All children who are growth faltering and requiring nutritional support should be referred to a paediatric dietitian or paediatrician for assessment. No adult ONS should be prescribed for a child weighing less than 30kg without expert advice.

For adults: Prescribers should consider providing patients with food advice first to optimise their dietary intake. Food fortification involves increasing the calorie and protein content of food and drink consumed, without increasing the volume.

Oral Nutritional Supplements (ONS) must only be prescribed if indicated by a patient’s malnutrition risk score i.e. a MUST (Malnutrition Universal Screening Tool) score of 2 or more, or if the patient has been assessed by a dietitian.

For further information, including printable resources for patients, please refer to guidance on Management of adult malnutrition.

The patient must also meet the Advisory Committee for Borderline Substances (ACBS) criteria for the specific product, which is most likely to be malnutrition related to the patient’s disease, disorder or condition, refer to part XV of the Drug Tariff for approved indications. This should be evidenced in the patient’s records.

This applies to all patients, including those patients in care homes.

Patients requiring nutritional support who do not meet the ACBS criteria should be advised to follow food fortification guidance and / or to purchase an over the counter ONS. Those patients already prescribed an ONS who do not meet, or no longer meet the criteria should have their prescription reviewed and discontinued.

For acute hospital, all ONS must be written and authorised on the prescription chart according to the individual trust policy. On discharge, patients should be given 7-14 days’ supply and if it is intended that supplements are to be continued, a dietitian will contact the patient's GP by email or letter to inform them of the patient's malnutrition risk score, nutritional goals, ONS prescribed, and plans for review.

Further oral nutritional supplements are available, that are not included in the formulary, but are suitable to be prescribed at a dietitian's request.

For patients with known allergies and intolerances, please refer to the manufacturer’s website for details or contact a dietitian specialist for advice.

Local videos to support people who face challenges with eating, diet and nutrition are available here.

For patient specific advice or further advice on appropriate nutritional supplements, please contact the relevant Department of Nutrition and Dietetics:

North Devon District Hospital (Royal Devon University Healthcare NHS Foundation Trust):

• Nutrition and Dietetics Department
  • Telephone: 01271 322306
  • Email: ndht.dietetics@nhs.net

Royal Devon and Exeter Hospital (Royal Devon University Healthcare NHS Foundation Trust):

• Nutrition and Dietetics Community Dietitians
  • Telephone: 01392 402576
  • Email: rduh.commdietitiansrde@nhs.net

Torbay and South Devon NHS Foundation Trust:

• Department of Nutrition and Dietetics
  • Telephone: 01803 654380

University Hospitals Plymouth NHS Trust:

• Department of Nutrition and Dietetics
  • Telephone: 01752 432243

Nutritional supplements: standard

The powder products in this section are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalaemic or have hyperphosphataemia.

They may be unsuitable for patients with poor manual dexterity.

Powder milkshakes (to be reconstituted with full fat milk)

AYMES Shake (AYMES International Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, ginger, neutral, strawberry, vanilla (£0.57 = 57g sachet)
• One sachet reconstituted with 200ml full fat milk provides approximately:

Foodlink Complete (Nualtra Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, neutral, strawberry, vanilla (£0.58 = 57g sachet)
• One sachet reconstituted with 200ml full fat milk provides approximately:

Notes

1. Foodlink Complete can be mixed with fruit juice for patients wanting a change from a milk-based drink. Nutritional content will depend on the fruit juice the powder is reconstituted with. Instructions and recipe ideas can be found here.
2. A fibre-containing version of Foodlink Complete is also available. Refer to Nutritional supplements: with fibre.

Low volume powder milkshakes (to be reconstituted with full fat milk)

May be more suitable for patients with a small appetite who struggle to drink a larger volume of fluid.

AYMES Shake Compact (AYMES International Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, ginger, neutral, strawberry, vanilla (£0.57 = 57g sachet)
• One sachet reconstituted with 100ml full fat milk provides approximately:

Foodlink Complete Compact (Nualtra Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, neutral, strawberry, vanilla (£0.58 = 57g sachet)
• One sachet reconstituted with 100ml full fat milk provides approximately:

Ready to drink milkshake style sip feeds (1.5Kcal/ml)

Ready to drink milkshake style sip feeds may be more suitable for patients with poor manual dexterity who are unable to prepare powder milkshakes.

