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Taste Test
Children Rate Flavoring Agents Used With Activated Charcoal
Elisabeth Guenther Skokan, MD, MPH;
Edward P. Junkins, Jr, MD;
Howard M. Corneli, MD;
Jeff E. Schunk, MD
Arch Pediatr Adolesc Med. 2001;155:683-686.
ABSTRACT
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Objective To compare flavoring agents added to activated charcoal (AC) to determine
which mixture is most palatable to children.
Design Healthy volunteers between the ages of 3 and 17 years participated in
a prospective masked trial. Five identical pitchers were prepared containing
AC alone, AC with chocolate milk, AC with Coca-Cola (Coca-Cola Corp, Atlanta,
Ga), AC with cherry-flavored syrup, and AC with sorbitol. Subjects tasted
all 5 substances in random order. Children younger than 8 years rated taste
on a 10-point Faces Scale. Children 8 years and older used a 100-point visual
analog scale to rate taste and, separately, ease of swallowing. All children
were asked which mixture was best. Ratings were compared using 1-way analysis
of variance, and comparisons for all pairs were made using the Tukey test. P<.05 was considered significant.
Results Mean age among the 53 children enrolled was 8.3 years; 23 children were
younger than 8 years. Girls made up 52% of the group. Taste scores for chocolate
milk, Coca-Cola, and cherry-flavored syrup were significantly better than
those for no flavoring agent. The scores for ease of swallowing for Coca-Cola,
chocolate milk, and cherry-flavored syrup were significantly better than those
for either no flavoring agent or sorbitol. When asked to choose a single best
flavoring agent, 39% chose chocolate milk, 23% picked Coca-Cola, and 23% chose
cherry-flavored syrup.
Conclusion The addition of chocolate milk, Coca-Cola, or cherry-flavored syrup
to AC improves palatability for children and is favored over no flavoring
agent or sorbitol.
INTRODUCTION
ACCIDENTAL and intentional toxic ingestions are an important problem
involving children and adolescents. In 1990, the American Association of Poison
Control Centers (Washington, DC) noted that activated charcoal (AC) had surpassed
syrup of ipecac as the gastrointestinal decontaminant of choice. Activated
charcoal is now the first-line therapeutic intervention recommended for pediatric
poisonings.1, 2
Despite its success in absorbing toxic substances from the intestinum,
the palatability of AC is problematic. It forms a thick, gritty slurry that
must be swallowed or administered enterally by a nasogastric tube. Children
often refuse to drink AC. Nasogastric tube placement is invasive and aversive.
This procedure also has several potential complications, including incorrect
tube placement, esophageal injury, and the induction of emesis with possible
aspiration risk.2, 3, 4
Studies of AC found that the addition of sorbitol seemed to improve its palatability
for adults, and this mixture is commonly used in the emergency department
setting.5, 6, 7 Unfortunately,
the addition of sorbitol to AC has been found to have an increased incidence
of adverse effects, particularly in children, including induction of emesis
as well as fluid and electrolyte abnormalities.6, 8, 9, 10
Studies of adults have demonstrated increased AC palatability with the addition
of other flavoring agents.11, 12, 13
It is difficult to extrapolate these findings to children, however, and there
have been no studies of flavoring agents in the pediatric population.
The objective of this study was to compare several flavoring agents
added to AC to determine which mixture was most palatable to children.
METHODS
A prospective double-blind study was conducted among a convenience sample
of healthy volunteers between the ages of 3 and 17 years who came to a tasting
booth at a hospital-sponsored bicycle fair in May 1999. Mixtures were given
to participants by a small group of pediatric emergency physicians. Participants
were told that this was a study of a substance used to absorb poisonous substances
from the stomach and intestines. The risks and benefits of participation in
the study were explained to both parents and participants. Parental consent
(and subject assent if  age 8 years) was obtained. Participation was rewarded
with an inexpensive toy or water bottle upon completion of the taste test.
Exclusion criteria included abnormalities of the airway or cardiorespiratory,
hepatic, renal, or central nervous systems; a history of adverse reactions
to AC; or lactose intolerance. Children taking any medications were also excluded.
The institutional review board of Primary Children's Medical Center (Salt
Lake City, Utah) reviewed and approved this study.
