Short Communication. Frequency of dispensing paediatric medicines with high sugar content by pharmacists in Barcelona.
Abstract: Aim: To determine which high sugar cough syrups sell most frequently in pharmacies in Barcelona. methods: 300 pharmacies in 10 districts of Barcelona (Spain) were visited and data collected on the type of syrup-based medicines dispensed most often over a 3-month period in 2008. Results: Data was collected in 142 out of 300 pharmacies. The percentage of the medicines sold by group of antibiotics (sweetener) were: Augmentine[R] (aspartame) 5.72%; Clamoxyl[R] (sucrose) 3.28%; Ceclor[R] (sucrose) 3.66%. In the anti-inflammatory group: Junifen[R] 2.0% (saccharine sodic); 3.59%, Junifen[R] 4.0% (sodic sucrose); 4.35%, Apiretal[R] Codeine (sucrose); 0.31%, Dalsy[R] (sucrose) 39.35%; Febrectal[R] (sodic saccharine): 0.89%. conclusions: It is very important to advise parents, pharmacists, paediatricians, and paediatric dentists about low-sweetener paediatric medicine alternatives to control the high content sucrose medicines. The aim should be to reduce the intake of over the counter medication.

Key words: Caries, medicines, sugars, sugar-free, sweetened.
Article Type: Survey
Subject: Pharmacists (Surveys)
Drugs (Dispensing)
Drugs (Surveys)
Authors: Noyola, A. Salinas
Jimeno, F. Guinot
Castelblanque, V. Barbero
Dalmau, L.J. Bellet
Pub Date: 02/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Feb, 2010 Source Volume: 11 Source Issue: 1
Product: Product Code: 8045000 Pharmacists NAICS Code: 44611 Pharmacies and Drug Stores
Geographic: Geographic Scope: Spain Geographic Code: 4EUSP Spain
Accession Number: 277106716
Full Text: Introduction

During childhood, children with chronic disease often take a lot of medication. In most cases, neither health personnel nor the parents are aware of the sweetener content of the medicines or the effect the sweeteners might have on children's teeth. Prescribers and pharmacists need to be aware of the importance of the sugar/sweetener content of these medicines. One of the drawbacks of such medicines is that their use is associated with caries. Hence, paediatric dentist should prescribe medicines with sugar substitutes in their chemical composition [Miegimolle et al., 2003]. The intake of medicines, prescribed or self-medicated, that contain sugar in their chemical composition might produce a health problem by increasing dental caries in a paediatric population [Grillaud et al., 2005].

Sucrose is often the main sweetener present in medicines, mostly as syrups. In vitro studies have demonstrated the fall in the pH of plaque produced by different medicines sweetened with sucrose [Imfeld, 1977; Feigal et al., 1981; Bigeard, 2000]. Common sugars (sucrose, lactose, glucose, fructose, and maltose) present in fruits and daily meals are quickly fermentable. Sugar substitutes such xylitol and sorbitol are not cariogenic, with the exception of manitol that has a low potential for the development of caries.

Mentes [2001] demonstrated the cariogenic effect of paediatric medicines, observing variations of pH in plaque produced after rinsing with two versions of the same medicine: one containing only sucrose and another containing saccharine, cyclamate and sorbitol, during a one hour period. It was observed that in sucrose substitution for another sweetened non-acid, the cariogenic potential effect was prevented. Birkhed et al. [1984] evaluated plaque acid production in a group of students after the intake of medicines as syrups or suspensions. The patients in the trial had low plaque buffering capacity and high counts of mutans streptococci (MS). It was concluded that xylitol and combinations made with xylitol (saccharine, sorbitol) used as sweeteners were non acid based and would not lower the pH of plaque.

Measures should minimize the use of potential cariogenic syrup medicines, health professionals, such as paediatricians and dispensing pharmacists. In this regard in 1991, British public health services and the UK Government agreed to ban the sale of any medicines that did not carry a sugar content warning on a bottle label [Rekola, 1989]. It was hope that this measure would encourage pharmaceutical manufactures to produce sugar-free paediatric syrups [Miegimolle et al., 2003]. The purpose of this study was to identify which high sugar medicines were being dispensed in pharmacies of selected districts in the City of Barcelona.

Materials and Methods

Surveys. Two surveys were made, one for pharmacists and one for a group of parents. The pharmaceutical information about the total sale of medicines previously selected during the last three months from 300 pharmacies in the 10 districts in Barcelona was used. The trial was conducted between January and February 2008. Six groups of medicines were studied that were known to contain sucrose or non cariogenic sweeteners as excipients in order to compare which of them were dispensed the most frequently.

Questionnaires. The pharmacist survey contained 2 questions:

* Are you aware of the existence of added sugar in some of the paediatric medicines that you dispense? Yes or No?

* Are you aware of the existence of added sugar substitutes in some of the paediatric medicines that you dispense? Yes or No?

