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If you do not have a relationship with your nearest Neonatal Intensive Care Unit, you should.


If you do not have a relationship with your nearest Neonatal Intensive Care Unit, you should.

A Neonatal Intensive Care Unit (NICU) has one of the highest concentrations of oral compounded medications per patient in healthcare. Commercially available infant dosage forms for the medications used in the NICU are largely unavailable. Hospital pharmacies have adapted to this challenge, but at discharge many families find themselves unprepared to find these specialty medications for home use.

By Stephanie Baumhover, PharmD, BCPS


Discharge Challenges

Discharge day from the Neonatal Intensive Care Unit (NICU) is a day for celebration. It is also a day filled with anxiety. Are the parents prepared, do they have all of the equipment, prescriptions and discharge teaching? While in the NICU, the infant has had doses customized for their individual condition and weight. Most medications have been individually compounded in the hospital pharmacy. Once discharged, it is up to the parents to find a new supply of these customized prescriptions. Almost all oral medications used in a NICU are   not available in dosage forms needed for the tiniest of doses. A 2010 study estimated only 35% of the most commonly prescribed medications are FDA-approved in infants. As a result, hospital pharmacies end up compounding doses for their inpatients. With licensing restrictions, these prescriptions can no longer be supplied to the parents after discharge. 


When planning for discharge, the focus can be on other logistical concerns, supplies and establishing care as an outpatient. Many times, the availability and specific prescriptions may only be decided on the day of discharge, and at times only hours before the infant is due to be released. For those medications where an evening dose will be needed, this can create an unexpected discharge crisis. This can lead to a delayed discharge while a compounding pharmacy is found, and a supply is confirmed for same day availability. If this occurs on a Friday, multi-day delayed discharges are even more likely, resulting in a tremendous increased cost for the hospital and parents. One of the first questions a parent will ask NICU staff is “Do you know where we can get this prescription filled”?


Regionalization of Compounding Services for NICUs

A regional NICU may serve many zip codes several hours away from a parent’s home. If the pregnancy was high-risk, the parents may have been planning on a delivery far away from home for months. Other times an unexpected complication can lead to a NICU stay for a family who lives over an hour away. Other times an infant is transferred to a NICU from an outlying rural hospital well baby nursery, resulting in a significant commute for the parents and complicated discharge planning.


Nationwide, NICUs tend to have a regionalized focus. One urban center may have multiple NICUs available. Rural addresses and other less populated areas may have a several hour drive to the nearest NICU. Since 1981, the percentage of live births per neonatologist has dropped by over 40%, indicating a significant expansion of NICU services. There has been an almost 70% growth of NICU beds since 1995 per the Dartmouth Atlas Report.  Specialized pharmacy care has been identified as a key indicator of success for a NICU. An expansion of this success is an outpatient compounding pharmacy who has the quality control and experience for individualized neonatal oral compounding. 


Compounding pharmacies can be regionalized as well adding a layer to the complication of discharge planning for oral compounded NICU medications. For a medication that may be adjusted based on a growing infant’s weight or needed with short notice, driving a significant distance each time a prescription is needed can be a significant strain for a family of a newly discharged infant. Advance planning before discharge can ease some of this strain and shuffling of resources at the last minute, leaving parents feeling frazzled and unprepared.


How Compounding Pharmacies Can Help

Some NICUs have a prepared listing of compounding pharmacies they share with their discharging families. Most NICU parents have never been through this experience before and are at a loss as where to begin, especially if distance is a complicating factor. Most parents will gladly accept recommendations and need assistance establishing a relationship with a compounding pharmacy.  This can be a significant issue leading some to adopt practices to assist families. 


Parents who live far away from a NICU may only need one dose filled until they can find another compounding pharmacy closer to home. After a long day of discharge instructions, follow-up appointments and care coordination, many families are eager to bring their infant home. An evening dose may be needed to be compounded on short notice. Using an AutoCompounder can ease the strain of compounding a last-minute high-risk prescription. Parents have already been taught how to administer doses from the NICU staff in most cases and are used to a certain concentration and volume of each dose. Communicating with the NICU staff is important to provide continuity of care and reduce potential medication errors. 


If their follow-up care will be near the NICU, they may prefer to keep the experienced compounding pharmacy and arrange refills along with follow-up appointments. Off-label compounding for an infant that weighs less than five pounds is a high-risk process, even for oral medications. Parents can be overwhelmed bringing one NICU baby home, and even more so with multiple births. Your compounding pharmacy can build a lifelong relationship with families by delivering the highest quality compounded product with the most advanced safety enhancements. Reassurance with NICU parents is important to ensure they understand appropriate dosing and administration of these specialty products. These relationships can be started with a NICU need and developed through continuing medical care. 


For those anxious parents who contact a compounding pharmacy they will need reassurance and medication administration teaching in this specialized population. Quality control of measurement and automated preparations can be significant trust building steps for both NICUs and parents. Contacting your regional NICU and describing your services with a flyer or pamphlet is an excellent way to expand services and grow your customer base. Most NICUs will gladly embrace any resources that will ease the strain of a potential delayed discharge.


Search the American Academy of Pediatrics directory of NICUs nationwide to find one near you. 


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Stephanie Baumhover, PharmD, BCPS is a board-certified clinical pharmacist and freelance medical writer. She has professional experience working in regulatory compliance, pediatrics, oncology, internal medicine, and infectious disease. Stephanie has over 20 years medical experience and over 10 years as a medical educator to health care professionals and patients.




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