What strategies can help a 6‑year‑old with severe otitis media take liquid amoxicillin‑clavulanate (90 mg/kg/day divided twice daily for 10 days)?

Practical Strategies to Help a Child Take Liquid Amoxicillin-Clavulanate

Mix the high-dose amoxicillin-clavulanate suspension with a small amount of chocolate syrup, applesauce, or yogurt immediately before administration, ensuring the child consumes the entire mixture within minutes to maintain drug stability and compliance. 1

Taste-Masking Techniques

• Chill the medication in the refrigerator for 30–60 minutes before dosing; cold temperatures reduce taste perception and can make the suspension more palatable 1
• Use a small volume of flavored vehicle: Mix each dose with 1–2 teaspoons (not more) of chocolate syrup, maple syrup, or fruit-flavored yogurt, then have the child consume it immediately 1
• Offer a "chaser": Provide a favorite juice, popsicle, or small candy immediately after swallowing to mask any aftertaste 1
• Avoid mixing with large volumes of liquid or food, as partial consumption will result in underdosing—a critical error when treating severe otitis media with high-dose therapy 1

Administration Methods

• Use an oral syringe (not a household spoon) to measure the exact dose and squirt it slowly into the back corner of the child's mouth, aiming toward the cheek rather than the throat to reduce gagging 1
• Position the child upright (sitting or standing) to facilitate swallowing and minimize aspiration risk 1
• Divide the dose into two smaller aliquots if the child struggles with the volume; administer the first half, wait 1–2 minutes, then give the remainder 1

Behavioral Strategies

• Establish a consistent routine: Administer the medication at the same times each day (e.g., breakfast and dinner) to build predictability 1
• Use positive reinforcement: Offer a sticker chart, small toy, or screen time immediately after successful dosing 1
• Avoid threats or force, which can escalate resistance and create long-term medication aversion 1
• Model the behavior: Pretend to take medicine yourself or have a sibling demonstrate, normalizing the process 1

Formulation Considerations

• Verify you are using the 14:1 ratio formulation (90 mg/kg/day amoxicillin with 6.4 mg/kg/day clavulanate), which causes significantly less diarrhea than older preparations and may improve overall tolerability 1, 2
• The twice-daily dosing schedule (rather than three times daily) improves compliance without reducing efficacy and minimizes disruption to the child's day 1, 3, 4

Common Pitfalls to Avoid

• Do not dilute the suspension in a full bottle of juice or milk, as the child may not finish it, resulting in subtherapeutic dosing 1
• Do not mix with acidic juices (orange, grapefruit) immediately before administration, as they can intensify bitterness 1
• Do not skip doses if the child refuses once; persistent refusal warrants contact with the prescriber to discuss alternative formulations or intramuscular ceftriaxone 5, 6
• Do not stop therapy early even if symptoms improve; the full 10-day course is required for children under 2 years to prevent treatment failure and recurrence 1, 5

When to Contact the Prescriber

• If the child vomits within 30 minutes of dosing, re-administer the full dose 1
• If the child consistently refuses medication despite these strategies, discuss switching to intramuscular ceftriaxone (50 mg/kg once daily for 3 days), which is equally effective and eliminates compliance issues 5, 6
• If diarrhea becomes severe (≥3 watery stools per day) or diaper dermatitis develops, contact the prescriber to assess whether the reduced-clavulanate formulation (80 mg/kg/day amoxicillin with 2.85 mg/kg/day clavulanate) might be better tolerated 2