ISMP Safe Medicine January/February 2012, Volume 10, Number 1. ©2012 ISMP

Brand name medicines appear in green; generic medicines appear in red.

Parents need to replace child-resistant caps after measuring liquid doses using an oral syringe and adapter

Measuring the correct dose of liquid medicine for children can be difficult. Today, many prescriptions and over-the-counter (OTC) medicines come with oral syringes. These devices help parents measure the correct dose of medicine. But we recently learned about a problem using an oral syringe with bottle adapters.

child with an irregular heartbeat needed to take Tambocor (flecainide) to treat his condition. The pharmacy dispensed the liquid medicine in a prescription bottle with a child-resistant cap. They gave the parents an oral syringe and screw-on bottle adapter (Figure 1 in PDF) to help measure the correct dose of medicine. Adapters have a hole in the middle to allow the bottle to be turned upside down to make it easy to draw the medicine into a syringe. After measuring out the correct dose, the parents did not remove the adapter from the bottle and replace it with the child-resistant cap before storing it in the refrigerator as required.

ne evening, the parents noticed their child coming up the stairs with a nearly empty bottle of this medicine in his hand. The child had gone into the refrigerator to get a juice box, but he picked up the medicine bottle and was able to drink most of it because the child-resistant cap was not on the bottle. The child was taken to the closest emergency department for treatment and then transferred to another hospital where he recovered.

his frightening incident should serve as a warning: bottle adapters must be removed and replaced with the child-resistant safety cap after each medicine dose is prepared. Otherwise, young children can access the medicine and take large doses. The screwed-on adapters may attract young children because they often look like the top of a sippy cup or infant bottle. Because adapters are not child-resistant caps, they can be easily removed. Also, many liquid medicine bottles are plastic. This makes it easy for a child to “squeeze” the bottle so a stream of medicine can come out even with the adapter in place.

he label on some oral syringes with adapters does not warn parents about this risk. For example, one popular oral syringe, EZY DOSE, is packaged with an adapter called a DOSAGE-KORC. This cork can easily be removed by a child to gain access to the medicine (Figure 2 in PDF). The removed adapter is also a choking hazard to children. There is a warning on the package in small print that says to recap the medicine to keep it stable. But there is no warning regarding accidental poisoning or choking hazard on the package.

ne type of bottle adapter plugs into the neck of any size prescription bottle (Figures 3 and 4 in PDF). The child-resistant bottle cap can fit over this plug without removing it. Target’s blunder proof container is one example.

Here’s what you can do: Ask your pharmacist for an oral syringe with an adapter that allows a child-resistant cap to be replaced on the medicine bottle without removing the adapter. Always replace the child-resistant cap immediately after each use. This will prevent a curious toddler or young child from accessing the medicine. Even when liquid medicines are intended for adults, these precautions should be taken to prevent a curious child from accessing adult medicines. With all liquid medicines, mark the bottle with a hash mark to identify how much medicine is left in the bottle after each dose has been removed. This way, if your child is able to access the medicine, you will be able to determine how much medicine the child has taken. This information can be crucial to poison control and healthcare providers who are treating your child.