Considerations for paediatric ONS from toddlers to teens

February 03, 2022 5 min read


Oral nutritional supplements (ONS) in paediatric patients are indicated if faltering growth continues despite other interventions (e.g., food fortification, positive mealtime behaviours) having been trialled. A systematic review of ONS intervention studies in children found that ONS resulted in a significant increase in energy intake and greater weight and height gain for undernourished children or those at risk of malnutrition when compared with dietary counselling alone. This article focuses on the considerations of ONS use across all paediatric age-groups.

ONS use in the early years

Nutritional considerations

Nutritional requirements significantly increase from one to four years old, reflecting the childs’ changing abilities both physically and cognitively. Healthy infants double their birth weight by five-months-old and triple it by the time they are one year old, however rates of weight gain decrease between one to four years of age. To meet micronutrient requirements, it is recommended that all children aged six months to five years are given a daily supplement containing vitamins A, C and D. An exception to this are babies who are consuming 500mls or more of infant formula daily.

Child considerations

In line with the child’s development, ONS should be offered in a cup or a beaker with a free-flow lid (without a non-spill valve). Using an open or free-flow cup helps to teach children how to sip and is better for their dental health. Bottles should be discouraged. To encourage ONS compliance, dietitians may wish to offer ONS in different flavours and formats, facilitate ONS taste test sessions and/or encourage modelling techniques whereby family play a role in the ONS experience (e.g., sitting together as a family whilst the child is consuming their ONS).

ONS use in the primary school years

Nutritional considerations

Children will now have an established meal and snack routine. Therefore, it’s important for nutritional intake to be regularly assessed to evaluate whether ONS prescriptions need changing to meet macronutrient and micronutrient intake.

Child considerations

It is important to consider the length of ONS use; make sure to review whether they are still indicated and if flavours or formats need adjusting to prevent taste fatigue. A child’s routine may be changing (e.g., they may be starting full-time education or attending after school clubs) therefore, ONS prescriptions may require adjusting to suit the child’s new routine.

Children may begin to verbalise an awareness of their hunger cues, which may be an appropriate time to initiate a change to high-energy, low-volume (HELV) ONS. At this stage, children should be involved in the decision-making process along with their clinician and family/carers.

ONS use in the older child

Nutritional considerations

Nutrition is one of the most important factors affecting pubertal development. Puberty triggers a growth spurt, which increases nutritional requirements for both macro- and micronutrients. Nutritional requirements significantly increase for energy, protein, iron, calcium, zinc and folate to support this critical period of rapid growth.Untreated malnutrition can delay the onset and progression of puberty.

Child considerations

A pragmatic approach towards ONS use is needed within this age group as there are many barriers to compliance (e.g., skipping meals or not wanting to appear different from peers). Older children may benefit from practical support including setting reminders on a phone/watch or using a flask/water bottle to ensure the ONS is discreet and cold when at school.

Age is no longer a primary consideration of ONS prescribing as adolescents are likely to have similar nutritional requirements to some adults. Opting for standard adult ONS may increase the variety of formats and flavours available. It’s likely that HELV ONS can be taken in lower volumes and can therefore be consumed less frequently than standard ONS. HELV ONS may help to increase compliance in older children as reducing the volume of ONS means it does not need to be taken as frequently, allowing them to be consumed outside of school hours. Some children may prefer these formats of nutritional supplement as they can be consumed in a similar way to medications. This can be a more time efficient method and have less of an impact on a child’s satiety.

Ways to get children involved

Parental modelling and use of rewards

Parental modelling (e.g., parents sitting with the child at the dinner table at mealtimes), telling stories which incorporate food, and the use of reward charts/stickers are great ways to engage with children who are prescribed ONS. There are websites like this where parents and children can design and print their own reward charts.

Include the child in menu planning

Involve the child in the meal planning process as much as possible. This could include flicking through recipe books together or discussing favourite family meals at the dinner table. Here are useful sample menus for children of all ages which contain the energy and nutrients they need – recipes can be useful to get children involved in cooking. A visual chart on the fridge can act as a visual reminder for children of when and how to have their ONS.

Let’s get cooking!

To add variety, parents could spend time with their child to devise recipes using their ONS each week. Older children may enjoy helping to cook these meals independently, whilst younger children may enjoy helping with age-appropriate roles (e.g., cutting up/stirring). Have a look at the recipes offered on our website for some inspiration.

Facilitate regular ONS tasting sessions

Facilitating regular ONS tasting sessions can be a useful way to prevent taste fatigue and allows children of all ages to play an active role in their medical care.

Have age-appropriate discussions with the child

Communicating with children at an age-appropriate level can strengthen motivation and compliance. Children may benefit from discussions around their motivations, and the role of ONS in helping them to achieve their goals. For example, you could explain to a younger child (5-12 years old) that ONS provides energy to go swimming. Whilst older children might benefit from a more detailed explanation of how ONS can help them to get physically stronger, which will help them when studying or working-out.