by Amy C. Reese, Pharm.D.
My pharmacy received a prescription for prednisolone solution written for a 5-year-old patient. We only had the manufacturer of prednisolone with 5% alcohol in it as a solvent. I did not want to deny the child medication, but I was hesitant about giving medication with alcohol to a child because some people are strictly opposed to the practice of giving children alcohol. When the mother arrived at the pharmacy, I explained the situation to her and told her what her options were. She could chose to give her child the prednisolone with alcohol or she could abstain from picking up the prescription. I did not know how sick the child was nor what the mother’s thoughts on alcohol were; therefore, it was not my decision to make whether the child ought to receive the medication. I gave her the ability to decide after educating her as much as I could about the alcohol content of the prednisolone. She decided on taking the medication due to the severity of her child’s illness. I counseled her on how she should give it to her child and what the side effects could be as my professional duty as a pharmacist.
There have been incidences when a parent refuses to give their child the medication due to the alcohol. This occurred once with promethazine syrup for cough suppression. Since there are limited medications for cough suppression in pediatric patients, I did not have options to give a physician in order to change the prescription. The patient had to go without the medication due to the presence of alcohol.
Community pharmacists face the ethical issue of shared decision making just as physicians face this conundrum, but with a different flavor. One shared decision-making issue I have faced as a pharmacist is the existence of alcohol in liquid medication for pediatric patients. There is no scientific evidence that small amounts of alcohol are harmful to infants, but this blog came out of countless conversations with parents about whether they should give their child medication due to the presence of alcohol in it. As a community pharmacist, it is my duty to inform the parents of the presence of alcohol in the medication. I also inform my patients about inactive ingredients in medications if they might be a concern (e.g. methylparaben), but I have never encountered such difficult conversations as I have with the presence of alcohol in medications used for infants and toddlers.
Parents ought to know what is in the medications they give to their children as an aspect of autonomy. An individual needs to know the relevant information in order to make the best decision for himself/ herself/ their selves; he/she/they cannot govern himself/ herself/ their selves fully without knowing the whole story – in this case, the information of alcohol. This warrants a conversation with the parents/guardians of the child to determine whether 1) the parent/guardian is comfortable giving the medication with alcohol to the child and 2) whether the benefits of the medication outweigh the risks of the alcohol. Through this conversation, a shared decision can be concluded, and drug treatment can either proceed or cease.
Pediatric patients require liquid medications in most incidences due to the ease of administration. Liquid medications mostly use ethyl alcohol to solubilize them. For instance, promethazine (an anti-nausea medication that is also used as a cough suppressant) has 7% ethyl alcohol as a liquid and prednisolone (an anti-inflammatory medication used for breathing difficulty) has 5% ethyl alcohol as a liquid. There is a formulation of prednisolone that comes without alcohol, but many prescribers do not know that it requires a specific method of writing the prescription.
Having alcohol in pediatric medication can pose a problem. For one, many parents are unaware of the presence of alcohol in the medication. Second, once the parents are aware of the alcohol, they may or may not feel comfortable giving their child the medication. Alcohol itself does not have any moral implications, but its negative effects on the human body can pose a moral issue when given to a young child or an infant. Parents must make a decision for the health of their child which requires discussing the risks versus benefits of administering the medication with a healthcare professional (in this case, the pharmacist).
If a toddler diagnosed with asthma recently experienced an exacerbation, it might be beneficial to give the child 5% alcohol along with the prednisolone that will open the airways. The child may experience drowsiness due to the alcohol content, but the child will be able to breathe again due to prednisolone. If the exacerbation was mild, the parents may decide the risk of alcohol exposure may outweigh the benefits. If the exacerbation was severe, the parents may worry about the detriments of not giving the medication over the detriments of the alcohol.
Some parents do not have any objection to giving their child alcohol: moral or health related. I inform them of the presence of alcohol, but their decision to administer the medication is not swayed. Some parents object to giving their child alcohol, but their child is sick enough to warrant the risk of alcohol versus the benefits of the medication. Some parents refuse to give their child the medication due to the presence of alcohol in it. This decision to give the child the medication can occur during a conversation to determine the best route of action for the goals and values of the parents/family unit. As a pharmacist, I have a duty to inform the parents and then discuss “what matters most” to the parents.