Post on 26-Sep-2020
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LEICESTERSHIRE PARTNERSHIP
NHS TRUST
LEICESTER NUTRITION
AND DIETETIC SERVICE
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ACKNOWLEDGEMENTS
Leicestershire Nutrition and Dietetic Service are grateful to
Nutricia Ltd for the production and printing of this
Community Hospital Nutrition Resource Folder.
Leicestershire Nutrition and Dietetic Service are also grateful to
Leicestershire Partnership NHS Trust for supporting this resource.
Revised: December 2014
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INTRODUCTION
This folder contains comprehensive, up to date information and advice about nutritional
issues in Leicester, Leicestershire and Rutland Community Hospitals.
It provides guidance to ward staff and interested patients and relatives, about the
provision of food for specific dietary needs.
The information contained in this folder replaces the following out of date documents,
which should now be disposed of:
– Manual of Therapeutic Diets for Community Hospitals (undated A4 booklet)
– Enteral Feeding Handbook for Nursing Staff (October 1998)
– Enteral Feeding Procedures for Community Hospitals (undated A5 booklet)
– Leicestershire & Rutland Community Hospitals Nutrition Resource Folder (2010)
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CONTENTS
Contact List
Training Available
Healthy Eating
Diabetes
Vegan Diet
Gluten Free Diet
Low Residue Diet
How to Identify and Treat Malnutrition
Nutritional Supplements Available
in Community Hospitals
Policies and Procedures
Websites
Appendix 1: Patient Suitability Charts
Enteral Feeding:
– Equipment
– Setting up Feed
– Starter Regimen
– Use of Flocare 800 Pump
– Gravity Feeding
– Bolus Feeding
– Medication & Enteral Feeding
– Problem Solving
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CONTACT LIST
HOSPITAL CONTACT NUMBERS
Department Name Contact No
Dietitian
Hotel Service
Kitchen
Pharmacy
NUTRICIA HELPLINES
Nutricia Resource Centre 01225 751098
Nutricia Homeward Customer Management Team 01225 711982
Account Manager Tracy-Lee Nel 07718 384519 tracy-lee.nel@nutricia.com
Websites www.nutricia.co.uk www.nutriciaONS.co.uk www.nutriciaflocare.co.uk
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TRAINING AVAILABLE
Please liaise with your ward dietitian regarding training needs in regard to nutrition.
Dietitian’s can arrange training on a range of topics, for example, identifying nutritional
risk and it’s management, diabetes, enteral nutrition and dementia.
A food and nutrition self-directed learning is also available from the ward dietitian on
request. This can be handed in to your ward dietitian on completion to receive feedback
and a certificate on request.
Other health professionals may be able to offer additional training on issues relevant to
nutrition, e.g. the ward SALT may be able to offer training on dysphagia on request.
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HEALTHY EATING
In August 1994, the Department of Health
published the first National Food Guide “The
Balance of Good Health”, which aims to help
people understand and enjoy healthy eating. In
September 2007 the Food Standards Agency
updated this model with the “eatwell plate”. Some
of the food groups have been renamed, the design
has been made more contemporary and the types
of food pictured reflect current eating patterns. The
eatwell plate provides us with a practical
interpretation of the scientific guidelines in the
(1991) COMA Report.
The eatwell plate applies to most people, including
vegetarians, black and minority ethnic groups,
people who are a healthy weight for height, as well
as those who are overweight* – it does not apply to
young children and some older people.
* Weight management of obese patients
whilst in hospital should be discussed
with the dietitian – weight loss may not
be appropriate during a hospital stay.
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THE EATWELL PLATE FOR PATIENTS
IN COMMUNITY HOSPITALS
FRUIT & VEGETABLES
Aim: 5 portions per day
Fruit juice is a source of vitamin C
and one glass should be offered with
at least 2 meals per day.
BREAD, RICE, POTATOES, PASTA
& OTHER STARCHY FOODS
1 or more helping should be provided
at each meal.
Encourage wholemeal varieties to
improve bowel function.
Portion size will vary according to
appetite.
MILK & DAIRY FOODS
1 pint milk per day should be offered
to each patient.
Full fat varieties should be offered to
undernourished patients or those with
a poor appetite / intake. FLUIDS
Aim to provide at least 8 cups of fluid
per day. Fluid helps to prevent
dehydration and constipation.
FOODS & DRINKS HIGH
IN FAT AND/OR SUGAR
Unless overweight or diabetic, fatty and
sugary food need not be restricted in the
elderly.
Sugar can provide useful calories, however
care must be taken that sugary foods do
not replace more nutritious foods.
MEAT, FISH, EGGS, BEANS AND
OTHER NON-DAIRY SOURCES OF
PROTEIN
2-3 portions should be offered daily.
Standard portion sizes of these
foods must be given and only
reduced if authorised by the dietitian.
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DIABETES
Dietary Guidelines for People with Diabetes
Eat regularly. Between meal and bedtime snacks** may be required if on insulin and certain medications** or if underweight.
Include a starchy food at each main meal, e.g. bread, cereal, potatoes, rice, pasta.
Limit fried and fatty foods unless undernourished / underweight.
Aim to eat five portions of fruit and vegetables each day.
Choose a low sugar diet. There is no need to completely exclude sugar from the diet, in practice this means avoiding very sugary foods, such as sugary drinks, cakes, sweets, chocolate, sweet biscuits.
Choosing Food Whilst in Hospital
Menu choices are no longer coded as “suitable for diabetes” as it is the
overall balance of foods that is important. This includes puddings with a
low sugar content, as well as diet yogurts and fruit.
Diet / low sugar yogurts are available if required, as a pudding or snack.
