PEDIATRICS HEMATOPOIETIC STEM CELL
TRANSPLANTATION
Haematology and Oncology Department
M.F. Hematopoietic Stem Cell Transplantation
Istituto G. Gaslini - Genova
To parents of children
who must undergo
bone marrow and/or stem cells
transplant
Dear Parents,
This booklet aims to inform you how to behave during the
hospitalization period
The objective is to ensure your child’s safety.
We are readily available for further information.
The nursing staff
INDEX
Rules for entering in the ward
The admission
Hygiene standards to be observed on the ward
Hospital room
Parental support
Rules for patients and visitors
A typical day in the ward
Visiting Rules
School service
The Psychologist
Religious Assistance
Cultural mediators
Theodora Foundation
Family’s accommodation
Useful phone number
Medical records office
Complaints office
Bar – Bank - ATM
Volunteering associations
Hygiene and oral care
General standards for nutritional care
Guidelines for Food safety
Hygienic Standards for the Selection, Preparation,
Handling and Cooking of Foods
page 05
page 07
page 07
page 09
page 10
page 11
page 13
page 15
page 15
page 16
page 16
page 17
page 17
page 18
page 19
page 20
page 20
page 21
page 22
page 27
page 31
page 43
page 48
RULES FOR ENTERING IN HSCT WARD :
A – RELATIVES
The ward has a local "filter" to allow the
parents’ access .
The parent in continuous support and the 2nd
parent (allowed to stay from 14 to 21) must
use the filter to :
• wear
the disposable gown uniform, cap and
overshoes
• remove rings, jewelry, artificial nails
• wash theirs hands thoroughly. (It should be
emphasized that a thorough cleaning is
essential for reducing microbial presence on
the skin)
• Store items that cannot be cleaned in a
plastic bag (see rules of conduct during
hospitalization)
It is strongly recommended not to allow the entry in the ward of relatives
who:
1.
are showing symptoms of possible infection in the respiratory tract
and gastrointestinal system,
2.
have recently had exposure to infectious diseases,
3.
present Herpetic lesions (Simplex or Herpes Zoster),
4.
have presented a rash in the days or weeks before,
5.
have been vaccinated with live virus recently.
B – JANITORIAL STAFF
The janitorial staff entering for a short period in the ward wear a disposable
coat and overshoes.
For long periods, it is worn the regular disposable uniform, just like the
medical/nursing staff.
HYGIENE RULES TO BE OBSERVED IN THE WARD
PERSONAL HYGIENE CARE
The most essential hygiene care to be
observed is frequent HAND WASHING,
which should be done in the following
situations:
 before entering the room
 after using the restroom;
 after coming into contact with organic material (urine,
feces, vomit) of their children (even if gloves were used)
 before and after meals or the administration of oral
therapy to children;
 after touching potentially contaminated items (newspapers, objects from
outside or collected from the floor, etc..);
 …When in doubt…ALWAYS!!
WARD HYGIENE - ROOMS
Rooms’ cleaning are performed several times a
day; during their execution, it is advisable to
removed from the surfaces any unnecessary
encumbrance.
Parents must make sure that in the room there
are only the bare essentials; games (only the
cleanable and disinfectable ones), books and
other personal objects that the child is wearing
or handling should always be kept clean and
stored in cabinets after use.
To prevent dust from accumulating, it is
important that the areas used by the patient are
free of objects that prevent cleaning, and that
these areas are also cleaned daily by a parent.
7
 It is forbidden to open the windows since it affects the proper functioning
of the Ward’s ventilation system, which ensures at least 12 complete air
changes with purified air per hour.
 Handle waste and used linen carefully. There are specific containers for the
disposal of various type of waste:
YELLOW BIOBOX diapers or biological material;
BLACK BAG food, waste, paper, etc.
WASTE
LINENS
8
WHITE BAG for laundry.
YOUR ROOM
The hospital room has a bathroom, sofa bed for parents, TV, play station,
stethoscope, thermometer. The ward is equipped with laptops that will be
delivered only to older patients upon request.
Every parent is asked to pay close attention
to the use of equipment that are common to
all our young patients. To prevent
accidental falls, please do not let children
use the remote control and all the medical
gear provided (thermometer, stethoscope,
etc.).
It‘s forbidden to affix stickers or write on walls, cabinets, beds, tables,
etc..
The sofa bed has to be recomposed by the parent each morning between 7.00
and 7.30 and covered with a clean sheet. I set up sheets for the bed should be
requested to auxiliary workers, stored in their own locker and changed every
day.
