Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
From the American Academy of PediatricsPolicy Statement

Metric Units and the Preferred Dosing of Orally Administered Liquid Medications

COMMITTEE ON DRUGS
Pediatrics April 2015, 135 (4) 784-787; DOI: https://doi.org/10.1542/peds.2015-0072
  • Article
  • Info & Metrics
  • Comments
Loading
Download PDF

Abstract

Medication overdoses are a common, but preventable, problem among children. Volumetric dosing errors and the use of incorrect dosing delivery devices are 2 common sources of these preventable errors for orally administered liquid medications. To reduce errors and increase precision of drug administration, milliliter-based dosing should be used exclusively when prescribing and administering liquid medications. Teaspoon- and tablespoon-based dosing should not be used. Devices that allow for precise dose administration (preferably syringes with metric markings) should be used instead of household spoons and should be distributed with the medication.

  • administration
  • drugs
  • medication
  • metric
  • milliliter
  • liquid
  • safety
  • syringe

Background

Each year, more than 70 000 children visit emergency departments as a result of unintentional medication overdoses.1 Volumetric dosing errors and use of incorrect dosing delivery devices are 2 frequent sources of these overdoses.2 In 2008, the PROTECT (Preventing Overdoses and Treatment Errors in Children Taskforce) Initiative3,4 was launched as a collaborative effort between public health agencies, private sector companies, professional organizations, consumer/patient advocates, and academic experts to develop strategies to prevent unintentional medication overdoses. Among the recommendations from the ongoing collaboration is the explicit preference for exclusive use of metric unit dosing of orally administered liquid medications.

Until May 2011, when the US Food and Drug Administration (FDA) finalized nonbinding recommendations to the pharmaceutical industry to address inaccurate dosing,5 there was no standard guidance for labels, packaging, or dosing devices for orally administered liquid medications. The need for such direction was emphasized in the 2010 study of Yin et al.6 This study showed that commonly used over-the-counter pediatric liquid medications often contained discordance between volumetric dosing instructions on the label and the markings on the delivery device devices (eg, metric dosing in milliliters on 1 device and alternative terms such as teaspoon on the other). These discrepancies were cited as a source of confusion for caregivers. Abbreviations for these units of measure also were inconsistent (mL, ml, ML, and cc for milliliter). One other study found that medications prescribed with metric dosing are, at times, dispensed with nonmetric instructions for administration.7

Recognizing the importance of clarity and precision for dosing orally administered liquid medications, numerous organizations (including the Institute for Safe Medication Practices, the Academic Pediatric Association, the American Academy of Family Physicians, the American Medical Association, the National Council for Prescription Drug Programs, and the FDA) have issued statements in support of metric dosing, a practice some electronic prescribing systems also are enforcing.8–13 Although some physicians may be concerned that milliliter-only dosing practices will increase confusion and errors by caregivers, experience from abroad suggests that minimal education of the public is needed to ensure safety.14 Furthermore, it is probable that most pediatric providers have some experience with dosing in milliliters, in particular for small volumes of concentrated infant medications (eg, 15 mg/mL of ranitidine syrup).

The American Academy of Pediatrics (AAP) has previously supported the recommendation for metric dosing of orally administered liquid medications through federal testimony before the FDA and metric-only labeling in a policy statement on electronic prescribing.15,16 Two articles in AAP News have further emphasized the metric-only dosing approach.17,18 These communications echo sentiments put forth by a policy statement from the AAP Committee on Drugs from a generation ago. In the 1975 statement entitled “Inaccuracies in Administering Liquid Medication,” the committee detailed that inconsistent volumes are administered when medications are dosed by using teaspoons (particularly when household spoons are the dose delivery device).19 One recent study demonstrated that medication-dosing errors are significantly less common among parents using milliliter-only dosing compared with those using teaspoon- or tablespoon-based dosing.20 The 1975 policy statement also suggested that oral syringes be used to deliver more precise volumes. Recent studies have demonstrated that syringes achieve more precise dosing than dosing cups or dosing spoons.21–23 Unfortunately, household spoons are still commonly used to administer liquid medications, particularly among those caregivers with low health literacy.24–26 Therefore, pediatricians should cease prescribing liquid medications to children that use teaspoon or tablespoon volumes and advocate for the use of oral syringes with metric markings. Notably, use of syringes combined with caregiver education on dosing has been shown to markedly improve dosing precision.27

