: Guidelines to Prevent Interactions

Medications	Interactions With Nutrients	Dietary Guidelines
Antacids
Nonprescription indigestion remedies	Foods lessen effects.	Take 1 hour after eating.
Antibiotics
In general	Reduce intestinal production of biotin (a B vitamin), pantothenic acid (vitamin B5), and vitamin K; can speed up passage of food through intestine, decreasing availability for absorption.	Eat a well-balanced diet, including plenty of vegetables, grains, and cereals, to ensure adequate intake of all vitamins.
Amoxicillin	Food slows absorption but does not alter dose effect.	None needed.
Erythromycin stearatePenicillin	Food decreases absorption.	Take 1 hour before or 2 hours after meals.
ClarithromycinErythromycin estolate/succinate	Food improves absorption; fruit juice or carbonated beverages interfere with absorption.	Take with meals.
Tetracycline	Binds calcium and iron so that neither antibiotic nor mineral can be absorbed.	Take 2 hours before or after meals and other medications such as iron supplements or calcium-based antacids.
Iron Supplements
Various brands in liquid or tablet form	Milk may interfere with absorption.	Should be taken with water or slightly acidic drinks like fruit juice to improve absorption.
Antifungal
Griseofulvin	Can interfere with effectiveness of birth control pills.	Take with fatty meal.
Anticonvulsant/Antiepileptic Medications
PhenobarbitalPhenytoinPrimidone	Interfere with vitamin D metabolism and thus with calcium absorption; also alter absorption of folic acid.	A good intake of vitamin D (found in fortified milk, egg yolks, oily fish, sunlight), calcium (dairy foods, leafy greens, broccoli, canned fish with bones), and folic acid (fresh fruits, vegetables, grains) should offset medication effects; ask your pediatrician about vitamin D and calcium supplements if your child is on long-term epilepsy treatment; folic acid supplements should not be used because overly high blood levels may decrease anticonvulsant efficacy.
Phenytoin	Better absorbed with food or milk.	Take with a meal or a glass of milk.
Thyroid Medications
Levothyroxine		Take on an empty stomach.
Nonsteroidal Anti-inflammatory Medications
Aspirin (acetylsalicylic acid)	Interferes with storage of vitamin C; may cause iron loss through bleeding in digestive tract.	Do not give aspirin to children unless your pediatrician specifically prescribes it because it has been associated with Reye syndrome, a rare but serious disease affecting the brain and liver following viral infections; use acetaminophen or ibuprofen.
Antituberculosis Medications
Isoniazid	Interferes with vitamin B6 (pyridoxine) metabolism.	Eat a well-balanced diet, including sources of vitamin B6 such as grains, spinach, sweet and white potatoes, bananas, watermelon, and prunes.
Corticosteroids
PrednisoneHydrocortisone	May promote excretion of potassium and calcium.	Reduce salt intake; eat foods high in potassium (fresh fruits and vegetables) and calcium (low-fat dairy foods) to counter loss of these minerals; take with food to lessen stomach upset.
Laxatives
Mineral Oil	Interferes with the absorption of fat-soluble vitamins in the first part of the intestine.	Provide a diet rich in vegetables and fruits for fiber and encourage your child to drink plenty of water; if constipation is a problem, ask your pediatrician’s advice; when mineral oil is prescribed, it should be given at bedtime, after most of the day’s food has passed through the first part of the intestine.
Oral Contraceptives
Various brands	Alter blood cholesterol levels; increase need for folic acid and vitamin B6.	Use another form of contraception if there is a family history of high blood cholesterol or heart disease; consume plenty of fresh fruits and vegetables, grains and cereals, potatoes, and other sources of folic acid and vitamin B6; take with food to prevent nausea; antibiotics may decrease the effectiveness of oral contraceptives.

Within the past decade, there has been a major change in infant’s and children’s liquid acetaminophen products (such as Tylenol) available on store shelves.

Since 2011, manufacturers changed the amount of acetaminophen in these medicines to one standard amount. Infant drops are no longer available and the syrup is available as 160 mg in 5 mL.

Children under age 2

Always call your pediatrician before giving acetaminophen to a child under 2 years of age, and call right away if your child is under three months of age and has a fever.

Children over age 2

For children over the age of 2 years, check the label to see how much medicine to give. If you know your child’s weight, use that. If you do not know your child’s weight, go by age for the dose amount.