For hygienic reasons, it is important that the children sleep in their beds
since their beds are equipped with clean mattresses.
If the child is used to sleep (or to go to
sleep) with the parent, it should be the
parent to sleep in the child’s bed, and
not vice versa.
9
IMPORTANT: In case the family member in assistance presents symptoms of
cold/the flu (cough, "sore throat, stuffy nose, fever), diarrhea, rashes or any
other symptoms related to a pathological condition, it shall immediately notify
the nursing staff. It will be evaluated the possibility to remove the person
from the ward until the complete
subsiding of symptoms, or it will be
given the necessary info on how to
behave. In addition, family members
who alternate in for assistance, must
report any contagious disease or of
recent contacts with people with
infectious diseases in place (chicken
pox, etc.)
CHILD ASSISTANCE
Only one parent can stay in continual
assistance
to
the
child.
Any
alternation between the parents is
allowed to take place from 7:00 to
8:00. The presence of both parents is
allowed from 14:00 to 21:00.
10
BEHAVIORAL STANDARDS IN THE
HOSPITAL FOR PATIENTS AND VISITORS
 Be aware of keeping maximum personal
hygiene, washing your hands frequently with
liquid soap provided in the dispensers and
drying them thoroughly with paper towels,
especially before touching the baby, after
changing him, every time you re-enter in
the room after a time out of it, and after
eating ; make sure that the sink and around
the faucets remain dry.
NB: Parents are invited to shower and
change into the gown provided daily by the
staff. They should also get clogs or shoes
to be used ONLY WITHIN THE WARD
 For hygiene reasons it is forbidden to keep flowers or plants in the ward and to
introduce unsealed newspapers or magazines
 Keep the bedroom door always closed
 It is recommended that parents in assistance do not visit hospitalized children in
other rooms.
11
 Children will be asked to wear special masks if they were to leave the department
to perform external procedures and / or examinations.
 Keep in the room only the strictly necessary for your
stay in the ward. Try to maintain the highest hygiene and
order in the room. Change the sofa-bed sheets every
day. Every morning the auxiliary staff will provide you
sheets and a new gown. Please note that personal
property left unattended are still under your
responsibility
 cooperate with staff on cleaning tables, beds, wardrobe,
table, chairs.
 You can not use appliances besides those supplied by the
ward.
 In some situations (use of medical equipment), the use of
mobile phones will not be allowed.
 Diapers are provided by the hospital.
 In the kitchen there are a microwave oven and an electric stove. There is also a
fridge/freezer with plastic boxes for storage of personal food. The inpatient is
strictly forbidden to enter in this room.
An harmonious co-existence always depends on the goodwill of everyone: that’s
why you are asked to keep the common areas as clean and tidy as possible, and not
to waste the material provided.
Finally, it should be pointed out that all these rules are primarily intended to
minimize the risk of infection.
12
A TYPICAL DAY IN THE WARD
07.00: starts the cleaning of the rooms
and the ward by the janitorial staff
08.00: The social/health staff (OSS) in
cooperation with the nursing staff work
on rearranging the patient's room and
bed. Throughout the morning several
healthcare activities are performed:
medicine
administration
(oral,
intravenous, etc ...), blood samples …
The parent must help recomposing the sofa-bed and keeping the room in
order.
The parent is allowed to prepare breakfast for her child.
09.30: the doctor in charge in the
ward, accompanied by the nurse
carries out a visit to the patient’s
bed
On this occasion, the parents will be
updated regarding diagnosis and
therapy programs, as well as on the
clinical progress of their child. This
is the appropriate time for asking
questions, so make sure you have
notes with all the subjects you may
want to ask your doctor.
13
09.00/12.00: during the school year, there are nursery
school teachers in the ward (identified by the badge),
who coordinate recreational and educational
activities and play with the children; once a week
the Dream Doctor comes to visit the ward; every
day there are volunteers from the ABEO
association, and the Child’s Cancer and Leukemia
Fund (indentified by the badge).
11.30 (approximately): water is handed
over for lunch (dinner)
12.00 (approximately): lunch time
13.00: deliveries and nursing staff shift
change.
In the afternoon, the treatment and care
activities continue being performed by
the staff on duty .
14.00: second parent (second accompanying person) admittance
Ore 18.30: dinner time.
Ore 20.00: nursing staff shift change. Night shift work continues, and the
children… all to sleep!!!!!
