Use of medicines in neonates and infants: A report of mothers’ practices

INTRODUCTION

A larger proportion of the population in developing countries are children, and they are exposed to several illnesses because of poverty. Drugs used in children include prescribed and nonprescribed drugs. Mothers of neonates and infants especially in developing countries often use medications recommended by persons other than healthcare professionals in the management of conditions which affect their young. Inappropriate use of medicines which could occur as a result of nonmedical prescription of drugs is a major contributory factor to drug-related problems. This is often common where there is poor regulation of drug distribution and in communities where communal lifestyles also include medical care of the young. Access to prescribed and nonprescribed medicines in Nigeria is possible, provided there is money to purchase them from the different available sources (Agbaje and Uwakwe, 2003).

Use of medicines in children has been studied previously: in a study conducted in England for children aged between 0 and 7.5 years, it was found that 75% of the study sample had used medicinal products before the age of 2 months (Headley and Northstone, 2007). Also, infants had a prevalence of drug use of 65% and 69% in their first and third months of life, respectively (Strina et al., 2001). Santos et al. (2009) had also studied drug use in children living in poor areas in Brazil and reported a prevalence of 48% in children aged between 4 and 11 years, and a population-based study among Finnish children also reported that 17% and 50% of children aged under 12 years used prescription medicines and self-medication, respectively, in the 2 days preceding the study (Ylinen et al., 2010).

Several studies on drug utilization in children have been conducted in Nigeria; the majority of these were in the hospital setting to determine rationality of drug use based on WHO prescribing indicators (Ahwinahwi et al., 2021; Nwolisa et al., 2006; Olayemi et al., 2006; Oshikoya et al., 2006). Also some studies have been done in Nigeria on caregivers self-medication in children (Adegboyega et al., 2005; Ezechukwu et al., 2005; Okunola 2020; Oshikoya et al., 2007).

Drugs commonly administered to children include analgesics/antipyretics and antibacterials, and in addition to these are teething mixtures and colic medicines for infants. Some are self-prescribed by the caregivers while others are prescribed by healthcare professionals. Oshikoya et al. (2009) reported 67.7% of infants were treated for colic by self-medication while 28.1% were treated by seeking medical intervention (Oshikoya et al., 2009). A study in south-eastern Nigeria also reported 73.1% caregivers using one form of medication or the other to treat colic in their children (Chinawa et al., 2013). Some of these medicines are used in oblivion of the medical implications in some children within an age bracket for which they are not recommended.

This study evaluated medicines used in neonates and infants with respect to incidence, types, personnel recommending medicines, and reasons for use.

METHODS

This was a cross-sectional study of mothers who had either a neonate or an infant (children aged 1 year and below). The study was conducted between November 2018 and January 2019 at vaccination clinics attached to three Central hospitals in the three senatorial districts in Delta state.

RESULTS

A total of 782 mothers of 734 infants (93.9%) and 48 neonates (6.1%) completed the interview process. Mean age of the mothers who were interviewed was 30.3 ± 5.38 years (range 16–47 years). Three hundred and eighty (48.6%) of the mothers had secondary level education while 6 (0.8%), 38 (4.9%), 186 (23.8%), 162 (20.7%), and 10 (1.28%) had no basic education, primary, OND/NCE, HND/bachelors, and postgraduate education, respectively. Trading was the commonest means of livelihood among the mothers (312, 39.9%); others included but not limited to artisans (193, 24.7%), public employees (58, 7.4%), private employees (12.25), and housewives (48, 6.1%). The Urhobos (266, 34.0%) and Ikas (183,23.4%) were the major ethnic groups in this study. The majority (531, 67.9%) delivered their children in the hospital/clinic and received prenatal care (762, 97.4%) while only about half (386, 49.4%), practiced exclusive breastfeeding. Details are as shown in Table 1.

A total of 714 (91.3%) mothers had administered one or more medicines to their children since birth (that is, within the last 1 year) and 354 (45.3%) had administered other remedies which were mainly of herbal origin.

