Key words:
Knowledge - pediatric liquid medicaments - pediatrician
INTRODUCTION
Pediatricians have the opportunity to influence the oral health of children as they
are the first health professionals to come in contact with infants and young children.
They are in an ideal position to influence the supply and use of pediatric medicines.
However, they often have a difficult task of ensuring the compliance of the patient
to a particular medication regimen.[1] Compliance of liquid medication can be improved by the addition of sugars such as
sucrose. Although artificial substitutes are used, sucrose is most widely used by
the pharmaceutical industry.[2]
Clinical observations linking long‑term oral medication to rampant dental caries were
performed since 1953.[3] The most conclusive evidence was given by Roberts and Roberts[4] and Feigal et al.[5] The medicines that have sucrose as sweetening agent also possess high viscosity
that results in low salivary clearance and high cariogenic potential.
There is growing concern among pediatric dentists about the increased consumption
of “hidden sugars” in pediatric liquid medicaments (PLMs) by children, especially
those who are chronically ill. Pediatricians are mainly responsible for pediatric
prescriptions and supply of information to parents. It is therefore essential for
the pediatricians to be aware of the infectious nature of dental caries and its association
with PLM and make appropriate decisions regarding their prescription. Hence, the purpose
of this study was to assess the knowledge, attitude, and practice of pediatricians
regarding PLMs and its effect on dental health.
MATERIALS AND METHODS
A cross‑sectional, descriptive study was conducted among pediatricians. A convenience
sample of 103 pediatricians, including private practitioners and doctors from government
hospitals, was asked to answer a questionnaire. Prior permission was obtained from
the concerned hospital authorities. Informed consent was obtained from each of the
respondents and their anonymity was assured by means of coding the returned questionnaires.
Both sexes were adequately represented and their ages ranged from 32 to 63 years.
The questionnaire was adapted from the work of Bradley and Kinirons[6] and Bawazir et al.[7] This questionnaire was subsequently modified according to the purpose of this study.
The modified questionnaire was validated from four experts on the subject. The questionnaire
elicited information on reasons for prescription and preferences in the selection
of PLM among the pediatricians. Questions also pertained to contents, properties of
PLM, and their relation to dental health. Following distribution of questionnaires,
all the responses were collected 1 day after delivery. Pediatricians who did not respond
by filled out questionnaires were contacted again after a week. All answers were treated
with utmost confidentiality. Data were collected and analyzed using SPSS 11.0, and
the results were expressed as absolute values and percentages.
RESULTS
A total number of 87 pediatricians completed the questionnaires. They considered age
and body weight of the child (58%), cost of the medicine (40%), and pharmaceutical
company (37%) to be relevant while prescribing PLM. None of them prescribed tetracycline.
Most the pediatricians (95%) preferred oral route of drug administration to children
and prescribed syrup form (79%). Although 88% of pediatricians knew that the PLM was
sweet in nature, only 20% felt that they can cause dental caries. Sixty‑seven percent
of pediatricians stated that pH of PLM is responsible for deleterious effect on teeth;
however, only 19% were aware that PLM is acidic and can cause tooth erosion (14%).
A large number of respondents (47%) thought that PLM causes staining of teeth. Although
72% of pediatricians were aware of the hidden sugars present in PLM, only 48% of them
provided oral health instructions following their intake. Concerning the sweetening
agents added in PLM, pediatricians cited sucrose (38%), fructose (25%), glucose (24%),
sugar substitutes (8%), and corn syrup (5%) [Table 1].
Only 48% of pediatricians were aware of availability of sugar‑free medicine, and their
main sources of information were conferences/seminars (30%), undergraduate training
(26%), and health literature (24%). Seventy percent of pediatricians were of the opinion
that sugar‑free medicine is not as sweet as sugar‑containing medicines and is more
expensive (65%). However, 62% of them agreed that all the PLMs should be made available
as sugar‑free medicines. Availability in pharmacy (31%) was the main factor that influenced
them during dispensing of drugs [Table 2].
