1. Sip Feeds and Guidelines Jon Durand Medicines Management NHS Hampshire

2. What are we trying to achieve? Weight gain Patient survival Better health/healing Better nutrition? Good patient experience?

3. What type of patient might be using sip feeds? Elderly Undernourished Terminally ill Drug addicts Care home patients Anybody

4. What are the pressures on clinicians to prescribe sip feeds? Patient requests Patient’s relative requests Care home requests Poor catering facilities Caring GP/Nurse requests/prescribers Guidelines

5. How appropriately are sip feeds used? Scenario – elderly patient in care home is given a sip feed for lunch. What happens next? Patient drinks whole carton happily Patient is left alone/forgotten about Cannot use straw Doesn’t like sip feed – texture/taste Sip feed gets taken away before patient can finish it Patient cannot communicate their needs

6. What do we need to do? Regular reviews of all patients Monitor patients Prescribe appropriately Use appropriately Follow guidelines – see next slides

7. Who are sip feeds for? Patients with a MUST score ≥ 2 or BMI ≤ 18.5. N.B. Patients with a BMI > 18.5 can still be malnourished. This could include patients with dysphagia or malabsorption. Patients who do not meet the criteria, but may be at risk might need sip feeds or some nutritional support from OTC products such as Complan and Build-Up. (MUST Tool available at www.bapen.org.uk).www.bapen.org.uk

8. What do I give? Treatment should be two bottles a day in addition to usual food intake for 30 days, or less if you wish to review earlier. Certain patients who rely on sip feeds as their sole source of nutrition will need advice from a dietitian and more than two bottles a day. To aid patient choice, endorse “mixed flavours”. Some manufacturers offer starter packs to assist with taste choice. Prescribe acutely, do not put on repeat. Review before prescribing again. Consider giving food fortification advice and appropriate diet/recipe sheets.

9. What are my options at review? Check weight and compliance. Continue for another month unchanged if necessary. Adjust quantity to suit patient requirements. Give dietary advice and or leaflets if available. Consider changing to OTC foods as a meal replacer such as Build-Up and Complan (non-prescribable, but available OTC). Refer to a Registered Dietitian if you feel it is necessary. Reassure patients that they have “permission” to eat foods that they might perceive to be unhealthy. E.g. full fat dairy foods. If no longer required, stop prescribing. (Target weight achieved, improved MUST score)

10. How do I stop prescribing? Re-screen and reassess. If patient no longer malnourished and no longer at risk, sip feeds should not be required. In order to maintain improved nutritional status, consider possible options as above plus care plans and motivational assistance from a Registered Dietitian.

11. Guidelines for Review of Patients on Long Term Sip Feeds A Review should include the following: 1.A re-assessment of patient’s current weight and comparison to expected weight. An assessment of nutritional requirements 2.An assessment of current intake alongside patient’s social and physical circumstances. 3.An estimate of which nutrients may be in short supply. 4.An individualised action plan. 5.A mechanism to ensure that the patient is reweighed at monthly intervals.

12. Who do I ask for advice? Registered Dietitians (RDs) are the only qualified health professionals that assess, diagnose and treat diet and nutritional problems at an individual and wider public health level. Dietary resources and advice leaflets are available from Dietetic Departments and/or Registered Dietitians. Community Nurses who have received full MUST training are also able to undertake such an assessment and understand when to refer on to a dietitian.

13. Commonly Prescribed Sip Feeds and Alternatives ManufacturerMilk Shake Style Fruit Juice Style Pudding Style Powdered Products Fresenius Kabi Fresubin Energy (300kcal in 200ml) Fresubin 2Kcal (400kcal in 200ml) Fresubin Energy Fibre (300kcal in 200ml) Fresubin 2Kcal Fibre (400kcal in 200ml) Provide Xtra (300kcal in 200ml) Fresubin Crème (225 kcal in 125g) Nutricia Fortisip Bottle (300 kcal in 200ml) Fortisip Compact (300 kcal in 125ml) Fortisip Multifibre (300 kcal in 200ml) Fortijuice (300 kcal in 200ml) Forticreme Complete (200 kcal in 125g) Abbot Ensure Plus (305 kcal in 220ml) Ensure Plus Fibre (305 kcal in 220ml) Ensure Plus Juice (305 kcal in 220ml) Nestlé Resource Energy (300kcal in 200ml) Resource Energy 2.0 Fibre (400kcal in 200ml) Resource Fruit (254kcal in 200ml) Resource Dessert Energy (200kcal in 125g) Build - up (263kcal per sachet with 200ml of FULL FAT milk) – NB OTC only. Complan Complan Shakes, various flavours (251 kcal in water, 387kcal with 200ml milk) Complan (382kcal per sachet with 200ml of FULL FAT milk) – NB OTC only.

14. Remember Prescribe Acutely Reassess and or Refer Before Repeating Review Frequently Thank you!