Why is food safety important?
After a peripheral blood stem cell transplant (PBSC) the number of white blood cells in your body is dramatically reduced. This is called neutropenia. White blood cells normally help to fight organisms that cause infection, including food related infections. Being neutropenic puts you at greater risk of infection from bacteria or fungus in foods. You are at an even greater risk of picking up any type of infection during a stem cell transplant and for a short period of time afterwards, whilst your immune system rebuilds itself, than when you have previously been neutropenic through treatment. Hence, further dietary restrictions are needed. These guidelines will help you and your family reduce the risk of infection by outlining foods to avoid.
When should a grade 2 neutropenic food safety diet be followed?
These guidelines should be started when you start your transplant and continued whilst your blood neutrophil count is less than 0.5 x 109/L.
How long should this diet be followed?
Until three months after your transplant. Once you are no longer neutropenic, you can be less cautious about eating the foods mentioned in this leaflet but please monitor the neutrophil count carefully. If you are at risk of being neutropenic, follow the food safety diet in this leaflet. In addition, whether neutropenic or not, it is important to continue to practice good food safety for a further three months after transplant.
Food service on the ward
To help avoid food-related infections:
We do not encourage you to bring in homemade, takeaway or frozen food from outside the ward If you wish to give your child foods brought in from outside the ward, they must be on the allowed food list and a food disclaimer form needs to be completed. Please ask a member of ward staff for this.
If wishing to store brought in food, it must be correctly labelled and stored. Please ask a member of ward staff for instructions.
Visitors may bring in snacks from the ‘allowed list’ (see below) or tinned food No parents, visitors, patients or children should enter the ward kitchen Parents and visitors are welcome to go into the parent’s room to make drinks. No hot drinks must be taken out of the parent’s room. Covered mugs are available to purchase on the ward if you wish to take hot drinks into your child’s room.
Food safety
One of the easiest ways to avoid food related infections is to practice good food safety. Good food safety and hygiene is important for the entire family. Food must be stored, handled and cooked properly to avoid food poisoning. Here are some important points to remember when preparing food:
Wash hands thoroughly in hot soapy water before and after handling food Keep your kitchen clean. Wash all work surfaces, chopping boards and utensils in hot soapy water after use.
Prepare and store raw and cooked food separately. Keep uncooked meat and fish at the bottom of the fridge in a covered container to avoid dripping or leaking into the fridge Check the fridge and freezer temperatures - fridge temperatures should be 5˚C or lower (check this regularly) and freezer temperatures should be set below minus 18˚C. Check use by dates. Avoid buying foods at or near the ‘use by’ date and do not eat food after this date.
Cook food well. Always follow the cooking instructions carefully. Avoid the use of microwaves for cooking foods; but they can be used for defrosting when followed by conventional cooking methods.
Take chilled and frozen food home quickly and put it in the fridge or freezer immediately Food can be reheated as long as it is piping hot throughout and consumed within 24 hours of cooking or defrosting. The only exception is reheating cooked rice. Rice which has been previously cooked must not be reheated. Only eat rice immediately after cooking whilst still hot
- Keep canned food clean by washing the outside of cans and the can opener with hot soapy water before using (this includes cleaning the top of canned fizzy drinks before drinking straight from the can)
- Avoid damaged foods and buying foods in damaged containers and do not eat mouldy foods
- Keep cold food cold and hot food hot
- If in doubt - throw it out
Other points to remember
Buy small sizes of condiments, preservatives, sauces, margarine, etc. Once opened keep in the fridge and use within seven days. Use clean cutlery every time you use these products.
Avoid salad bars, buffets and condiments from large containers especially when eating out Avoid refreezing thawed foods Avoid eating leftover food from another meal.
- Wash and peel fruit, vegetables and salads thoroughly
When eating out
Choose freshly prepared foods from reputable outlets. Make sure food is piping hot when served and cooked all the way through. If eating out, choose take-away or restaurant food that is cooked after being ordered rather than food that has been kept in a heated cabinet or on a hot plate. Avoid salad bars, street vendors, market stalls and ice cream vans.
The National Food Hygiene Rating Scheme is a useful tool to be able to check Take away, catering and restaurant outlet standards.
Useful wed links: To search for a food outlets hygiene rating.
For further information on the rating scheme.
When neutropenic only choose to eat from outlets with a high food hygiene rating of 4 or 5.
Nutritional supplement drinks
If you are advised by your Dietitian to take nutritional supplements, these can be stored unopened at room temperature. Once opened these drinks should be stored as followed:
- Unrefrigerated in your child’s room up to 4 hours
- And when at home, refrigerated for up to 24hrs
‘High risk’ foods
The following table shows foods that often contain organisms that can cause food related infections and should be avoided if you become neutropenic grade / stage 1 with a neutrophil count below 1 x 109/l alongside alternatives that are safe to eat. When you are severely neutropenic, with a neutrophil count less than 0.5x109/l, there are additional foods you must avoid, which are highlighted in bold.