Snacks are available in between meals**.
A bedtime snack may be required if on insulin and certain medication.
Patients may order additional starchy carbohydrate at main meal time,
e.g. additional bread or larger portion of potatoes.
For patients with Type 1 diabetes on a basal bolus regimen who wish to
know the carbohydrate content of meals, please contact your ward
dietitian.
Patients who are Underweight
Nutritional requirements should be discussed with your community
hospital dietitian.
Dietary recommendations for people with diabetes are in line with recommendations for
healthy eating for the general population. The “eatwell” plate model (see Healthy Eating
sections) therefore applies to the majority of people with diabetes.
**Check with your dietitian if unsure about snacks
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VEGAN DIET
Individuals who are vegan avoid foods that contain any animal products, including eggs,
milk and other dairy products (butter, cheese and cream). The diet normally consists of
vegetables, cereals, pulses, nuts and fruit.
Foods containing pure vegetable oil margarine can be included and soya products can be
used as a substitute for dairy products, e.g. soya milk, soya yogurt-style desserts and
soya cheese. These products should be fortified with calcium where possible.
The standard vegetarian menu is often unsuitable for patients who are vegan but Tillery
Valley Foods (TVF) do provide vegan meals, which can be ordered from the Hotel
Services Kitchen.
Guidance on suitable choices can be obtained from TVF Talking Technical Allergen and
TVF.
Please also refer to the Catering Resource Guideline for a list of vegan meals available
form TVF.
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VEGAN DIET
If vegan dishes are not available from the menu, order vegan meal from TVF.
Alternative choices while awaiting order are:
– Jacket Potato and Baked Beans
– Toast and Baked Beans
– Fresh Fruit
– Tinned Fruit in natural juice
Due to the limited amount of vegan choice, it may be necessary to discuss choice with the kitchen and Hotel Services to source additional items.
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GLUTEN FREE DIET
Patients with Coeliac Disease or Dermatitis Herpetiformis will need to be on a gluten free
(GF) diet. This means avoiding wheat, rye, barley, and oats, and any dish containing
these foods. This includes foods such as ordinary bread, pasta, cakes and pastry.
Gluten can also be hidden in manufactured and processed foods where flour or cereal
may be used as a processing aid.
It is also important to ensure gluten free food is not contaminated by gluten containing
foods. This can be prevented in the community hospital by remembering the following:
– Use a separate toaster or toastabag when toasting bread
– Use individual portion packs of butter/margarine and preserves or separate jars
– Removing gluten containing foods, such as butter or pastry does NOT make food safe to eat as it
will already have been contaminated with gluten
– Use separate utensils to serve.
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GLUTEN FREE DIET
TVF do provide non-gluten containing ingredient (NGCI) meals, which will need to be
ordered in by Hotel Services.
NGCI means the food has been made with ingredients that do not contain gluten and
controls are in place to minimise cross-contamination with gluten-containing ingredients.
A list of NGCI meals is available from Catering Resource Guidelines or by the ward
dietitian.
Some community hospitals may keep a small selection of gluten free meals in stock.
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GLUTEN FREE DIET
Alternatively, or while waiting for NGCI meals to be delivered, the following options are
suitable:
Breakfast
Gluten-free cereal (e.g. suitable brands of Corn Flakes, Rice Krispies, Coco Pops), Fruit/fruit
juice, gluten free bread*, butter/margarine, jam, marmalade – these can be ordered
through local “hub”
Dinner and Supper
Jacket potato/other suitable potatoes (refer to TVF information list of gluten free foods) or
gluten-free bread* with cheese, ham, tuna, salad
Suitable Puddings
Jelly, fresh fruit, fresh fruit salad, tinned fruit, suitable brands of yoghurt, rice pudding,
mousse (check with ward dietitian)
Between Meals/Snacks
Gluten-free biscuits*, fruit, NGCI items from the snack list provided by Hotel Services
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GLUTEN FREE DIET
*Gluten free bread/biscuits may be supplied by the patient/relatives or ordered by the
ward via pharmacy. If the patient does wish to have bread and biscuits provided by
pharmacy, it is important that this is ordered in by the ward as soon as possible as
emergency supplies are not held on the ward.
NOTE: Several loaves will be delivered from pharmacy and the additional loaves will
need to be kept frozen until required.
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LOW RESIDUE DIET
Patients may be advised to follow a low residue diet prior to endoscopy investigations.
The dietary information below has been provided by LRI / LGH Endoscopy Units.
The following foods only should be offered:
Meat: Lean meats, chicken, turkey, bacon, liver, kidney
Fish: Any kind, fresh or frozen, or tinned in brine
Cheese: Any type
Milk: 284ml per day (any kind)
Fats: 14g per day butter or margarine, or 28g reduced fat spread
Bread: White only – no more than 4 slices per day
Potatoes: Boiled or mashed – up to 4 egg-sized per day
OR
Rice: White – up to 4 tablespoons per day
Crackers: Plain, e.g. cream crackers (but not high fibre crackers)
Biscuits: Rich Tea or Morning Coffee (not digestives)
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LOW RESIDUE DIET
Sweets: Boiled sweets, mints, jellies
Sugar: Brown or white, honey, syrup, jelly-type jam or marmalade (no bits)
Desserts: Jelly
Drinks: Water, tea, coffee (milk from ½ pint), Lucozade, fizzy drinks, Ribena, Oxo,
Marmite
Seasonings: Salt, pepper, vinegar
NOTE: All high-fibre foods should be avoided, i.e. fruit, vegetables, salad, high-fibre /
wholemeal cereals / bread, jacket potatoes.
