Two Techniques to Make Swallowing Pills Easier

Your paper on swallowing medications reinforced the instructions provided by my letter to JAMA (JAMA 248:1833-4. Oct. 15. 1982). In that letter, I passed on a tip that was not original to me, but was seemingly unknown by medical professionals: Capsules, being lighter than water, are best swallowed by having water in your mouth and leaning forward, so they float back into your throat. If you tilt your head back, they float away from your throat and swallowing is more difficult. Tablets sink, so tilting your head backwards makes swallowing them easier.

James Ace Brown, M.D.

Competing interests: None declared

We *wanted* to study head posture training in seniors, using our training video http://www.research4kids.ucalgary.ca/pillswallowing in seniors, but we discovered that seniors in nursing homes tend to be rather set in their ways....and their primary preferences are a) putting pills in yogurt and b) in applesauce. It's pretty universal!

Competing interests: None

The National Public Radio blog http://www.npr.org/blogs/health/2014/11/11/363024822/trouble-swallowing-pills-try-the-pop-bottle-or-the-lean-forward includes videos that show the techniques described in the article being tried by Nina Totenberg, Alison Richards, and Maanvi Singh.

Also, please be sure to check out Dr. Kaplan's posting, which contains very helpful clarifying comments and a training video.

Competing interests: Annals Editor

I congratulate Schiele et al for their systematic assessment of two approaches to pill swallowing, but I would like to set the record straight about my own research on the topic (which they cited erroneously) and perhaps advance the discussion by describing our more clinically-effective method [1].

In 2010 my colleagues and I reported on 4 studies in a single manuscript [1]; it was only in one of those four that Down and Centre were equally well-liked by our participants.

Here's a brief summary of the first three studies:
* Study 1: 106 adults and children, no difficulties with pill swallowing, single trial; result - Centre was favourite position (Left/Right were second).
* Study 2: 134 adults only, no difficulties with pill swallowing, 14 days practice; result - Centre was favourite (Left/Right were second).
* Study 3: 108 adults only, did have difficulty swallowing pills, 14 days practice; result - Centre and Down were tied for favourite (Left/Right were next).

After studying these 348 mostly-adult, mostly unchallenged individuals, we studied the method of head posture training in 41 children, all of whom were clinical referrals --- they had serious health problems (cancer, arthritis, cystic fibrosis, etc) that required oral meds and they had never successfully swallowed a pill in their lives. Eight of the children were either too ill to learn the method, or too oppositional (mental health referrals), leaving 33 children in the sample.

100% of those 33 children successfully learned to swallow their medications in pill form, after 14 days of practicing with TicTacs for 5 minutes/night.

We were very fortunate to receive a private donation to make a training video, which is posted on our university's website, and is being used all over the world. www.research4kids.ucalgary.ca/pillswallowing

What about head position? In this final, fourth study, which is the one that is of greatest importance because the children were all ill and in need of help, only 3% liked the Down position; the most popular was Up, followed by Centre, followed by Left/Right.

Recently, we published an investigation of swallowing dynamics in each head position using fibre-optic endoscopic evaluation [2]. The results were reassuring in that varying head position did not result in any difficulties with laryngeal penetration or aspiration.

As we said in our manuscript [1], 14 days of home practice was essential for most of these children, but there was no systematic preferred position.

We agree with what one 5-year-old girl with leukemia said after she learned how to swallow pills (thus eliminating 6 hours/day of parental coaxing): this is a skill that every child should have. So she taught everyone in her Kindergarten class.

We encourage clinicians to use the training video which has resulted in 100% success in our hands. www.research4kids.ucalgary.ca/pillswallowing

(1) Kaplan BJ, Steiger RA, Pope J, Marsh A, Sharp M, Crawford SG (2010). Better than a spoonful of sugar: Successful treatment of pill swallowing difficulties with head posture practice. Paediatr Child Health, 15(5), e1-5.
(2) Badenduck LA, Matthews TW, McDonough A, Dort JC, Wiens K, Kettner R, Crawford S, Kaplan BJ (April 2014). Fiber-optic endoscopic evaluation of swallowing to assess swallowing outcomes as a function of head position in a normal population. Journal of Otolaryngology - Head & Neck Surgery. J Otolaryngol Head Neck Surg. 2014 Apr 22;43(1):9. doi: 10.1186/1916-0216-43-9.

Competing interests: None declared