Oral Nutritional Supplements (Wakefield) Guidance

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • 6 steps to prescribing Oral Nutritional Supplements (ONS) in primary care
  • Adults age 18+ receiving ONS orally

This guidance does not refer to:

  • People on tube (artificial) feeding
  • Under 18s

STEP 1: Establishing if patient is at risk of ‘malnutrition’

The following criteria are used to identify those who are at risk or malnourished: 1

  • Those who have eaten little or nothing for >5 days
  • Those who have poor absorptive capacity or high nutrient losses
  • Body Mass Index (BMI) <18.5kg/m2
  • Unintentional weight loss >10% in the past 3-6 months
  • BMI <20kg/m2 and an unintentional weight loss > 5% in past 3-6months

Weigh patient + obtain height + obtain weight history over last 6 months

Calculate Malnutrition Universal Screen Tool score (MUST). Link to MUST calculator or MUST App for iPhone

If MUST score 2 or BMI <18.5kg/m 2, consider referral to Community Dietitian

STEP 2: Assess underlying causes of malnutrition

Assess underlying causes of malnutrition and consider availability of adequate diet

  • Environmental, social and signposting for food access
  • Ability to chew and swallowing issues
  • Eating & drinking ability skills
  • Psychological issues - Review treatment plan & refer to appropriate local service
  • Substance/alcohol misuse
  • Impact of medication
  • Physical symptoms (i.e. vomiting, pain, GI symptoms)
  • Medical prognosis
  • Highly specialist products require assessment by specialists

STEP 3: Set goals: What are you trying to achieve within what timescale?

Examples of treatment goals

  • Improve weight/nutritional status
  • Maintain weight/nutritional status
  • Minimise decline in weight /nutritional status
  • Optimise nutrient intake during acute episode
  • Facilitate wound healing
  • Improve function/quality of life

What to measure at each review

  • Improve weight/nutritional status
  • Weight & MUST score before & after intervention
  • Maintain weight/nutritional status
  • Weight before & after intervention
  • Minimise decline in weight /nutritional status
  • Rate of weight loss/percentage of weight lost before & after intervention
  • Optimise nutrient intake during acute episode
  • Reported food intake/appetite before & after intervention
  • Facilitate wound healing
  • Wound severity/size before & after intervention
  • Improve function/quality of life
  • Reported ability to undertake activities of daily living or reported quality of life before & after intervention


STEP 4: Offer ‘Food First Advice’. Promote & encourage

  • High calorie, high protein dietary advice - Food First daily dietary advice information (1 pint fortified milk, 2 nourishing snacks, 3 fortified meals)

If patients do not meet ACBS prescribing indications*and it is not contraindicated (i.e. diabetes, renal disease, liver disease) consider over the counter (OTC) alternatives such as Aymes ® Retail, Complan®, Meritene Energis® (formerly known as Build Up®), Nurishment®

STEP 5: When to prescribe a sip feed & what

  • Patients meet ACBS prescribing indications: *Short Bowel Syndrome, Intractable malabsorption, Pre-operative preparation of patients who are undernourished, Proven inflammatory bowel, Following total gastrectomy, Dysphagia, Bowel fistulas, Disease-related malnutrition, (evidence of indication documented)
  • AND one of the following criteria is applicable:
  • 1. Patient is at high risk of malnutrition
    • AND patient is not meeting treatment goals after 1 month of 'food first' nutrition support + homemade milkshake or OTC supplements
    • AND evidence suggests that patient is more likely to take therapeutic dose of prescribed sip feed compared with homemade or OTC supplements.
  • 2.Patient is at high risk of malnutrition AND evidence suggests that patient or carer is unable to prepare homemade or OTC supplements

Which sip feed to prescribe4

Criteria

Suggestions

  • Pt/carer can prepare powder sip feed #
  • Pt can manage 2 x 200ml sip feeds per day
  • Pt likes sweet, milky drinks

Food first advice +

Powder choice bd e.g. Aymes Shake®, Complan Shake®, Ensure Shake®

  • Pt/carers cannot prepare powder sip feed*
  • Pt can manage 2 x 200ml sip feeds per day
  • Pt likes sweet, milky drinks

Food first advice +

Carton choice bd

  • e.g. Aymes Complete®, Ensure Plus®, Fortsip Bottle®, Fresubin Energy®
  • Pt/carer can prepare powder sip feed #
  • Pt cannot manage 2 x 200ml sip feeds per day
  • Pt likes sweet, milky drinks

Food first advice +

Low volume choice bd

  • e.g. Aymes Shake® made with ½ (100ml) volume of milk
  • Pt/carers cannot prepare powder sip feed *
  • Pt cannot manage 2 x 200ml sip feeds per day
  • Pt likes sweet, milky drinks

Food first advice +

Low volume carton choice bd

  • e.g. Ensure Compact®, Altraplen (formely Nutriplen®), Fortisip Compact ®
  • Pt does not like milky drinks
  • Pt can manage 2 x 200ml sip feeds per day
  • Pt likes sweet drinks

Food first advice +

Juice carton choice bd

  • e.g. Fresubin Jucy ®, Ensure Plus Juce®
  • Pt does not like sweet drinks
  • Pt can manage 2 x 200ml sip feeds per day
  • Pt/carers can prepare sip feeds (require heating) #

Food first advice +

Savoury carton choice bd

  • e.g. Ensure Plus Savoury®
  • Pt does not like sweet drinks
  • Pt cannot manage 2 x 200ml sip feeds per day
  • Pt/carers can prepare sip feeds (hot water) #

Food first advice +

Savoury powder choice bd

  • e.g. Vitasavoury 300® (powder made with milk)

# Will always apply if patient is resident in a care home * Will never apply if patient is resident in a care home


  • Prescribe 1 week's supply initially, then prescribe monthly as 'acute' script. Specify dosage, timing and length of treatment
  • Please ensure that requests from Dietitian/ HCPs provide the following information: 2
    • Reason for requesting this sip feed with clinical reasoning & which ACBS indication (See STEP 5 overleaf)
    • Aims/goals of prescription request (See STEP 3 overleaf)
    • Likely timescale for prescription or length of treatment
    • Plan for monitoring/review

Please see additional supporting information - Preferred cost effective options in primary care

STEP 6: Review & deprescribing of ONS

Review regularly to monitor, food, weight, compliance ONS against set goals and continued need for ONS

If patients no longer meet ACBS indications but wish to continue ONS, recommend over the counter supplements such as Aymes ® Retail, Complan®, Meritene Energis® (formerly known as Build Up®), Nurishment® can be recommended unless contraindicated.

When to stop prescribing a sip feed

  • When treatment goal/s are met (consider taper dosage in a stepwise manner over an agreed timespan)
  • When patient is unable or unwilling to take sip feed in therapeutic dose (i.e. as prescribed) (consider whether another product is suitable instead)
  • When patient is reaching end of life and continuing to try to take sip feed is likely to diminish (rather than improve) quality of life

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 02.2018
  • Publication Date: 02.2018
  • Review Date: 03.2019
  • Ref No: NU1 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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