Download Oral Nutritional Supplement (Sip Feed) Guidelines for Adults

Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Oral Nutritional Supplement
(Sip Feed) Guidelines for Adults
October 2013
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31.12.10
D2
8.10.10
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SS
SS
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28.1.11
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31.1.11
ss
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D19
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22.10.13
SS
1st revision
09.03.15
SS/AR
Minor
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By whom
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CityCare
QualityAssurance
Forum
CityCarePatient
Safety
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Nottinghamshire
APC Committee
Nottinghamshire
APC Committee
Include
formulary
update and
links to
MUST tool
IMPORTANT NOTICE: If the review date of any policy or procedure has
expired staff should seek advice form their clinical lead or manager
regarding the appropriate action to be taken.
Page 1 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
CONTROL RECORD
Title
Oral Nutritional Supplement (Sip Feed) Guidelines
Reference
Purpose
To ensure that oral nutritional supplements are used, prescribed
and reviewed appropriately across the health community
Audience
Issue
NHS Nottinghamshire County, Nottingham CityCare, County
Health Care Paternership., Nottingham University Hospitals,
Nottinghamshire CCGs
Issue date 25.10.13
Version
V 19
Date 15.4.11
Status
Review date
01.02.15
Owner
Nottingham Community Nutrition and Dietetic Service
Author
Nottingham Community Nutrition and Dietetic Service and NHS
Nottingham City Medicines Management Team
Development
group
Nottinghamshire Sip Feed Guideline Review Group
Approved by
Area Prescribing Committee
Date
Approved by
CityCare Quality Assurance
Forum
Date
Ratified by
CityCare Patient Safety
Committee
Date
Target audience
All Clinical Staff across Nottinghamshire Health Community
Distribution list
All Clinical Staff across Nottinghamshire Health Community
Method
Paper copies
Archived
Date
Intranet 
Other
Location
Access
Page 2 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Page 3 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Contents
Page
1
Introduction
4
2
Purpose
4
3
Role of the Registered Dietitian
4
4
Background
5
5
Risk Management
6
6
Equipment List
6
7
Patient Assessment Malnutrition Universal Screening Tool (MUST)
8
Nutritional Screening and the provision of first line dietary advice
9
Prescription of Sip Feeds and the review process
7-8
10
Sip Feed formulary
8-9
11
Education and Training Programme
9
12
Implementation and dissemination
9
13
Monitoring
9
14
Equality and Diversity Statement
9
15
References and additional supporting documents
6-7
7
10-12
Appendices
Appendix 1 –Malnutrition Universal Screening Tool (‘MUST’ Tool)
13
Appendix 2 – Food and Fluid Checklist
14
Appendix 3 –“Little and Often” Information Sheets for patient/carers
15&16
Appendix 3 – Sip Feed Implementation Pathway
17
Appendix 4 – Sip Feed Formulary
18
Appendix 6 - “Using a Sip feed” Information Sheet for patient/carers
19
Page 4 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
1. INTRODUCTION
Prescribable oral nutritional supplements (sip feeds) are liquid nutrient formulations containing the
complete range of nutrients, which generally are administered by mouth to supplement or to provide the
complete nutritional requirements for an individual.
These guidelines have been developed to provide clear evidence based guidance about how and when
to use oral nutritional supplements effectively in adults. Their content is based on NICE guidance for
nutrition support in adults, a review of current literature, particularly two systematic reviews suggesting
positive benefits when using oral nutritional supplements with patients who are underweight (BMI < 20)
and local good practice discussions with GP’s and Community Nurses.
2. PURPOSE
The guidelines should be considered as an aid to good practice and not a rigid protocol.
Using this guidance will ensure:
 Nutritional risk screening of all adults using a validated nutrition risk screening tool (Appendix 1).
 Effective multidisciplinary working.
 The appropriate and cost effective prescribing of sip feeds in the community.
 Patients’ nutritional needs are evaluated correctly and reviewed regularly.
 Patients will be prescribed products only for as long as is necessary.
 Patients will be prescribed the most appropriate product to meet their nutritional needs
 Patients will only be prescribed flavours and forms of nutritional supplement that are acceptable
to that patient.
 Repeat prescriptions are not generated without regular review.
 Ensuring sip feeds are prescribed appropriately will minimise waste, and potentially provide a
cost saving to the CCGs.
3. ROLE OF THE REGISTERED DIETITIAN
Patients meeting the following criteria should be referred to the appropriate Nutrition and Dietetic
Department.




