Oral Nutritional Supplements in Paediatrics: Practical Use and the Path Back to Solid Food

Children may require ONS when the diet alone cannot meet energy, protein or micronutrient needs, and when growth, development or clinical outcomes are at risk. Reasons include:

• Faltering growth (i.e., weight or height gain below expected trajectory)

• Increased nutrient requirements: e.g., chronic lung disease, cardiac disease, cystic fibrosis, neuromuscular disorders, increased work of breathing, malabsorption

• Restricted oral intake: due to poor appetite, early satiety, vomiting/reflux, dysphagia, feeding fatigue

• Fluid restriction or volume intolerance: situations where standard nutritional intake is difficult

• As a transitional strategy (e.g., tube weaning) or supplement to oral intake rather than sole nutrition source.

The evidence shows that ONS can lead to improved growth, improved nutrient intake and better outcomes when used appropriately. A recent systematic review in children at risk of faltering growth found that ONS use was associated with greater gains in weight (mean difference ~0.4 kg) and height (~0.3 cm) compared to controls.[3] In one randomised controlled paediatric trial (n=51 children aged ~5.8 yrs) comparing a high–energy–density/low-volume ONS (2.4 kcal/mL) vs a standard 1.5 kcal/mL ONS, the high‐density product achieved significantly higher total energy and protein intake, and significant increases in weight and height z-score.[4] Thus, the evidence supports ONS as a valid tool in the dietitian’s toolbox.

There is a wide variety of ONS available. As dietitians working in particular settings, we may be limited for choice by local guidelines, but the varieties of types and flavours of supplement are expanding.  The supplement you choose for the patient will depend on their age and how it is to be used. Some supplements may be mixed with food and a more neutral flavour preferred, while some can be taken as a drink, yoghurt, jelly or taken from the bottle as a milkshake.  It is important to consider taste fatigue for these patients as a high number often find the ongoing reliance on supplements difficult and prefer to change flavours to help improve compliance.  Some children will struggle with certain textures, and due to the large number of supplements on the market, you can nearly always find a suitable type for each patient.[2] 

When discussing the introduction of supplements to a child or young person’s diet you should explore with them what their preferred tastes are prior to your recommendation. A child who dislikes drinking milk is unlikely to accept a milk-based supplement.  Some children can tolerate juce-based supplements diluted down with water.  While the yoghurt supplements can be useful, they have on average 150kcal per pot and some shop-bought products can have similar calories but not have the micronutrient supplementation.  The child’s preferred flavours should be discussed along with reward schemes or charts that parents can use to try and encourage compliance.  Some children will accept the drinks better from school rather than at home.  Timing of supplements should be advised. The supplements can cause satiety and therefore mealtimes should be avoided if possible. Ideal timing if the child is to take one supplement daily would be after evening meal as a bedtime snack to have minimal impact on appetite. 

From the table below, you can see that supplements vary in concentration from 1kcal/ml to 2.4kcal/ml. Some children may struggle with supplementation in terms of tolerance and adverse GI side effects, such a vomiting or loose stools.  If this happens, then the supplement prescribed should be reviewed to determine if an alternative is suitable.  Once established on supplements, growth should be reviewed regularly to ensure the supplements are increasing calorie intake and improving growth. Regular reviews should occur to support tolerance and praise the young person and their parent/carer.  Reviews should also focus on compliance and any problems with taste fatigue. 

Supplements are usually better tolerated cold from the fridge, although some children like to warm the chocolate flavour for a ‘hot chocolate style drink’.  Many young people prefer to take the drinks through a straw as they feel this helps improve palatability.  Some young people will respond to stickers to mark off their supplements, which can be useful in the early days to help establish a routine.  The paediatric dietitian should work with the child and wider family to work out a bespoke plan for the young person that will help improve compliance. 

As per the ESPGHAN guidelines, as paediatric dietitians we should be recommending food first for fortification of the diet and promoting weight gain in children who are unable to gain weight adequately without support.[1]  When food fortification has been trialled and the young person is unable to gain adequate weight, we progress on to oral nutritional supplements.  It is important that dietitians don’t promote ONS as a meal replacement and as above, timing of supplement is key to ensure the young person doesn’t decrease the intake of solid food and replace with supplementation. 

Paediatric dietitians want to ensure that we manage the expectations of parents around the use of supplements for children. Some parents will be accepting of supplements and happy to use them, and others will be anxious around the supplements replacing food and will require more support and discussion to accept supplements as part of their child’s meal plan.  Supplements are a key tool for paediatric dietitians to enable weight gain for children and young people who are struggling; however, it is important we ensure they are used positively and after all solid food and food fortification have been trialled.

ONS should not be a permanent solution for the majority of children and young people.  It is important when commencing ONS that as paediatric dietitians we have an exit strategy to try and discontinue supplements and return to oral food.  For some patients, they will discontinue supplements once they have recovered from an illness or post op, for others they will be needed for longer with no fixed endpoint. 

Paediatric patients who are taking ONS should remain under dietetic follow-up for review of progress, tolerance, weight and growth to ensure that the supplements are being prescribed correctly.[2] How often patients are reviewed will depend on their clinical need as well as family needs. Sometimes patients can be weighed at school and telephone reviews can be carried out to decrease the need for families to travel to appointments. 

Paediatric dietitians should keep GPs and other MDT members up to date with prescribing needs for each individual patient. This ensures that all parties know what needs prescribed and that the patient gets what they need with preferred flavours stated.  Exit goals can be variable; it may be as simple as an operation date for which enhanced nutrition support has been requested or it may be an improved weight.  When stopping supplements, some weight loss may occur, and it is important that families are supported to wean supplements and are aware of the challenges associated with this.

1. Braegger, C., Decsi, T., Dias, J. A., Hartman, C., Kolacek, S., Koletzko, B., Koletzko, S., Mihatsch, W., Moreno, L., Puntis, J., Shamir, R., Szajewska, H., Turck, D. & van Goudoever, J. (2010) ‘Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN Committee on Nutrition’, Journal of Pediatric Gastroenterology and Nutrition, 51(1), pp. 110–122.

2. National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children (NG75). London: NICE. Available at: https://www.nice.org.uk/guidance/ng75 (Accessed: 21 November 2025).

3. Zhang Z, Li F, Hannon BA, Hustead DS, Aw MM, Liu Z, Chuah KA, Low YL, Huynh DTT. Effect of Oral Nutritional Supplementation on Growth in Children with Undernutrition: A Systematic Review and Meta-Analysis. Nutrients. 2021 Aug 30;13(9):3036. doi: 10.3390/nu13093036. PMID: 34578914; PMCID: PMC8468927.

4. Hubbard GP, Fry C, Sorensen K, Casewell C, Collins L, Cunjamalay A, Simpson M, Wall A, Van Wyk E, Ward M, Hallowes S, Duggan H, Robison J, Gane H, Pope L, Clark J, Stratton RJ. Energy-dense, low-volume paediatric oral nutritional supplements improve total nutrient intake and increase growth in paediatric patients requiring nutritional support: results of a randomised controlled pilot trial. Eur J Pediatr. 2020 Sep;179(9):1421-1430. doi: 10.1007/s00431-020-03620-9. Epub 2020 Mar 13. PMID: 32170451; PMCID: PMC7413916.