| Avoid | Alternatives |
|---|---|
|
Avoid
All unpasteurised dairy products eg milk sold on local farms Ice cream from ice cream vans |
Alternatives
Any pasteurised milk/ milk products, soya milk, Jersey milk or UHT milk Ice cream from reputable sources, individual portions, wrapped or in small pots |
|
Avoid
Soft cheeses made with unpasteurised milk e.g. Brie, Camembert, goat’s cheese, feta, parmesan and ripened/blue veined cheeses like Stilton, Danish blue and any salad dressings containing such cheeses |
Alternatives
Cheeses made with pasteurised milk and processed cheese like Dairylea, Kraft, and Philadelphia. Pasteurised parmesan and mozzarella. Paneer made with pasteurised milk. Vacuum-packed, pasteurised and hard cheese e.g. cheddar, edam |
|
Avoid
Raw and lightly cooked shellfish, cold seafood (prawns, mussels, crab) |
Alternatives
Hot well-cooked shellfish such as prawn curry |
|
Avoid
Raw/under cooked meat, poultry, fish like meat which is still pink such as sushi, caviar and oysters Cured/smoked meats eg Parma ham, salami |
Alternatives
Well cooked meat, poultry, and fish. Vacuum packed cold meats and poultry such as turkey, ham and peperami sticks stored below 5ºC and eaten following manufacturer’s instructions. Tinned meat and fish Ready to eat smoked fish from a vacuum packet is allowed, if consumed immediately from a freshly opened new packet Crab sticks |
|
Avoid
Raw or undercooked eggs such as omelettes, boiled or scrambled eggs with a ‘runny’ yolk. Any dressing or products containing raw egg such as home/restaurant made mayonnaise, hollandaise/béarnaise sauce, Caesar salad dressing, ice-cream, mousse, egg-nog, home / restaurant made meringue |
Alternatives
Hard boiled eggs, shop bought mayonnaise and other products made with pasteurised egg |
|
Avoid
Probiotic or bio products such as probiotic containing supplements and drinks eg Actimel, Yakult, probiotic tablets/capsules |
Alternatives
Any product that does not describe itself as “bio or probiotic” this includes: Live, Plain, fruit or natural yogurts |
|
Avoid
All meat and veg pâtés, fish paste, fresh or cold deli meats and poultry from delicatessen counters |
Alternatives
Pasteurised paté and paste in tins or jars that do not need to be refrigerated until opened |
|
Avoid
Raw, unpeeled, and unwashed fruit or vegetables including salad items, stuffed vine leaves, fattoush and tabbouleh Damaged or over ripe fruits and vegetables Salads from salad bars or delicatessens Raw dried fruit i.e. raisins, coconut and products containing these, eg muesli, Bombay mix, confectionary Unpasteurised or freshly squeezed fruit or vegetable juice or smoothies |
Alternatives
*Good quality fruit, vegetables that are well washed, peeled or well cooked Canned and frozen fruit. Cooked frozen, fresh or canned vegetables and potatoes. UHT or long life fruit juices – in cartons or jars *NB Ensure fresh fruit and vegetables are washed and peeled before being brought into, or eaten whilst in, the isolation unit. Do not store raw fruit or vegetables in the isolation unit Cooked and processed dried fruits in products eg fruitcake, flapjacks, cereal bars, fruit scones Well-cooked dried pulses eg kidney beans, chickpeas and tinned pulses eg baked beans that are well cooked Pasteurised smoothies *Homemade smoothies made from washed and peeled fruit from the allowed list or tinned/frozen fruit and vegetables |
| Avoid Fresh nuts, nuts in shells |
Alternatives
Cooked nuts, nuts in cans, peanut butter, roasted nuts |
Miscellaneous
| Avoid | Alternative |
|---|---|
|
Avoid
Unpasteurised or farm fresh honey and honeycomb |
Alternative
Pasteurised or heat treated honey, ideally try to use individual sachets or portions |
|
Avoid
Large packets of food items from pick and mix, universal jars |
Alternative
Ideally packets should be individual portions for personal use only e.g. butter, sweets, pickles, small packets of food |
|
Avoid
Non – drinking water, bottled mineral or spring water, water from wells, coolers, domestic water filters and water fountains |
Alternative
NB do not drink tap water in the isolation unit, use cool boiled water or sterile water instead. At home drink: Freshly run tap or carbonated water |
|
Avoid
Ice when away from home e.g. in a restaurant and slush puppies |
Alternative Ice made from appropriate water sources |
|
Avoid
Deli counter foods e.g. cold pasta salads, olives, hummus, shawarma and baklava |
Alternative |
|
Avoid
Uncooked herbs and spices e.g. pepper/salt and herbs sprinkled on food after cooking |
Alternative
Cooked herbs and spices added to food during cooking |
Hepatitis E food infection
If your child is receiving irradiated blood products there is also an additional risk from hepatitis E food infection. The risk of catching hepatitis E from food is very small but please:
- Wash hands thoroughly after being to the toilet especially if using a toilet away from home
- Ensure any meat products, but especially pork, venison, rabbit, wild boar, offal and shell fish are cooked thoroughly until steaming throughout, the meat is no longer pink and the juices run clear
- Avoid unpasteurised milk
What happens when my child has finished treatment?
If your child has finished all of their chemotherapy treatment and their white cell count has fully recovered, it is safe to reintroduce the “high risk” foods.
If your child is now receiving maintenance chemotherapy (oral chemotherapy) for a condition such as leukaemia, this chemotherapy shouldn’t make them neutropenic; therefore it should be safe to reintroduce the ‘high risk’ foods. There are occasions when your child may still become neutropenic such as their maintenance chemotherapy dose is high or they are unwell. In these situations, it would be safer to avoid the ‘high risk’ foods as listed above.
Your Dietitian is…………………………………...
If you require any further information or wish to comment on this leaflet, please contact:
Department of Nutrition & Dietetics
Box 119, Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
Hills Road, Cambridge, CB2 0QQ
Telephone 01223 216655
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CB2 0QQ
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