14
VISITING RULES
It is strongly recommended to limit visits in
general, and not to request changes in visiting
time unless absolutely necessary. Phone calls
can be received by parents only after 21.00
and up to 22.30 by dialing 010 5636507. In
order to ensure that all patients equally use
this possibility, we may limit the number/time
of calls for each patient. The patient can
receive mail sent to the following address:
Dipartimento Ematologia Oncologia - UTCSE
Istituto G. Gaslini - Largo G. Gaslini 5 16148
GENOVA
SCHOOL SERVICE
The hospitalized children have the opportunity to attend kindergarten,
elementary or middle school. Everyday, Monday to Friday, kindergarten and
elementary teachers are present for several hours in the morning and afternoon,
while the middle school teacher will be with your kids upon the Department’s
recommendation. During the hospitalization, your children will be able to carry
out the school programs to which they belong, and also to tackle the exams
required by their school curriculum.
It‘s also possible to activate a
home-school service. For more
information, please do not
hesitate to ask the teachers in
the ward.
15
THE PSYCHOLOGIST
There is a counselling service in our
Department.
The psychologists are available to
support the family and the patient.
They work closely with the medical and
nursing staff, as well as with teachers
and educators in an ongoing basis.
RELIGIOUS ASSISTANCE
Our Institute is home to the St. Jerome’s parish entrusted to the Capuchin Friars of
the Curia’s Province of Genoa. The Capuchin priests provide religious assistance upon
the families and patients request, and can be contacted at the phone number
0105636247/249.
The Mass is celebrated in the chapel at the
following times: weekdays 16.30, holidays
11.00 and 16.00 hours, the S. Rosario 16.00.
During the winter, the eleven o’clock holiday
Mass is celebrated at the Lecture Hall
(pavilion 16).
The Institute assures, in consultation with the
respective religious authorities responsible for
territory, the assistance from other religious
cults that have an agreement with the Italian
State. Ministers of other religions, which do
not have agreements with the State may
have access to the Institute after having
requested permission to the Health Direction.
For any other information you can contact the Institute’s Public Relations
Office located at pavilion 16 or call the following phone number 0105636328
CULTURAL MEDIATORS
Our social workers have a list of several
cultural mediators (native speakers on
Arabic, Albanian, Romanian, Russian, etc. ...).
To use this service you must apply with the
head nurse who will contact the Bureau of
Socio-Medical Assistants.
THEODORA FOUNDATION
The Theodora Foundation ONLUS has been working at our
institute for several years with the objective to bring a smile
on our children’s face. The artists, professional actors, come
To the hospital once a week,
and - with jokes and pranks
– cheer up the patients and
whoever else is in the ward.
17
ACCOMMODATION FOR THE FAMILY
The families of hospitalized children may receive information on hotel
availability in the Gaslini ’s surrounding areas through the City of Genoa’s
Call Center (01020041) or by picking up the ATP brochure available at the
ABEO ’s office.
18
Useful phone numbers
Gaslini Institute ’s phone operator
01056361
Secretary –Medical offices
0105636405
0103777133
FAX
TRANSPLANTATION UNIT
0105636507
0105636508
DAY HOSPITAL
0105636682
0105636551
0105636421
FAX
HOMECARE
0105636665
A.B.E.O.
0103073659
CALL CENTER (hotel availability)
01020041
PUBLIC RELATIONS OFFICE
0105636328
RAILWAY
147888088
ALITALIA
147865641
TIRRENIA (Ferry-boat) 0102758041
RADIO TAXI
0105966
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MEDICAL RECORDS OFFICE
The Medical Records (Central Archives) office is located at Pavilion 16 - 3rd floor
(tel. 010 376 5636 fax. 010 3761017). A copy of the medical record can be
obtained only by the patient in person (if adult) or by his legal representative.
The interested parties may delegate
somebody else for picking up the
documentation. The applications, duly
signed by the right holders, may also be
sent by mail or fax. The timetable for
requests and pick ups is as follow:
Monday, Tuesday and Wednesday from
8.00 to 12.00 and from 14.00 to 15.00 and
Thursday and Friday from 8.00 am to
12.00 pm. The documentation may also be
sent by registered mail to the patient’s
address.
COMPLAINTS OFFICE
Adults and minor’s parents are entitled to submit
comments, complaints and claims. To do so you may:
Send a simple letter or deliver it directly to the
Institute’s Information and Communications Office
(UIC) at Pavilion 18, first floor (in front of the bar),
or the Information Point at the ground floor Pavilion
10;
Fill out the form available at the SC, UIC and the
Information Point;
Call (010 5636628-637) or send a fax to (010
3742023) UIC.