A switch to exclusive metric dosing for orally administered liquid medications is consistent with other AAP recommendations for the use of metric units. The 2009 joint policy statement “Guidelines for Care of Children in the Emergency Department,” issued by the AAP, the American College of Emergency Physicians, and the Emergency Nurses Association, emphasized that weights be measured and recorded in kilograms.28 In 2012, the AAP endorsed the position statement of the Emergency Nurses Association, which further advocated that pediatric weights only be measured and documented in kilograms, that scales used to weigh pediatric patients only be configured to record weights in kilograms, and that e-healthrecords be standardized to allow only kilograms for pediatric weight entries.29,30 Metric-only labeling was also recommended for electronic prescribing systems by the AAP in a 2013 policy statement entitled “Electronic Prescribing in Pediatrics: Toward Safer and More Effective Medication Management.”16 Therefore, to advance the adoption of consistent metric-only prescription and distribution of orally administered liquid medications for children by all stakeholders, numerous recommendations are now warranted.

Recommendations

  1. Orally administered liquid medications should be dosed exclusively by using metric-based dosing with milliliters (ie, mL) to avoid confusion and dosing errors associated with common kitchen spoons.

    1. Orally administered liquid medications should be dosed to the nearest 0.1, 0.5, or 1 mL, as appropriate based on the margin for safe and effective dosing, but dosing to the hundredth of a milliliter should be avoided.

    2. The only appropriate abbreviation for milliliter is “mL,” and the use of alternatives (eg, ml, ML, cc) for dosing orally administered liquid medications should be avoided.

    3. Milliliter-based dosing should include leading zeros preceding decimals for doses less than 1 mL (eg, 0.5 mL) to avoid 10-fold dosing errors.

    4. Trailing zeros after decimals should not be included when dosing in whole number units to avoid 10-fold dosing errors.

  2. The concentration (strength) of all orally administered liquid medication (eg, in milligrams per milliliter [mg/mL]) should be clearly noted on prescriptions to enable accurate calculation of the medication dose administered.

  3. The frequency of administration of all orally administered liquid medications should be clearly noted, avoiding the use of abbreviations that could lead to dosing errors (eg, use of “daily” is preferred over “qd,” which could be misinterpreted as “qid”).

  4. Pediatricians should review milliliter-based doses with patients and families at the time that orally administered liquid medications are recommended or prescribed to ensure adequate health literacy for metric dosing units.

  5. E-health record vendors should use metric units for orally administered liquid medications and eliminate the ability of providers to prescribe medications using non-milliliter–based dosing regimens.

  6. Pharmacies, hospitals, and health centers should dispense orally administered liquid medications with metric dosing on the label.

  7. Pharmacies, hospitals, and health centers should distribute appropriate-volume milliliter-based dosing devices with all orally administered liquid medications.

    1. Syringes (optimally, those designed to partner with flow restrictors) are the preferred dosing device for administering oral liquid medications. Cups and spoons calibrated and marked in milliliters are acceptable alternatives.

    2. Dosing devices should not bear extraneous or unnecessary liquid measure markings that may be confusing to caregivers.

    3. When possible, dosing devices should not be significantly larger than the dose described in the labeled dosage to avoid twofold dosing errors.