Patients with Stage 3-4 Pressure Ulcers
Patients scoring 4 or above on the Malnutrition Universal Screening Tool (‘MUST’)
Patients scoring 2-3 or above if there has been no significant improvement in condition,
following the provision of Food First advice and 1-2 months on 1.5 Kcal/ml sip feeds.
Patients with complex medical conditions and/or complex nutritional needs.
For patients whose GP practice is in the Nottingham City and South of the County please
Community Nutrition and Dietetic Service. All referrals should be made via the Nottinghamshire
Health Care Action Point wither by phoning 0300 300 3333 or using the on-line referral form
which can be accessed via Nottingham CityCare website.
For patients whose GP practice is in the North of the County please contact Nottinghamshire
County Nutrition and Dietetic Service on 01623 676025
The Dietitian will assess a patient’s current nutritional status whilst also considering their medical
condition and the provision of nutrients from their current diet. Previous medical, social and nutritional
information will also be considered. Appropriate anthropometrics will be taken when possible.
The Dietitian will re-enforce advice already given, to improve a patient’s nutritional intake through the use
of normal foods and non-prescribable products. Prescribed nutritional supplements will be
recommended, in addition to this advice, when these methods have not been sufficient to meet their
Page 5 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
treatment goals. The patient must meet the standard Advisory Committee on Borderline Substances
(ACBS) indications.
The Dietitian will initially review the needs of the patient (frequency of review will be determined on an
individual basis) and will liaise with all relevant healthcare/ medical professionals regarding changes in
nutritional status. When appropriate the dietitian will discharge the patient either to the referring health
professional or to their GP for monitoring.
4 BACKGROUND
Reported prevalence of malnutrition varies according to the method of assessment. Using the criteria of
weight status, the proportion of underweight adults in the UK ranges from 10-40% in hospitals and care
homes, ≤5% in the general population and >10% in those with chronic diseases living at home. 1 The
Nutrition Screening Survey (BAPEN, 2008) found that 42% of recently admitted residents in care homes
were malnourished. 2
The consequences of malnutrition include vulnerability to infections, delayed wound healing, impaired
function of heart and lungs, muscle weakness and depression. Individuals who are malnourished consult
their GP more frequently and have a higher rate of hospital admissions for longer periods. This is
compounded by higher complication and mortality rates for similar conditions. 1, 5
There has been concern regarding the significant expenditure on oral nutritional supplements across
Nottingham City and County. Oral nutritional supplements are a valuable resource to reduce the burden
of disease related malnutrition and associated health care costs; they may however represent a
significant waste of resources if they are being inappropriately prescribed or poorly monitored.
In 2003 the cost of malnutrition and associated disease to the NHS was estimated at £7.3 billion. The
majority of this expenditure was related to hospital admissions, length of stay and long-term care
facilities. Small contributions arose from GP visits, outpatient visits, parenteral and enteral nutrition and
oral nutritional supplements in the community3,5.
In 2007 the cost to the NHS was estimated at in excess of £13.0 billion, about 80% of which was in
England1. The majority of those identified as being either malnourished or at risk of malnutrition were
living in the community 3,4,5.

There is evidence that malnourished patients
 Visit their GP more often.
 Need more prescriptions
 Have more hospital admissions and remain in hospital for longer
 Have increased morbidity and mortality
 Reduced quality of life
The causes of malnutrition are multi-factorial therefore its management may require a team approach
involving a number of health care professionals and / or support workers to identify the underlying
issues, and to develop and support implementation and monitoring of nutritional care strategies. These
may include adapted eating / drinking utensils, modified food and or fluid texture, practical advice relating
to eating patterns or food and fluid choices, help with eating or food preparation, food and fluid
enrichment, oral nutritional supplements and tube feeds. 3,4,5
NICE guidance on Nutrition Support for Adults was produced in 2006 1 and the key clinical priorities for
implementation which are relevant to community settings are listed below:

Screening for malnutrition or the risk of malnutrition should be carried out by healthcare
professionals with appropriate skills and training.
Page 6 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines

Nutrition support should be considered in people who are malnourished, as defined by any of the
following:
o A body mass index (BMI) of less than 18.5 kg/m²
o Unintentional weight loss greater than 10% within the last 3 – 6 months
o A BMI of less than 20 kg/m² and unintentional weight loss greater than 5% within the last
3 – 6 months.