20
THE BAR
The Bar is located at the connecting hallway
between Pavilion 16 and Pavilion 17. The
opening hours are daily from 08.00 to 21.00
(Saturday and Sunday closing at 19.30),
from 11.00 to 11.15 and from 14.30 to 14.45
there is a pause to do the cleaning. At the
bar you can buy phone cards and bus tickets
(there are also vending machines at the
main
entrance
and
throughout
the
Institute).
Nearby the bar, on the wall in front of it, you will find a poster with the train
schedules leaving and arriving in Genoa.
In the institute, there is a magazine and newspaper booth every morning at
Pavilion 16 from 07.00 to 09.00. From 09.00 the service will be taken to all the
SC to ensure the possibility of purchasing such items for the parents that can not
be removed.
BANK - ATM
On the Institute’s main entrance (Largo Gaslini – sea side) is the Bank agency
CARIGE 138 with a 24-hour ATM
21
ASSOCIAZIONI
The associations’ purposes are many, and range from supporting research to the
dissemination of knowledge about cancer and blood diseases that are treated at
our Unit. The associations take their means from funds raised in connection with
promotions and work from people who donate their time. Everyone can contribute
financially or with a “time donation" to the associations’ activities.
L’A.B.E.O. (Associazione Bambino Emopatico Oncologico) the association is
made up of parents and volunteers, who are involved in supporting families of
children in care in this Department, always trying to meet up as much as possible
all their different needs. And with the scope of being as much effective as
possible, there is always an ABEO representative in the Office located to the
left after the department of Hematology-Oncology’s main entrance.
In the Department, there are
several other organizations involved
in supporting research and service,
with resources collected during
promotional fundraising events. For
more detailed information, please
contact the above mentioned office.
The references to the various
associations can be seen in the
following pages.
22
A.B.E.O. Liguria (Associazione Bambino Emopatico Oncologico)
Largo Gaslini 5 – Genova
Tel. 010/3073659 – Fax: 010/3742715
www.abeoliguria.it
e-mail: info@abeoliguria.it
c/c postale 39969282
c/c bancario n° 2222/80, ABI 6175.4 – CAB 01583.4 Ag 58 CARIGE/Gaslini
The A.B.E.O. Liguria Onlus is an association founded in Genoa in 1982 with the
scope of meeting the needs for assistance, moral and economic support for the
families of children hospitalized in the Department of Hematology and Oncology
Pediatric Institute G. Gaslini.
To reach this goal, it works:
 promoting, supporting and financing interventions aimed at improving care and
quality of life of hospitalized children within the Department of Hematology and
Oncology;
 helping families in their various problems through its volunteers, who are properly
prepared due to training and apprenticeships programs;
providing housing for families and children reported by our social workers and
assistants;
 preparing and/or funding assistance of professionals in psychological, educational,
and recreational matters;
 funding research, conferences, courses and seminars;
 donating to the Institute G. Gaslini scientific equipment, furniture and other
materials aimed at improving the hospital’ structural conditions;
 by providing families with an Association’s representative located in the Office to
the left of the hematology and oncology ward’s entrance.
The Association operates exclusively in the Italian region of Liguria.
23
A.D.M.O. Liguria (Associazione Donatori di Midollo Osseo)
Via Maddaloni, 1/8, Genova
Tel. 010/541784
www.admo.it
e-mail: admoliguria@admo.it
Postbank account n° 18131169 (playable to ADMO Liguria)
Bank account n° 13388/80, ABI 6175 – CAB 01407 Ag. CARIGE n° 7 Genoa
Its main goal is to increase the number of Bone Marrow donors, in order to
increase the possibilities for those who do not have a compatible family donor. It
supports typing laboratories the National Donors’ Registry and the
transplantation centers. Performs work of informing the population and
stimulation on the National and Regional Health Authorities.
ASSOCIAZIONE NB (Associazione Italiana per la Lotta al Neuroblastoma)
Largo Gaslini 5 – Genova Tel. 010/6018938 – Fax: 010/6018961
www.neuroblastoma.org
e-mail: neuroblastoma@neuroblastoma.org
Postbank account n ° 609164 (payable to Associazione NB)
Bank account n° 4413/80, ABI 06175 – CAB 01583 Ag 58 CARIGE/Gaslini
It was created by the will of a group of parents and doctors with the primary
objective to promote scientific research on neuroblastoma treatment, which is a
malignant tumor in childhood hardly curable with currently available therapies,
knowing that this will could bring more care effectiveness not only for children
with neuroblastoma, but for all cancer patients.