A total of 2,236 medicines were reported to have been used by the mothers for their infants and neonates. Four hundred and thirty-seven (19.5%) of the medicines were prescribed by a physician, 646 (29.0%) were by a nurse, 573 (25.6%) were self-prescribed, and 71 (3.2%) were recommended by a pharmacist. Patent medicine vendors, health workers at immunization clinics, relatives, neighbors, friends, and traditional midwives recommended most of the other drugs. Details are shown in Table 2.

Paracetamol was the most frequently used medicine by the mothers for their children (673, 30.1%). Other frequently used medicines were vitamin C, (308; 13.8%), antibacterials (295; 13.2%), multivitamins (291; 13.0%), and gripe water (228; 10.2%).

Cough syrups were also reported to be administered in 92 (4.1%) cases, 69 (75%) of which were for cough, and 23 (25%) for catarrh and other indications.

Antimalarials were only administered in 56 children (2.5%) as reported by the mothers. Thirty-nine (75%) of these were for the treatment of malaria, 9 (17.3%) for fever, and 4 (7.7%) for other reasons they did not know. There were three instances where Convulsan^® (contains chloroquine and paracetamol) was administered for convulsion. Antihistamine syrups (with or without paracetamol) were also administered to the children, 20 (69%) of the total 29 cases of administration were for the relief of catarrh. Cod liver oil was used in 22 of the children with majority of the users (14, 63.6%) indicating that they used the medicine to improve the child’s overall health. Piccan^® was used in eight children to relieve the discomfort associated with teething. Other vitamins which included vitamin A, vitamin B complex, folic acid, and vitamin D were also administered to the children for various reasons like appetite enhancement (6,40%), prevention or treatment of infections (2, 13.3%), overall health (2, 13.3%), and unknown reasons (5, 33.3%). Other medicines administered included Otrivin^® nasal drops (contains xylometazoline), phenobarbitone, teething powder, and Actifed^® (contains pseudoephedrine and triprolidine). Details of the drugs used are shown in Table 3.

Table 1. Demographics of study population. [Click here to view]

Table 2. Personnel recommending drugs used in neonates and infants. [Click here to view]

Fever and pain (635, 28.7%) were the major reasons for which medicines were used, with paracetamol accounting for use in 606 (27.1%) of such cases. Colic accounted for 303 (13.7%) of the reasons for medicine use. Gripe water^® was the most frequently used medicine for colic (207, 9.3%). Gripe water^® contains varying constituents depending on the manufacturer, a common brand contains dill seed oil, bicarbonate, ginger tincture, and a small percentage of alcohol. Nospamin^® syrup which contains homatropine methylbromide was also administered for colic (68, 3.0%). Some 178 (8.0%) children received medication for appetite stimulation and 107 (4.8%) of the children received multivitamins for this purpose. Easing the discomfort associated with teething was the indication for which medicines were administered in 123 (5.5%) instances and the majority of drugs used were commonly known as teething mixtures; Bonabebe^®, Babyrest^®, and Bentotit^® were used in 110 (5.0%) of the cases. Vitamin C (114, 37.6%) was used in children for catarrh in majority of the cases. Details of reasons for medicine use are shown in Table 4.

Paracetamol was used frequently on nurse’s recommendation (250, 37.2%) and self-medication by the mothers (212, 31.5%), physician (95, 14.1%), pharmacist (8, 1.2%), patent medicine vendor (22, 3.3%), relative (31, 4.6%), and immunization clinic staff (39, 5.8%), and others (14, 2.1%) were neighbor, friend, and traditional midwife.

In the study, 94 (31.9%) antibacterial agents were prescribed by physicians, 40 (13.6%) by mothers, and 26 (8.8%) by relatives. Ampicillin/cloxacillin was the most frequently used antibacterial agent accounting for 195 (66.1%).

Gripe water^® was often recommended by nurses (70, 31.4%) and by the mothers for their infants (59, 26.5%). Similarly, Nospamin^® was frequently recommended by nurses and mothers at a frequency of 23 (28.8%) and 18 (22.5%), respectively.

Multivitamins were recommended by 75 (26.8%), 74 (26.4%), and 60 (21.4%) physicians, nurses, and mothers, respectively. Of the cases in which they were administered, vitamin C was most frequently recommended by the mothers (82, 26.8%), nurses (75, 24.5%), and physicians (70, 22.9%); others were patent medicine vendors (26, 8.5%) and relatives, friends, and neighbors (31, 10.1%), pharmacists (12, 3.9%), and immunization clinic workers (8, 2.6%).

