From liquids to solids: resetting paediatric prescribing for a safer, sustainable future

Liquid medicines remain the default for paediatric prescribing in the UK, despite increasing evidence showing that children can be taught to swallow solid dosage forms^​1​. 

For children from pre-school age upwards, liquids often bring higher costs, greater operational burden, more fragile supply, avoidable excipient exposure and increased risk of dosing error^​2​. 

Pharmacists are well placed to lead a safe, evidence-based shift towards solid oral dosage forms, including tablets, capsules and flexible solids such as dispersible or orodispersible tablets^​2​.

The continued preference for syrups and suspensions reflects custom and practice. Liquids have long been seen as the child-friendly option, but, in practice, they are often harder for families to use, more cumbersome for pharmacies to supply and more expensive for the NHS to sustain^​3​. 

Measuring doses accurately can be difficult, particularly where devices vary or strengths differ between products. Some liquids require refrigeration, have short shelf lives and create avoidable waste when supplies are interrupted or cold-chain requirements are breached. They may also contain excipients that families or clinicians would prefer to minimise^​2,4​.

This matters beyond convenience. A system built around liquids is less resilient in the face of shortages, more administratively burdensome for pharmacy teams, challenging for parents already under pressure owing to child sickness, and more likely to generate repeat contacts when a product is unavailable, unpalatable or unsuitable. The result is a model that can undermine patient experience while adding pressure to already stretched services.

A stronger case in 2026

What has changed in recent years is not simply the evidence base, but the context in which paediatric medicines are prescribed. We now know that many children can learn to swallow tablets far earlier than is commonly assumed: programmes such as KidzMed and ‘Pill School’ have shown that a brief, structured intervention can teach children and families a practical six-step technique in minutes, widening access to licensed solid formulations^​5–7​.

At the same time, international and European guidance has increasingly prioritised age-appropriate formulations over a simple assumption that younger patients need liquids. The World Health Organization and European Medicines Agency support the use of alternative formulations, including dispersible, orodispersible and chewable tablets, where clinically appropriate^​8,9​.

The UK supply environment has shifted. Medicines shortages are no longer exceptional events. National policy now places greater emphasis on early identification, escalation and communication of supply problems^​10,11​. In that context, a prescribing culture that defaults to solid formulations where appropriate is not merely efficient; it is strategically sensible. Solid oral dose forms typically have longer shelf-lives, are less reliant on cold-chain storage and are available from a wider range of manufacturers, making them easier to stock, substitute and maintain during disruptions^​9,12​.

The case for change

There are four pillars that make up the case for change:

Patient care

Switching to solid dose forms can improve patient safety because liquid medicines create more opportunities for error than solid formulations^​13​. Doses must be measured, devices may be used inconsistently, and concentrations can vary between brands or preparations. By contrast, tablets, capsules and dispersible products offer fixed strengths, more predictable stability and fewer opportunities for confusion^​14​. A solid-first approach therefore supports safer prescribing, dispensing and administration.

When a licensed solid oral dose form is clinically suitable, it should be the default: it avoids off-license manipulation, reduces reliance on unlicensed specials that require additional governance and procurement safeguards, and minimises endorsement/reimbursement pitfalls linked to drug tariff rules for specials^​15,16​. 

Pharmacists can support this by routinely assessing suitability for solid-dose forms and using a structured training approach, such as the ‘Pill School’ model to help children develop tablet swallowing skills^​7​. In practice, this should be reinforced by configuring paediatric formularies and electronic prescribing systems so that suitable solid formulations appear before liquids, with dispersible and orodispersible tablets easy to find and prescribe, and liquids reserved for infants or clearly documented clinical reasons. Feeding back to prescribers, such as GPs, when a child can take tablets can result in solid preparations being prescribed in future. 

Excipient exposure

Unnecessary excipient exposure should be minimised^​4​. Many paediatric liquids contain sugars, polyols or other excipients that are not clinically appropriate for most children. For example, sorbitol and fructose may cause gastrointestinal adverse effects, and are contraindicated in hereditary fructose intolerance, while ethanol is not considered appropriate in paediatrics^{​4,17,18​}. Favouring solid formulations, where suitable, can reduce cumulative excipient exposure and make prescribing choices more transparent and defensible.

Pharmacists can champion excipient-aware prescribing by highlighting safer solid alternatives to clinicians/prescribers to reduce unnecessary exposure. In practice, excipient review should become part of formulation choice rather than an afterthought. 

Where modification of a solid formulation is necessary, it should be standardised. Teams should follow summaries of product characteristics and Specialist Pharmacy Service guidance on crushing, dispersing or opening products, document any off-licensed use and record the counselling provided^​17​. As part of this standardisation approach, teams should routinely check for a licensed solid alternative before considering a liquid, special or manipulating sold formulations.

Operational burden

The third pillar is lower operational burden for pharmacy teams. Liquids impose a disproportionate workload on the system, which often require refrigeration, closer stock rotation and more intervention when supplied as unlicensed specials. They can also be harder to source, store and dispense. In addition, liquids generate more avoidable administrative work when products are unavailable or need replacement. By contrast, solid oral formulations are generally simpler to manage across procurement, storage and supply^​2​. 

Pharmacists can reduce operational pressure by steering practice toward solid formulations wherever clinically appropriate and by promoting sustainable switching pathways. In practice, this can be supported by rationalising liquid stock holdings, limiting routine use of unlicensed specials and embedding clear local guidance on when liquids are genuinely required, so that avoidable supply queries, substitutions and administrative work are reduced at source.

Supply resilience

The last pillar focuses on supply resilience, workload and waste reduction. Solid formulations are usually easier to get hold of or substitute, are less dependent on cold-chain storage and are available from a broader supplier base. They also reduce waste associated with temperature excursions, shorter expiry and part-used bottles^​9,12​.

In addition, a shift away from liquid-heavy prescribing supports wider NHS sustainability goals by reducing refrigerated storage, unnecessary deliveries, carbon footprint and avoidable product loss. The sustainability case is therefore not separate from the clinical one; it is part of the same argument for a more resilient medicines system.

In both primary and secondary care settings, pharmacists can strengthen supply resilience by prioritising stable solid options and working with prescribers to embed solid-first thinking into medicine selection, substitution and waste minimisation. In practice, this should be supported by building shortage resilience into local standard operating procedures, with pre‑agreed solid alternatives, clear communication pathways and standard advice for families. This enables services to respond quicker when supply problems arise and reduces wasted journeys, prescription rewrites and delays, while improving continuity of care^​11​.

At the Royal Berkshire NHS Foundation Trust, plans are in place to introduce the ‘Pill School’ initiative. This is expected to enable earlier transition to solid formulations, reduce reliance on liquid medicines and support more consistent prescribing. Such approaches demonstrate how a solid-first model can be operationalised in routine care, improving continuity and reducing friction during supply disruptions.

An opportunity for pharmacy leadership

Resorting to liquids in children should no longer be the default option. Tablets, capsules and flexible solids are safer, cheaper and usually more convenient. 

Pharmacy professionals can lead this transition — coaching families to swallow tablets, guiding prescribers toward licensed flexible solids, reducing excipient exposure, and protecting the NHS from avoidable cost and fragility. 

With clear standard operating procedures, small commissioning tweaks and smarter shortage policies, we can make tablets before liquids the new normal, improving care for children and making the medicines system work better across the board.