FONDO TUMORI E LEUCEMIE DEL BAMBINO
Via Maddaloni, 1/8, Genova
Tel. 010. 591232
c/c postale 26873166
Bank account n° 2831/80 ABI 6175 – CAB 01401 Ag 1 CARIGE, Genoa
Bank account n° 2172/80 ABI 6175 – CAB 01583 Ag 138 CARIGE, Genoa
It supports research programs and scientific update, clinical care and special care
needs within the Department of Hematology and Oncology.
A.R.L.A.F.E.–ONLUS
Associazione Regionale Ligure Affiliata alla Federazione Emofilici
V.le Centurione Bracelli 142r
16142 GENOVA Fax 010/868541
www.arlafeliguria.it
e.mail: info@arlafeliguria.it
Postbank account n° 20016168 int. A.R.L.A.F.E.
Bank account n° 9145/80 ABI 06175 - CAB 01403 Ag 3 CARIGE, Genova
It is a volunteering association for the scientific study and publicization, social
education, rehabilitation, medical and social problem-solving for hemophilia and
other congenital bleeding disorders.
MAKE & WISH (M.AW.F)-ONLUS
P.zza S .Matteo15/1, Genova
Tel .010/8681370 Cell.334 3446288
www.makeawish.it
e-mail: info@makeawish.it
Bank account n° 940876 ABI 03332 – CAB 01400 – CIN “G” Passadore Bank,
Genoa
The association was established with the scope of fulfilling the wishes of children
aged between 3 and 17 years with serious illnesses.
It devotes all its efforts to the realization of a desire, no matter how
complicated it is, because the goal is to bring joy to the children and their
families .
HYGIENE AND ORAL
CARE
MUCOSITE E IGIENE DEL CAVO ORALE
Oral mucositis is an inflammation that goes from a local reddening to severe
ulceration.
The CURE PROTOCOL provides different levels of oral care
1.
2.
3.
Rinsing with Chlorhexidine 0,
2% at least 4 times daily
especially after meals.
Use of toothbrush if, allowed.
Plenty of rinsing with saline
solution
Benzydamine (Tantum) 50%
Benzydamine (Tantum) 50%
Gel Clair
It is recommended the use of lip balms.
Once the mucositis abates, patients should return to normal oral care.
29
GENERAL RULES FOR
NUTRITIONAL
SUPPORT
Dip. Ematologia-Oncologia Pediatrica
SS Trapianto di Midollo
Direzione Sanitaria
Servizio di Dietologia
Feeding of patients undergoing high-dose therapy and hematopoietic stem
cell transplantation (HSCT)
General rules for nutricional support
During high-dose chemotherapy and total body irradiation, and in the treatments'
immediate aftermath, the patient may suffers from nausea, vomiting and other
digestive disorders, and can completely lose the appetite.
However, it is important to take small meals, respecting the list of foods allowed
and strong hygienic food standards. All this to maintain a good nutritional status,
and simultaneously to ensure that the food does not become an infection’s vehicle.
Thereafter, it may take over a period in which mucosal inflammations (mucositis) of the mouth and other parts of the digestive tract – will appear. During this
period, the patient will not be able to take enough food by mouth (orally) and will
be fed via the central venous catheter (TPN) until the patient is able to ingest the
amount of food that meets its needs.
The phase of weaning from parenteral nutrition will be gradual and, in parallel, oral
feeding will be reintroduced. This will be a very important phase for both the
state of nutrition, and the patient’s overall health.
The oral re-feeding, or transition feeding, will be made with properly-prepared
regular food, and special dietary products. All this to make the transition best
suited to the patient’s clinical condition and to facilitate a faster improvement on
his general condition.
Patients who will undergo an allogenic transplant, may have more severe
gastrointestinal problems and, consequently, total parenteral nutrition will take
longer and the subsequent period of re-feeding will be more complex.
Parents cooperation in this aspect is very important because it is essential that
you adhere strictly to the allowed food, as well as to the methods of preparation
and cooking, and also that you adopt the recommended strict hygiene standards.
33
During the hospital stay, the daily meals will be provided by the Institute’s dietary
kitchen. With a special menu made available to patients, we will try, as much as
possible to meet all the patient’s needs and requests.
For any problem concerning the patient’s feeding, both in the pre, or posttransplantation period, you may contact the doctors or competent staff (ward
nurses and nutritionists). The same applies after the child’s discharge or during
scheduled follow-up visits.