Nutrition support should be considered in people at risk of malnutrition, as defined by any of the
following:
o
o
o
Have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for
the next 5 days or longer
Have a poor absorptive capacity and/or have high nutrient losses and/or have increased
nutritional needs from causes such as catabolism.
Potential swallowing problems should be taken into account.
A reference list of further supporting evidence can be found in appendix 7.
The Nottingham Guidelines provide additional local guidance on the specific issue of the use of oral
nutritional supplements (sip feeds). The guidance will help to improve good practice by supporting
healthcare professionals to correctly identify patients who require nutritional intervention along with
implementation of the most appropriate method of nutritional support.
5. RISK MANAGEMENT
If the guidelines are not used there is a risk that service users requiring nutritional intervention would not
be identified and thereby be at greater risk of all the complications associated with malnutrition.
The risk of not using the guidelines could be inappropriate prescribing of nutritional supplements with
increased costs to the health community.
6. EQUIPMENT LIST
Equipment required for monitoring
A means of measuring patients height e.g. height stick, tape measure
Suitable sit on, stand on or hoist digital scales should be used, which must be calibrated on a regular
basis according to the manufacturer’s recommendations to reduce the risk of inaccuracies. Health
professionals and local authority run Care homes should use Grade 3 class scales and it is
recommended that all other Care homes should also be using this type of scales for weighing residents.
If it is difficult or impossible to weigh the patient, due to their condition either make a visual assessment
or see the ‘MUST’ Explanatory Booklet for alternative measurements (
http://www.bapen.org.uk/must_notes.html)
7. PATIENT ASSESSMENT MALNUTRITION UNIVERSAL
SCREENING TOOL (‘MUST’)
See Appendix 1 ‘MUST’ Tool
One of the critical components of raising awareness of the risks of malnutrition in the community is to
ensure that the means to detect and treat malnutrition are in place and properly communicated to all
stakeholders in the community.
Page 7 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Detecting malnutrition requires a screening tool. NICE guidance1 suggests that screening should assess
Body Mass Index and percentage unintentional weight loss and should also consider the time over which
nutrient intake has been unintentionally reduced and/or the likelihood of future impaired intake. It
suggests that the Malnutrition Universal Screening Tool (MUST) http://www.bapen.org.uk/screening-formalnutrition/must-calculator is an example of a validated tool, which can be used. ‘MUST’ has been
advocated for use in the community and has been validated in a range of settings e.g. general practice,
community settings including care homes, and outpatient clinics. It has proved to be quick and easy to
use and give reproducible results.
The ‘MUST’ tool identifies adult patients who are malnourished, at risk of becoming malnourished by
means of a score. The ‘MUST’ score is used to classify patients into one of three groups either: low risk,
medium risk or high risk. These groups are used to determine the actions the clinician/ patient/ carer
should take in order to manage the patient, Details of these actions are given in Appendix 1 MUST Tool
and Appendix 3 Supplement Pathway
8. NUTRITIONAL SCREENING AND PROVISION OF FIRST LINE
DIETARY ADVICE
See


Appendix 2. Food and Fluid Checklist
Appendix 3 Little and Often advice leaflet
The Food and Fluid Checklist enables the health professional to evaluate the current nutritional intake of
the patient and highlights any problem areas in their diet. This will allow for practical tips to be given to
improve nutritional intake in conjunction with Appendix 5 “Little and Often” information leaflet.
Where further information is required this can be provided by the completion of a 3-day food diary by the
patient or carer.
9. PRESCRIPTION OF SIP FEEDS AND REVIEW PROCESS
See
Appendix 4. Supplement Pathway
Outlines the process of and prescribing and reviewing sip feeds for a patient with a MUST score of 1
and above. It enables the health professional to follow a clear step wise approach to prescribing
supplements when Food First advice, using the Little and Often patient information leaflet, has not been
sufficient to improve the patients nutritional status and achieve treatment aims.
Patients with a MUST score of 4 or above or those with Stage 3-4 pressure ulcers should be
referred for Specialist Dietetic advice.
For patients whose GP practice is in Nottingham City or South of the County need to be referred
to Nottingham Community Nutrition and Dietetic Service. All referrals should be made via the
Nottinghamshire Health Care Action Point wither by phoning 0300 300 3333 or using the on-line
referral form which can be accessed via Nottingham CityCare website.
For patients whose GP practice is in the North of the County please contact Nottinghamshire
County Nutrition and Dietetic Service on 01623 676025
If the patient is alert and has swallowing problems please discuss with the relevant Speech &
Language Therapy Service.
For patients with a County GP please ring 0115 9691169 ext.55350
For Patients with a City GP please ring 0115 8834707 and Fax – 0115 8834755)
Page 8 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
If the patient has dexterity problems relating to meals please refer to Occupational Therapy
Service, via Health Care Access Point referral system. Contact numbers CityCare 0300 300 300:
County 08449 808080
Important points to consider





The aims of treatment should always be identified at the onset of prescribing any supplement.
We would normally expect supplements to be prescribed on an acute basis. However there will
be some patients whose condition dictates that they require a repeat prescription. For further
information regarding the review process please see Appendix 3.
Patients need to be reviewed on a regular basis (within 3 months) to ensure the patient’s
continued compliance with the supplements and that treatment aims/goals are being met.
Where the aims/goals are not being achieved or the patient’s condition deteriorates they should
be referred for specialist dietetic advice.
People who have eaten little or nothing for more than 5 days should have nutrition support
introduced at no more than 50% of requirements for the first 2 days. Increase feeding rates to
meet full needs if clinical and biochemical monitoring reveals no re-feeding problems.1
10. SIP FEED FORMULARY
Specified ACBS indication conditions are:


Disease related malnutrition including
o Head, neck and oesophageal tumours
o Severe COPD – FEV1<30% and MUST score of 2 or more
o Patients with a complex chronic conditions requiring specialised feeds e.g. Stage 4
Pressure Ulcers (N.B. These patients must be referred for Specialist Dietetic advice)
 Dysphagia related to :
o Stroke
o Neurological conditions e.g. MND, MS.
 Pre-operative preparation of malnourished patients
 Following Total Gastrectomy
 Intractable malabsorption
 Proven Inflammatory bowel disease
 Short bowel syndrome
 Bowel fistulae
Renal failure on CAPD or haemodialysis
Appendix 5. Supplement Formulary
Provides details of suitable 1.5/1.75 kcal/ml sip feeds and powder style feeds which need to be made up
with full cream milk, that can be initiated by any health care professional for patients who score 3 or
above on the MUST tool, without seeking dietetic advice.
Ideally milk or yoghurt style supplements should be trialled first as these have a higher nutritional value
then juice style versions. Powder style feeds can be more palatable as they are made with fresh full
cream milk. However consideration needs to be made with regard to an individuals ability to make them
up, their ability to consume an entire sachet as they have greater volume 1 x BD and should be used
with caution for patients with diagnosed renal impairment stage 4 and above
Where possible patients with diabetes should be prescribed milk/yoghurt style as juice style have a
higher sugar content. They should be advised to sip drinks slowly, blood sugars should be closely
monitored and medication changed if necessary.
For queries about supplements suitable for patients with specific dietary requirements e.g. Halal, food
allergies or vegan, please contact your local Dietetic Department.
Page 9 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
A variety of other nutritional support products are available on prescription, however the nutritional
content of these products varies considerably. Therefore they have not been included in the formulary
and should be prescribed under the advice of a Registered Dietitian.
They include:





Specialised sip feeds (e.g. high protein sip feeds, 2 kcal/ml sip feeds)
Semi-solid desserts
High energy fat emulsions
Soluble Glucose polymers
Liquid and powder supplements, providing calories and protein
Appendix 6 “Using a sip feed”
This leaflet should be provided and discussed with all patients and/or their carers who require sip feeds.
In particular highlighting the need to drink supplements slowly, to have them between meals and to
feedback problems re compliance to the relevant health professional involved in their care
11. EDUCATION / TRAINING PROGRAMMES
BAPEN have an excellent web site with free resources which can be down loaded for use in training on
use of the MUST tool. http://www.bapen.org.uk/musttoolkit.html
To discuss training opportunities please contact your relevant dietetic team:
City and south of the County staff
 Nottingham Community Nutrition and Dietetic Service: 0115 8834327
 Department of Nutrition and Dietetics City Hospital Campus Community Outreach team 0115
9691169 ext 54103 / 54008
North County staff:
Nottinghamshire County Nutrition and Dietetic Service: 01623 676025
12. IMPLEMENTATION AND DISSEMINATION
The guidelines will be available to view and download on the Nottinghamshire Area Prescribing
Committee Website and via the routes for clinical guideline dissemination in each healthcare
organisation.
13. MONITORING
Audit Criteria
 Is there documented assessment of patient’s needs (MUST Tool) recorded in the medical
records?
 Is there a record of the condition for which oral nutritional supplement prescribed?
 Has the oral nutritional supplement been prescribed for an approved condition?
 Is there an explicit nutritional goal/aim identified in the medical records?
 Is there a specified review interval?
 Is there evidence that review has been undertaken in relation to set goals/aims?
 Have first line dietary measures been tried (‘Little & Often’, food first) as well as prescribing oral
nutritional supplements?
 Do prescriptions contain clear instructions about the dose and quantity to be used?
 Does the prescribing interval correlate with the intended frequency and quantity?
Page 10 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
14. EQUALITY AND DIVERSITY STATEMENT
No impact on equality issues were identified using the Equality Assessment Tool for NHS Nottingham
City, Nottingham CityCare or County Health Partnerships
15. REFERENCES AND ADDITIONAL SUPPORTING DOCUMENTS
1. NICE December 2012 Clinical Guideline Nutrition Support in Adults
2. British Association for Parenteral and Enteral Nutrition (BAPEN) (2008) Nutrition Screening
Survey in the UK in 2008: Hospitals, care homes and mental health units
3. BAPEN (2005) The cost of disease-related malnutrition in the UK and economic considerations
for the use of oral nutritional supplements in adults
4. BAPEN (2009) ‘Combating Malnutrition’: Recommendations for Action
5. Pennington Lecture, Proceedings of the Nutrition Society (2007), 66, 522–529. Dr R. J. Stratton
“Malnutrition: another health inequality?”
6. Managing Adult Malnutrition in the Community2012. Document produced by a multi professional
consensus panel and endorsed by a wide range of professional bodies e.g. RCGP, BDA, RCN,
PCPA, BAPWN, BPNG, PCSG, and RPS. N.B. This includes a pathway for the appropriate use
of ONS, which mirrors the pathway in the Nottinghamshire Sip Feed Guidelines.
7. Elia M et al. The cost of disease-related malnutrition in the UK and economic considerations for
the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. 2005.
8. National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding
principles on improving the systems and processes for ONS use.
Paper 1:
Title:
Collins C.E, Kershaw J, Brockington S (2005) Effect of nutritional supplements on wound healing
in home-nursed elderly: A randomized trial. Nutrition, 21: 147-155.
Main findings: Home-nursed elderly with wounds represent a vulnerable population group in whom
malnutrition is common. This group demonstrated a high acceptance of oral nutritional
supplements. Improvements in some indicators of wound healing and cognition were
observed in those who received the energy, protein and nutrient dense supplements.
Paper 2:
Title:
Heyman H, Van De Looverbosch D.E.J, Meijer E.P, Schols J.M.G.A (2008) Benefits of an oral
nutritional supplement on pressure ulcer healing in long-term care residents. Journal of Wound
Care, 17 (11): 476-80.
Main findings: After nine weeks the average pressure ulcer area significantly decreased. A high protein
oral nutritional supplement enriched with arginine, vitamin C, vitamin E and zinc when
used with standard pressure ulcer care significantly reduced the mean pressure ulcer
area of long term nursing residents.
Paper 4:
Title:
Schols J. Heyman, H., Meijer, EP., (2009), Nutritional support in the treatment and
prevention of pressure ulcers: an overview of studies with an arginine enriched Oral
Nutritional Supplement. Journal of Tissue Viability.
Page 11 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Main findings: * Cubitan specific * A review of practice-based studies with the specific ONS specifically
developed for patients with pressure ulcers show positive effects of ONS on pressure
ulcer healing. In addition the ONS might potentially reduce the risk of developing pressure
ulcers.
Paper 5:
Title:
Faxen-Irving G, Andren-Olsson B, af Geijerstam A et al (2002). The effect of nutritional
intervention in elderly subjects residing in group-living for the demented. Eur J Clin Nutr
56:221–227. 19.
Main findings: Being underweight was common in those who had dementia and was related to low
cognitive capacity. After five months of oral supplementation and education of the
personnel the weight increased by about 3kg (6%) which was lost about nine months after
the withdrawal of the liquid supplement.
Paper 6:
Title:
Smith KL, Greenwood CE. Weight loss and nutritional considerations in Alzheimer
disease. J Nutr Elder. 2008;27(3-4):381-403.
Weight loss and nutritional considerations in Alzheimer disease. (Smith & Greenwood,
2008)
Main findings: Supplementation is generally effective but tends to be least beneficial for those with the
lowest body mass index.
Paper 8:
Title:
Stratton R.J and Elia M (2007) A review of reviews: A new look at the evidence for oral
nutritional supplements in clinical practice. Clinical Nutrition Supplements, 2: 5-23.
Main findings: This review of reviews found largely consistent clinical benefits with oral nutritional
supplements in meta-analysis of trials across patient groups. Benefits included significant
reductions in mortality and complication, e.g. infections and pressure ulcers, particularly in
acute settings and acutely ill geriatrics. Across reviews of all patient groups, oral
nutritional supplements consistently improved total nutritional intake, with little
suppression of food intake. In general, reviews indicated improvements in weight (weight
gain or less weight loss) with oral nutritional supplements.
Paper 9:
Gary P. Hubbard, Marinous Elia, Anne Holdaway and Rebecca J Stratton
2011 Elsevier LTD and European Society for Clinical Nutrition and Metabolism
A systemic review of compliance to oral nutritional supplements
Main Findings: This systemic review suggests that compliance to ONS is good, especially with higher
energy-density ONS, resulting in improvements in patients’ total energy intakes that have
been linked with clinical benefits.
Paper 10
Peter F Collins, Rebecca J Stratton and Marinous Elia.
Nutritional support in chronic obstructive pulmonary disease: a systemic review and Meta
analysis. American Journal of Clinical Nutrition 2012
Main findings: Conclusion: this systemic review and meta-analysis showed that nutritional support.
Mainly in the form of ONS, improves total intake, anthropomorphic measures and grip
strength in COPD. These results contrast with the results of previous analyses that were
based on only cross-sectional measures at the end of intervention trials
Paper 11
Floor Neelmaat, Judith E. Bosmans, Abel Thijs, Jaap C. Seidell, Marion A.E. van der
Schueren Oral
Nutritional support in malnourished elderly decreases functional limitations with no extra
costs
Page 12 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Main findings: Conclusions: A multi-component nutritional intervention for malnourished elderly patients
for 3 months after hospital discharge led to significant improvement in functional
limitations and is neutral in cost.
Paper 12
Sharon Carey, Susie Ferrie, Jane Young, Margaret Allman-Farinelli
2011Long term nutritional support in gastrointestinal disease- A systemic review of the
evidence
Main findings Results; Overall evidence supports the use of ONS for improving outcomes such as
weight, function, calorie intake and quality of life.
Conclusion: there is strong evidence to support the use of ONS in a long term setting for
gastrointestinal patients.
Page 13 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 1 BAPEN Validated MUST tool
Page 14 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 2 – Food and Fluid Check List Information from this will highlight problem areas and influence advice given to patient/carer.
Name
NHS number
Do you eat?
Please give details e.g. meal examples
Breakfast
Yes