DISCUSSION

This study determined the use of medicines in neonates and infants as reported by their mothers. The prevalence of drug use among children in our study was high and this is comparable with a previous study among Dutch children where the annual prevalence of drug use in children aged 0–1 year ranged from 87% to 97% (Schirm et al., 2000).

Paracetamol was the most frequently used medicine in the study population. This corroborates findings among children aged between 0 and 23 months old where it (acetaminophen) had the highest prevalence of use of 23% (Vernacchio et al., 2009). Paracetamol had also been reported as the most frequently used over-the-counter drug for fever and pain in children (Pileggi et al., 2015). In this study, paracetamol was used more for its antipyretic property than analgesic effects which could be due to a higher frequency of occurrence of pyrexia than pain in children; also fever is more easily detected than pain in children. The high incidence of use of paracetamol and self-medication with it as observed in our study supports findings from other studies: 62.7% of caregivers of children aged between 0 and 16 years had administered paracetamol to their children for fever, 45% of the cases being self-prescribed by caregivers and only 20% by a physician (Obu et al., 2012); 75% of parents studied in Riyadh, Saudi Arabia gave unprescribed antipyretics in their home management of fever (Al Ateeq et al., 2018). Fever was adjudged by 94% of parents as the most common reason parents practice self-medication for their children (Gohar et al., 2017). Furthermore, it was also reported by caregivers of children on admission that analgesics/antipyretics were the most frequently used drugs (47.6%) for self-medication, with self-medication accounting for 74.1% of the main therapeutic path of first recourse (Penda et al., 2018). Self-medication was determined in 60% of children to whom paracetamol was administered for fever (Lubrano et al., 2016) and 65.2% of caregivers also reported administration of paracetamol for no or minimal elevations in body temperature. It was, however, reported by Lawani and Akhogba (2015) that only 8% of parents of under-five children administered paracetamol at home (Lawani and Akhogba, 2015).

Table 3. Medicines used by neonates and infants. [Click here to view]

Table 4. Conditions for which medicines were used. [Click here to view]

The use of medications to ease the discomfort associated with teething was common in our study. Medications such as Bonababe^®, Babyrest^®, and Bentotit^® were the most commonly used. Bonababe^® and Babyrest^® contain paracetamol, chlorpheniramine, and dill water/oil while Bentotit^® contains paracetamol and conc dill oil. Dill is Anethum graveolens which contains essential oils believed to have carminative effects. Some of the mothers administered these drugs to their children daily for a prolonged period of time completely unaware of the paracetamol content and concurrently administered paracetamol to control fever and pain in the same children, inadvertently overdosing which could lead to paracetamol toxicity in such children. Although chlorpheniramine can reduce the itchiness of the gum during teething, prolonged use in children is not encouraged. Piccan^® was administered by a few of the mothers to ease the discomfort of teething. Piccan^® available for sale in the Nigerian market today contains paracetamol and diphenhydramine, an antihistamine. The use of antihistamines is not recommended for use in children below 24 months and children to whom Piccan^® is administered for teething are infants who are younger than 12 months old. The medications administered for teething in our study were also consistent with those in other studies in Nigeria. A study in Benin city, a southern Nigerian city revealed 74.4% of remedies for teething problems to be teething syrups (Adam and Abhulimhen-Iyoha, 2015). About 37.6% of mothers attending an out-patient department in southwest Nigeria also administered teething mixtures to infants (Olatunya et al., 2020). Furthermore, 31% and 42% of adults in a rural community recommended teething powder and teething mixtures, respectively (Bankole and Lawal, 2017). Another study had earlier reported that teething powder was administered in 46.9% of cases in South-East Nigeria (Adimorah et al., 2011). Up to 68% and 66.8% of mothers who participated in an Indian study used systemic and topical analgesics, respectively, among other nonpharmacological measures to soothe their infants’ discomfort of teething (Elbur et al., 2015). Healthcare professionals in New Zealand suggested various measures to reduce the discomfort associated with teething with 65% and 60% suggesting paracetamol and teething gels respectively as pharmacological remedies (Ispas et al., 2013). The majority of mothers in Nigeria tend to find ways to alleviate symptoms which they perceive are associated with teething and this quest for remedies has led to the unfortunate incidence of “my pikin^®” where 84 deaths were recorded among children (Boseley, 2009).