Your nutritionists are:
Tel0105636 517 (10.30 a.m.-1230p.m. Mon-Fri)
34
Dip. Ematologia-Oncologia Pediatrica
SS Trapianto di Midollo
Direzione Sanitaria
Servizio di Dietologia
Feeding of patients undergoing high-dose therapy and hematopoietic stem
cell transplantation (HSCT)
1. Feeding Transition (semi-liquid diet) Post Parenteral Nutrition
Food reintroduction after a long period of fasting can be difficult and must comply
with a proper choice of foods and adequate timing in its deployment.
The patient often has no appetite and may refuse to eat. In addition, there may
be nausea and other digestive disorders which may lead to an even more decisive
eating refusal.
The re-feeding diet is designed to encourage a gradual recovery of the
gastrointestinal tract functions, and allow proper digestion and absorption of food
and its nutrients. Along with these indications, two manuals will be provided:
Guidelines for Food Safety
Hygienic standards for food selection, preparation, handling and cooking.
Both must be strictly followed for as long as needed.
The principles on which the re-feeding diet is based are:
no lactose: milk, and many of its products, contain a type of sugar – lactose –
which is difficult to digest after a long period of fasting
Low fat: fats are difficult to digest and may increase diarrhe
low fiber: some types of vegetable fiber may increase diarrhea and flatulence
no irritating food (acidic or spicy): more acidic foods (tomato sauce, spicy foods
or with vinegar, lemon juice, other citrus fruits, many other fruits, etc..) can be
irritating to mucous membranes - mouth and digestive tract in general
35
The diet consists in various stages of variable duration each.
 Patients undergoing autologous HSCT will, in most cases, have a faster
progression on their diet, and must follow the Guidelines for Food Safety and
hygiene requirements for information contained in the Food Selection,
Preparation, Handling and Cooking until the clinical condition advises
 The duration of transition diet in patients undergoing allogeneic HSCT, if they
develop gastro-intestinal GvHD, will generally take longer (time and
recommendations of all the phases outlined below must be strictly respected,) and
the information contained in the Guidelines for Food Safety and hygiene
requirements for the Food Selection, Preparation, Handling and Cooking will be
protracted until the clinical condition advises.
The diet during the post-transplant period is different from what is normally
recommended in the healthy population. Above all, the transition diet in the first
weeks post transplantation is deficient in several micronutrients (minerals,
vitamins, trace elements). Therefore, we will also prescribe nutritional
supplements and / or vitamin-mineral supplements to help cover all the patient’s
nutritional needs.
For children under 2 years of age, it will be prepared a special diet with special
attention to the weaning period, and the immediately following months.
You should always remember that as each person is different from the other, and
so are the patients themselves. A food that is good for one patient may not be
appreciated nor recommended for another. Therefore, it is necessary for the
patient and parents to patiently collaborate in this aspect of the care, since the
resumption of a balanced and proper diet is of the utmost importance.
36
First step
In the days immediately preceding the beginning of the transition diet(24-72
hours), it would be appropriate for the patient to ingest small quantities (initially
to 50 ml) every 3-4 hours of a liquid isotonic diet, low-fat, and with no residue
It is available for the patient : saccharinate or slightly sweet decaffeinated tea;
Polilat®, Similac RA®, Osmolite® hydrolyzed milk, or rice milk
Please note: The re-feeding timing is generally related to the duration of the
TPN and the patient's clinical condition (no gastrointestinal issues, early
resumption of appetite and food demand). In practice:
 TPN with duration of 0 to 10 days, the patient goes quickly (48-72 hours) to a
"normal" diet (fourth stage)
 TPN with duration> 10 days but <30 days: the first phase will last at least 24
hours and the progression is expected to be fast
 TPN with duration> 30: The first phase lasts over 24 hours and up to 72 hours
and progression time should be strictly respected
Second step (at least for 48 hours)
Start of solid foods intake. The patient's diet still has a semi-liquid consistency.
It is recommended taking small, frequent meals (every 3-4 hours) to allow for
easier digestion.
It is necessary to introduce a new food at a time (6-12 hours each) to assess
levels of tolerance, and if gastrointestinal issues appear or increase.
It is recommended to introduce new foods at breakfast, at mid-morning snack
and lunch (but no later than 02:00 p.m.)
In this and subsequent stages, the introduction of each food and the meal serving
will always be gradual.
