Why learning how to swallow pills is good for patients, parents, and the planet

Why change is needed

Medicines and chemicals account for 25% of the NHS England carbon footprint.1 Few environmental impact studies compare liquid and tablet medicines, although available evidence suggests that pills have a lesser carbon footprint than equivalent liquid medications. A life cycle assessment based in India found that the carbon footprint of paracetamol pill production is 15 times less than an equivalent dose of liquid.2 Pills typically come in smaller, lighter packets than liquids, take up less space in distribution lorries, and create less packaging waste. Liquids also require dosing syringes or spoons, contributing to increased plastic waste.

Importantly, pills have a longer shelf life and can be stored out of the fridge so have lower energy requirements during their use, and are less likely to be discarded as a result of inadequate storage conditions. Pill packets can be divided up to dispense a specific number of doses, whereas liquid formulations must be dispensed in whole bottles, meaning excess doses from short term prescriptions (such as antibiotics) are often wasted. For long term prescriptions, pills can be dispensed in larger quantities than liquids, reducing the number of patient journeys to and from the pharmacy.

Switching from liquid medicines to pills also has benefits in terms of cost, safety, and adherence. In one US single centre retrospective study of 150 paediatric discharge prescriptions, one third of children aged 5 and over who could have been taught to swallow pills were discharged from hospital with liquid medicines.3 Switching to pills could have saved $436 per prescription, and an estimated $200 000 for discharge prescriptions annually.

Liquid medicine is hard to measure out accurately.4 A US multi-site randomised controlled trial of 2110 parents found that >80% made at least one dosing error when measuring out nine doses of liquid medicine for their children, and 21% of parents made at least one large dosing error of more than twice the intended dose.5 Even among experienced healthcare professionals, medication dosing errors occur more frequently with liquids than pills.6 Liquid formulations may also be associated with poorer adherence. A small retrospective US study of 23 children with HIV found improved adherence to medication regimens six months after pill training.7 Adults can also find pill swallowing challenging, and pill aversion in adults has been linked to poor adherence.8910 Liquid medications can be unpalatable and contain sugar, colourings, and preservatives to improve their taste or texture and shelf life but these additives increase the risk of dental caries and erosion.1112 Bitter taste in medicine was the second most frequently cited reason for non-adherence with short term antibiotic therapy in a questionnaire study of 414 patients in Saudi Arabia.13 Furthermore, modified-release liquids are rarely available, leading to increased dosing frequency, which presents additional challenges for children, parents, and teachers when doses are required during the school day.

Evidence for the solution

Pill swallowing is a life skill that can be learnt early on to improve experiences for children and their parents, and increase medication adherence in adulthood. Children with a normal swallow can be successfully taught to swallow pills from the age of 4.14 Healthcare professionals can offer pill swallowing training to both children and adults when required.

A single centre UK based quality improvement project used an interactive training package with a supplementary online video and comic poster to provide pill training to children attending renal clinics.14 Twenty one children aged 5-15 were successfully converted from liquids to pills in a three month period, equating to savings of £46 588 per year.

The exact carbon impact of switching from liquids to pills has yet to be calculated and is an area of research that would support the move to more sustainable prescribing practices.

What you can do

Pill training can be started from age 4 in children who don’t have swallowing difficulties. In our view, patients of any age should be asked about pill swallowing ability, and by age 10 children should be prescribed pills as standard. Children and young people with chronic diseases who are on long term daily medication, (eg, epilepsy or cystic fibrosis) or require long term courses of unpalatable oral antibiotics (eg, osteomyelitis) are most likely to benefit from learning pill swallowing.

Some countries have developed specific resources to facilitate pill swallowing. One of these in the UK is KidzMed an evidence-based six-step technique, illustrated with videos, cartoons, and a quiz, to teach professionals, parents, children, and young people how to swallow pills (box 1).

Pills are safer, cheaper, and—with less packaging and wasted doses—are more environmentally sustainable than liquid preparations. Early attention to recognising pill swallowing difficulties and training patients to learn this life skill will have numerous short and long-term benefits.