    4. Advanced counseling strategies (eg, teach-back, drawings/pictures, dose demonstration, show-back) may further reduce dosing errors when combined with provision of a dosing device.31

  8. Manufacturers should eliminate labeling, instructions, and dosing devices that contain units other than metric units.

  9. Researchers should study the effect of caregiver health literacy on dosing precision to determine the best strategies to prevent unintended dosing errors among minorities, immigrants, and those with low health literacy.

lead author

Ian M. Paul, MD, MSc, FAAP

Committee on Drugs, 2013–2014

Kathleen Neville, MD, MS, FAAP,Chairperson

Jeffrey L. Galinkin, MD, MS, FAAP

Thomas P. Green, MD, FAAP

Timothy D. Johnson, DO, MMM, FAAP

Ian M. Paul, MD, MSc, FAAP

Janice Sullivan, MD, FAAP

John N. Van Den Anker, MD, PhD, FAAP

Liaisons

John J. Alexander, MD, FAAP – US Food and Drug Administration

James D. Goldberg, MD – American College of Obstetricians and Gynecologists

Janet D. Cragan, MD, MPH – Centers for Disease Control and Prevention

Michael J. Rieder, MD, FAAP – Canadian Pediatric Society

Adelaide S. Robb, MD – American Academy of Child and Adolescent Psychiatry

Hari Sachs, MD, FAAP – US Food and Drug Administration

Anne Zajicek, MD, PharmD, FAAP – National Institutes of Health

Staff

James Baumberger, MPP

Tamar Haro

Raymond J. Koteras, MHA

Footnotes

    • Accepted January 12, 2015.
  • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

  • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

  • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

  • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

References

  1. ↵
    1. Schillie SF,
    2. Shehab N,
    3. Thomas KE,
    4. Budnitz DS
    . Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009;37(3):181–187pmid:19666156
    OpenUrlCrossRefPubMed
  2. ↵
    1. Bronstein AC,
    2. Spyker DA,
    3. Cantilena LR Jr,
    4. Rumack BH,
    5. Dart RC
    . 2011 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th annual report. Clin Toxicol (Phila). 2012;50(10):911–1164pmid:23272763
    OpenUrlCrossRefPubMed
  3. ↵
    Centers for Disease Control and Prevention (CDC). The PROTECT initiative: advancing children’s medication safety. Available at: www.cdc.gov/MedicationSafety/protect/protect_Initiative.html. Accessed November 29, 2013
  4. ↵
    Budnitz DS, Salis S. Preventing medication overdoses in young children: an opportunity for harm elimination. Pediatrics. 2011;127(6). Available at: www.pediatrics.org/cgi/content/full/127/6/e1597
  5. ↵
    US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Guidance for industry: dosage delivery devices for orally ingested OTC liquid drug products. Available at: www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm188992.pdf. Accessed November 29, 2013
  6. ↵
    1. Yin HS,
    2. Wolf MS,
    3. Dreyer BP,
    4. Sanders LM,
    5. Parker RM
    . Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010;304(23):2595–2602pmid:21119074
    OpenUrlCrossRefPubMed
  7. ↵
    1. Shah R,
    2. Blustein L,
    3. Kuffner E,
    4. Davis L
    . Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy. J Pediatr. 2014;164(3):596–601, e1pmid:24367987
    OpenUrlCrossRefPubMed
  8. ↵
    American Academy of Family Physicians. Preferred unit of measurement for liquid medications. Available at: www.aafp.org/about/policies/all/preferred-unit.html. Accessed December 5, 2013
  9. Institute for Safe Medication Practices. ISMP quarterly action agenda, October-December 2011. Available at: http://www.ismp.org/Newsletters/acutecare/articles/A1Q12Action.asp. Accessed November 29, 2013
    1. Sanders L,
    2. Yin H
    . Health literacy. APA Focus: The Official Newsletter of the Academic Pediatric Association. December 2011;48(6). Available at: http://www.academicpeds.org/publications/newsletters/2011/newsdec2011.pdf. Accessed March 4, 2015
  10. American Medical Association. Medication (drug) errors in hospitals. Available at: https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fhtml%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-120.968.HTM. Accessed March 4, 2015
  11. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Safety considerations for container labels and carton labeling design to minimize medication errors. Available at: www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm349009.pdf. Accessed December 5, 2013
  12. ↵
    National Council for Prescription Drug Programs. NCPDP recommendations and guidance for standardizing the dosing designations on prescription container labels of oral liquid medications. Available at: http://ncpdp.org/NCPDP/media/pdf/wp/DosingDesignations-OralLiquid-MedicationLabels.pdf. Accessed April 17, 2014
  13. ↵
    1. McQueen MJ
    . Conversion to SI units. The Canadian experience. JAMA. 1986;256(21):3001–3002pmid:3773219
    OpenUrlCrossRefPubMed
  14. ↵
    Testimony of Daniel A.C. Frattarelli, MD, FAAP, on behalf of the American Academy of Pediatrics before the Food and Drug Administration, Joint Meeting of the Nonprescription Drugs Advisory Committee and the Pediatric Advisory Committee, May 17, 2011. Available at: https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Documents/Dan_Frattarelli_Testimony_5-17-11.pdf. Accessed March 4, 2015
  15. ↵
    1. American Academy of Pediatrics Council on Clinical Information Technology Executive Committee, 2011–2012
    . Electronic prescribing in pediatrics: toward safer and more effective medication management. Pediatrics. 2013;131(4):824–826pmid:23530170
    OpenUrlAbstract/FREE Full Text
  16. ↵
    1. Paul IM,
    2. Yin HS
    . Out with teaspoons, in with metric units: pediatricians urged to prescribe liquid medications in mLs only. AAP News. 2012;33(3):10
    OpenUrl
  17. ↵
    1. Yin HS,
    2. Kressly SJ
    . Antidote for medication overdoses: use metric dosing, educate parents. AAP News. 2013;34(12):4
    OpenUrl
  18. ↵
    1. Yaffe SJ,
    2. Bierman CW,
    3. Cann HM,
    4. et al
    . Inaccuracies in administering liquid medication. Pediatrics. 1975;56(2):327–328pmid:1161381
    OpenUrlAbstract/FREE Full Text
  19. ↵
    1. Yin HS,
    2. Dreyer BP,
    3. Ugboaja DC,
    4. et al
    . Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2). Available at: www.pediatrics.org/cgi/content/full/134/2/e354pmid:25022742
    OpenUrlAbstract/FREE Full Text
  20. ↵
    1. Sobhani P,
    2. Christopherson J,
    3. Ambrose PJ,
    4. Corelli RL
    . Accuracy of oral liquid measuring devices: comparison of dosing cup and oral dosing syringe. Ann Pharmacother. 2008;42(1):46–52pmid:18056832
    OpenUrlAbstract/FREE Full Text
    1. Ryu GS,
    2. Lee YJ
    . Analysis of liquid medication dose errors made by patients and caregivers using alternative measuring devices. J Manag Care Pharm. 2012;18(6):439–445pmid:22839684
    OpenUrlPubMed
  21. ↵
    1. Yin HS,
    2. Mendelsohn AL,
    3. Wolf MS,
    4. et al
    . Parents’ medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164(2):181–186pmid:20124148
    OpenUrlCrossRefPubMed
  22. ↵
    1. Yin HS,
    2. Dreyer BP,
    3. Foltin G,
    4. van Schaick L,
    5. Mendelsohn AL
    . Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambul Pediatr. 2007;7(4):292–298pmid:17660100
    OpenUrlCrossRefPubMed
    1. Madlon-Kay DJ,
    2. Mosch FS
    . Liquid medication dosing errors. J Fam Pract. 2000;49(8):741–744pmid:10947142
    OpenUrlPubMed
  23. ↵
    1. Bailey SC,
    2. Pandit AU,
    3. Yin S,
    4. et al
    . Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009;41(10):715–721pmid:19882395
    OpenUrlPubMed
  24. ↵
    1. McMahon SR,
    2. Rimsza ME,
    3. Bay RC
    . Parents can dose liquid medication accurately. Pediatrics. 1997;100(3 pt 1):330–333pmid:9282701
    OpenUrlAbstract/FREE Full Text
  25. ↵
    1. American Academy of Pediatrics,
    2. Committee on Pediatric Emergency Medicine,
    3. American College of Emergency Physicians,
    4. Pediatric Committee,
    5. Emergency Nurses Association Pediatric Committee
    . Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233–1243pmid:19770172
    OpenUrlAbstract/FREE Full Text
  26. ↵
    Emergency Nurses Association. Weighing pediatric patients in kilograms. Available at: www.ena.org/SiteCollectionDocuments/Position%20Statements/WeighingPedsPtsinKG.pdf. Accessed November 29, 2013
  27. ↵
    American Academy of Pediatrics. Weighing pediatric patients in kilograms. Pediatrics. 2013;131(1). Available at: www.pediatrics.org/cgi/content/full/131/1/e342
  28. ↵
    1. Yin HS,
    2. Dreyer BP,
    3. Moreira HA,
    4. et al
    . Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014;14(3):262–270pmid:24767779
    OpenUrlCrossRefPubMed
  • Copyright © 2015 by the American Academy of Pediatrics
PreviousNext
Back to top

