Clinical Observation: Spoons Systematically Bias Dosing of Liquid Medicine

Abstract

Background: Spoon dosing has been identified as 1 of the 3 major causes of dosing errors and pediatric poisonings (1). Although the U.S. Food and Drug Administration recommends against using kitchen silverware to dose liquid medicine (accessed June 28, 2009) most persons still use spoons when pouring medicine for themselves and their families (2). Although dosing errors remain modest when using teaspoons, they may increase when using various sizes of larger spoons (3). If the size of a spoon leads a teaspoonful of liquid medicine to seem like markedly more or less than 5 mL (4), a person may compensate by under- or over-dosing (Figure).