*If a patient requires advice on modifying the fibre content of their diet for any other
condition, please contact the ward dietitian for advice.
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OTHER SPECIAL/THERAPEUTIC DIETS
Community hospitals can only cater for some therapeutic diets and the management of conditions requiring a therapeutic diet and food allergies/hypersensitivities will need to be considered on an individual basis. This will involve liaison between ward staff, the ward dietitian and hotel services.
TVF Talking Technical Allergen and Dietary Information on Chilled Products 2013 contains further information on the presence of common allergens in menu items including:
– Milk
– Wheat
– Soya
– Celery
– Mustard
– Peanuts
– Sulphur dioxide and sulphites
– Egg
– Gluten
– Fish
– Nuts
– Crustaceans
– Sesame seeds
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OTHER SPECIAL/THERAPEUTIC DIETS
From 13th December 2014 if a product contains any of these common allergens they will have to be highlighted on the menu. These will be shown in CAPITAL letters on TVF labels.
The Catering Resource Guideline contains detailed information regarding special / therapeutic diets.
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HOW TO IDENTIFY & TREAT MALNUTRITION
WHY DO PATIENTS BECOME MALNOURISHED? CONSEQUENCES OF
MALNUTRITION
Weight loss
Weakness and fatigue
Depression and apathy
Poor wound healing
Impaired immune function
Prolonged recovery
Reduced quality of life
Increased risk of infection
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HOW TO IDENTIFY & TREAT MALNUTRITION
The LNDS Nutrition Screening Tool should be completed for each patient within 24 hours
of admission, and fortnightly subsequently.
If the NST score is > 10 action should be taken to increase the patients nutritional intake
by: – Offering snacks between meals
– Encouraging milky drinks
– Offering Build Up Soups and milkshakes
– Encouraging energy-dense menu choices (i.e. menu code E)
Additional food fortification may be possible, e.g. – Add extra butter/margarine on vegetables, potatoes and bread
– Add sugar to drinks (unless patient is diabetic)
– Add preserves to bread and puddings
If the NST score is > 15, please refer to the dietitian – offer high protein, high energy diet
as above.
The dietitian will assess the need for nutritional supplements in addition to high protein,
high energy diet.
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NUTRITION CHECKLIST
Ability to eat Suggested action
Able to eat independently
Poor dentition/chewing problems Consider referral to community dentist
Ill fitting dentures Consider referral to community dentist
Poor oral hygiene Consider referral to community dentist
Requires help with feeding Develop treatment plan for behaviours
Swallowing problems Refer to Speech and Language Therapist
Choke risk Refer to Speech and Language Therapist
Symptoms/side effects of drugs
Nausea Request review of meds
Vomiting Request review of meds
Constipation Request review of meds
Diarrhoea Request review of meds
Psychological state
Does not enjoy mealtimes Offer support during meal times
Mental state not affecting food intake
Loss of interest in food
Disruptive behaviour at meal times Develop treatment plan for behaviours
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NUTRITION CHECKLIST
Psychological state (continued) Suggested action
Easily distracted by noise/other clients Develop treatment plan for behaviours
Regurgitates/self induces Develop treatment plan for behaviours
History of erratic or chaotic eating
Severe depression
Mild anxiety/confusion relating to food
Paranoia relating to food Offer support during mealtimes
Extreme anxiety/agitation Offer support during mealtimes
Appetite and dietary intake
Normal appetite, all meals eaten
On special diet, e.g. supplements, liquidized Follow nutrition care plan
Reduced appetite, ½ - ¾ of meals eaten Follow nutrition care plan
Poor appetite, less than ½ of meals eaten Follow nutrition care plan
Can manage finger foods Contact catering
Has particular cultural dietary requirements Contact catering
Seems to have foods they do not like Discuss with relations/carers
Needs specially adapted cutlery Refer to OT for assessment
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NUTRITION CHECKLIST
Skin type Suggested action
Healthy
Oedematous
Poor wound healing
Grade 4 pressure ulcers Refer to Tissue Viability Nurse
Dry and flaky
Other issues
Difficulties with posture when eating Refer to Physiotherapy Department
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TOP TIPS FOR GIVING SUPPLEMENTS
IT IS IMPORTANT THAT THE DIETITIAN ASSESSES THE NEED FOR
NUTRITIONAL SUPPLEMENTS AND MONITORS THEIR EFFECTIVENESS
If a patient is admitted to the ward on prescribed oral nutritional supplements (this does
not include Build Up Shakes or Build Up Soup) they should be referred to the ward
dietitian for review, regardless of their NST Score
– Give supplements as stated on the prescription chart
– Serve chilled to improve acceptance
– Serve supplements in an appropriate container
– Offer a variety of flavours
– Offer appropriate help and encouragement
– Record intake and inform dietitian if the patient does not take full amount prescribed
– Check the ‘use by’ date and make sure all stock is used in rotation
– Contact the dietitian if the patient wants to change their supplement
The dietitian will give guidance to the patient’s GP regarding whether continued use of
supplements is appropriate
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BENEFITS OF ORAL NUTRITIONAL SUPPLEMENTS
