Pediatric drugs are the most affected therapeutic category in active drug shortage with 16 shortages, and six of those involve IV fluids and additives — a challenge that hits children’s hospitals harder than most adult health systems.
A different kind of complexity
Managing drug shortages at a pediatric institution requires more than finding an alternative product — often, there isn’t one. Children’s hospitals deal with smaller vial sizes, specialized concentrations, preservative-free formulations, and sole-source products that have no clinically appropriate substitute.
The additional operational steps often required for alternative product preparation compound the challenge when alternatives do exist, said Nikolaus Lawson, PharmD, director of pharmacy at Children’s Hospital of The King’s Daughters in Norfolk, Va.
At St. Jude Children’s Research Hospital in Memphis, Tenn., pharmacy manager William Mabry, PharmD, said the dosing complexity amplifies every shortage. “Drug shortages have a greater impact on children’s hospitals because pediatric therapies often require wide dosing ranges, specialized formulations, and limited alternatives that are difficult to substitute safely,” Dr. Mabry said.
Diana Elnemr, PharmD, director of pharmacy at Golisano Children’s Hospital in Fort Myers, Fla., part of Lee Health, said the isolation many pediatric institutions face compounds the problem.
“Because there are not too many pediatric hospitals to network together, or to borrow medication from, we have to rely on ourselves in so many ways and come up with a decision or alternative,” Dr. Elnemr said. The closest pediatric hospital to Golisano is roughly two and a half hours away and operates under a different system.
That dynamic plays out on the ground at Valley Children’s Healthcare in Madera, Calif., where Director of Pharmacy Melissa Chase, PharmD, said even a routine-seeming product substitution can ripple across a dozen systems.
“What appears to be a single product substitution often represents a significant multidisciplinary effort,” Dr. Chase said. When a new National Drug Code enters the formulary, her team must update barcode scanning, billing units, medication concentrations, Epic order sets, smart pumps, automated dispensing cabinets, packaging equipment, IV workflow software, and master compounding formulas — and then train pharmacists, nurses and providers across each change.
What’s in shortage now
The drugs creating the most operational strain today span several categories. At Valley Children’s, the most significant active shortages include injectable narcotics — morphine, hydromorphone, in syringe, vial and Carpuject presentations — contrast media, Bicillin L-A, chemotherapy agents including ifosfamide and carboplatin, and oral liquid medications such as chlorothiazide and furosemide.
St. Jude’s list overlaps considerably: generic injectable oncology medications including ifosfamide and carboplatin, injectable benzodiazepines such as midazolam, and injectable opioids including hydromorphone and morphine.
At Golisano, Dr. Elnemr said her team has managed shortages of ketamine syringes, sodium bicarbonate in lower concentrations used for NICU patients and pediatric codes, TPN multivitamins, and chemotherapy agents. Looking ahead, she said chemotherapy medications are her biggest concern given the absence of therapeutic alternatives, along with epinephrine, antibiotics and oral syringes needed to deliver oral medications.
At CHKD, the most pressing shortage is for contrast agents. “As a result, we are spending additional time ensuring that the contrast agents we receive are used in accordance with regulatory standards and clinical practice,” Dr. Lawson said. Of the 223 drugs on the ASHP shortage list, CHKD is actively managing 21, Dr. Lawson said.
Downstream effects of IV fluid and additive shortages
Six of the 16 active pediatric drug shortages involve IV fluids and additives — a category that can cascade into shortages across other drug classes by constraining diluents and altering dosing protocols.
At Valley Children’s, those shortages have historically created significant strain on both inpatient and home infusion programs. Parenteral nutrition component shortages, involving amino acids, D70, sterile water and multivitamins, have forced pharmacy teams to evaluate whether patients on home parenteral nutrition can safely remain at home or require hospital admission.
“These situations require close collaboration among pharmacy, nutrition support, physicians and home care services to develop individualized mitigation strategies while preserving patient safety,” Dr. Chase said.