Once they had answered those questions they were requested to carry out the search using the national code of each medicine to determine their total sales from the last 3 months of the medicines as listed in Table 1.

The parents' survey was conducted because it was known that in Spain the intake of over-the-counter medication is a common practice by parents for their children. This survey was conducted on a random selection of the first 100 parents that visited the paediatric dental clinic at International University of Catalonia during the same time period. A secondary aim was to make parents aware of medicines containing sucrose or substitutes.

The parental survey aimed to obtain data to evaluate possible intake of syrups with a high content of sucrose and/or non-cariogenic sweets, and also to value oral hygiene habits (brushing teeth) after taking these medicines. These questions were:

* Do you often give your son/daughter medicines without prescription when he/she is sick? Yes or No?

* What kind of medication do you often have at home for your son/daughter?

* Do you know that some of the syrups your children take contain sugar that produces caries? Yes or No?

* Do you know that some of the syrups your children take contain sugar substitutes? Yes or No?

* Do your children brush their teeth after the intake of syrups? Yes or No?

Statistical analysis. The data collected from the surveys was statistically analysed using Microsoft Office Excel 2007. The statistical program Statgraphics[R] 5.1 Plus was also used to analyse the results.

Results

Pharmacies. After visiting a total of 300 pharmacies, only 142 agreed to take part in the study. Objections were registered as: lack of time, lack of belief that the study was anonymous, lack of knowledge and uncertainty on how to obtain the requested data, or simply lack of interest. The responses to the pharmacists' questions were: 72% said they were aware of the existence of added sugar in some of the paediatric medicines that they dispensed. Whereas 67% of the pharmacists said they were aware of the existence of the availability of sugar substitutes in some of the paediatric medicines.

Frequencies of dispensing by medicine type. Among the antibiotics that sell the most in Barcelona, Augmentine[R] (market share 45%) contains the non-cariogenic sweetener aspartame unlike Clamoxyl[R] (26%) and the two presentations of Ceclor[R] (22% and 7%). In the anti-inflamatory group of drugs Dalsy[R] had the highest percentage of sales (84%) compared with Junifen 2%[R] (7%) and Junifen 4%[R] (9%).

In the antihistaminic group Atarax[R] was the most popular (market share 39%) followed by Polaramine[R] (27%), both containing sucrose as excipients. In the antitusive group no alternative medicine that contained a non-cariogenic sweetener was found, as both medicines: Flutox[R] (93%) and Tautoss[R] (7%) contained sucrose. Mucosan[R] with a non-cariogenic sweetener (sorbitol) sold the most in the mucolytic group (64%) followed by Ambroxol[R] (18%), Pectox[R] (11%) and Viscoteina[R] (7%).

Parental results. The global results showed that Dalsy[R] and Augmentine[R] were the most popular medicines (Figure 1). After analysing the results obtained from the survey on the parents: 81% of the parents answered they did not medicate their children; and 19% give medication without prescription. From the medicines studied, 53% of the parents give Dalsy[R] to their children, 24.3% Apiretal[R], 13% paracetamol, 6% Junifen[R], 1% Febrectal[R], 7.9% Flutox[R] and 3.9% Augmentine[R].

Most of the parents (70%) were not aware of the presence of sucrose in paediatric medicines. Only 29% were aware and 90% of parents did not know that non-cariogenic sweets may substitute sucrose, only 9% knew this. Disappointingly 94% of the parents did not get their children to brush their teeth after taking the medicines.

Discussion

Pomarico et al., [2005] in a Brazilian hospital study surveyed parents of two groups of children: 70 without special needs (G1) and 83 children with special needs (G2). Parents or caretakers were asked if their children's teeth were cleaned after the intake of their medication. In the group G1 the 84.3% answered they did not clean their teeth, only a 15.7% answered they did. In the G2 group 69.2% answered they did not and 30.8% did. In our survey 94% of parents did not brush their children's teeth after taking their syrup. These very low levels of compliance are disturbing.

Medical prescriptions should always be supervised by professional personnel; pharmacists can also recommend sugar free medicines. That pre-supposes that pharmacists are knowledgeable about sugar-free medicines. In our study 71.8% of the 142 interviews knew of the existence of sacarose or non cariogenic sweeteners in medicines. In a similar study by Bradley and Kinirons, [1998] of 29 pharmacists interviewed 20 mentioned they always recommended them and 9 only sometimes.

[FIGURE 1 OMITTED]

When we asked parents if they were offered a non-sucrose option of medicine by their pharmacists only 24 of the 210 always used the non-sucrose option, 70 sometimes and 116 never. This finding highlights the need for paediatricians, paediatric dentists, and pharmacists to be aware and recommend medicines that contain substitutes of sucrose.

To diminish the intake of sucrose containing paediatric medicines it is important that oral health education be enhanced particularly to our fellow professionals caring for children. Other researchers have attempted studies to educate populations in this regard such that of Maguire et al., [1999].