Improves nutritional intake
Does not affect normal food intake
Improves clinical outcome
Maintains muscle function
Cost effective
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AVAILABLE ORAL NUTRITIONAL SUPPLEMENTS
Fortisip Compact
(Nutricia) Milkshake style
High energy (2.4kcal/ml)
Nutritionally complete
125ml bottle
Vanilla
Strawberry
Banana
Forest Fruit
Mocha
Fortisip Compact
Fibre (Nutricia) Milkshake style
High energy (2.4kcal/ml)
Enriched with
3.6g fibre/100ml
Nutritionally complete
125ml bottle
Vanilla
Strawberry
Mocha
Fortisip Compact
Protein (Nutricia) Milkshake style
High energy (2.4kcal/ml)
14.4g protein/100ml
Nutritionally complete
125ml bottle
Vanilla
Fortisip Multi Fibre
(Nutricia) Milkshake style
High energy (1.5kcal/ml)
Enriched with
2.3g fibre/100ml
Nutritionally complete
200ml bottle
Vanilla
Fortisip Bottle
(Nutricia) Milkshake style
High energy (1.5kcal/ml)
Nutritionally complete
200ml bottle
Vanilla
Fortisip Extra
(Nutricia) Milkshake style
High energy
(1.6kcal/ml)
10g protein/100ml
Nutritionally
complete
Fortimel Regular
(Nutricia) Milkshake style
High energy
(1.0kcal/ml)
10g protein/100ml
Nutritionally
complete
200ml bottle
Vanilla
Strawberry
Chocolate
200ml bottle
Vanilla
Strawberry
Forest Fruit
Fortijuce
(Nutricia) Juice style
High energy
(1.5kcal/ml)
Fat free
200ml bottle
Blackcurrant
Forest Fruit
Lemon
Orange
Fortisip Yogurt
Style (Nutricia) Drinking yogurt style
High energy
(1.5kcal/ml)
Nutritionally complete
200ml bottle
Peach & Orange
Raspberry
Vanilla & Lemon
Scandishake Mix
(Nutricia) Milkshake style powder
for reconstituting with
240ml milk. If full cream
milk: 588kcal & 12.4g
protein/serving
85g sachet
Vanilla
Strawberry
Banana
Chocolate
Unflavoured
Forticreme
Complete
(Nutricia) Semi solid
200kcal/pot
High protein
(11.9g/pot)
125g pot
Vanilla
Banana
Chocolate
Forest Fruit
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AVAILABLE ORAL NUTRITIONAL SUPPLEMENTS
Build Up Soup*
(Nestlé) Sachet
Mixed with hot water contains
200kcal and up to 7.6g protein
49g sachet
Potato and Leek
Chicken
Vegetable
Tomato
Build Up Shake*
(Nestlé) Powder
Mixed with full cream milk contains
240kcal & 14g protein per 200ml
38g sachet mixed with 200ml whole milk
Vanilla
Strawberry
Chocolate
Banana
Calogen**
(Nutricia) Liquid energy (fat) supplement
135kcal per 30ml
500ml bottle
Strawberry
Neutral
Polycal Powder**
(Nutricia) Powdered energy (carbohydrate)
supplement
19kcal per scoop
5g powder
Used to fortify food
and drinks
400g resealable tin
Unflavoured
*These products can be used as a nurse-led intervention
**Use under guidance of the ward dietitian
Build Up Original*
(Nestlé) Powder
20g serving (approximately 2 tbsp)
provides 72kcal and 4.8g protein
Neutral – can be added to sweet and savoury
food and drinks, e.g. tea, coffee, custard and
yoghurt
Calogen Extra**
(Nutricia) Liquid energy (fat) supplement
containing some protein and
vitamins and minerals
160kcal and 2g protein per 40ml
200ml bottle
Strawberry
Neutral
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ENTERAL FEEDING
Enteral feeding is used for people who are unable to obtain some, or all of, their
nutritional needs from food or oral supplements.
The majority of patients who need to be fed via a tube will have either a nasogastric tube
(NG) or gastrostomy tube (PEG).
The following pages illustrate:
– What equipment is required to set up a feed
– Recommended procedure for setting up a feed
– Starter regimen for NG or PEG feed
– Use of Flocare 800 enteral feeding pump
– Gravity feeding
– Bolus feeding
– Medication and enteral feeding
– What to do if… (problem solving)
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BEFORE SETTING UP
THE ENTERAL FEEDING SYSTEM
Make sure preparation area is clean
The tube feed is sterile until opened (it should be stored in a cool, dry place, out of direct
sunlight, but does not need to be kept in a fridge)
Before opening a feed container, check the expiry date. Do not use if date has expired or
if you notice any sign of damage to the pack
Ensure all equipment is to hand before opening feed container (see following page)
Wash and dry hands before opening the feed
Do not allow the connection points, e.g. of giving set, to come into contact with other
surfaces, e.g. floor
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ENTERAL FEEDS & EQUIPMENT
VARIANT 500ML
PACK
1000ML
PACK
1500ML
PACK
Nutrison
Multi Fibre
Energy
Energy Multi Fibre
Sterile Water
If you require other feed types please contact your Dietitian
FLOCARE INFINITY PUMP (Pumps allocated to wards)
NG TUBE PUR FG8 110cm Code No: 41651 (Box of 10)
(500ml x 8) (1000ml x 8) (1500ml x 6)
For variant name
see label (sample below)
* Please note, individual connectors are not provided separately – each giving set pack contains one connector
FLOCARE INFINITY PACK SET *CODE NO: 50562 (Box of 30)
(Order Giving Sets via Stores)
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SETTING UP AN ENTERAL FEED
1. Attach pump to drip stand, ensuring it is level.
2. Wash hands thoroughly.
3. Check expiry date on feed Pack and shake thoroughly.
4. Stand the Pack of feed upside down, with the purple cap end upwards. Remove the purple
cap from the end of the giving set, taking care not to touch the ENPLUS spike under the
purple cap. Pierce the foil seal on the feed and screw the purple end onto the feed Pack.
5. Remove purple plastic top from feed Pack and attach giving set. For pre-filled Packs, do
not attempt to remove or touch foil seal. Ensure giving set is tightly connected to the feed
Pack to avoid leakage.