Important medication safety reminders

• Keep all medicines out of reach of children.
• Use only the dosing device that comes with the product (do not use a household teaspoon). See “How to Use Liquid Medicines for Children.”
• Never give adult medicines to children.
• Always read and follow the instructions on the label.
• Talk to your pediatrician if you have any questions.
• If you think your child has taken too much of this or any medicine, call poison control at 800.222.1222.

​Diphenhydramine (also known as Benadryl) is a medicine used to treat allergic reactions, hives and allergies that affect the nose (called nasal allergies).

It is an “over-the-counter” medicine, meaning that you can get it without a doctor’s prescription. There are other medicines like diphenhydramine that might be safer for young children.

The table* below can help you figure out the right amount of diphenhydramine to give. Use your child’s weight to decide on the right amount. You can find the weight in the top row of the chart.

*Table notes:

• Age of child: Do not give diphenhydramine to children less than 6 years of age unless your child’s doctor tells you to. There are other medicines that are like diphenhydramine but will not make your child sleepy (like loratadine, cetirizine, fexofenadine) that can be bought without a prescription and are safer for young children.
  
• Measuring the dose for liquid medicines (should be in “mL” or metric units): It is easier to give the right amount of medicine when using a syringe than when using a kitchen teaspoon or tablespoon. Use the tool that comes with the medicine. If a tool does not come with the medicine, ask your pharmacist for one.
  
• How often to give the medicine (frequency): You can give diphenhydramine every 6 hours as needed.
  
• Adult dose: 50 mg
  
• Side effects: This medicine can make a child sleepy. Some children, however, may get more excited and active instead of getting sleepy. Because this medicine can make people sleepy, it is important to be careful when driving or using heavy machines after taking this medicine. This is especially important for teens who are driving.

Over-the-Counter Medicines

Medicine bought in stores off the shelf is called over-the-counter or OTC medicine. Common reasons to use OTC medicines include the following:

Fever, pain

Acetaminophen and ibuprofen can help your child feel better if your child has head or body aches or a fever. They can also help with pain from injuries such as a bruise or sprain and from soreness caused by a needle shot.

Acetaminophen comes in liquid and chewable forms and also as a rectal suppository if your child is vomiting and can’t keep down medicine taken by mouth. Ibuprofen comes in concentrated drops for infants, liquid (in the form of syrup or elixir) for toddlers, and chewable tablets for older children.
 
With ibuprofen, keep in mind that infant drops are stronger (more concentrated) than syrup for toddlers. For example, more medicine is in 5 mL of infant drops than in 5 mL of syrup for toddlers. Never give the same amount of infant drops as you would syrup.
 
Always look carefully at the label on the drug and follow the directions. Each type of drug has different directions based on the age and weight of a child. You may need to ask your doctor about the right dose for your child. For example, you will need to ask your doctor how much acetaminophen is the right dose for a child younger than 2 years.
 
Make sure you do not overdose your child by giving too much acetaminophen. Acetaminophen is an ingredient in many OTC and prescription medicines (eg, pain relievers, fever reducers, cough/cold medicines). If your child is taking more than one medicine, read the ingredient list to prevent double dosing.
 
Note: Aspirin is another medicine taken by adults for aches and fever. However, never give aspirin to your child unless your child’s doctor tells you to. Children who take aspirin may get a serious illness called Reye syndrome.

Cold and cough

The American Academy of Pediatrics recommends that OTC cough and cold medicines not be given to infants and small children because they have not been proven effective and can be harmful. Discuss other ways to treat cold symptoms with your doctor, such as saline nasal sprays or drops for children and bulb suctioning of the nose for babies.

Allergy, itching

 Antihistamines can be used to treat your child’s runny nose, itchy eyes, and sneezing due to allergies. They can also help reduce itching from chickenpox, insect bites, and other rashes including hives.

Stuffy nose

Your doctor may advise you to use saline nose drops or spray for a stuffy nose.

Rash, itching

Hydrocortisone cream or ointment is used for itching from bug bites, skin rashes such as poison ivy, and eczema.

Wound, cuts, and scrapes

Antibiotic ointment is used to prevent or control infection in wounds, cuts, and scrapes.

