Knowledge, Awareness, and Prescribing Practices Regarding Sugar-Free Paediatric Liquid Medicines Among Healthcare Professionals in Uttarakhand: A Cross-Sectional Study

This cross-sectional study of 431 healthcare professionals in Uttarakhand reveals that while awareness of sugar-free paediatric liquid medicines is high, critical gaps exist in recognizing their link to dental caries and providing oral health advice, with prescribing practices hindered by concerns over cost, palatability, and availability.

The Gist

Imagine your child's medicine cabinet as a flavorful buffet. To make bitter medicines taste like candy so kids will actually swallow them, doctors often add a secret ingredient: sugar. It's like putting chocolate syrup on broccoli to get a child to eat their veggies.

But here's the problem: that "chocolate syrup" (sugar) is actually a tiny, invisible enemy to your child's teeth. It feeds the bad bacteria in their mouth, which then attack the enamel, leading to cavities.

This study is like a detective report from the hills of Uttarakhand, India. The researchers wanted to know: Do the doctors and dentists who hand out these "sweet" medicines actually know they are hurting teeth? And if they know, do they try to offer a sugar-free version?

Here is the story of what they found, broken down simply:

1. The "Sweet" Blind Spot

The researchers asked 431 healthcare workers (doctors, pediatricians, and dentists) a simple question: "Do you know that sweet liquid medicines can cause cavities?"

• The Shocking Answer: Only 1 out of 5 doctors (20%) said "Yes."
• The Analogy: It's like a chef knowing that a dish is salty, but having no idea that eating too much salt will make your blood pressure spike. They know the medicine is sweet (88% knew this), but they don't connect the dots that "sweet = tooth decay."

2. The "Sugar-Free" Supermarket

The good news? Most doctors (83%) knew that sugar-free versions of these medicines exist. Think of these as the "diet" or "sugar-free" options on a menu.

However, doctors aren't ordering them for two main reasons:

• The Taste Test: 80% of doctors think the sugar-free versions taste like "cardboard" or "bad medicine." They worry the child will spit it out.
• The Price Tag: 85% believe the sugar-free versions are more expensive (about 10% pricier). In a world where families are watching their wallets, this is a big barrier.

3. The "Who Knows What" Game

The study found a funny pattern based on who you asked:

• Dentists were the experts. They knew the most about sugar-free options (90% awareness).
• General Doctors and Pediatricians were less aware. They were like the "general shoppers" who didn't read the fine print on the nutrition label.
• The Result: Because the general doctors prescribe the most medicine, their lack of knowledge means most kids are getting the sugary version by default.

4. The "Talk" Gap

Even when a doctor does know the medicine is bad for teeth, they often forget to mention it.

• Only 48% of doctors routinely tell parents, "Hey, this medicine has sugar; make sure to brush your child's teeth after."
• The Analogy: It's like a mechanic selling you a car with a known defect but forgetting to tell you to check the oil every week. They fix the immediate problem (the illness) but miss the long-term damage (the cavities).

The Big Takeaway

The study concludes that while the doctors in Uttarakhand are well-meaning, they are stuck in a loop. They want to cure the child's fever or infection, but they aren't equipped to protect the child's smile at the same time.

What needs to happen?

1. Training: Doctors need a "refresher course" (like a software update) to learn that sugar-free medicines exist and how to prescribe them.
2. Better Labels: Medicine bottles need big, bold warning labels that say "SUGAR CONTAINED" or "SUGAR-FREE," just like food packages do.
3. Cheaper Options: If the sugar-free versions were cheaper and tasted better, doctors would switch to them instantly.

In short: The doctors have the power to save teeth, but they need the right tools (knowledge, affordable sugar-free options, and clear labels) to do it. Until then, many children are getting their medicine with a side of cavities.

Technical Summary

1. Problem Statement

Paediatric liquid medicines (PLMs) are essential for treating childhood illnesses but frequently contain sucrose to enhance palatability. This practice creates a cariogenic oral environment through increased viscosity, prolonged salivary clearance, and the provision of fermentable substrates for acidogenic bacteria. Additionally, the acidic pH of many syrups can cause enamel erosion, and certain formulations lead to tooth staining.