37
It is availabe for the patient:
Drinks : lightly sweetened decaffeinated tea, rice milk, clear diluted apple juice.
Rice cream, corn cream, and tapioca cream prepared in lean meat broth and/or
clear vegetable broth, rice prepared in meat broth and / or clear vegetable broth,
rusks and/or type00 wheat breadsticks; puffed rice prepared with rice milk,
boiled potatoes (1)
Condiments: MCT olive oil(2-3 tsp / day), grated Parmesan cheese(2 teaspoons /
day)
Third step (at least for 48-72 hours)
If tolerated, begin to introduce one of these foods (1 every 8-12 hours)
 Semolina in meat or clear vegetable broth
 Pastina or pasta of durum wheat flour prepared in meat broth and / or clear
vegetable broth
 Biscuits for children
 Well-cooked, boiled, skinless chicken and turkey
 Homogenized beef, veal, chicken, turkey
boiled carrots and homogenized vegetables (small amounts)

 Homogenized fruit (apple or pear or banana)
 soy cream, fruit jelly
 banana (1/2) or apple (1/2) - mashed
 Fruit juices(if tolerated and preferably clear) of pineapple, orange, mixed fruit
type ace
 Jam and honey(single portion)
 Milk type ZYMIL
 Coca Cola or Gatorade diluted in water (50%)
 Packaged ice pop
38
Forth step
If tolerated, begin to introduce one of these foods (1 every 8-12 hours)
 Well-cooked lean meat of any kind, fibrous free, boiled, grilled or roasted
 Well-cooked lean fish of any kind, boiled or baked. Fresh salmon allowed. To be
evaluated the packed smoked salmon single-portion
 Lean cooked ham
 Hard-boiled eggs or scramble eggs without any fat/oil (anti-adherent pan)
 Parmesan cheese
 small portion (2-3 tablespoons / day) of vegetable soup (without legumes) to be
added to beef broth or vegetable broth
 Butter (single portion) - max 1-2/day)
to include later (at least 4-5 days after the beginning of fourth step) and
gradually:
 Non-stuffed egg pasta; fresh pasta : gnocchi or trofiette(gnocchi similar)
toast bread slices, breadsticks.
 pizza, initially without mozzarella and anchovies, with little oregano, well cooked
 corn flakes and other low fiber breakfast cereals

 Dry biscuit type Plasmon, “biscotto della salute” or “Lagaccio”, biscuit type Maria
(Oro Saiwa or similar), “anicini”, Pavesini
 Sweet or salty snack (single portion) - non spicy, not too salty, no creams or
fillings
 cooked or compote fruit, single portion
 Skinless and seedless tomato sauce (if tolerated); well-cooked non-fibrous
vegetables, boiled or on vapor (previously mashed) asparagus, beets, extra fine
green beans, pumpkin, zucchini, lettuce, mashed potatoes
 extra-virgin olive oil (initially 50% OEO / 50% MCT)
39




Hard cheese type Emmental (single portion)
Sliced cheese (Tigre o Kraft)
Cheese Philadelphia Light Kraft
Pasteurized ricotta (single portion)
 mozzarella (single portion)
 mayonnaise e ketchup (single portion) - max g 5-10/day if tolerated
 Skim milk (in small quantities, 30-40 mL = 2-3 tb spoon/day)
 dessert (single portion) or yogurt
Even at this stage, as well as in previous ones, the re-introduction of each food
item (maximum re-introduce 1-2 new foods per day) will be agreed with the
nutritionist.
Gradually, more varieties of fruit, vegetables and other foods will be introduced,
and more suitable methods of preparation and cooking for a reliable feeding
normalization will be suggested.
Throughout the period of admission and right after the discharge, in addition to
the regular food intake, it could be recommended the ingestion of specific
dietary products.
It is very important to continue having extreme caution in preparing and handling
food (Guidelines for food safety and hygiene requirements for the food
selection, preparation, handling and cooking).