No

Sometimes
Lunch/midday meal
Yes

No

Sometimes
Tea/evening meal
Yes

No

Sometimes

Snacks between meals Yes

No

Sometimes

Do you have a cooked meal daily?
Yes 
No

Sometimes

Please give details e.g. who supplies or cooks the meals

Do you have a drink?
With every meal
Between meals
During the evening
Please give details e.g. what type of drinks do you have? Do you use a cup or mug?
Yes
Yes
Yes



No
No
No



Sometimes 
Sometimes 
Sometimes 
Do you have any difficulties eating?
e.g. nausea, chewing and swallowing or dexterity problems
Yes

No

Please give details e.g. texture modification, amount of assistance needed
Are you on a therapeutic diet because of a medical problem?
Yes 
No

Please give details
Are you taking any food, drink or vitamin supplements? (e.g.
Complan, Build Up, Fortisip)
Yes 
No

Please give details
Do you drink alcohol, if so how much in a week
………………………………………………….…..………………………………
………………………..…
Please give details
Page 15 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 3. 2 Page Little and often Advice leaflet
If you have lost weight unintentionally or have a small appetite it is important that what you do eat is as
nourishing as possible. You will need to eat a variety of foods, choosing higher calorie options whenever
you can.
This information will give you ideas for food and drinks to have when your appetite is small and suggest
ways to increase the amount of nourishment in your meals.
Include the following each day
3 small meals + 2-3 snacks or milky drinks
Bread, rice, pasta, cereal, chapatti or potatoes at each meal
Meat, chicken, fish, eggs, cheese, yoghurt, nuts, lentils or beans twice a day
Fruit, vegetables or fruit juice at each meal
Use one pint of full cream milk each day or ½ pint of fortified milk ( see recipe below)
8 cups of fluid
Adding extra nourishment to your food
Fortified milk: mix 2 tablespoons of milk powder into half a pint of full cream milk.
Use this fortified milk in place of ordinary milk or water to make up coffee, packet soup, condensed
soup, sauces, mousses, milk puddings, porridge and other breakfast cereals.
Breakfast Cereals: add one or more of the following - fortified or evaporated milk,
cream, thick and creamy yoghurt, fresh or dried fruit, nuts, syrup, honey or sugar. If you have
diabetes, please ask your dietitian or diabetes healthcare team before adding extra sugar, syrup and
honey to foods and drinks.
Soups and Sauces: add one or more of the following - grated or cream cheese,
cream, milk powder, fortified or evaporated milk, crème fraîche, thick and creamy yoghurt, fried
onions, margarine, butter, croutons, lentils or pasta.
Potatoes and Vegetables: roasting potatoes and vegetables in olive, rapeseed or sunflower
oil will provide more energy than boiling them. Or add one or more of the following to potatoes or
vegetables - grated cheese, cream, milk based sauces, margarine, butter, mayonnaise, salad cream
or fried onions.
Puddings and cakes: add one or more of the following - cream, evaporated milk,
crème fraîche, thick and creamy yoghurt, custard, ice cream, jam, honey, syrup, treacle, chocolate or
fruit sauces, dried fruit. If you have diabetes, please ask your dietitian or diabetes healthcare team
before adding extra sugar, jam, syrup, treacle, honey and chocolate or fruit sauces to foods and
drinks.
Using convenience foods such as frozen, chilled or packet ready meals can help if your appetite is
affected by cooking smells or you are unable to stand for long periods of time.
As well as considering food, other simple measures may help to stimulate your appetite. Fresh air, gentle
exercise and eating in company may be helpful.
Page 16 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
* Meal Ideas *
Breakfast
Porridge or other breakfast cereal with fortified milk and sugar and a glass of fruit juice.
Cereal with full fat yoghurt and fresh or dried fruit.
Toast, crumpets, croissants or bagel with extra butter, jam, marmalade, honey, lemon curd, chocolate
spread, peanut butter, or spreading cheese, and a glass of fruit juice.
Scrambled egg, fried bacon and tomato with buttered toast.
Boiled, scrambled or poached egg with buttered toast and a glass of fruit juice.
Light Meals
Soup with a buttered bread roll. Make up condensed or packet soup with full cream milk, or add a swirl of
cream or grated cheese to home made or tinned soup.
Sandwiches or toasties filled with cheese, egg, meat or tinned fish with added mayonnaise, or salad
cream, and salad (such as tomato, cucumber, beetroot or lettuce).
Baked beans or tinned ravioli on buttered toast topped with grated cheese.
Omelette (such as cheese and tomato, or ham and mushroom) with buttered bread.
Macaroni cheese with extra cheese and sliced tomato.
Jacket potato with lots of butter and fillings such as baked beans, tuna mayonnaise and sweetcorn, or
cheesy coleslaw.
Puddings
Individual chilled desserts such as thick and creamy yoghurts, fromage frais, trifles, cheesecakes or
mousses.
Tinned fruit in syrup with evaporated milk, cream or ice cream.
Fruit crumble with cream, custard or ice cream.
Tinned or home made rice pudding.
Sponge or tart with custard .
Gateau with cream.
Snack Ideas
 Crisps, nuts or dried fruit
 Crackers with cheese or dips with
breadsticks or vegetable sticks
 Sausage rolls, bhajis or samosas
 Naan bread
 Toast, crumpets, bagels or teacakes with
butter, peanut butter or cream cheese
 Breakfast cereals with fortified milk (good
at any time) or cereal bars
 Chocolate or shortbread biscuits
 Ice creams - try chocolate bar ones for
extra calories
 Cream or fruit cakes, muffins, doughnuts,
scones with cream and jam
 Sweet or toffee flavoured popcorn