Advertising Disclaimer »

In this issue

Pediatrics
Vol. 135, Issue 4
1 Apr 2015
  • Table of Contents
  • Index by author
View this article with LENS
PreviousNext
Email Article

Thank you for your interest in spreading the word on American Academy of Pediatrics.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications
(Your Name) has sent you a message from American Academy of Pediatrics
(Your Name) thought you would like to see the American Academy of Pediatrics web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Request Permissions
Article Alerts
Log in
You will be redirected to aap.org to login or to create your account.
Or Sign In to Email Alerts with your Email Address
Citation Tools
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications
COMMITTEE ON DRUGS
Pediatrics Apr 2015, 135 (4) 784-787; DOI: 10.1542/peds.2015-0072

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications
COMMITTEE ON DRUGS
Pediatrics Apr 2015, 135 (4) 784-787; DOI: 10.1542/peds.2015-0072
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Print
Download PDF
Insight Alerts
  • Table of Contents

Jump to section

  • Article
    • Abstract
    • Background
    • Recommendations
    • lead author
    • Committee on Drugs, 2013–2014
    • Liaisons
    • Staff
    • Footnotes
    • References
  • Info & Metrics
  • Comments

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • Resources Recommended for the Care of Pediatric Patients in Hospitals
  • Health Literacy: Implications for Child Health
  • Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care
  • Compatibility of proton pump inhibitors in a preservative-free suspending vehicle
  • Pediatric Medication Safety in the Emergency Department
  • Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study
  • Liquid Medication Dosing Errors
  • Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment
  • US Poison Control Center Calls for Infants 6 Months of Age and Younger
  • Google Scholar

More in this TOC Section

  • Recommended Childhood and Adolescent Immunization Schedule: United States, 2021
  • Ethical Considerations in Pediatricians’ Use of Social Media
  • 2021 Recommendations for Preventive Pediatric Health Care
Show more From the American Academy of Pediatrics

Similar Articles

Subjects

  • Pharmacology
    • Pharmacology
  • Current Policy
  • AAP Policy Collections by Authoring Entities
    • Committee on Drugs

Keywords

  • administration
  • drugs
  • medication
  • metric
  • milliliter
  • liquid
  • safety
  • syringe
  • Journal Info
  • Editorial Board
  • Editorial Policies
  • Overview
  • Licensing Information
  • Authors/Reviewers
  • Author Guidelines
  • Submit My Manuscript
  • Open Access
  • Reviewer Guidelines
  • Librarians
  • Institutional Subscriptions
  • Usage Stats
  • Support
  • Contact Us
  • Subscribe
  • Resources
  • Media Kit
  • About
  • International Access
  • Terms of Use
  • Privacy Statement
  • FAQ
  • AAP.org
  • shopAAP
  • Follow American Academy of Pediatrics on Instagram
  • Visit American Academy of Pediatrics on Facebook
  • Follow American Academy of Pediatrics on Twitter
  • Follow American Academy of Pediatrics on Youtube
  • RSS
American Academy of Pediatrics

© 2021 American Academy of Pediatrics