It's been hard enough to find swine flu vaccine for kids. But if they get the flu, it also can be tough to get a prescription filled for the drug used to treat it.

The early and unexpected H1N1 flu outbreak, along with kids' vulnerability to the illness, has created a national shortage of the liquid form of the anti-viral drug Tamiflu. The liquid drug is prescribed to small children and anyone else who has trouble swallowing pills.

The federal government last week released its last 234,000 doses of liquid Tamiflu from a national stockpile. More supplies from Roche, the manufacturer, are not expected until January.

Because H1N1 qualifies as a national health emergency, the U.S. Food and Drug Administration issued an emergency use authorization for Tamiflu, which relaxes some of the prescription rules and allows some expired but still effective products to be used.

Health officials also have encouraged pharmacists to open Tamiflu capsules and mix the powder inside with a flavored syrup to create a liquid form. But the compounding process adds about 30 minutes to the prescription filling process and adds about $50 to the cost, pharmacists said.

Walgreens announced in September that almost all of its pharmacies nationwide would make the liquid Tamiflu.

But insurance companies don't always want to pay for it.

A survey of 100 pharmacists found that some prescription plan providers, including St. Louis-based Express Scripts, have balked at approving costs for the liquid Tamiflu mixes. The prescription can cost about $100 out-of-pocket.

Three out of five pharmacists surveyed reported having problems getting the approvals for making the liquid, according to the National Community Pharmacists Association.

The pharmacy group sent a letter this week to Express Scripts and other pharmaceutical benefits companies calling for a relaxation of billing policies on Tamiflu mixes "so that folks don't have the anxiety of trying to get this medication or being put through a bunch of hoops to get this medication for a sick child," said Douglas Hoey, the pharmacy group's chief operating officer.

In a statement, an Express Scripts spokeswoman said the company hasn't received any complaints from pharmacies about processing Tamiflu prescriptions and that the company "recognizes the importance of easy access to Tamiflu and other agents critical in treating the H1N1 flu."

Brett Williams of Williams Pharmacy in University City said pharmacists sometimes have to be diligent and even aggressive to get the prescriptions approved by the benefits companies. One patient had to be reimbursed after it took a week to get approval for the prescription cost, Williams said.

The University City pharmacy makes several Tamiflu liquid compounds each day.

"They're all going for young children," Williams said. "With Tamiflu, it's something that's just really blown up this year."

Children are at higher risk for catching H1N1 and developing serious complications. There have been 114 reported deaths from H1N1 in U.S. children since April. Between 50 and 100 children die of seasonal flu each year.

While most people who catch H1N1 won't need Tamiflu, the drug can be taken within 48 hours after symptoms start to reduce the severity of the illness. The drug is typically taken for five days.

While pharmacists in the St. Louis area said they're taking the extra time to make the compound liquid Tamiflu, that's not the case everywhere.

Angelo Gioia of New Hyde Park, N.Y., said he called more than 100 pharmacies in the Long Island area Thursday with no luck finding liquid Tamiflu for his 5-year-old daughter who was diagnosed with swine flu.

"Every pharmacy doesn't care and doesn't have it," Gioia said. "Everyone's answer is to break them down. I just really don't know how safe that is."

It's not ideal, but it works, according to the federal Centers for Disease Control and Prevention. The agency took the unusual step of teaching parents how to break down the Tamiflu pills themselves. In step-by-step instructions on its website, the CDC explains that chocolate syrup is best for mixing with the powder from the pills.

Luckily, some pharmacists still add their own spoonfuls of sugar.

Jerry Callahan said his pharmacies in Troy, Montgomery City and Elsberry fill up to 30 Tamiflu prescriptions a week, with about half of those getting mixed into liquids.

"I take the time to make it up, whatever I need to do to take care of my customers," he said.