Five AC mixtures were prepared in identical pitchers. A commercially
available formulation of AC (Liqui-Char; Jones Pharma Inc, St Louis, Mo) with
an adsorption power of 99%14 was used for 4
of the preparations. This consists of 25 g of AC, 1.5 g of carboxymethylcellulose,
and 75 mL of distilled water. The flavoring agents selected are typically
available in the emergency department. Most had been shown to have little
effect on the adsorptive capacities of AC.11, 12, 14, 15
The following 4 flavoring agents were used: (1) chocolate milk, (2) Coca-Cola
(Coca-Cola Corp, Atlanta, Ga), (3) cherry-flavored syrup, and (4) sorbitol.
the fifth preparation consisted of AC alone. Chocolate milk was added to AC
in 1:1 volume equivalents, as was Coca-Cola. Cherry-flavored syrup was obtained
from the hospital pharmacy and mixed per pharmacy recommendations as 5 mL
of syrup per 30 mL of AC. A commercially available preparation of AC with
sorbitol (Liqui-Char) consisting of 25 g of AC, 27 g of sorbitol, and 118.3
mL of distilled water was used for the fourth preparation.
Children and researchers were blinded to the AC preparations. Enrolled
study subjects tasted 5 mL each of all 5 mixtures once, in random order, separated
by sips of water. Randomization was achieved by forming 4 tasting stations
and allowing participants to line up in front of each station. Children younger
than 8 years rated the taste of each mixture on a 10-point Faces Scale.16, 17 These children were told that a score
of 0 meant "great" and a score of 10 meant "horrible." Children 8 years and
older used a 100-mm visual analog scale for taste and, separately, ease of
swallowing.18 Here, 0 signified "great" and
100, "horrible." Investigators also recorded the subject's age, sex, and any
adverse events.
Ratings were compared using a 1-way analysis of variance, with comparison
of all pairs using the Tukey test. Taste scores for the 2 age groups were
analyzed separately and then together. For the pooled analysis, taste scores
from the Faces Scale were multiplied by a factor of 10 to standardize these
with the scores from the 100-mm visual analog scale. Because only children
8 years and older ranked ease of swallowing, these scores were analyzed as
a single group. All scores were inverted for ease of ranking, so higher scores
reflected increased preference. Statistical significance was defined as P <.05. An a priori power analysis showed that 50 subjects
would yield 80% power to detect a significant difference of 20 points on a
100-point scale.
RESULTS
Fifty-five children were considered for enrollment in the study. One
child, an oncology patient who was receiving chemotherapy, was excluded from
participation prior to data collection. Of the 54 enrolled children, all were
able to complete the tasting with the exception of a 3-year-old girl who became
upset and was excused from completing the study. Her scores were not included
in this analysis. Therefore, final data were available for 53 children. Participants
ranged in age from 3 to 17 years, with a mean age of 8.3 years. Twenty-two
subjects were younger than 8 years, and 31 children were 8 years or older.
Girls constituted 52% of the group.
Taste scores for the 2 age groups were analyzed separately and pooled.
Because the results of the separate analyses did not differ from the pooled
results, only the pooled results are presented here. The mean scores for taste
and ease of swallowing by flavoring agent are shown in Table 1. In all-pairs comparisons for taste, chocolate milk, Coca-Cola,
and cherry-flavored syrup scored significantly better than no flavoring agent.
Chocolate milk also scored significantly better than sorbitol. No other flavoring
agents achieved statistically significant differences for taste. Figure 1 graphically depicts the mean scores
for taste among all children. Regarding ease of swallowing, chocolate milk,
Coca-Cola, and cherry-flavored syrup all achieved significantly higher mean
scores than either sorbitol or no flavoring agent. Figure 2 shows mean scores for taste among children 8 years and
older.
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Scores for Taste and Ease of Swallowing by Flavoring Agent
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Figure 1. Mean scores for taste among all
children (N = 53). Daggers represent the SEM. The dashed line denotes the
grand mean. Boxes are drawn around groups of means that do not differ significantly
(P >.05). Coca-Cola is manufactured by the Cola-Cola Company,
Atlanta, Ga.
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Figure 2. Mean scores for ease of swallowing
among children 8 years and older (n = 28). Daggers represent the SEM. The
dashed line denotes the grand mean. Boxes are drawn around groups of means
that do not differ significantly (P >.05). Coca-Cola is manufactured
by the Coca-Cola Company, Atlanta, Ga.