Conclusions

Paediatric medicines with high sucrose content were found to be those that parents used the most in Barcelona. One sucrose containing paediatric medicine in particular, the anti-inflammatory Dalsy[R] had a market share of 84%. The existence of non-cariogenic sweeteners in paediatric medicines was known by 67% of pharmacists.

References

Bigeard L. The role of medication and sugars in pediatric dental patients. Dent Clin North Am 2000; 44(3): 443-56.

Birkhed D, Edwardsson S, Kalfas S, Svensater G. Cariogenity of sorbitol. Swed Dent J 1984; 8(3): 147-54.

Bradley MB, Kinirons MJ. Choice of sugar-free medicines by a sample of dentists, doctors and pfarmacists in Northern Ireland: the views of parents and health professionals. Community Dent Health 1998; 15 (2): 105-8.

Feigal RJ, Jensen ME, Mensing CA. Dental caries potencial of liquid medications. Pediatrics 1981; 68 (3): 416-9.

Grillaud M, Bandon D, Nancy J, Delbos Y, Vaysse F. The polyols in pediatric dentistry: advantages of xylitol. Arch Pediatr 2005; 12(7): 1180-6.

Imfeld TN. Cariogenic cough medicines. Schweiz Mnschr Zahnheilkd 1977; 87: 773-7.

Maguire A, Evans DJ, Rugg-Gunn AJ, Butler TJ. Evaluation of a sugar-free medicines campaing in North East England: quantitative analysis of medicines use. Community Dent Health 1999; 16(3): 138-44.

Mentes A. pH changes in dental plaque after using sugar-free pediatric medicine. J Clin Pediatr Dent 2001; 25(4): 307-12.

Miegimolle M, Planells P, Martfnez E, Gallegos L. Relation in dental caries and sugar medicine in children. Odontol Pediatr 2003; 11(1): 21-5.

Pomarico L, Souza IP, Rangel Tura LF. Sweetned medicines and hospitalization: caries risk factors in children with and without special needs. Eur J Paediatr Dent 2005; 6(4): 197-201.

Rekola M. In vivo acid production from medicines in Syrup form. Caries Research 1989; 23(6): 412-6.

A. Salinas Noyola, F. Guinot Jimeno, V. Barbero Castelblanque, L.J. Bellet Dalmau

Dept. of Paediatric Dentistry, Faculty of Dentistry, International University of Catalonia, Barcelona, Spain.

Postal address: Prof. L. J. Bellet Dalmau. Dept. of Paediatric Dentistry, Faculty of Dentistry, International University of Catalonia. General Hospital in Catalonia, Josep Trueta, s/n. 08190, St. Cugat del Valles (Barcelona)

Email: ljbellet@csc.uic.edu
Table 1. Paediatric medicines and their sweeteners dispensed in
different Barcelona pharmacies in 2008.

Commercial name             Medicine group              Sweetner

Augmentine[R] 100/12.5      Antibiotics                 Aspartame
suspension pediatrica 60
ml

Clamoxyl[R] 250 mg/5 ml     Antibiotics                 Sucrose
susp 120 ml

Ceclor[R] Suspension        Antibiotics                 Sucrose
125ml/100ml

Ceclor[R] Suspension        Antibiotics                 Sucrose
250ml/100ml

Junifen[R] 2% Suspension    Anti-inflammatories/        Sucrose sodium
150ml                       analgesics

Junifen[R] 4% Suspension    Anti-inflammatories/        Sucrose sodium
150ml                       analgesics

Apiretal[R] codefna         Anti-inflammatories/        Sucrose
120-12 mg/5 ml solucion     analgesics

Dalsy[R] Suspension 100     Anti-inflammatories/        Sorbitol,
mg /5 ml                    analgesics                  sucrose

Febrectal[R] Infantil       Anti-inflammatories/        Sucrose sodium,
Solucion24 mg/ml            analgesics                  sucrose

Atarax[R] Jarabe 125ml      Antihistaminics             Sucrose
10mg/5ml

Polaramine[R] Jarabe 60ml   Antihistaminics             Sucrose
2mg/5ml

Zyrtec[R] Solucion 200ml    Antihistaminics             Sorbitol

Zyrtec[R] Solucion 60ml     Antihistaminics             Sorbitol

Flutox[R] Jarabe 200m       Antitussives                Sucrose

Tautoss[R] Jarabe 120ml     Antitussives                Sucrose

Ambroxol Edigen EFG[R]      Mucolytics                  Sorbitol
Jarabe 200ml

Mucosan[R] Jarabe 200ml     Mucolytics                  Sorbitol

Pectox[R] Solucion 120ml    Mucolytics                  Sucrose

Viscoteina[R] 200ml         Mucolytics                  Sucrose

Aldobronquial[R] Jarabe     Selective agonist           Unsweetened
100ml                       receivers beta-2
                            adrenergics

Terbasmin                   Selective agonist           Sorbitol
expectorante[R] 180ml       receivers beta-2
                            adrenergics
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