Drinks
Milky tea or coffee made using
fortified milk, and sugar
Fruit juice
Smoothies
Fruit squash
Milky drinks e.g. full cream or fortified
milk, flavoured milk drinks
(strawberry, chocolate, or banana
milk), hot chocolate, Horlicks®,
Ovaltine®, Complan®, or Build Up®
milkshakes
If you have diabetes, please ask your dietitian or diabetes healthcare team before adding sugar cereal or
having sugary, sweet snacks and drinks.
Page 17 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 4 Supplement Pathway
BMI kg/m²
Score
>30 obese
>20
18.5 – 20
<18.5
=0
=0
=1
=2
Unplanned weight loss in past 3
months
%
Score
<5
=0
5 – 10
=1
>10
=2
Score =
Score =
Patient has acute illness and there has
been and is likely to be a significantly
decreased nutritional intake for > 5 days
Score 2
NB these criteria only apply to patients
who have suffered a severe CVA
traumatic brain injury or similar
Score = 0
Total malnutrition risk MUST*score =
Score 1 = medium risk score
2-3 = high risk
Score 4 = Very high risk
MUST calculator tool is available at www.bapen.org.uk/screening-for-malnutrition/must-calculator
or on SystemOne
Key points:
1. Food First - SIP feeds are supplements and should not usually be used as a substitute for food,
MANAGING MEDIUM RISK PATIENTS MUST SCORE 1
Set treatment goal: e.g. prevent further weight loss/ promote weight gain, improve nutritional status and
/or promote wound healing. Record ‘MUST’ score in patients’ notes. Read code 687C
Check for underlying causes: e.g. control pain/nausea; treat any constipation/diarrhoea, check for
medications that may affect appetite etc.
Use the Food First approach. Talk through “Little & Often” sheets with patient and /or carer
MANAGING HIGH RISK PATIENTS MUST SCORE 2 -3
As medium risk plus:
MUST= 2 Recommend over the counter (not FP10) Complan, Build Up drinks etc and document agreed
actions. Ensure useage and overall dietary intake is monitored either in own home or Care Home.
If there is no improvement after 2-3 weeks OR MUST =3 Initiate 1 week’s trial prescription for Sip
Feeds as detailed overleaf 1 x BD. N.B. patient should meet ACBS indications- see over
Use milk based sip feeds in preference to juice based ones as these have a higher nutritional content
Juice style can be used if patients dislike milky drinks, or cannot tolerate milk based varieties.
N.B. Juice based sip feeds should only be used for patients with diabetes if their blood glucose levels can
be adequately monitored and their medication adjusted appropriately.
Talk through “Using a Sip feed” leaflet with patient and /or carer to improve compliance.
If supplement is tolerated, arrange acute prescription for 1 month’s supply of preferred flavours, review 3
monthly.
If a brand is not tolerated continue trialling different brands until a suitable supplement has been
identified.
MANAGING HIGH RISK PATIENTS MUST SCORE 4 + OR WITH STAGE 3-4 PRESSURE ULCERS
As all above, plus refer for Specialist Dietetic Advice:
CityCare area/South of the County - Nottingham Community Nutrition and Dietetic Service 0300 33 33
North of the County - Nottingham County Health Partnership Nutrition and Dietetic Service 01623 676025
The Dietitian will review the needs of the patient, provide them with specialist advice and support and update
all relevant healthcare/ medical professionals involved in their care. When appropriate, the dietician will
discharge the patient either to the referring health professional or to their GP for monitoring.
ON GOING MANAGEMENT AND REVIEW
If the treatment goal is achieved:
Supplements should be reduced gradually to ensure progress is maintained. Continue to monitor for 3
months.
If the treatment goal is not achieved: There will be some patients with long term conditions who will
continue to have an on-going need for supplements as defined in the ACBS criteria. These patients should
be reviewed every 3-4 months to ensure compliance. If necessary refer for Specialist Dietetic advice.
Page 18 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 5 Sip feed formulary
Specified ACBS indication conditions for the prescription of nutritional supplements are:
 Disease related malnutrition including
- Head, neck and oesophageal tumours
- Severe COPD – FEV1<30% and must score 2 or more
- Patients with complex chronic conditions requiring specialised feeds
 Dysphagia related to: Stroke and other Neurological conditions e.g. MND, MS.
 Pre-operative preparation of malnourished patients
 Following Total Gastrectomy, Intractable malabsorbition, Proven Inflammatory bowel disease,
Short bowel syndrome, Bowel fistulae
 Renal failure on CAPD or haemodialysis
1.5 Kcal/ml OR **2.4 Kcal Sip Feed Formulary