Constipation

Many OTC treatments are available for constipation, including stool softeners, laxatives, enemas, and suppositories. Call your doctor for advice if your child is having hard stools or pain or blood with bowel movements, because some constipation medicines can be too harsh for infants and children.

“Over-the-counter” (OTC) means you can buy the medicine without a doctor’s prescription. Talk with your child’s doctor or pharmacist before giving your child any medicine, especially the first time.

All OTC medicines have the same kind of label. The label gives important information about the medicine. It says what it is for, how to use it, what is in it, and what to watch out for. Look on the box or bottle, where it says “Drug Facts.”

Check the chart on the label to see how much medicine to give. If you know your child’s weight, use that first. If not, go by age. Check the label to make sure it is safe for infants and toddlers younger than 2 years. If you are not sure, ask your child’s doctor.

Call the doctor right away if..

Your child throws up a lot or gets a rash after taking any medicine. Even if a medicine is safe, your child may be allergic to it.

Your child may or may not have side effects with any drug. Be sure to tell the doctor if your child has any side effects with a medicine.​​

Using antibiotics when they are not the right medicine will not help and may even cause more harm than good. Why? Because antibiotics are medicines used to treat infections—and they target bacteria—not viruses. 

Before prescribing an antibiotic, your child’s doctor will find out if it is the right medicine to treat your child’s infection. 

In this article, the American Academy of Pediatrics (AAP) answers common questions about the use of antibiotics. Talk with your child’s doctor if you have other questions and see 10 Common Childhood Illnesses and Their Treatments for more information.

1.  My child has a really bad cold. Why won’t the doctor prescribe an antibiotic?  

Colds are caused by viruses. Antibiotics are used specifically for infections caused by bacteria. In general, most common cold symptoms—such as runny nose, cough, and congestion—are mild and your child will get better without using any medicines. 

Many young children—especially those in child care—can get 6 to 8 colds per year.

2.  Don’t some colds turn into bacterial infections? So why wait to start an antibiotic?  

In most cases, bacterial infections do not follow viral infections. Using antibiotics to treat viral infections may instead lead to an infection caused by resistant bacteria. Also, your child may develop diarrhea or other side effects. 

If your child develops watery diarrhea, diarrhea with blood in it, or other side effects while taking an antibiotic, call your child’s doctor. 

3.  Isn’t a nose draining yellow or green mucus a sign of a bacterial infection?  

Yellow or green mucus in the nose does not automatically mean that antibiotics are needed. During a common cold, it is normal for mucus from the nose to get thick and to change from clear to yellow or green. Symptoms often last for 10 days. 

Sinusitis is a term that means inflammation of the lining of the nose and sinuses. A virus or allergy can cause sinusitis and in some cases, bacteria can be the cause. 

There are certain signs that bacteria may be involved in your child’s respiratory illness. If your child has a common cold with cough and green mucus that lasts longer than 10 days, or if your child has thick yellow or green mucus and a fever higher than 102°F (39°C) for at least 3 or 4 days, this may be a sign of bacterial sinusitis. 

If your child has developed bacterial sinusitis (which is uncommon), an antibiotic may be needed. Before an antibiotic is prescribed, your child’s doctor will ask about other signs and examine your child to make sure an antibiotic is the right medicine. 

4.  Aren’t antibiotics supposed to treat ear infections?  

Many true ear infections are caused by viruses and do not require antibiotics. If your pediatrician suspects your child’s ear infection may be from a virus, he or she will talk with you about the best ways to help relieve your child’s ear pain until the virus runs its course. At least half of all ear infections go away without antibiotics.

Because pain is often the first and most uncomfortable symptom of ear infection, your child’s doctor will suggest pain medicine to ease your child’s pain. Acetaminophen and ibuprofen are over-the-counter pain medicines that may help lessen much of the pain. Be sure to use the right dose for your child’s age and size. In most cases, pain and fever will improve within the first 1 to 2 days. 

Over-the-counter cold medicines (decongestants and antihistamines) don’t help clear up ear infections and are not recommended for young children. Ear drops may help ear pain for a short time, but always ask your child’s doctor if your child should use these drops. 

Your child’s doctor may prescribe antibiotics if your child has fever that is increasing, more severe ear pain, and infection in both eardrums. 