6. Close the purple roller clamp on the giving set. Hang the feed Pack on the drip stand.
Insert the drip chamber into the drip detector slot.
7. Remove the cap from the end of the giving set, and slowly open the roller clamp. The
tubing will then fill with feed. Control the speed at which the tubing fills by adjusting the
roller clamp. Close the roller clamp once the feed has run through to the end of the giving
set.
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SETTING UP AN ENTERAL FEED
8. Stretch the tubing around the pump rotor wheel and insert the plastic retainer into the
pump bracket. Then pull the tubing through the tubing guide, the tubing will then be
correctly positioned on the pump. Replace the end cap on the giving set to keep it
clean.
9. Flush the feeding tube with sterile water before starting the feed.
10. Switch the pump on by pressing the ‘ON/OFF’key for two seconds. Set the desired
flow rate (ml/hr) by pressing the ‘+/-’ button until the desired rate is reached. Once
the correct rate appears on the display panel press the ‘START/STOP’key to start
the feed.
11. Connect the giving set to the feeding tube, open the roller clamp fully to begin
feeding.
12. Once the feed is completed, switch off the pump by pressing the ‘ON/OFF’ key,
holding it down until the alarm stops and the display appears. Flush the feeding tube
with sterile water.
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STARTER REGIMEN FOR ENTERAL FEED
In the event of your dietitian being unavailable, it is important to establish whether the patient may be
at risk of refeeding syndrome.
The Enteral Nutrition policy for Community Hospitals is currently being updated but will contain the
following starter regimens depending on refeeding risk.
Nutrison (Nutrison 1.0 kcal) feed to be used.
Starting a feed for a patient who is NOT AT RISK of re-feeding syndrome
– Refer to ward dietitian
– Commence feed at 25ml/hour for 10 hours (observe for diarrhoea, nausea or vomiting, or signs of
abdominal distension)
– If tolerating feeds, increase rate to 50ml/hour for 10 hours (consider total fluid requirements, adjust
IV fluids if necessary; observe for diarrhoea, nausea or vomiting, or signs of abdominal distension)
– Give 4 hour break from feed
– If tolerating feeds, continue at 50ml/hour for 20 hours
– Give 4 hour break from feed
– Continue feeds as per regimen from ward dietitian
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STARTER REGIMEN FOR ENTERAL FEED
J2. Starting a feed for a patient who is AT RISK of re-feeding problems.
Initiating feeds in this situation may be undertaken in community hospitals ONLY where appropriate consultant
medical input is available.
Refer to Ward Dietitian
Check urea and electrolytes to identify low levels of potassium, magnesium and phosphate. If depressed, refer to
Appendix J. If, with medical input, it is decided to continue to treat in community hospitals, bloods should be checked daily
until normalised and the need to prescribe thiamine and vitamin B co strong or Forceval should be considered.
Commence feed at 25ml per hour for 20 hours
Consider total fluid requirements; adjust IV fluids if necessary
Observe for diarrhoea, nausea or vomiting, or signs of abdominal distension
Give 4 hour break from feed
If tolerating feed, recommence at 25ml per hour for 20 hours
Check serum biochemistry 24-48 hours after commencing feeds, for levels of potassium, phosphate and magnesium. If the
levels are depressed covering doctor should be contacted and asked to correct. Potassium, magnesium and phosphate
should be monitored every 24 hours until corrected
Give 4 hour break from feed
Increase feeds as per regimen from Ward Dietitian if biochemistry normal (review biochemistry if indicated) (Currie, 2006)
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STARTER REGIMEN FOR ENTERAL FEED
J3. Starting a feed for a patient who is AT HIGH RISK of re-feeding problems.
In this situation for Learning Disabilities and Mental Health the patient is generally referred back to UHL to initiate
enteral feeds safely, however patients with eating disorders are usually at high risk but have been dealt with
successfully on both CAMHS and adult unit. This must be discussed with a Senior Clinician on an individual
patient basis
For community hospitals a medical decision is required, based on clinical condition, to determine if the patient
should be referred back to UHL/acute.
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FLOCARE INFINITY ENTERAL FEEDING
PUMP – PROBLEM SOLVER CHART
PROBLEM INSTRUCTIONS
No Set
Press ‘on/off’ to switch of the pump
Insert the Flocare Infinity set into the pump following instructions for use
Restart the pump
Push Strt
The pump has been untouched in hold mode for over 3 minutes
Extend the hold mode by a further 3 minutes by pressing ‘ start/stop’
Program the pump and press ‘start/stop’ to start the pump
End of Dose
The programmed dose/volume has been administered
Switch off the pump by pressing ‘on/off’ for 2 seconds
Clear the memory by pressing ‘clr’
Prog No flow rate is installed
Make sure the correct flow rate is programmed
Door The door is not correctly closed
Make sure the door is properly closed prior to starting a feeding programme
Air Check if the set is inserted correctly and check the air sensor
Remove the air in the set by using ‘fill set’ key
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FLOCARE INFINITY ENTERAL FEEDING
PUMP – PROBLEM SOLVER CHART
PROBLEM INSTRUCTIONS
Batt Connect the adaptor to the pump and mains and charge the pump for approx 6 hours – the pump can be used during charging
Batt E+F Battery failure – please refer the pump for service
Occ In
Out Out
Press ‘start/stop’
Check the feeding set (IN) or feeding tube (OUT) for blockages
Reinsert the set and start the pump, if necessary clean the sensors
Occ Out (repeated)
Stop the pump by pressing ‘start/stop’ or let it run briefly by pressing ‘start/stop’ key
Stop the pump again with ‘start/stop’, ensuring there has been no OCC OUT alarm
Remove the set from the pump and reinsert it into the pump, restart the pump by pressing ‘start/stop’
Lock The programming feature is blocked in the set up mode of the pump
Refer to instruction booklet to de-block
ER01-ER99 Electronic error – switch the pump off, make sure the pump door is closed and turn the pump back on; if the error persists please refer the pump for service
No Plug Symbol
The wall outlet or the adaptor does not work, connect to another wall outlet
If there is still no symbol request replacement of the adaptor
Page 42
GRAVITY FEEDING
In the event of problems with a feeding pump, or further pumps being required, please
contact the dietitian. Even if there is a delay in obtaining a pump please do not delay
starting a feed as this may compromise patient treatment and recovery.