DISCUSSION
In the present study, most of the pediatricians considered age and body weight of
the child during prescribing liquid medicaments. Some of them also considered pharmaceutical
company and cost of the medicines. The cost of the medicines was considered by many
of the doctors working at the government hospitals as they mostly attend to children
from economically weaker sections of society. However, contrary to this, a study reported
that factors such as patient’s financial status, availability of the medicines, habits,
and drug companies’ preferences were the least relevant according to pediatricians.[8] Syrup form was the most preferred choice of pediatricians probably because most
of the PLMs are sweetened to improve the palatability of children. Although majority
of the pediatricians knew that hidden sugars present in PLM make them palatable, they
were unaware of its role in causation of dental caries and erosion. The pharmaceutical
company incorporates large quantity of sugars, especially sucrose, in the formulation
of PLM. Sucrose is widely used due to its properties as a preservative, antioxidant,
solvent, and thickening agent. It is also available in low‑cost, nonhygroscopic and
can be easily processed.[6],[9] The medicines that have sucrose as sweetening agent also possess high viscosity
and can be readily fermented by oral acidogenic bacteria. Furthermore, these PLM have
slow salivary clearance rate and high cariogenic potential. Although pediatricians
were knowledgeable of the ill effect of tetracycline on teeth, they appear to be unaware
of the effect of liquid medicaments on dental health.
Pediatricians were aware of the hidden sugars in the PLM, but only a few of them informed
child’s parents about the risk of dental caries associated with liquid medications
and recommended for oral hygiene measures. This finding is concurrent with studies
which stated that most of the pediatricians did not give oral health instructions
to be followed after intake of medicines.[8],[10] As high sucrose exposure increases the cariogenicity by the modification of bacterial
virulent properties,[11] it is advisable to chew sugar‑free gum immediately after the intake of sweetened
PLM.[12]
Due to the concern of sugar‑containing PLM, pharmaceutical companies have introduced
sugar‑free medications into the market. Sugar‑free medications are known to be as
effective as sugar‑containing medications and only 10% are more expensive.[6],[13] In the present study, around 50% of pediatricians were aware of availability of
sugar‑free medications. Their main source of information was by attending conferences
and seminars, followed by reading health literature and training during undergraduate
course. These findings suggest that there is a need for an educational input at undergraduate
level and continuing training even after graduation to remain up to date with the
changing situation. This finding was similar to other studies.[7],[14] Most of the pediatricians were of the opinion that sugar‑free medications are not
as sweet as sugar‑containing medicaments and more expensive. Similar results were
also reported by Bawazir et al.[7] The sugar‑free medicaments are actually sweet which are sweetened with anticariogenic
and anti‑acidogenic sweetening agents such as xylitol, mannitol, and sorbitol.[15] Other misconception about sugar‑free medications may be due to the term “sugar free”
as pediatricians would have thought that it is synonym to “sweet‑free;” therefore,
the use of “sucrose‑free” or “noncariogenic medications” could improve the attitude
toward sugar‑free medications.[7]
In a study,[16] 30% of pharmacists believed that sugar‑free medicaments are more expensive than
sugar‑containing medicaments while the same number thought that safety and benefits
outweigh this higher cost difference. The higher cost spent on these sugar‑free medications
will protect the patients from further medical and dental complications, which need
much more higher cost. Around 62% of pediatricians wanted all liquid medications to
be available as sugar‑free medicines. In Belfast, 87% of pharmacists felt that all
medications should be available in sugar‑free form.[13] This was attributed to the pressure applied by the British Association of Community
Dentistry. Thus, strict implementation of rules of dental societies will improve the
oral health of society.[14],[16] Mentioning as sugar‑free product during prescription will enhance the use of sugar‑free
medications.[17]
Table 1:
Knowledge, attitude, and practice of pediatricians regarding sugar containing pediatric
liquid medicaments
|
Question number
|
Questions
|
Frequency (%)
|
|
PLM: Pediatric liquid medicament
|
|
1
|
What factors do you consider before prescribing medication to children?
|
|
Cost of the medicine
|
35 (40.22)
|
|
Patient’s preference
|
13 (14.94)
|
|
Body weight of the child
|
25 (28.73)
|
|
Age and body weight of the child
|
51 (58.62)
|
|
Pharmaceutical company
|
33 (37.93)
|
|
Type of sugar present
|
0
|
|
2
|
Do you prescribe tetracyclines to children?
|
|
Yes
|
‑
|
|
No
|
87 (131)
|
|
3
|
Which route of drug administration do you prefer for children?
|
|
Oral
|
83 (95.40)
|
|
Intramuscular
|
4 (4.59)
|
|
Intravenous
|
3 (3.44)
|
|
Rectal
|
4 (4.59)
|
|
Others (please mention)
|
0 (0)
|
|
4
|
Do you dispense or offer the choice of form of medication?