Altraplen Energy (Nualtra Ltd)

(Ready to drink liquid)

• Available flavours: banana, chocolate, strawberry, vanilla (£0.99 = 200ml bottle)
• One 200ml bottle provides approximately:

AYMES Actagain 1.5 Complete (AYMES International Ltd)

(Ready to drink liquid)

• Available flavours: banana milkshake, double chocolate*, strawberry burst, smooth vanilla (£1.11 = 200ml bottle)
• One 200ml bottle provides approximately:

Notes

1. *Chocolate flavour is not suitable for patients requiring a strict fibre-free diet.

Ensure Plus (Abbott Nutrition)

(Ready to drink liquid)

• Available flavours: banana, chocolate, coffee, fruits of the forest, neutral, peach, strawberry, vanilla (£1.48 = 200ml bottle)
• One 200ml bottle provides approximately:

Low volume ready to drink milkshake style sip feed

Low volume ready to drink milkshake style sip feeds may be suitable for patients with poor manual dexterity who are unable to prepare powder milkshakes and who also have a small appetite and may struggle to drink a larger volume of fluid.

They may also be helpful for patients with fluid restriction.

Ensure Compact (Abbott Nutrition)

(Ready to drink liquid)

• Available flavours: banana, café latte, strawberry, vanilla (£1.73 = 125ml bottle)
• One 125ml bottle provides approximately:

Fortisip Compact (Nutricia Advanced Medical Nutrition)

(Ready to drink liquid)

• Available flavours: apricot, banana, chocolate, forest fruits, mocha, neutral, strawberry, vanilla (£1.65 = 125ml bottle)
• One 125ml bottle provides approximately:

Nutritional supplements: patient preferences

The powder products in this section are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalaemic or have hyperphosphataemia.

They may be unsuitable for patients with poor manual dexterity.

Juice style powder supplement

Foodlink Complete (£0.58 = 57g sachet) (see Nutritional supplements: standard) can be mixed with fruit juice for patients wanting a change from a milk-based drink. Nutritional content will depend on the fruit juice the powder is reconstituted with. Instructions and recipe ideas can be found here.

Savoury style powder supplement

AYMES ActaSolve Savoury (AYMES International Ltd)

(Powder in sachets)

• Available flavours: chicken, vegetable (£0.93 = 57g sachet)
• One sachet reconstituted with 200ml hot water provides approximately:

Smoothie style powder supplement (suitable for vegans)

AYMES ActaSolve Smoothie (AYMES International Ltd)

(Powder in sachets)

• Available flavours: mango, peach, pineapple, strawberry & cranberry (£1.08 = 66g sachet)
• One sachet reconstituted with 150ml water provides approximately:

Nutritional supplements: with fibre

Fibre-containing ONS are useful for those with constipation. They are not suitable for those requiring a fibre-free diet.

The powder products in this section are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalaemic or have hyperphosphataemia.

They may be unsuitable for patients with poor manual dexterity.

Powder supplements with fibre (to be reconstituted with fresh full fat milk)

Foodlink Complete with Fibre (Nualtra Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, natural, strawberry, vanilla (£0.95 = 63g sachet)
• One sachet reconstituted with 200ml full fat milk provides approximately:

Ready to drink milkshake style sip feed with fibre

Ready to drink fibre-containing sip feeds are significantly more expensive than fibre-containing powders and should be avoided unless a powder supplement is not suitable. Dietitian specialist input is required before patients begin these supplements.

Fresubin Energy Fibre (Fresenius Kabi)

(Ready to drink liquid)

• Available flavours: banana, caramel, cherry, chocolate, strawberry, vanilla (£2.69 = 200ml bottle)
• One 200ml bottle provides approximately:

Specialist nutritional supplements

Dietitian input is required before patients begin these supplements.

There are further specialist ONS available not listed here. Specialist nutritional supplements should only be prescribed on the advice or request of a dietitian specialist.

Juice style ready to drink sip feed

Juice style ready to drink sip feeds are lower in protein than most other sip feeds.

They also have a high carbohydrate content and may be unsuitable for people with diabetes.

Altrajuce (Nualtra Ltd)

(Ready to drink liquid)

• Available flavours: apple, blackcurrant, orange, strawberry (£1.89 = 200ml bottle)
• One 200ml bottle provides approximately:

Notes

1. Contains cow’s milk protein.

High protein ready to drink milkshake style sip feed

For patients with higher protein requirements.