Gravity feeding can be used as follows:
– Connect the giving set to the feed container and feeding tube as normal. The feed container should
hang approximately one metre above patient’s head during gravity feeding
– Open the roller clamp to commence feeding and set the flow rate by counting drips per minute in
the drip chamber, and use the roller clamp to adjust the flow rate
– The following table shows how drip rate equates to flow rate in ml per hour:
Flow rate (ml/hr) Drip rate (drips/min)
125
100
75
50
25
35
28
21
14
7
Page 43
BOLUS FEEDING
In some circumstances bolus feeding may be used rather than pump-assisted or gravity feeding.
Patients may already be on bolus feeds before arriving on the ward, or consultation with the dietitian
may have led to regimen change. Important points to remember are:
– Wash hands thoroughly before assembling equipment and administering bolus feed
– Shake the contents of the feed container and check expiry date
– Flush the feeding tubes (NG or PEG) with 30-50ml of sterile water using a 50ml syringe
– Using the same syringe, remove the plunger and attach the tip of the syringe to the end of the tube, using a
connector if needed
– Pour the required amount of feed into the syringe, it may be necessary to refill the syringe depending on the
amount of feed needed.
– Hold the syringe and allow the feed to run through the tube. If the feed is running too slowly, raise the syringe
slightly. If the feed will not run through at all replace the plunger and apply gentle pressure. Ensure the feed does
not run in too quickly
– Never attempt to rush bolus feeding – a feed should take at least 20 minutes
– When the feeding is finished, flush the tube with 30-50ml of sterile water
– Remove the syringe and replace the cap / stopper on the feeding tube
– Discard the syringe, which should be for single use only
– Store any unused feed in the fridge, but discard after 24 hours if not used
Page 45
WHAT TO DO IF…
The tube is blocked:
– Prevention is better than cure! Always flush with the recommended amount of water
before and after feed and medication
– If blocked, try flushing with 30-50ml warm water and allow up to 20 minutes for the
tube to clear. Then flush again with the same amount of water. It may be necessary to
use gentle pressure from the syringe
– If this does not work, try very gentle manipulation of the tube by rolling between finger
and thumb, then re-flush if clear
The patient feels full and uncomfortable after feeding
– Slow the rate of feeding and extend the feeding time. If the problem persists, contact
the dietitian
Page 46
WHAT TO DO IF…
The patient develops diarrhoea:
– Do not discontinue the feed
Discuss the prescription of anti-diarrhoeal agents with medical / pharmacy staff and
check the following:
– Is the patient receiving antibiotics or have they received antibiotics in the past few
weeks?
– Check the flow rate – it may be too fast, so slow down if necessary
– Check recent food intake. If patient has not eaten for a long period prior to
commencing feed, then a very low rate initially may be required. Discuss with your
dietitian
– Check clean handling procedures are being used to set up feed
– Is the patient receiving any laxatives or syrups containing sorbitol?
– Could the cause be infective (i.e. send stool culture)?
Page 47
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. How should I use Nutricia tube feeds?
A. Shake well before opening immediately prior to use at room temperature.
Maximum hanging time is 24 hours and then any unused contents should be discarded.
Nutrison Packs can be attached directly to a Flocare 800 giving set.
Q. What are the recommended hanging times for your enteral tube feeds in the Pack
presentation?
A. The recommended maximum hanging times for Nutricia tube feeds are in accordance with the
Parenteral and Enteral Group of the British Dietetic Association guidelines:
For sterile feeds provided in pre-filled nutrient containers (i.e. Pack) ensuring that a ‘clean‘
technique is used at ward level the maximum hanging time is 24 hours.
However, reference should always be made to local Infection Control Policies.
Q In what volume are Nutricia feeds nutritionally complete?
A. The Nutricia range of enteral tube feeds comply with the EC Directive (1999/21/EC) for Foods for
Special Medical Purposes and are suitable as a sole source of nutrition in adults. The Nutricia
enteral tube feeds used in Leicestershire are nutritionally complete in 1500kcals.
Page 48
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. Are Nutricia tube feeds suitable for patients with Diabetes?
A. When providing nutritional support to patients with diabetes, a main treatment aim should be to avoid the
extremes of hyperglycaemia and hypoglycaemia. It is important to note that, as with any patient who is
not managing to achieve an adequate diet from 'normal' foods, it is essential that a diabetic patient
receives some form of nutritional support to ensure that their nutritional requirements are met. In
addition, patients with diabetes on medication should receive a regular intake of carbohydrate in order to
prevent hypoglycaemia.
The management of enterally fed patients with diabetes (using Nutricia tube feeds) is in accordance with
the Parenteral and Enteral Group of the British Dietetic Association guidelines.
All Nutricia feeds are suitable for use in diabetic patients. The main source of carbohydrate in these
feeds is maltodextrin and the tube feed range contains an average of 1g sugars per 100ml.
