Appendix I: Pill swallowing protocol

Family HIV Service, St. Mary's NHS Trust.

The worker who will be carrying out the instructions with the child should be a neutral member of the team who has no prior history with the child. Ask parents not to let the child drink before coming to the clinic so they are slightly thirsty, as s/he will have to drink water during the session.

Obtaining information

At the appointment, meet with the parents alone initially, in order to explain the procedure and gather information. The following questions are important:

• How well does your child eat?
• Does your child have a good appetite and eat a variety of foods?
• Are meal times difficult, stressful or overly long?
• Can your child swallow meat or other chewy foods?
• Has your child ever had to take pills before?
• Could s/he manage them?
• Has your child ever choked on pills or had any difficulties swallowing them?
• >How does your child manage liquid medication?
• How is your child managing at school? (This may highlight difficulties following instructions or learning in general).
• Does your child have lactose intolerance? (Placebos contain lactose).
• What have you told your child (if anything) about taking pills?
• Is there anything else we need to know about your child?

Setting the scene

Parents should be out of the room for the session. To avoid possible disruption later, the child should be encouraged to use the bathroom beforehand. The room used must be free from distractions such as toys or books. A sign on the clinic door will help prevent interruptions.

The worker and child should sit across from each other at a small table. Talk enthusiastically about what the child will learn during the session. This will help establish a rapport. It is important not to hold up the process by chatting about other things. Explain to the child that s/he will be learning how to swallow pills.

It is helpful to mention that the good thing about pills is that you don't taste them when you swallow them and that pill taking will be much quicker than taking liquids. It is important not to let the child know that they will soon be taking a new kind of pill as this may deter them from learning the technique.

The Process

Before the first attempt, encourage the child to swallow a mouthful of water. This may help demonstrate any problems the child has with swallowing and the general level of motivation.

Demonstrate the steps to pill swallowing as follows:

• Sit or stand up straight
• Take a deep breath
• Breathe out with pursed lips, making an 's' sound.
• Put the pill in the middle of your tongue.
• Keep your head straight.

Keep the range of pill bottles that will be used out of the child's sight. Present the child with the first (smallest) pill, placing two pills on a piece of paper. Let the child choose which pill they want to swallow. Show the child how to swallow the pill by going through the steps as outlined above. Then encourage the child to swallow the pill themselves, reminding them of the steps. You can hold the child's chin gently in order to keep their head straight. A mirror may be useful to help show the child where to place the pill.

Maintain a neutral face and tone of voice throughout, but praise the child for his/her effort, in particular after the pill has been swallowed successfully. Social reinforcement is the primary reward for successful pill swallowing. Rewards such as sweets, toys should not be used unless absolutely necessary.

If the child has difficulties swallowing a pill, encourage the child to repeat the process with another pill of the same size before moving on to the next pill. The child can also teach the worker the correct way to take the pill. Both these moves will help increase their confidence.

If the first or second pill cannot be swallowed on the first attempt, encourage the child to say, 'It's OK, I just need to keep trying'. It is important not to mention this with later pills as this may reinforce the child getting the pill stuck.

When moving from one pill to the next, it is important not to mention that the child is moving on to taking a bigger pill but the next pill. Any mention of size may increase a child's anxiety. Direct the child to swallow the next pill without asking them if they can do it. Repeat the process as before by using short, repetitive commands, reminding the child of the steps and maintaining a neutral expression throughout.

Repeat the process until the largest pill the child can manage has been swallowed. As the session progresses, decrease the amount of coaching and instruction but continue to praise the child when successful. The worker is more involved when the child is successful than when s/he is unable to complete the task. This will encourage the child to continue.

Limit the session to half an hour - any longer and the child will become tired and frustrated. End the session on a positive note. When the child has demonstrated the technique successfully, ignore them while they are swallowing, only paying attention and praising when they have completed the task. When the child has demonstrated that they can swallow pills successfully, it is no longer necessary to coach them.

And finally...

At the end of the session, bring the parents into the room so that the child can show off their new skill. Instruct the parents to sit to one side quietly, withholding comments or praise until the child swallows successfully.

If parents are supportive and keen to be involved, send them home with enough pills of the largest size the child is able to swallow so that they can practice once a day for a week (until the next appointment). Parents should be supplied with written instructions so that they can practice with the child. Parents are advised to stop practising if the child experiences any problems during the practice at home so that negative experiences are kept to a minimum. Contact details should also be given to parents so that they can ring the clinic if they have any problems or have any questions.