Medication is administered through various routes: oral, via enteral tubes, subcutaneously, intramuscular, intraosseous, intravenous, inhaled, or intrathecal. The eye, ear, nose, rectum and skin are also routes through which medication can be instilled, inserted or applied. The route chosen will depend on the drug formulation available, the urgency of the treatment required, the need for the medication, local or systemic, or the speed of absorption. The preference of the child should also be a consideration. The principles of medication administration and local policy should be adhered to irrespective of the route of administration.

If the child is able to swallow, is conscious and the medication is available in an oral formulation, then this is the preferred and most convenient route. Oral medication is available as syrups, suspensions, tablets or capsules.

A sterile medication syringe or spoon should be used for liquids, and tablets should be administered in a disposable medicine pot. The syringe should be placed between the cheek and gums and the medicine gently squeezed into the child’s mouth.

The infant may need to be swaddled prior to administration and incentives are beneficial when encouraging young children to take their medication.

Choice is important and should be offered.

This route should only be used if the child is unable to take their medication by mouth. Medications administered via this route are frequently ‘off-label’, so are unlicensed. It is best to discuss this route and the medication to be administered with the pharmacist.

The principles of administration of medication via enteral tubes are the same as for enteral feeding, see Chapters 38 and 39 on nasogastric/enteral feeding.

Enteric-coated medication should not be administered via the enteral tube route.

This route is best avoided if possible, however, many vaccinations are administered IM. The rate of absorption is quick and this route should only be used to administer small volumes, no more than 1 ml. The preferred sites for use are:

• vastus lateralis for infants;
  
• deltoid for young and older children;
  
• ventrogluteal;
  
• dorsogluteal for older children only.

The gauge and length of the needle are dependent on the age of the child and the viscosity of the fluid to be administered: 25–27 gauge for infants and 22–25 for children. The injection site should be socially clean and the skin and underlying tissue should be spread to the side with a Z track technique. The needle is inserted into the skin at an angle of 90°. The plunger should be pulled back, if blood is aspirated, then discard and commence the procedure again. Otherwise inject the medication slowly, 1 ml over 10 seconds. Any faster than this will result in pain for the child. Once completed, withdraw the needle, apply gentle pressure over the site and apply a dressing if required. Dispose of waste as per local policy.

The subcutaneous (SC) route may be used for a single administration of medication or for infusions. The absorption rate is slower than IM and this route is suitable for small volumes. Insulin, de-chelating agents, immunoglobulins, anti-coagulants are administered via the SC route. The sites that may be used for subcutaneous administration are the abdomen, upper arms, upper thighs, and buttocks. The site should be socially clean before injection. The skin should be pinched and the needle inserted at either a 45° or a 90° angle. Local policy will dictate which angle to use. The medications should be injected slowly (1 ml per 10 seconds). Withdraw the needle and dispose of as per local policy. Apply gentle pressure to the site. If the child is receiving regular SC injections, then the site should be rotated to avoid fibrosis occurring. If an infusion has been delivered SC, then an appropriate SC cannula or device should be inserted and secured as per local policy.

Administration via the eye

Administration of medication into the eye is not painful but may be uncomfortable for the child. Medication that has a local action only should be instilled or applied (ointment), e.g. antibiotics, mydriatics, to the eye.

The child should be lying down and the drop instilled into the inner cantus of the eye. Once this has been swept across the eyeball, a second drop, if prescribed, should be instilled. Ointment should be instilled inside the lower lid. The lower lid should be pulled back and a line of ointment applied. Care should be taken when administering eye drops or ointment not to touch the child with the dropper or nozzle of the ointment tube as this will contaminate the medication. If both eyes are being treated, then there should be two tubes of ointment or eye drops.

Locally acting medication may be instilled into the ear, e.g. antibiotics, steroids. It may be difficult to gain the cooperation of the very young child. The child should lie with the ear to be treated facing upright. Having prepared and checked the medication, pull the pinna up and back and gently insert the prescribed number of drops directly into the ear canal. Massage the tragus of the ear and ask the child to lie still for 5 minutes. If the child is less than 3 years of age, pull the pinna down and back in order to access the ear canal.

Privacy and dignity must be maintained when administering medication per rectum. This route should only be used when it is not possible to administer the medication through any other route, e.g. the child is vomiting and has not got an intravenous cannula in situ or it is required for local treatment.

The child should be asked to void urine first and then once returned to their bed, asked to lie on their left side with their legs flexed. If possible, ask the child to breathe deeply as this will help to relax them. Lubricate the suppository or enema tube, insert the rounded end of the suppository first for the nozzle. Remove the nozzle once the liquid has been inserted. Hold the buttocks gently together as this will help the child retain the medication. A toilet or commode should be nearby for the child to access if required.