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Thirty-nine percent of the children (95% confidence interval, 29%-51%)
rated chocolate milk the best flavor. Twenty-three percent of the children
each rated Coca-Cola and cherry-flavored syrup the best. All 3 supplemental
flavors (chocolate milk, Coca-Cola, and cherry-flavored syrup) were rated
best significantly more often than were sorbitol (15%) or no flavor (6%).
COMMENT
To our knowledge, this study is the first to examine the effect of the
addition of flavoring substances to AC and the resulting palatability to children.
The addition of chocolate milk, Coca-Cola, or cherry-flavored syrup to AC
resulted in a significantly better score for both taste and, separately, ease
of swallowing.
A review of the literature verifies the poor palatability of AC. As
early as 1976, recommendations were made to flavor AC preparations.19 In 1994, Scharman and Krenzelok20
found that the primary perceived problem with AC administration among emergency
department nurses was its poor palatability. Follow-up recommendations by
the authors included the addition of a flavoring agent to AC.
Studies of flavoring agents, however, have been limited to adults. Cooney
and Roach15 found that a 1:1 mixture of sucrose
and AC provided sufficient flavor without substantial loss of adsorbance.
Cooney13 also compared the palatabilities of
AC formulations flavored with sucrose, sorbitol, or saccharin with regard
to taste, texture, ease of swallowing, and overall impression. No significant
differences were noted among the flavored mixtures, but all 3 flavored formulations
were significantly more acceptable than the unflavored mixture (P <.005). In a review, Katona et al21
recommended the addition of carboxymethylcellulose, sucrose, saccharin, chocolate
syrup, or sorbitol to increase the palatability of charcoal. No similar studies
of AC and various flavoring agents were performed in the pediatric population.
This study looked specifically at children. As per a priori power calculations,
a total of 53 participants completed the series of different flavoring agents.
Interestingly, no significant differences were noted among the mixtures flavored
with chocolate milk, Coca-Cola, or cherry-flavored syrup. However, these 3
flavored formulations were significantly more acceptable to children than
the unflavored mixture (P <.05). Although subject
order effect could not be analyzed because of randomization, it should not
affect the results.
This study had several limitations. The concentration of AC was not
identical for each mixture; the mixtures containing chocolate milk and Coca-Cola
were half as concentrated as the other 3. Children would need to drink twice
the volume of these mixtures to receive the same dose of AC as in the others.
However, if AC is significantly more palatable in this formulation, a larger
quantity of liquid might be taken more readily. In addition, the concentration,
and therefore the consistency of AC with cherry-flavored syrup, was similar
to that of AC with no flavoring agent. For both taste and ease of swallowing,
AC with cherry-flavored syrup was rated significantly better than no flavoring
agent. Therefore, it was probably not dilution of AC alone that was responsible
for the ratings difference. Another possible limitation is that tasting trials
were conducted in full view of other study participants and parents. Parental
presence may have led to interference, such as encouraging children to complete
the trial. Finally, this was a convenience sample, which may have led to biased
results. As an aside, caution should be exercised when giving chocolate milk
as a flavoring agent to children with potential allergies to cow's milk.
In conclusion, we found that the addition of chocolate milk, Coca-Cola,
or cherry-flavored syrup to AC significantly improved both the taste and the
ease of swallowing for children when compared with no added flavoring agent
or sorbitol. It would require further study to determine if the use of these
flavoring agents may decrease the need for nasogastric tube placement. Further
studies should also address the acceptance of flavoring agents, including
the more diluted mixtures used in our study, in clinical practice.
AUTHOR INFORMATION
Accepted for publication January 12, 2001.
Presented at the regional meeting of the Ambulatory Pediatrics Association,
Carmel, Calif, February 13, 2000, and at the National Congress on Childhood
Emergencies, Baltimore, Md, March 28, 2000.
This study was not sponsored or endorsed by Coca-Cola, Jones Pharma
Inc, or any other manufacturer of products used.
From the Division of Pediatric Emergency Medicine, Department of Pediatrics,
University of Utah School of Medicine and Primary Children's Medical Center,
Salt Lake City.
Corresponding author and reprints: Elisabeth Guenther Skokan, MD,
MPH, Division of Pediatric Emergency Medicine, Department of Pediatrics, Primary
Children's Medical Center, University of Utah School of Medicine, 100 N Medical
Dr, Salt Lake City, UT 84113 (e-mail: eskokan{at}hsc.utah.edu).
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