Despite the availability of sugar-free alternatives (formulated with xylitol, sorbitol, or saccharin), their adoption by prescribers remains limited. While global studies exist, there is a significant data gap regarding healthcare professionals' knowledge, attitudes, and prescribing practices (KAP) in Uttarakhand, India, a region characterized by heterogeneous geography and variable healthcare access. The study aims to evaluate these factors to identify gaps amenable to targeted intervention.

2. Methodology

• Study Design: Descriptive cross-sectional study conducted between January and March 2024.
• Setting: Multiple districts in Uttarakhand, including tertiary institutions (AIIMS Rishikesh, Seema Dental College & Hospital, Uttaranchal Dental & Medical Research Institute) and semi-urban/rural clinics.
• Participants:
  • Target: 500 licensed healthcare professionals (HCPs) aged ≥25 years with ≥1 year of clinical practice involving paediatric patients.
  • Exclusion: Administrative-only roles and incomplete responses.
  • Final Sample: 431 participants (Response rate: 86.2%).
  • Demographics: General Medicine Practitioners (49%), Paediatricians (27%), and Dental Practitioners (24%).
• Instrument: A pilot-tested, structured 20-item questionnaire (Cronbach's α = 0.85) covering demographics, prescription patterns, knowledge of PLM properties, awareness of sugar-free alternatives, and counselling practices.
• Data Analysis: SPSS version 27.0 was used for descriptive statistics and Chi-square tests to assess associations between categorical variables (e.g., specialty vs. awareness). Statistical significance was set at p < 0.05.

3. Key Contributions

• Regional Data: Provides the first comprehensive KAP assessment regarding sugar-free PLMs specifically for the Uttarakhand region.
• Interprofessional Comparison: Quantifies the disparity in knowledge and practices between dental practitioners, paediatricians, and general physicians.
• Barrier Identification: Systematically identifies structural barriers (cost, palatability, availability) preventing the adoption of sugar-free alternatives.
• Policy Recommendations: Offers evidence-based recommendations for Continuing Medical Education (CME) and regulatory changes (e.g., labelling mandates) tailored to the Indian context.

4. Key Results

• Prescribing Drivers: Decisions were primarily driven by the child's age/weight (58%), cost (40%), and brand (37%). Oral liquids (syrups) were preferred by 95% of respondents.
• Knowledge Gaps:
  • Caries Awareness: Only 20% of HCPs associated PLMs with dental caries, despite 88% recognizing their sweetness.
  • Specialty Disparity: Dental practitioners showed the highest caries awareness (30%), compared to paediatricians (20%) and general practitioners (15%) (p = 0.03).
  • Hidden Sugars: 73% were aware of hidden sugars, but only 48% routinely provided oral health advice post-prescription.
• Attitudes Toward Sugar-Free Alternatives:
  • Awareness: 83% knew of sugar-free alternatives, but only 50% reported local availability.
  • Barriers: 80% perceived sugar-free options as less palatable, and 85% noted a cost premium (~10%).
  • Adoption: Despite barriers, 70% reported prescribing sugar-free options "always" or "often," and 90% expressed interest in CME on the topic.
• Statistical Associations: Significant associations were found between specialty and sugar-free awareness (p = 0.03) and between practice location (urban/rural) and prescription form preference (p = 0.04).

5. Significance and Conclusions

The study highlights a critical disconnect between awareness and practice. While awareness of sugar-free PLMs is high (83%), the low recognition of caries risk (20%) and low frequency of oral health counselling (48%) among non-dental practitioners pose a significant threat to paediatric oral health in Uttarakhand.

Key Implications:

1. Educational Gap: Medical curricula require integration of oral health modules, as dental practitioners demonstrated significantly higher awareness than their medical counterparts.
2. Structural Barriers: Perceived cost and palatability issues are major deterrents. Policy interventions, such as mandatory sucrose-free labelling and institutional formulary inclusion, are necessary to bridge the gap between awareness and prescribing behavior.
3. Future Action: Targeted Continuing Medical Education (CME) and interdisciplinary training programs are urgently needed to translate knowledge into clinical practice and reduce the burden of PLM-associated dental caries.

Note: As this is a preprint (medRxiv), the findings have not yet undergone peer review and should not be used to guide immediate clinical practice without further validation.