The American Society for Parenteral and Enteral Nutrition (ASPEN) is a professional society of physicians, nurses, dietitians, pharmacists, other allied health professionals, and researchers. ASPEN envisions an environment in which every patient receives safe, efficacious, and high-quality patient care. ASPEN's mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. ASPEN has developed parenteral nutrition (PN) shortage considerations in order to assist its members and other clinicians in coping with PN shortages for their patients. American Society of Health-System Pharmacists (ASHP), Drug Shortages Resource Center (http://www.ashp.org/shortages) U.S. FDA Drug Shortages (http://www.fda.gov/Drugs/DrugSafety/DrugShortages/) ASPEN Product Shortage Latest News (https://www.nutritioncare.org/public-policy/product-shortages/) Assess and routinely reassess each patient as to the indication for PN and provide nutrition via the oral or enteral route when possible. Consider switching to oral or enterally administered multivitamin/multimineral/multi–trace element supplement products when oral/enteral intake is initiated (excluding patients with malabsorption syndromes). Supplements may not have a full spectrum of trace elements or contain a daily enteral maintenance dose. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. Food and Drug Administration (FDA) and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after intravenous (IV) administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. Reserve IV trace elements for those patients solely PN-dependent or those with a therapeutic medical need for IV trace elements. If IV multi–trace element products are no longer available, administer individual parenteral trace element entities. Dosing guidelines for individual trace elements can be found in the 2012 ASPEN position paper “Recommendations for Changes in Commercially Available Parenteral Multivitamin and Multi–Trace Element Products.”1 Purchase only as much supply as needed. In the interest of patient safety and fair allocation to all patients nationally, please do not stockpile. During prolonged shortages of IV trace element products, the FDA may approve the temporary importation of alternative products. These products may have different trace element entities, ratios (doses), packaging, and labeling than U.S. products. The Dear Healthcare Professional Letter accompanying imported products should be read carefully. Compound PN in a single, central location (either in a centralized pharmacy or as outsourced preparation) in order to decrease inventory waste. Consider a supply outreach to other facilities in your geographic location. Facilities and practitioners need to continue to observe and be compliant with the product labeling (eg, package insert), USP General Chapter <797> Pharmaceu-tical Compounding-Sterile Preparations, and state Boards of Pharmacy and federal rules and regulations. Include PN component shortages and outages in the healthcare organization's strategies and procedures for managing medication shortages and outages. These procedures should include the following: a process to identify and monitor patients who receive no IV multi–trace elements or individual trace element entities, a process to notify providers when this situation occurs, and a process to notify patients receiving long-term (eg, more than 1 month) PN therapy when their PN formulation has been adjusted for shortages and outages of PN components. Observe for deficiencies when your institution is experiencing ongoing shortages. Increase your awareness and assessment for signs and symptoms of trace element deficiencies. Monitor serum trace element concentrations or other appropriate serum biochemical markers to evaluate trace element status.123–4 Report severe drug product shortage information to the FDA Drug Shortage Program (DSP; http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm142398.htm). Report any patient adverse events or medication hazard related to shortages to the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program (MERP; https://www.ismp.org/errorReporting/reportErrortoISMP.aspx). The use of Pediatric and Neonatal IV multi–trace element products for adults is strongly discouraged. Using pediatric or neonatal IV multi–trace elements for adults may contribute to a shortage of pediatric and/or neonatal products. A shortage of pediatric or neonatal IV trace elements could create a potential risk of trace element deficiencies in neonatal and pediatric patients who may have an even greater need for trace elements. Furthermore, pediatric and neonatal IV multi–trace elements contain trace elements in doses or ratios that may be unsuitable for adults. When all options to obtain IV Adult multi–trace element products have been exhausted, ration IV Adult multi–trace element products in PN, such as reducing the daily dose by 50% or giving 1 multi–trace element product infusion 3 times a week. Withhold IV Adult multi–trace element products from adult patients receiving partial enteral/parenteral nutrition or who can tolerate oral/enteral supplements. Consider withholding IV Adult multi–trace element products for the first month of therapy to newly initiated adolescent and adult PN patients who are not critically ill or have preexisting deficits. Reserve Neonatal IV multi–trace element products for neonatal patients. Reserve Pediatric IV multi–trace element products for pediatric patients. Use caution and carefully review formulations if using IV neonatal multi–trace element products in pediatric patients. The routine use of IV Adult multi–trace element products in pediatric and neonatal patients is not recommended. Use the full dose of IV Adult multi–trace element product for children greater than 5 years of age. (Refer to the Adult IV multi–trace element shortage recommendations in the event of a concurrent shortage.) Use oral/enteral supplementation if possible. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. FDA and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after IV administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. Note that oral/enteral zinc supplementation increases the expression of metallothionein in the enterocytes, which can decrease the oral absorption of copper and may result in copper deficiency. For general information on zinc, see the 2012 ASPEN position paper on “Recommendations for Changes in Commercially Available Parenteral Multivitamins and Multi–Trace Element Products.”1 Signs and symptoms of zinc deficiency: dermatitis (skin rash of face, groin, buttocks, hands, and feet), alopecia, nonhealing ulcers, anorexia, low birth weight, growth failure, delayed sexual development, diarrhea, reduced taste and smell sensitivity, poor night vision, impaired cognitive function, recurrent infections, immune compromise, and impaired wound healing.1,2,45–6 Recent papers on zinc deficiency associated with PN component shortages are listed below: Palm E, Dotson B. Copper and zinc deficiency in a patient receiving long-term parenteral nutrition during a shortage of parenteral trace element products. JPEN J Parenter Enteral Nutr. 2015;39:986-989. Centers for Disease Control and Prevention. Notes from the field: zinc deficiency dermatitis in cholestatic extremely premature infants after a nationwide shortage of injectable zinc—Washington, DC, December 2012 [published correction appears in MMWR Morb Mortal Wkly Rep. 2013;1562(10):196]. MMWR Morb Mortal Wkly Rep. 2013;62(7):136-137. Ruktanonchai D, Lowe M, Norton SA, et al. Zinc deficiency–associated dermatitis in infants during a nationwide shortage of injectable zinc—Washington, DC, and Houston, Texas, 2012-2013 [published correction appears in MMWR Morb Mortal Wkly Rep. 2014;63(4):82]. MMWR Morb Mortal Wkly Rep. 2014;63(2):35-37. Franck AJ. Zinc deficiency in a parenteral nutrition–dependent patient during a parenteral trace element product shortage. JPEN J Parenter Enteral Nutr. 2014;38:637-639. Sant VR, Arnell TD, Seres DS. Zinc deficiency with dermatitis in a parenteral nutrition–dependent patient due to national shortage of trace elements. JPEN J Parenter Enteral Nutr. 2016;40:592-595. Maskarinec SA, Fowler VG. Persistent rash in a patient receiving total parenteral nutrition. JAMA. 2016;315:2223-2224. Use oral/enteral supplementation if possible. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. FDA and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after IV administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. Note that oral/enteral zinc supplementation increases the expression of metallothionein in the enterocytes, which can decrease the oral absorption of copper and may result in copper deficiency. For general information on copper see the 2012 ASPEN position paper on “Recommendations for Changes in Commercially Available Parenteral Multivitamins and Multi–Trace Element Products.”1 Signs and symptoms of copper deficiency: hypochromic, microcytic anemia, leukopenia, and neutropenia are common findings. Hypercholesterolemia may be observed. Children may exhibit skeletal demineralization (osteopenia). In premature infants, signs may include depigmentation of hair and skin, aortic aneurysm associated with impaired elastin formation, neurologic dysfunction, and hypotonia.1,2,7 Myopathy, neuropathy, and myeloneuropathy have been reported in copper-deficient adults. Recent papers on copper deficiency associated with PN component shortages are listed below: Pramyothin P, Kim DW, Young LS, Wichabnsawakun S, Apovian CM. Anemia and leukopenia in a long-term parenteral nutrition patient during a shortage of parenteral trace element products in the united states. JPEN J Parenter Enteral Nutr. 2013;37:425-429. Palm E, Dotson B. Copper and zinc deficiency in a patient receiving long-term parenteral nutrition during a shortage of parenteral trace element products. JPEN J Parenter Enteral Nutr. 2015;39:986-989. No need to supplement (during shortage) unless signs and symptoms of clinical deficiency. Deficiency is rare. Chromium is present as a contaminant in other PN components. When a clinical deficiency is identified, use oral/enteral supplementation if possible. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. FDA and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after IV administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. For general information on chromium, see the 2012 ASPEN position paper on “Recommendations for Changes in Commercially Available Parenteral Multivitamins and Multi–Trace Element Products.”1 Signs and symptoms of chromium deficiency: glucose intolerance refractory to insulin, hyperlipidemia, elevated plasma free fatty acids, weight loss, peripheral neuropathy, and encephalopathy.1,2,8 No need to supplement (during shortage) unless signs and symptoms of clinical deficiency. Deficiency is rare. Manganese is present as a contaminant in other PN components. When a clinical deficiency is identified, use oral/enteral supplementation if possible. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. FDA and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after IV administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. For general information on manganese, see the 2012 ASPEN position paper on “Recommendations for Changes in Commercially Available Parenteral Multivitamins and Multi–Trace Element Products.”1 Signs and symptoms of manganese deficiency: weight loss, transient dermatitis, ataxia, and occasionally nausea and vomiting. In animals, manganese deficiency has been shown to affect reproductive function and carbohydrate metabolism.1,2,9 Use oral/enteral supplementation if possible. Oral dietary supplements, including over-the-counter products containing trace elements, are not regulated by the U.S. FDA and therefore are not evaluated for purity, efficacy, or safety. The bioavailability of orally administered micronutrients is generally lower than that after IV administration. Bioavailability also varies depending on the salt form. Consult a pharmacist for product information and selection. For general information on selenium, see the 2012 ASPEN position paper on “Recommendations for Changes in Commercially Available Parenteral Multivitamins and Multi–Trace Element Products.”1 Signs and symptoms of selenium deficiency: deficiency usually takes years to develop. Symptoms include cardiomyopathy, myalgias, myositis, anemia, hemolysis, and impaired cellular immunity. Keshan disease is an endemic cardiomyopathy associated with selenium deficiency in China.1,2,10 Recent papers on selenium deficiency associated with PN component shortages are listed below: Davis, C, Javid PJ, Horslen S. Selenium deficiency in pediatric patients with intestinal failure as a consequence of drug shortage. JPEN J Parenter Enteral Nutr. 2014;38:115-118. Chen CH, Harris MB, Partipilo ML, Welch KB, Teitelbaum DH, Blackmer AB. Impact of the nationwide intravenous selenium product shortage on the development of selenium deficiency in infants dependent on long-term parenteral nutrition. JPEN J Parenter Enteral Nutr. 2016;40:851-850.