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.
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.
All unpasteurised dairy products eg milk
sold on local farms
Ice cream from ice cream vans
Any pasteurised milk/ milk products, soya
milk, Jersey milk or UHT milk
Ice cream from reputable sources,
individual portions, wrapped or in small
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
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
Raw and lightly cooked shellfish, cold
seafood (prawns, mussels, crab)
Hot well-cooked shellfish such as prawn
Raw/under cooked meat, poultry, fish like
meat which is still pink such as sushi, caviar
Cured/smoked meats eg Parma ham,
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
Ready to eat smoked fish from a vacuum
packet is allowed, if consumed
immediately from a freshly opened new
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
Hard boiled eggs, shop bought
mayonnaise and other products made with
Probiotic or bio products such as probiotic containing supplements and drinks eg
Actimel, Yakult, probiotic tablets/capsules
Any product that does not describe itself
as “bio or probiotic” this includes: Live,
Plain, fruit or natural yogurts
All meat and veg pâtés, fish paste, fresh or
cold deli meats and poultry from
Pasteurised paté and paste in tins or jars
that do not need to be refrigerated until
Raw, unpeeled, and unwashed fruit or
vegetables including salad items, stuffed
vine leaves, fattoush and tabbouleh
Damaged or over ripe fruits and
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
*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
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
Cooked and processed dried fruits in
products eg fruitcake, flapjacks, cereal bars,
Well-cooked dried pulses eg kidney beans,
chickpeas and tinned pulses eg baked
beans that are well cooked
*Homemade smoothies made from washed
and peeled fruit from the allowed list or
tinned/frozen fruit and vegetables
|Avoid Fresh nuts, nuts in shells||
Cooked nuts, nuts in cans, peanut butter,
Unpasteurised or farm fresh honey and
Pasteurised or heat treated honey, ideally
try to use individual sachets or portions
Large packets of food items from pick
and mix, universal jars
Ideally packets should be individual portions
for personal use only e.g. butter, sweets,
pickles, small packets of food
Non – drinking water, bottled mineral or
spring water, water from wells, coolers,
domestic water filters and water
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
Ice when away from home e.g. in a
restaurant and slush puppies
|Alternative Ice made from appropriate water sources|
Deli counter foods e.g. cold pasta
salads, olives, hummus, shawarma and
Uncooked herbs and spices e.g.
pepper/salt and herbs sprinkled on food
Cooked herbs and spices added to food
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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Cambridge University Hospitals
NHS Foundation Trust
Hills Road, Cambridge
Telephone +44 (0)1223 245151