Altraplen Protein (Nualtra Ltd)

(Ready to drink liquid)

• Available flavours: strawberry, vanilla (£2.30 = 200ml bottle)
• One 200ml bottle provides approximately:

Low volume high protein powder milkshake style ONS (to be reconstituted with full fat milk)

For patients with higher protein requirements who also have a small appetite and may struggle to drink a larger volume of fluid.

The powder products in this section are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalaemic or have hyperphosphataemia.

May be unsuitable for patients with poor manual dexterity.

AYMES ActaSolve Protein Compact (AYMES International Ltd)

(Powder in sachets)

• Available flavours: banana, chocolate, neutral, strawberry, vanilla (£1.17 = 57g sachet)
• One sachet reconstituted with 100ml full fat milk provides approximately:

Notes

1. AYMES ActaSolve Protein Compact is not suitable for patients requiring a strict fibre-free diet.

Low volume high protein ready to drink milkshake style sip feed

For patients with higher protein requirements who also have a small appetite and may struggle to drink a larger volume of fluid.

Fresubin PRO COMPACT (Fresenius Kabi)

(Ready to drink liquid)

• Available flavours: apricot-peach, cappuccino, vanilla (£1.65 = 125ml bottle)
• One 125ml bottle provides approximately:

High energy ready to drink milkshake style sip feeds

The higher energy and protein content of 2Kcal per ml ready to drink milkshakes may allow for some patients to be treated with one pack per day.

AYMES Actagain 2.0 (AYMES International Ltd)

(Ready to drink liquid)

• Available flavours: berry medley, café latte, dulce de leche, golden apricot, neutral, smooth vanilla (£2.10 = 200ml carton)
• One 200ml carton provides approximately:

High energy powder supplements (to be reconstituted with fresh full fat milk)

For disease related malnutrition and for hypoproteinaemia. Not nutritionally complete.

Calshake (Fresenius Kabi)

(Powder in sachets)

• Available flavours: banana, chocolate*, neutral, strawberry, vanilla (£3.03 = 87g sachet (*90g sachet))
• One sachet reconstituted with 240ml full fat milk provides approximately:

Notes

1. *Chocolate flavour is not suitable for patients requiring a strict fibre-free diet.

Enshake (Abbott Nutrition)

(Powder in sachets)

• Available flavours: banana, chocolate, strawberry, vanilla (£3.56 = 96.5g sachet)
• One sachet reconstituted with 240ml full fat milk provides approximately:

Specialist macronutrient supplements

Carbohydrate-based liquid supplement

For conditions requiring fortification with a high or readily available carbohydrate supplement. Not to be used as a sole source of nutrition. Use with caution in patients with diabetes.

Polycal Liquid (Nutricia Advanced Medical Nutrition)

(Ready to drink liquid)

• Available flavours: neutral (£2.56 = 200ml)
• One 200ml bottle provides approximately:

Carbohydrate-based powder supplement

Use as an energy enhancer in disease related malnutrition. Not to be used as a sole source of nutrition. Use with caution in patients with diabetes. Lactose free.

Maxijul Super Soluble (Nutricia Advanced Medical Nutrition)

(Powder in sachets / tins)

• Available flavours: neutral (£2.42 = 132g sachet, £3.90 = 200g tin)
• 100g of powder contains approximately:

Notes

1. Dosage should be determined by a clinician or dietitian only.

Carbohydrate and fat-based powder supplement

For high energy, low fluid, low electrolyte requirements e.g. renal disease, catabolic states.

Duocal Super Soluble (Nutricia Advanced Medical Nutrition)

(Powder in tins)

• Available flavours: neutral (£27.28 = 400g)
• 100g of powder contains approximately:

Notes

1. Dosage should be determined by a clinician or dietitian only.

Carbohydrate, fat and protein-based powder supplement

For hypoproteinaemia.

Pro-Cal Powder (Vitaflo UK)

(Powder in sachets)

• Available flavours: neutral (£28.45 = 30 x 15g sachets)
• One 15g sachet provides approximately:

Notes

1. Quantity required is dependent on dietitian recommendation.

Fat-based liquid supplement

For conditions requiring fortification with a high fat supplement. Not to be used as a sole source of nutrition. Do not exceed recommended doses.