Milk/Yoghurt style/ Fibre rich
NB Flavour ranges may change
Nutriplen
**
Compact Sip feed, Vanilla, Strawberry
Fortisip Bottle
Neutral, Vanilla, Toffee, Orange, Strawberry, Banana, Tropical fruit,
Chocolate
Fortisip Compact
**
Strawberry, Vanilla, Apricot, Banana, Mocha, Forest Fruit
Fresubin Energy
Vanilla, Strawberry, Chocolate, Blackcurrant, Banana, Neutral, Lemon,
Tropical Fruits, Cappuccino
Ensure Plus Milkshake
Banana, Blackcurrant, Caramel, Chocolate, Coffee, Fruits of the Forest,
style
Neutral, Orange, Peach, Raspberry, Strawberry, Vanilla. (starter packs are
available) Savoury version – Chicken mushroom
Ensure compact
**
Banana, Strawberry, Vanilla
Resource Energy
Apricot, Chocolate, Strawberry & Raspberry, Banana, Coffee, Vanilla
Fortisip Yoghurt style
Raspberry, Peach & Orange, Vanilla & Lemon
Ensure plus yoghurt
Strawberry swirl, Orchard peach, Pineapple twist, Orange burst
Fresubin Energy Fibre
Strawberry, Chocolate, Cherry, Caramel, Vanilla, Banana
Fortisip MultiFibre
Vanilla, Strawberry, Orange, Chocolate, Banana, Chicken
Ensure Plus Fibre
Banana, Chocolate, Forest Fruits, Raspberry, Strawberry, Vanilla
Powder sachets
Each sachet needs to be made up with 200 mls full cream milk
Complan Shake
Box contains 24 sachets of either: Vanilla, Strawberry, Chocolate, or
Banana flavoured powder. (starter
Fresubin Powder Extra
Box contains 7 sachets of either Chocolate, Strawberry, Vanilla, Neutral.
Aymes Shake
Box contains 7 sachets of either Banana, Vanilla, Strawberry, Chocolate,
Neutral.
Ensure Shake
Box contains 7 sachets of Banana, Vanilla, Strawberry or Chocolate
Juice Style
Should only be used for diabetic patients if their blood glucose levels can be
adequately controlled
Ensure Plus Juce
Apple, Fruit punch, Grapefruit, Lemon & lime, Orange, Peach, Pineapple,
Strawberry.
Resource Fruit
Apple, Pear & Cherry, Orange, Raspberry and Blackcurrant
Fortijuce
Blackcurrant, Forest Fruit, Orange, Lemon, Apple, Strawberry, Tropical
Fresubin Jucy
Apple, Orange Pineapple, Blackcurrant, Cherry
Other prescribed Nutritional Supplements
A variety of other nutritional support products are available on prescription, however the nutritional
content of these products varies considerably. Therefore, they have not been included in the formulary
and should be prescribed under the advice of a Registered Dietitian.
They include:
 Specialised sip feeds (e.g. high protein sip feeds, 2 kcal/ml sip feeds, pre thickened sip feeds
 Milk shake powders
 Semi-solid deserts
 High energy fat emulsions
 Soluble glucose polymers
 Liquid and powder supplements, providing calories, protein and other micronutrients
Page 19 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016
Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines
Appendix 6 – Using a Sip feed
Using a sip feed……
Sip feeds are prescribable drinks that provide extra nourishment in an easy to take form. The
following information contains ideas on how to make the most of them…
Patients name …………………………………
Sip Feed …………………………
Number to take per day ………………………
Date for review ………………….
The person recommending sip feeds should have provided information about how many
bottles or sachets (which should be made up with full cream milk) to take each day.
Drink sip feeds slowly, it should take 20 -30 minutes to drink one bottle
Sip feeds are most effective if they are taken every day as prescribed.
Take sip feeds after or between meals so they don’t put you off eating meals.
Sip feeds should not replace ordinary food – meals and snacks should be eaten as well.
If the sip feeds cannot be taken as prescribed or you think that they are no longer
required, please contact the person who recommended them for more advice.
Sip feeds come in many flavours – ask to try other flavours.
Shake the bottle first before taking.
Sip from the bottle or pour into a glass. Many sip feeds taste better chilled. Some can
even be frozen to make ice-cream or ice-lollies for a delicious change.
Sip feeds can be warmed but remember not to boil them. Try warmed chocolate, coffee
or soup flavours.
Sip feeds can be used in cooking. Companies producing sip feeds can usually provide
recipe booklets.
Storing your sip feed
Some chemists will deliver sip feeds. Remember to ask when you hand in the
prescription.
Store sip feeds in a cool place. Do not store them next to radiators or other sources of
heat.
If you want chilled sip feeds, keep those needed for the next few days in the fridge.
Once opened, store the sip feed in the fridge for up to 24 hr
Page 20 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service
Please see Section 15 for full references and further reading
Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016