Barriers and facilitators to the buccal route of administration
| Barriers | Taste | Taste/palatability important, there could be a need to mask the flavour. Buccal midazolam does not taste very nice, and teenagers often refuse it until they get agitated; one clinician experienced this with young adults having buccal diamorphine. Young children do not mention taste, but maybe they are not asked. |
| Mucositis/ulcerations | Concerns about mucositis or ulcerations, particularly with the cancer population having more modalities of treatment. | |
| Drooling | Buccal midazolam has a risk of increasing salivation. | |
| Consistency | Teenagers do not like the fizz of buccal/sublingual fentanyl, preferring the lolly stick, or the ones that dissolve. | |
| Flexible dosing | Flexible dosing is difficult. A device to administer prefilled, buccal diamorphine would be required to avoid making different strengths with different coloured bottles for different doses, as with buccal midazolam. Some clinicians used a licensed product for nasal use buccally. | |
| Administration | Some children purse their lips, making it impossible to administer. One PI had difficulties with administration in children on high dose antiepileptics who had gum hypertrophy. While a lot of mucous is exposed, buccal medicines slough off when administered and it is not possible to get it into the cheek itself. | |
| Facilitators | Ease of use | Buccal was felt to be easier to use than intranasal as it is a squirt around an area, and is absorbed immediately after massaging it in. There is no need to coordinate with inhalation. However, as it is a liquid it would not be a problem in patients with a dry mouth. As with buccal midazolam, it is possible to spray on one side of the cheek, and if the dose is increased, the other cheek can be sprayed using the same dose and concentration. |
| Experience of families and staff | Families have been taught how to give it and have experience of it. Many patients with multiple symptoms towards end of life are on buccal midazolam for agitation alongside pain relief. Some care teams use buccal diamorphine, and it would be easier than intranasal for them in terms of talking to families. Having one technique could mean fewer safety incidents. | |
| Information | There are already information leaflets, often pictorial, on delivery of buccal medication and instructions are on symptom management plans. Different instructions would be needed for delivery of an intranasal medicine. | |
| Applicability | Buccal was felt to be applicable to more children than intranasal. For very young children preprepared solutions cannot be used. |
PI, principal investigator.