|
|
Yes
|
24 (27.58)
|
|
No
|
63 (72.14)
|
|
5
|
For a young patient (1–6 years), do you prefer to prescribe?
|
|
Syrups
|
69 (79.31)
|
|
Dispersible tablets
|
9 (10.34)
|
|
Both
|
15 (17.24)
|
|
6
|
Are PLMs sweet/acidic/bitter?
|
|
Sweet
|
77 (88.50)
|
|
Acidic
|
17 (19.54)
|
|
Bitter
|
27 (31.03)
|
|
7
|
Which property of PLM do you feel causes deleterious effects on teeth?
|
|
Viscosity
|
19 (21.83)
|
|
pH
|
59 (67.81)
|
|
stickiness or adherence
|
23 (26.43)
|
|
sugar content
|
31 (35.63)
|
|
All of the above
|
29 (33.33)
|
|
None of the above
|
0
|
|
8
|
Are you aware of the hidden sugars present in the PLM?
|
|
Yes
|
63 (72.41)
|
|
No
|
25 (28.73)
|
|
9
|
Name the commonly used sweetening agent (s) present in PLM?
|
|
Glucose
|
21 (24.13)
|
|
Fructose
|
22 (25.28)
|
|
Sugar substitutes
|
7 (8.04)
|
|
Sucrose
|
33 (37.93)
|
|
Corn syrup
|
4 (4.59)
|
|
10
|
Can PLM cause tooth erosion or decay or stains?
|
|
Erosion
|
12 (13.79)
|
|
Decay
|
18 (20.68)
|
|
Stain
|
41 (47.12)
|
|
11
|
Do you usually inform and guide child’s parents about the risk of dental caries associated
with PLM?
|
|
Yes
|
26 (29.88)
|
|
No
|
61 (70.11)
|
|
12
|
Do you recommend oral hygiene measures to be taken following intake of PLM?
|
|
Yes
|
42 (48.27)
|
|
No
|
45 (51.72)
|
|
If yes
|
|
Brushing
|
18 (20.68)
|
|
Rinsing
|
69 (79.31)
|
Table 2:
Awareness of pediatricians regarding sugar‑free pediatric liquid medicaments
|
Question number
|
Questions
|
Frequency (%)
|
|
PLM: Pediatric liquid medicament
|
|
1
|
Have you heard about sugar‑free medications?
|
|
Yes
|
42 (48.27)
|
|
No
|
45 (51.72)
|
|
2
|
What is the source of information?
|
|
Health literature
|
21 (24.13)
|
|
Professional journal
|
7 (8.04)
|
|
Conferences/seminars
|
26 (29.88)
|
|
Postgraduate training
|
6 (6.89)
|
|
Undergraduate training
|
23 (26.43)
|
|
News media
|
0
|
|
Print media
|
0
|
|
From pharmacists sales representatives
|
5 (5.74)
|
|
Others
|
3 (3.44)
|
|
3
|
Sugar‑free medicine is not as sweet as sugar‑containing medicines
|
|
Agree
|
61 (70.11)
|
|
Disagree
|
20 (22.98)
|
|
Not sure
|
6 (6.89)
|
|
4
|
Sugar‑free medicines are more expensive than sugar‑containing medicines
|
|
Agree
|
57 (65.55)
|
|
Disagree
|
13 (14.94)
|
|
Not sure
|
17 (19.54)
|
|
5
|
Should all PLM be available as sugar‑free medicines?
|
|
Agree
|
54 (62.06)
|
|
Disagree
|
11 (12.64)
|
|
Not sure
|
22 (25.28)
|
|
6
|
What are the factors that influence your decisions to dispense sugar‑free medicines
if made available at your place?
|
|
Parental requests
|
25 (28.73)
|
|
Medical status of patient
|
63 (72.41)
|
|
Information from health literature
|
21 (24.13)
|
|
Detailing by pharmaceutical representative
|
19 (21.83)
|
|
Availability in pharmacy
|
27 (31.03)
|
|
Recommendation by national health policy
|
23 (26.43)
|
|
Affordability
|
24 (27.58)
|
|
Mass media advertisement
|
4 (4.59)
|
|
Reports of clinical trial
|
17 (19.54)
|
CONCLUSION
Knowledge, attitude, and practice of pediatricians regarding PLMs and its effect on
dental health were not satisfactory.
Financial support and sponsorship
Nil.
