Berkshire Adult Oral Nutritional Supplement & Tube Feed Formulary

Overview

The Berkshire formulary for adult patients includes a range of oral nutritional supplements (ONS) and enteral tube feeds designed to meet the diverse metabolic and clinical needs of adults at risk of or experiencing malnutrition. All products are manufactured in compliance with UK Medicines and Healthcare products Regulatory Agency (MHRA) standards and are listed on the NHS Supply Chain.

Oral Nutritional Supplements (ONS)

When to prescribe ONS

• Patients with inadequate oral intake (<75% of estimated requirements) for >7days.
• Weight loss >5% in the last month or >10% over 6months.
• Clinical conditions that increase metabolic demand (e.g., infection, wound healing, cancer).
• Patients who can safely swallow but require additional calories, protein, or specific micronutrients.

Product categories

Dosing and administration

Typical dosing is 200ml (~300kcal) taken 23 times daily, adjusted to meet 3040% of the patients total energy and protein needs. ONS can be given with or between meals; if prescribed with meals, advise a gap of at least 30minutes.

Monitoring

• Weight: baseline and weekly thereafter.
• Biochemical markers: albumin, prealbumin, CRP (if indicated).
• Tolerance: assess for nausea, diarrhoea, or constipation.
• Compliance: record volume consumed each day.

Enteral Tube Feed Formulary

Indications for tube feeding

• Inability to meet >60% of nutritional requirements orally for >7days.
• Neurological disorders affecting swallowing (stroke, Parkinsons, ALS).
• Severe headandneck cancers or postoperative patients.
• Critical care patients requiring early nutrition support.

Feed types and product list

Administration routes

• Gastrostomy (PEG/PEJ): preferred for longterm feeding.
• Nasogastric (NG) tube: shortterm (<4weeks) use.
• Jejunostomy (Jtube): patients with high aspiration risk or intolerance to gastric feeds.

Startup protocol

1. Confirm tube placement with pH testing or radiography.
2. Begin with 20ml bolus of water, observe for 15minutes.
3. If tolerated, start feed at 25% of target volume (e.g., 250ml for a 1000ml/day target).
4. Increase by 1020% every 1224hours as tolerated until target volume is reached.
5. Maintain a flush of 30ml water before and after each feeding to prevent tube blockage.

Monitoring and safety

• Daily fluid balance and output.
• Weight and midupper arm circumference weekly.
• Blood glucose for diabetic feeds (prefeed and 2h postfeed).
• Electrolytes (Na, K, Cl, Mg, PO) weekly for the first month, then monthly.
• Signs of intolerance: abdominal distension, high gastric residuals (>250ml), vomiting.

Tube care

Replace PEG tubes according to manufacturer instructions (usually every 612months). Clean the stoma site with sterile water and a mild antiseptic. Prevent backup by ensuring the tube is not kinked and that the external bumper is secured but not too tight.

Clinical Considerations & Special Populations

Elderly patients

Agerelated changes in taste, dentition, and swallowing increase the risk of ONS refusal. Offer flavour choices (vanilla, chocolate, strawberry) and consider a lowvolume, highenergy product such as VitalCare Light.

Patients with chronic kidney disease (CKD)

Use the Renal formulation; monitor serum creatinine, urea, and electrolytes closely. Protein provision should be individualized (0.60.8g/kg/day) while avoiding excess potassium and phosphate.

Oncology patients

High metabolic demand, catabolism, and treatmentrelated mucositis make both ONS and tube feeds critical. The Immuneenriched ONS and Energy 1.5 feed provide additional omega3 fatty acids that may modulate inflammation.

Diabetic patients

Select the Diabetic ONS or Diabetic tube feed. Adjust insulin regimens based on carbohydrate content and conduct frequent capillary glucose checks during the initiation phase.

Pregnant or lactating women

Only prescribe supplements when a dietitian confirms a clear nutritional gap. Choose products with appropriate micronutrient profiles (folic acid, iron). Consult obstetrics for safety.

Resources for Staff

• NICE Guideline NG24 Nutrition Support in Adults
• British Dietetic Association Clinical Nutrition Handbook
• NHS Enteral Nutrition Overview
• Local formulary handbook (PDF) available on the Trust intranet.