Calogen (Nutricia Advanced Medical Nutrition)

(Ready to drink liquid)

• Available flavours: banana*, neutral, strawberry (£6.58 = 200ml, £16.19 = 500ml)
• Recommended dose: 30ml three times daily
• 90ml recommended daily dose provides approximately:

Notes

1. *Banana flavour only available in 500ml bottle.

Fresubin 5kcal Shot (Fresenius Kabi)

(Ready to drink liquid)

• Available flavours: lemon, neutral (£3.45 = 120ml)
• Recommended dose: 30ml three or four times daily
• One 120ml bottle provides approximately:

Fat- and protein-based liquid supplement

For conditions requiring fortification with fat and for hypoproteinaemia.

Altrashot (Nualtra Ltd)

(Ready to drink liquid)

• Available flavours: strawberry, vanilla (£2.90 = 120ml bottle)
• Recommended dose: 30ml three or four times daily
• One 120ml bottle provides approximately:

Notes

1. Contains added vitamins and minerals.

Calogen Extra (Nutricia Advanced Medical Nutrition)

(Ready to drink emulsion)

• Available flavours: neutral, strawberry (£5.80 = 200ml bottle)
• Recommended dose: 30ml three or four times daily
• One 200ml bottle provides approximately:

Notes

1. Contains added vitamins and minerals.

Pro-Cal Shot (Vitaflo UK)

(Ready to drink liquid)

• Available flavours: banana, neutral, strawberry (£3.50 = 120ml bottle)
• Recommended dose: 30ml three or four times daily
• One 120ml bottle provides approximately:

Notes

1. Contains no added vitamins and minerals.

MCT fat-based liquid supplement

For patients with fat malabsorption (e.g. pancreatic insufficiency, cystic fibrosis).

Liquigen (Nutricia Advanced Medical Nutrition)

(Ready to drink emulsion, 50% MCT oil / 50% water)

• Available flavours: unflavoured (£13.97 = 250ml)
• One 30ml dose provides approximately:

Notes

1. Quantity required is dependent on dietitian recommendation.

Protein-based liquid supplement

For the dietary management of hypoproteinaemia.

ProSource Liquid (Nutrinovo Ltd)

(Ready to drink liquid)

• Available flavours: citrus berry, lemon, neutral, orange crème (£1.48 = 30ml sachet)
• One 30ml sachet provides approximately:

Renapro Shot (Stanningley Pharma Ltd)

(Ready to drink liquid)

• Available flavours: apple, cola, peach, wild berry (£2.32 = 60ml bottle)
• Recommended dose: one 60ml shot per day
• One 60ml bottle provides approximately:

Notes

1. Also suitable for the dietary management of dialysis patients on the recommendation of a dietitian specialist.

Protein-based powder supplement

For hypoproteinaemia.

Protifar (Nutricia Advanced Medical Nutrition)

(Powder in tins)

• Available flavours: unflavoured (£13.17 = 225g tin)
• One 2.5g scoop provides approximately:

Notes

1. Contains residual lactose.

Disease specific supplements

Anti-inflammatory (Crohn's disease)

Modulen IBD (Nestlé Health Science)

(Powder in tins)

• Available flavours: slight vanilla (£20.36 = 400g)
• Dosage dependent on age, weight, and clinical condition of the patient
• 100g of powder contains approximately:

Notes

1. For use as a sole source of nutrition during active phase of Crohn’s disease and for nutritional support during remission phase if patient is malnourished.

Peptide-based supplement

For disease-related malnutrition and malabsorption.

Vital 1.5kcal (Abbott Nutrition)

(Ready to drink liquid)

• Available flavours: café latte, mixed berry, vanilla (£4.58 = 200ml bottle)
• One 200ml bottle provides approximately:

Amino acid formula

For the dietary management of conditions where there is a severe impairment of the GI tract.

Elemental 028 Extra (Nutricia Advanced Medical Nutrition)

(Ready to drink liquid)

• Available flavours: grapefruit, orange & pineapple, summer fruits (£5.52 = 250ml carton)
• Dosage dependent on age, weight, and clinical condition of the patient
• One 250ml carton provides approximately:

Thickeners, pre-thickened drinks, and desserts

The following products have been considered based on The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework. The new standards for Texture Modified Foods and Thickened Liquids can be found here.

Feed thickeners

Indicated for patients with dysphagia, as identified by a Speech and Language Therapist (SALT), who have advised on the stage of thickened fluids.