Enteral feeds have been found to produce a more rapid rise in blood glucose levels than a nutritionally
equivalent solid meal. However, as the majority of feeds are delivered via a pump at a relatively slow
rate, this is more of an issue in bolus fed patients.
If blood glucose levels regularly exceed 11mmol/l then request a review of diabetes treatment first. It is
essential that blood glucose levels are monitored regularly and oral hypoglycaemics / insulin are
modified accordingly. Discuss with your diabetes specialist nurse and dietitian.
There is evidence to suggest that some fibre containing foods slow the rate of glucose absorption.
Nutrison Multi Fibre and Nutrison Energy Multi Fibre are liquid products and the carbohydrate in any
liquid product will be absorbed more rapidly than carbohydrate that is part of a food.
Page 49
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. Are Nutricia tube feeds Nut Free?
A. Yes, all Nutricia enteral tube feeds are free from any source of nuts.
Q. Are Nutricia tube feeds Lactose Free?
A. Yes, all Nutricia enteral tube feeds are clinically lactose free.
Q. Are Nutricia tube feeds suitable for vegetarians and / or vegans?
A. Unless detailed below, Nutricia feeds are suitable for vegetarians/vegans:
- Nutrison, Nutrison Energy, Nutrison Multi Fibre, Nutrison Energy Multi Fibre,
Nutrison Protein Plus, Nutrison Protein Plus Multi Fibre and the Nutrison Complete
Multi Fibre range contain fish oils and may not be suitable for strict vegetarians or
vegans.
- Vitamin D in feeds is prepared from the wool of healthy living sheep and may not
be suitable for strict vegetarians or vegans.
- Nutrison Peptisorb uses Trypsin (pork enzyme) in the manufacture of the product
and may not be suitable for strict vegetarians or vegans.
Please see Appendix 1 for more details.
Page 50
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. Do you have any guidelines on the interactions of medications with enteral
feeds?
A. A comprehensive document relating to various drug interactions with enteral feeds
has been produced by Nutricia in conjunction with Brenda Tan (pre-registration
pharmacist, Queen Elizabeth Hospital, Birmingham). You can obtain this document
via the Nutricia Resource Centre Helpline: 01225 751098.
Page 51
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. Are Nutricia products suitable for Kosher and Halal diets?
A. KOSHER DIETS – According to Jewish dietary law
Forbidden foods
1. Pork and all products of the pig
2. Birds of prey
3. All shellfish and seafood without fins and scales
4. Meats must not be cooked with milk or milk derivatives, or be served at the same
meal. Utensils, pots, pans, plates, cutlery used for meat and milk must be washed,
dried and stored separately
5. Animals and birds must be ritually slaughtered and soaked in salt to render it
‘kosher’, which means permitted
Nutricia products do not contain any ingredients forbidden in a Kosher diet
Nutricia products are Kosher approved, with the exception of Fortisip Savoury
Multi Fibre Chicken flavour
Please see Appendix 1 for more details
Page 52
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. Are Nutricia products suitable for Kosher and Halal diets?
A. HALAL DIETS – According to Islamic dietary law
In Islamic tradition all foods permitted are “lawful” (Halal) unless declared “unlawful”
(Haram)
Forbidden (Haram) foods
1. Pork and all products of the pig
2. Any meat that has not been ritually slaughtered including any meat derivatives
3. All shellfish and seafood without fins and scales
4. Alcohol – including any in foods or medicines
All of the ingredients used in the Nutricia products (with the exception of Fortisip
Savoury Multi Fibre Chicken flavour & products containing Carminic acid) are suitable
for a Halal diet. However, our manufacturing process is not observed by the relevant
religious body and therefore our products do not have official Halal certification
Please see Appendix 1 for more details
Page 53
TUBE FEEDS
FREQUENTLY ASKED QUESTIONS
Q. How should Nutricia tube feeds be stored?
A. The recommended storage temperature for all Nutricia products is 5-25°C. At this temperature
the product will be stable and contain the levels of vitamins and minerals stated on the label
throughout its shelf life
Our manufacturers have looked at the possible effects of storing products at a temperature higher
than recommended and have the following comments:
- All Nutricia tube feeds are supplied sterile so microbiologically the product will remain safe
whilst sealed
- The vitamins (in particular vitamins A, C and E) present in the feeds are likely to degrade faster
at higher temperatures. It is extremely difficult to say by how much as factors such as the
products remaining shelf life, storage temperature and duration of storage at a high temperature
will have an impact. This will not make the product unsafe
- It is possible that over a long period of storage at a high temperature separation of the product
may occur, although this is unlikely. This can be checked visually, and if separated should, as a
matter of precaution, not be given to the patient
Q. Where can I find the expiry date on the Pack and plastic bottle?
A. The expiry date on the Pack can be found at the top of the Pack on the back below the drip stand
cut out area
Page 54
POLICIES AND PROCEDURES
The following policies are available from Leicestershire Partnership NHS Trust
staff resource:
Protected Mealtimes Policy, August 2012
Procedure for Monitoring Food and Fluid Intake (the Red Tray System) within Adult
Inpatients, September 2013
Adult Nutrition and Hydration Policy for Hospitals, May 2012
Guideline for the Prevention and Management of Pressure Ulcers, July 2013
Enteral Tube Feeding Clinical Guidelines, July 2014.