At St. Jude, sodium chloride vial sizes required modification for IV fluid and total parenteral nutrition preparation when additive shortages hit. “This is a time- and labor-intensive process,” Dr. Mabry said. His team’s response involved collaboration across pharmacy supply chain, pharmacy operations, medication safety and pharmacy informatics to optimize available products and build alternative products into the electronic health record.
CHKD said it is not currently affected by IV fluid and additive shortages, though Dr. Lawson noted prior instances where the hospital has employed alternate preparation methods including compounding, dilution and clinically appropriate alternative product selection.
Building operational infrastructure
Each institution has developed formal infrastructure to manage shortages, reflecting how embedded the problem has become.
Valley Children’s established a dedicated Drug Shortage Committee roughly 10 years ago. The committee, which began as a paper-based workflow, now operates through electronic communication tools and draws on programs including Vizient NES Reserve and expanded direct purchasing from manufacturers.
“Drug shortage management has become a permanent operational responsibility,” Dr. Chase said.
Kendra Blevins, pharmacy buyer at Valley Children’s, handles much of the procurement work on the ground — including the multistep process now required to obtain ifosfamide, which involves contacting the manufacturer directly to request approval for a desired quantity, obtaining NES Reserve approval, then placing the order through Cardinal with both approvals attached before the medication ships.
Golisano operates a backorder committee made up of pharmacy directors and buyers across all campuses in the Lee Health system. When a buyer identifies a potential supply disruption, often before it hits the market, the committee convenes to decide on a course of action, whether that means securing supply across campuses, pursuing a therapeutic substitution, working with IT to update medication options in the system, or implementing clinical decision support warnings. In one example, Dr. Elnemr said the hospital implemented a warning in the system to encourage IV-to-oral antibiotic conversion as early as possible, preserving IV supply for cases where it was truly needed. “We try to stay proactive, but also network the information among us,” she said.
St. Jude uses acuity scores to guide supply chain redundancy planning. Based on a medication’s score, the team will utilize a GPO committed program, a wholesaler virtual sequestration program, or increased safety stock. The institution also runs a weekly medication shortage meeting that includes pharmacy supply chain, pharmacy operations, clinical pharmacy, outpatient pharmacy, medication safety and formulary, and pharmacy informatics.
At CHKD, a team-based approach spans operations, clinical, medication safety, pharmacy procurement and frontline staff. The hospital also uses third-party shortage management software to track and communicate shortages to internal non-pharmacy staff.
What needs to change
Across institutions, pharmacy leaders pointed to similar systemic gaps.
Dr. Lawson cited weather events in unexpected parts of the country as a vulnerability that has exposed the fragility of medication supply chains, and flagged manufacturer discontinuations as a particular threat for products used in IV nutrition for children and neonates.
“Two strategies that might help children’s hospitals facing shortages would be increasing manufacturing of essential generic medications and reducing sole-source products,” he said.
Dr. Mabry highlighted the risks created by continued reliance on single- or dual-source generic medications, particularly oncology agents. He also called for greater transparency and earlier communication among manufacturers, wholesalers and healthcare institutions when a potential shortage is identified, and noted a lack of standardized shortage categories among supply chain partners.
Dr. Elnemr called for manufacturers to reserve supply specifically for pediatric hospitals during shortages and to prioritize allocation for pediatric-specific medications.
“A lot of times the alternatives are not suitable” for infants and young children, she said, making adult-style allocation formulas inadequate. She also called for stronger networking infrastructure among pediatric hospitals to allow institutions to share strategies and sourcing options. “There’s not so much literature out there,” Dr. Elnemr said.
Dr. Chase pointed to the need for greater supply chain transparency, increased manufacturing redundancy, expanded domestic production capacity and earlier communication on anticipated shortages. She also noted that IV narcotic shortages have become an almost annual challenge, particularly toward the end of each calendar year.
“Greater supply chain transparency, increased manufacturing redundancy, expanded domestic production capacity and earlier communication regarding anticipated shortages would help children’s hospitals prepare more effectively and reduce disruptions to patient care,” Dr. Chase said.
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