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