A not-so-bitter pill to swallow

Psychologist uses pill-swallowing training to keep treatment on track for pediatric patients

Mallorie Gordon, PhD, makes it her business to know the size in millimeters of candy sprinkles, Mini M&Ms, Tic Tacs and Nerds.

A postdoctoral fellow in the Department of Psychology at St. Jude Children’s Research Hospital, Gordon sometimes treats children with pill-swallowing problems. She uses the candies to help them with these issues.

Nerds pose more of a problem than other candies.

“That’s a larger Nerd,” Gordon said, during a recent presentation to colleagues about the problems some patients encounter swallowing pills. “Those really vary in size.” Uniformity in candy size is important when conducting pill-swallowing training.

According to Gordon, a typical 6-year-old child can swallow a pill with little or no difficulty; however, some children struggle with this skill. She noted one study found 16% of children in an academic children’s hospital, ages 3 to 17, couldn’t swallow pills. Tablets and capsules typically range in size from 5 to 25 millimeters.

Why is this skill important in a children’s hospital?

Well, a child who has trouble swallowing pills might not have access to effective treatments or demonstrate adherence when a tablet or capsule has been prescribed. Both circumstances might result in a less-than-optimal outcome.

At a research institution such as St. Jude, pill-swallowing difficulty can affect a child’s participation in treatment protocols requiring pills. That may decrease the likelihood of an optimal outcome and impede research designed to learn more about a potentially promising therapy.

But this one “conceptually simple intervention with high efficacy”—pill-swallowing training—can often teach a child the necessary skills to swallow pills and circumvent those problems.

Taking a pill, not so simple

Taking a pill is often synonymous with achieving some desired effect quickly. And, explained Gordon, pills have many other characteristics to recommend them: low-cost, ease of administration (particularly compared to intravenously administered medications), and predictable pharmacokinetic properties.

So what’s the hang-up? Why do some children in medical settings struggle with this skill?

“When the clock is ticking and people are in incredibly high-stress situations,” said Niki Jurbergs, PhD, director of the St. Jude Psychology clinic, “it’s more complicated.” The complications are pediatric cancer and other life-threatening diseases.

In normal circumstances, a parent might hide an over-the-counter medication in a spoonful of yogurt. St. Jude patients need to take medication in strict adherence to instructions, Gordon said, to ensure precision in dosing accuracy, bioavailability and pharmacokinetic stability.

And some qualities inherent in the formulation and administration of pills make swallowing them an overwhelming task for some children. For instance, some capsules tend to stick to the mucous membranes lining the mouth and esophagus. Large-sized pills may evoke anxiety even before a child attempts to swallow them. And some clinical trials require that patients take several pills at one time.

A chill pill: Psychology’s role

Gordon said both psychologists and child life specialists at St. Jude know how to help patients overcome pill-swallowing difficulties. If a patient exhibits a high level of pill-swallowing anxiety or other complex psychosocial problems, psychologists can take the lead and use additional therapies that complement pill-swallowing training.

For example, a psychologist can teach a child to pause and do an “emotion check” during a pill-swallowing session. If an interfering emotion is identified, then the child can take a moment to practice a relaxation technique.

Although anxiety and other emotions play a key role in the development and maintenance of pill-swallowing difficulties in pediatric patients, Gordon said physical, cognitive and behavioral factors need to be examined, too. For example, a pill-swallowing problem might be caused or worsened by a neuromuscular abnormality, difficulty understanding instructions or uncooperative behavior.

Gordon noted that parents don’t always know if their child will need help with pill swallowing until the start of treatment, a time of stress that can ratchet up anxiety. A normally calm parent might be less patient when trying to get the child to take a pill, which can make the problem worse.

My pill please

Gordon said she tries to build good rapport with children to increase the odds that pill-swallowing training will work.

Candy helps.

She needs a quiet space, a table, some cups of water and a pill-swallowing kit. She keeps the Nerds and other candies in the kit along with age-appropriate rewards (stickers work well for a younger child).

She teaches the child proper pill placement on the tongue, proper posture and other requisite skills. Then she helps the child, in multiple trials, go from swallowing with water to swallowing a cake decoration, a sprinkle; a Mini M&M; a Tic Tac, etc. Then she makes a big jump in size from candies to capsules—placebo capsules of increasing size.

When the child can swallow a placebo capsule equal in size to the largest prescribed medication without difficulty, she’s done.

Who ya’ gonna call? Pill busters

If the pill-swallowing prospects for a patient don’t look promising, Gordon advises physicians to consult with psychologists—particularly for complex cases—and child life specialists. She also advises psychologists to be flexible and tailor the intervention to individual patient characteristics.

In Gordon’s recent pill-swallowing talk, she held up a pebble-sized piece of candy and told colleagues, “Don’t go looking for these in any of our pill-swallowing kits.”

A collective gasp at the grisly glob.

With parent approval, she had searched grocery store aisles for the perfect candy to appeal to a patient with a ghoulish sense of humor. It was just the right size, of course.

Problem solved.