5.  Aren’t antibiotics used to treat all sore throats? 

​​No. More than 80% of sore throats are caused by a virus. If your child has sore throat, runny nose, and a barky cough, a virus is the likely cause and a test for “strep” is not needed and should not be performed. 

Antibiotics should only be used to treat sore throats caused by group A streptococci. Infection caused by this type of bacteria is called “strep throat.” 

Babies and toddlers under 3 rarely get it strep throat, but they are more likely to become infected by streptococcus bacteria if they are in child care or if an older sibling has the illness. Although strep spreads mainly through coughs and sneezes, your child can also get it by touching a toy that an infected child has played with.

If your child’s doctor suspects strep throat based on your child’s symptoms, a strep test should always be performed. If the test is positive, antibiotics will be prescribed. 

6.  Do antibiotics cause any side effects?  

Side effects can occur in 1 out of every 10 children who take an antibiotic. Side effects may include rashes, allergic reactions, nausea, diarrhea, and stomach pain. Make sure you let your child’s doctor know if your child has had a reaction to antibiotics in the past. 

Sometimes a rash will occur during the time a child is taking an antibiotic. However, not all rashes are considered allergic reactions. Tell your child’s doctor if you see a rash that looks like hives (red welts); this may be an allergic reaction. If your child has an allergic reaction that causes an itchy rash, or hives, this will be noted in her medical record. 

7.  How long does it take an antibiotic to work?  

Most bacterial infections improve within 48 to 72 hours of starting an antibiotic. If your child’s symptoms get worse or do not improve within 72 hours, call your child’s doctor. If your child stops taking the antibiotic too soon, the infection may not be treated completely and the symptoms may start again. 

8.  Can antibiotics lead to resistant bacteria?  

The repeated use and misuse of antibiotics can lead to resistant bacteria. Resistant bacteria are bacteria that are no longer killed by the antibiotics commonly used to treat bacterial infection. These resistant bacteria can also be spread to other children and adults. 

It is important that your child use the antibiotic that is most specific for your child’s infection rather than an antibiotic that would treat a broader range of infections. 

If your child does develop an antibiotic-resistant infection, a special type of antibiotic may be needed. Sometimes, these medicines need to be given by IV (vein) in the hospital. 

9.  What are antiviral medicines?  

An antiviral medicine may be prescribed for children that are at higher risk of becoming severely ill if they get the flu. For most other viruses causing cough and cold symptoms, there are no antiviral medicines that work or are recommended. 

10.  How can I use antibiotics safely?

• Give the medicine exactly as directed.
• Don’t use one child’s antibiotic for a sibling or friend; you may give the wrong medicine and cause harm. 
• Keep antibiotics and other prescription medicine in a secure place. Count and monitor the number of pills you have and lock them up. Ask your friends, family members, and babysitters to do the same.
• Dispose leftover antibiotics and other prescription medication. Return leftover prescriptions to a hospital, doctor’s office, or pharmacy. Many counties now offer “take-back” events to collect unused medication. For more information​.

​​If your child needs medications during school hours, it is important to keep in mind the following information.

Actions Before School

• Ask your pharmacist to divide your child’s medication into 2 bottles, each with its own label so that one can be kept at home and one can be kept (if allowed) at the school.

Getting Medicine to School

• All medication should be transported to the school by an adult and handed to another adult. Do not allow your child to carry his or her medication unless he or she is old enough and mature enough to handle the responsibility. Also, make sure it is allowed by the school.
• Your child should not carry his or her medication during school hours unless you, the doctor, and the school believes it is necessary for immediate access to emergency medication. Younger children are generally not mature enough to self-carry their own medications, but the school should make sure there is immediate access to emergency medications.
• All prescription and nonprescription medication (including vitamins) given in school settings require written authorization from your child’s doctor, as well as parent written consent. This is a requirement of the rules that school nurses must follow in most states. Ask your school for the medication administration forms they use.
• All medication must be brought to school in the original labeled container prepared by the pharmacy, doctor, or pharmaceutical company (i.e., no envelopes, foil, or baggies). The label should include the following:
  • Child’s name
  • Name of medication
  • Dosage of medication to be given
  • Frequency of administration
  • Route of administration
  • Name of physician ordering medication
  • Date of prescription
  • Expiration date

Medication Instructions for School Staff

• School staff involved in medication administration receives special training and work in consultation with a nurse or other health care consultant.
• Your child’s doctor must include the following instructions with the medication:
  • Date of order
  • Name of child
  • Reason for medication
  • Name of medication to be administered
  • Dosage
  • Time of administration
  • Route of administration
  • Length of time the medication needs to be given
  • Possible side effects
  • Special requirements such as “take with food”
  • Whether or not medication may be self-administered
• School staff is not authorized to determine when an “as needed” medication is to be given. Specific instructions are necessary (e.g., every 4 hours, as needed for headache). For children with chronic health conditions, this can be determined in collaboration with the consulting nurse.