Colic was another major condition for which drug was administered to neonates and infants in our study. These medicines are not only self-recommended by the mothers but also by some healthcare professionals. In a study conducted in Lagos, Nigeria, mothers reported the use of herbal remedies (51.8%), Nospamin^® (35.4%), Gripe water^® (30.0%), Bonabebe (5.4%), and teething powder (1.1%) for self-medication, while Nospamin, Gripe water^®, Piccan^®, Erythromycin, and Abidec^® syrups were prescribed by the physicians for colic in 49.5%, 43.05%, 12.9%, 10.8%, and 9.7% of infants respectively (Oshikoya et al., 2009). It was also reported in another Nigerian study that paracetamol, Gbomoro^® (a herbal mixture which contains paracetamol and compound oil tincture), teething powder, salt water, Buscopan^® (Hyoscine butylbromide), and Gripe water were administered by 33.1%, 16.2%, 15.45%, 13.2%, 7.75%, and 4.6% of mothers, respectively, to their infants for the relief of colic (Chinawa et al., 2013)

The majority of mothers in this study administered multivitamins to their children from birth to enhance their appetite. Multivitamin use has also been reported among children in the US with a prevalence of 7.4%, 24%, and 19% among those aged 0–23 months, 2 years, 5 years, and 6–11 years, respectively (Picciano et al., 2007). In a similar study, vitamins accounted for 37% of medicines used among Finnish children below age 12 (Ylinen et al., 2010). The use of vitamin C among Nigerian infants can be said to be high as our study portrayed and this is also supported by a previous study among another pediatric population in Nigeria (Oshikoya et al., 2007).

Antibacterials were used to a substantial proportion in this population with ampicillin /cloxacillin being the most frequently used; this trend corroborates another study in Nigeria where ampicillin/cloxacillin accounted for the most frequently used antibacterial and it was mostly not prescribed by the physician (Oshikoya et al., 2007). However, a recent study by Ahwinahwi et al. (2021) reported that antibacterials were frequently prescribed for young children attending an outpatient clinic for young children. This is concerning as the trend could result in antimicrobial resistance in this age group and portends the danger of antimicrobial therapy failure in young children.

Cough syrups were also used for cough and colds among our study population. The use of mucokinetic and mucolytic agents in children under 2 years is however deemed inappropriate by a prescribing tool in pediatrics (Prot-Labathe et al., 2014). Antihistamines were also used for treating catarrh in this population and this is inappropriate as it is contraindicated in the age bracket studied (Prot-Labathe et al., 2014).

Self-medication was predominant in this study. About a quarter of medicines used in infants was recommended by mothers, which was next only to those recommended by nurses. This may be due to mothers trying to take responsibility for the health of their children. There is, however, the need to educate them on responsible self-medication to forestall the danger of exposing their infants to inappropriate medications. Relatives play a huge role in recommending medicines used in infants in our community as seen in our study. This buttresses the assertion that the African child belongs to all.

CONCLUSION

The majority of neonates and infants in the study were exposed to medicines. Self-medication by mothers for their young ones was a major therapy recourse. There was inappropriate use of medicines for teething and other infantile conditions and these were mostly administered without a physician’s prescription.

ACKNOWLEDGMENTS

The authors wish to thank all the mothers of infants who participated in this study.

AUTHOR CONTRIBUTIONS

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work. All the authors are eligible to be an author as per the international committee of medical journal editors (ICMJE) requirements/guidelines.

FINANCIAL SUPPORT

There is no funding to report.

CONFLICTS OF INTEREST

The authors report no financial or any other conflicts of interest in this work.

ETHICAL APPROVALS

This study was approved as part of a large study by the Central Hospital, Warri Ethics and Research Committee with protocol number CHW/ECC/VOL1/159.

DATA AVAILABILITY

All data generated and analyzed are included in this research article.

PUBLISHER’S NOTE

This journal remains neutral with regard to jurisdictional claims in published institutional affiliation.

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