Page 55
WEBSITES
Leicestershire Nutrition & Dietetic Service www.lnds.nhs.uk
Partnership NHS Trust eSource www.leicspart.nhs.uk
Nutricia Advanced Medical Nutrition www.nutricia.co.uk
British Association of Parenteral & Enteral Nutrition www.bapen.org.uk
Department of Health www.dh.gov.uk
Food Standards Agency www.food.gov.uk
National Institute for Clinical Excellence www.nice.org.uk
Coeliac UK www.coeliac.org.uk
Diabetes UK www.diabetes.org.uk
Flocare 800 Online Training www.nutriciaflocare.com
NHS National Patient Safety Agency www.npsa.nhs.uk and www.rcn.org.uk
Page 56
Appendix 1: Patient Suitability Chart
Core Tube Feed Range
Revised: December 2013
Product Name Contains
gluten
Contains
wheat
Contains
egg
Contains
fish
products
Contains
milk
Contains
nuts
Contains
soya
Contains
lactose
Suitable
for
vegetarians
Suitable
for
vegans
Suitable
for
Kosher
Suitable
for
Halal
Nutrison 1
2
3 3,4,8
5 6
Nutrison
Multi Fibre 1
2 3
3,4,8 5
6
Nutrison
Energy 1
2 3
3,4,8 5
6
Nutrison
Energy
Multi Fibre
1 2
3 3,4,8
5 6
Nutrison
800 Complete
Multi Fibre
1 2
3 3,4,8
5 6
Nutrison
1000 Complete
Multi Fibre
1 2
3 3,4,8
5 6
Nutrison
1200 Complete
Multi Fibre
1 2
3 3,4,8
5 6
1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it
contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any
ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)
is used in the manufacture of the product. 8. Product not suitable as it contains milk.
Page 57
Appendix 1: Patient Suitability Chart
Specialised Tube Feed Range
Revised: December 2013
Product Name Contains
gluten
Contains
wheat
Contains
egg
Contains
fish
products
Contains
milk
Contains
nuts
Contains
soya
Contains
lactose
Suitable
for
vegetarians
Suitable
for
vegans
Suitable
for
Kosher
Suitable
for
Halal
Nutrison
Advanced
Protison
1
2 4,8
5 6
Nutrison
Protein Plus 1
2 3
3,4,8 5
6
Nutrison
Protein Plus
Multi Fibre
1 2
3 3,4,8
5 6
Nutrison Soya 1
2 4
5 6
Nutrison Soya
Multi Fibre 1
2 4
5 6
Nutrison
Concentrated 1
2 4,8
5 6
Nutrison
Low Sodium 1
2 4,8
5 6
Nutrison
Peptisorb 1
7 4,7,8
5 7
Nutrison MCT 1
2 4,8
5 6
1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it
contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any
ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)
is used in the manufacture of the product. 8. Product not suitable as it contains milk.
Page 58
Appendix 1: Patient Suitability Chart
Core Oral Nutritional Supplements
Revised: August 2014
Product Name Contains
gluten
Contains
wheat
Contains
egg
Contains
fish
products
Contains
milk
Contains
nuts
Contains
soya
Contains
lactose
Suitable
for
vegetarians
Suitable
for
vegans
Suitable
for
Kosher
Suitable
for
Halal
Fortisip
Compact 1
8
4,8,10 5,8
6,8
Fortisip
Compact
Fibre
1 8
4,8,10 5,8
6,8
Fortisip
Compact
Protein
1 8
4,8,10 5,8
6,8
Fortisip Extra 1
8 4,8,10
5,8 6,8
Fortisip Bottle 1
2 8
4,8,10 5,8
6,8
Fortisip
Multi Fibre 1
2 8
4,10 5
6
Fortimel
Regular 1
8 4,8,10
5,8 6,8
Fortijuce 1
2 8
4,10 5
6
Fortisip
Yogurt Style 1 trace
8 4,8,10
5,8 6,8
1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it
contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any
ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)
is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. These products do not contain any ingredients that are forbidden in the Kosher diet. 10.
Product now suitable as it contains milk.
Page 59
Appendix 1: Patient Suitability Chart
Specialised Oral Nutritional Supplements
Revised: August 2014
Product Name Contains
gluten
Contains
wheat
Contains
egg
Contains
fish
products
Contains
milk
Contains
nuts
Contains
soya
Contains
lactose
Suitable
for
vegetarians
Suitable
for
vegans
Suitable
for
Kosher
Suitable
for
Halal
Calogen 1
8
8 5,8
6,8
Calogen
Extra 1
8 4,8,9
5,8 6,8
Calogen
Extra Shots 1
8 4,8,9
5,8 6,8
Renilon 7.5 1 trace
8 4,8,9
5,8
6,8
Nutricia preOp 1
2 5
6
FortiCare 1 trace
2 3
3,4,8,9 5,8
6,8
Respifor 1
8 4,8,9
5,8
6,8
Nutilis Clear 1
5 6
Nutilis Powder 1
5
6
1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it
contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any
ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)
is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. Product now suitable as it contains milk.
Page 60
Appendix 1: Patient Suitability Chart
Specialised Oral Nutritional Supplements
Revised: December 2014
Product Name Contains
gluten
Contains
wheat
Contains
egg
Contains
fish
products
Contains
milk
Contains
nuts
Contains
soya
Contains
lactose
Suitable
for
vegetarians
Suitable
for
vegans
Suitable
for
Kosher
Suitable
for
Halal
Nutilis Complete
Stage 1 1
8 4,8,9
5,8 6,8
Nutilis Complete
Stage 2 1
8 4,8,9
5,8 6,8
Nutilis Fruit
Stage 3 1
2 8
4,8,9 5,8
6,8
Protifar 1
9 5
6
Polycal Powder 1
2 5
6
Polycal Liquid 1
2
5 6
1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it
contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any
ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)
is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. Product now suitable as it contains milk.