Clear (gum based) thickeners retain the clarity of clear liquids; they are amylase resistant when in contact with saliva and maintain stable viscosity over time. They are shown to improve the safety of swallowing without increasing oropharyngeal residue over their starch based counterparts.

Starch based thickeners are often not well accepted by patients however if an individual is tolerating starch thickener with no hydration concerns, this may continue.

MHRA Drug Safety Update (April 2021): Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration

• Some PEG laxative products such as Movicol, Macrogol 3350, and Moviprep are available in the form of a powder which must be dissolved in liquid before administration.
• Addition of a PEG laxative to a liquid that has been thickened with a starch-based thickener may counteract the thickening action and result in a thin watery liquid. Avoid directly mixing together PEG laxatives and starch-based thickeners.

Thick and Easy Clear

• Powder (£6.50 = 126g tin)

Nutilis Clear

• Powder (£10.13 = 175g tin)

If a patient is prescribed thickener whilst in hospital, it is important to continue the same product into primary care for clinical continuity and to reduce errors in mixing.

Clear (gum based) products have very specific mixing instructions which must be adhered to, to ensure the product is the correct thickness for patient safety. Please refer to mixing instructions on the tins or seek appropriate advice.

Sachets are significantly more expensive than tins. Sachets do not display mixing instructions and can be cumbersome to use. Routine use of sachets is not recommended.

The following tables provide guidance on approximate quantities of feed thickeners to prescribe per month (28 days):

Thick and Easy Clear (126g tin)

Nutilis Clear (175g tin)

The Speech and Language Therapist will inform GPs of the required consistency in terms of IDDSI descriptors after an assessment. If a different quantity is required a clinical reason should be stated.

Pre-thickened drinks

Indicated for patients with dysphagia and disease related malnutrition (see ACBS indicators above).

Only to be given if patient is malnourished (identified by a high Malnutrition Universal Screening Tool (MUST) score or by a Dietitian) with swallowing problems (identified by a Speech and Language Therapist).

Powder milk shakes are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who have hyperkalaemia or have hyperphosphatemia.

Changes in temperature of pre-thickened drinks could affect consistency.

IDDSI Level 2

Slõ Milkshake+ IDDSI Level 2 (IDDSI Level 2, Mildly Thick)

(Powder in sachets)

• May not be suitable for patients with poor manual dexterity
• Available flavours: chocolate and strawberry (£61.32 = 28 sachets)
• One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
• Follow instructions on the packet exactly to achieve the correct consistencies
• Leave for 10 minutes before drinking and consume within 3 hours

Fresubin Thickened Level 2 (IDDSI Level 2, Mildly Thick)

(Ready to drink liquid)

• Gluten- and lactose-free
• Available flavours: vanilla, wild strawberry (£2.64 = 200ml)
• 300kcal, protein 20g, carbohydrate 24.4g, fat 13.4g per 200ml
• Drink slowly at room temperature

IDDSI Level 3

Slõ Milkshake+ IDDSI Level 3 (IDDSI Level 3, Moderately Thick)

(Powder in sachets)

• May not be suitable for patients with poor manual dexterity
• Available flavours: chocolate and strawberry (£61.32 = 28 sachets)
• One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
• Follow instructions on the packet exactly to achieve the correct consistencies
• Leave for 10 minutes before drinking and consume within 3 hours

Fresubin Thickened Level 3 (IDDSI Level 3, Moderately Thick)

(Ready to drink liquid)

• Gluten- and lactose-free
• Available flavours: vanilla, wild strawberry (£2.64 = 200ml)
• 300kcal, protein 20g, carbohydrate 24g, fat 13.4g per 200ml
• Drink slowly at room temperature

Semi-solid Dessert

Indicated for patients with dysphagia.

IDDSI Level 4

Nutricrem (IDDSI Level 4, Extremely Thick)

• Gluten- and lactose-free dessert: chocolate orange, mint chocolate, strawberry, vanilla (£2.29 = 125g)
• Starter pack: chocolate orange, mint chocolate, strawberry, vanilla (£8.84 = 4 x 125g)
• 225kcal, protein 12.5g, carbohydrate 23.5g, fat 9g per 125g

Fresubin 2kcal Crème (IDDSI Level 4, Extremely Thick)

• Gluten- and lactose-free dessert: cappuccino, chocolate, praline, vanilla, wild strawberry (£2.04 = 125g)
• 250kcal, 12.5 g protein, 28g carbohydrate, 9.57g fat per 125g