Parents Often Give the Wrong Dose of Medication to Their Children

Abstract

Using oral syringes may reduce errors.

Pediatric medications typically come in liquid form and are commonly administered by parents. Past studies have shown that more than 40% of parents commit dosing errors when dispensing liquid medications to children. These mistakes are often blamed on drug labeling, packaging, and dosing tools, which employ assorted measurement units and frequently confusing instructions.

To assess how particular characteristics of pediatric drug labels and dosing tools impact error rates, researchers conducted a randomized controlled experiment in three urban pediatric clinics with 2,110 English- or Spanish-speaking parents of children ages eight years or younger. Participants were randomly assigned to one of five groups that used different pairings of measurement units—“mL,” “teaspoon,” and “tsp”—on the medicine label and on the dispensing tools. Caregivers used three tools (a dosing cup and two syringes—one displaying 0.2-mL increments, the other 0.5-mL increments) to measure amounts of 2.5, 5, and 7.5 mL. Over nine attempts, 84.4% of parents made one or more dosing errors, defined as deviating more than 20% from the label's amount. Overdosing errors were the most common (68%), and 21% of parents gave more than double the dose at least once.

Use of dosing cups was four times more likely to result in errors than either syringe. The error rate was also greater with smaller doses, suggesting that replacing cups with syringes may be advisable for smaller dose prescriptions.

Measurement unit pairings between labels and dosing tools generally had little impact on error rates except in the group given teaspoon-only labels paired with dosing tools marked in both milliliters and teaspoons. Parents in this group made significantly more errors than parents given milliliter-only labels and tools. Yet even the milliliter-only pairing, recommended by numerous organizations, including the American Academy of Pediatrics, produced enough errors to warrant concern.

While parents commonly administer medicines at home, these experiments were conducted at clinics serving predominantly low-income families. The authors acknowledge that their results may not be generalizable. They urge more research to test whether changes in labeling, dosing tools, and other strategies, such as caregiver training and use of pictograms, can reduce errors and enhance safety.—Lucy Wang Halpern