Unused or Expired Medicines 

• Unused medications should be returned to the parent/guardian for disposal. In the event medication cannot be returned to the parent or guardian, it should be disposed of according to the recommendations of the US Food and Drug Administration. 
• Make a note of expiration dates and discuss with school what procedure they have to communicate with parents about expired medications that need to be replaced. 

Field Trip Considerations

• Ask your child’s doctor if your child’s medication can be taken at an alternate time.
• All school field trips must make it possible for your child’s medication to be transported, stored, and given properly.
• If your child has a chronic condition and requires regular or emergency medications, work with the school to allow enough time prior to the trip for arrangements to be made for the medications to be administered during the trip.

Medication at College

• Ask the college health center staff what kind of medical information they will need related to your teen, and how to arrange for prescription refills.
• If your teen is taking medication to treat a health or mental health condition, make sure he or she knows the name of the medication, how is it taken, side effects, and whether any foods or drinks should be restricted (e.g., alcohol).  
• Make sure your teen’s roommates, resident advisor (RA) and/or the college health center staff know about any emergency medications your teen may need and where he or she keeps them. If your teen’s condition is particularly complex or challenging, consider talking with or meeting with a health center staff member before the academic year starts.

Giving the wrong amount, or dose, of medicine is one of the biggest problems parents have when giving acetaminophen to children.

The tables* below can help you figure out the right amount to give.  Use your child’s weight to decide on the right amount to give. If you do not know your child’s weight, use your child’s age. Be sure to check with your child’s doctor to make sure you are giving the right amount. 
Acetaminophen Dosage Table for Fever & Pain: Birth to 3 Years of Age:

Acetaminophen Dosage Table for Fever & Pain: Age 4 Years and Older:

​*Table notes:

• Caution: In 2011, the U.S. Food and Drug Administration (FDA) recommended liquid, chewable, and tablet forms of acetaminophen be made in just one strength. Since that time, manufacturers and retailers of pediatric acetaminophen have voluntarily worked to change the amount of acetaminophen in these medicines to one standard amount (160 milligrams [mg]). Some manufacturers have recently made chewable tablets into a single strength of 160 mg. Infant drops are no longer available. Liquid syrup acetaminophen is available as 160mg/5mL. Dissolvable powder packs are available for children ages 6-11 years old and 48-95 pounds. Pediatric acetaminophen products on store shelves can continue to be used as labeled.
• Age of child: Do not use acetaminophen under 12 weeks of age unless your pediatrician tells you to. This is because fever in the first 12 weeks of life should be recorded in a health care setting. If there is a fever, your baby will need to be checked to see what tests are needed. (Note: Fever may happen after a vaccine in a child 8 weeks of age or older. If this happens, please talk to your child’s doctor.)
• Medicines with more than 1 ingredient (also called combination products): It is best not to give medicines with more than one ingredient to children less than 6 years of age. Avoid multi-ingredient products in children under 6 years of age.
• Measuring the dose for liquid medicines (should be in “mL” or metric units): It is easier to give the right amount of liquid medicine when using a syringe than when using a kitchen teaspoon or tablespoon. Use the syringe or tool that comes with the medicine. If a tool does not come with the medicine, ask your pharmacist for one.
  
• How often to give the medicine (frequency): You can give acetaminophen every 4 to 6 hours as needed. Do not give more than 4 doses in 24 hours.
  
• Oral disintegrating tablets: These are dissolvable tablets that come in 80 mg and 160 mg (junior strength)
• Suppositories (medicine that is put in the rectum, or butt): Acetaminophen also comes in 80, 120, 325 and 650 mg suppositories. The amount to give each time is the same as the amount to give by mouth.
• Extended-release: Do not give 650 mg oral extended-release products in children.