40
2. Forbidden Foods
Full freedom - regarding what to eat - takes time and varies from each
patient. The consumption of those foods listed below should be considered
strictly forbidden until the Transplantation Unit’s medical staff says
otherwise:
Unpasteurized milk and dairy products
Soft fermented cheese
Yogurt
Raw fish and meat
Fat meat or fish
Ground beef, hamburger
Molluscs
Cold cuts of any sort (except lean cooked ham)
Raw or undercooked eggs
Cereals and whole-grain baked goods
Focaccia
Acid fruits or with small seeds (* citrus, strawberries, figs, kiwi)
Fibrous vegetables (artichokes, cabbage and alike, fennel, non-mashed legumes)
and not explicitly allowed
Mushrooms and truffles
Tap water and non-bottled beverages
Unpasteurized mayonnaise and foods that contain it (e.g., potato salad,
sandwiches, etc)
Non pasteurized and non single-portioned creams and sauces
Non processed stuffed cakes, whipped cream or ice cream
Pre-made food and pastry
Pre-made take away food and all that does not appear in the list of allowed foods
* if tolerated, it may be gradually introduced sweet pasteurized diluted orange
juice
41
Examples of appropriate cooking methods:
Meat (well-cooked): grilled, roasted, with fat-free broth, boiled, steamed
Fish (wEll-CookED): grilled, roasted, with fat-free broth, boiled, steamed,
baked, in the microwave oven
Eggs(well-cooked): hard-boiled, scrambled without added fat, baked omelet with
a special parchment paper, as an ingredient in vegetable pie
Vegetables (well washed, wellcooked): boiled, steamed,
stewed, with microwave
All cooking must be understood
as without added fat
Further variations of the
cooking methods are to be
agreed with the dietician
42
Dip. Ematologia-Oncologia Pediatrica
SS Trapianto di Midollo
Direzione Sanitaria
Servizio di Dietologia
Feeding of patients undergoing high-dose therapy and hematopoietic stem
cells transplantation
(HSCT)
Guidelines for Food Safety
Food-borne diseases occur with significant frequency in the world’s population. A
food-borne disease is an illness caused by food contaminated by bacteria, mold or,
less frequently, by virus.
Causes and sources of such diseases, also called food poisoning, may be while
handling the food, the environment (i.e. the place where food is prepared or
preserved) or the food itself.
Bacteria and other microorganisms are commonly found in many common foods.
The regular population in good health is at much less risk of contracting infections
such as people undergoing chemotherapy and / or total body irradiation, who are at
increased risk.
If patients and their caregivers follow precise rules and hygienic dietary
guidelines for the selection, preparation, handling and cooking of foods, the risk of
contracting a disease spread by food is reduced.
And this is the reason that we recommend you to stick strictly to what is stated in
the following pages and read the other attachments that will be handed out.
In case of any questions, please do not hesitate in asking our nurses and dieticians
for more information
1. Hygienic standards for food preparation, handling and cooking
Dairy Products
Milk (UHT pasteurized or sterilized), to be consumed only - if tolerated immediately after preparation. Once the package is open, it can be stored in a
refrigerator at 0-4 ° C for 24 hours.
The same goes for butter, cheese, cream cheese (single portion or not)
43
Meat and other protein sources
All these foods should be well cooked, especially poultry. It should not be served
ground beef or hamburger. Well stewed meatballs are allowed
Cooked meat should be stored in the refrigerator for no longer than 12 hours
Ham must be packed in single portions
Eggs must be washed with antiseptic solution * (boiled for 10 minutes or wellcooked scrambled egg, or in well done omelettes). Discard eggs showing veins,
cracks or breaks. After washing, keep eggs in a special container in the fridge,
separated from other foods
* Wash thoroughly in running water, and for a final decontamination soak food for
a few minutes in an aqueous solution of Amuchina® or Milton® (1,5-2%) or other
suitable disinfectant for food. Cook or peel
Do not serve molluscs of any kind
Do not consume cured meats and sausages (except cooked ham)
Bread, pasta, cereals and other Baked Goods
The pasta dishes are prepared, cooked and served right away. Prepare and use
sauces and condiments only for daily use. Packaged and pasteurized sauces available
in the market can be used, and stored tightly closed in the refrigerator for up to 24
hours.
Do not store any baked pasta for over 6 hours.
Cakes, pies, cookies and other snacks must be packaged in single portions, and need
to be consumed within the day, once the packaging is opened.
If possible, the breakfast cereal should be packaged in single portions
Fruits
Fruits must be cooked or washed thoroughly in running water, decontaminated with
antiseptic solution *, peeled and eaten immediately
* Wash thoroughly in running water, and for a final decontamination soak food for a
few minutes in an aqueous solution of Amuchina® or
Milton® (2%) or other suitable disinfectant for food. Cook or peel.
Fruit juices and nectars must be consumed once opened
Vegetables and legumes
Raw vegetables should not be consumed, except for tomatoes
Vegetables and legumes should be thoroughly washed in running water, well cooked
(steamed or stewed).
Tomatoes can be consumed raw, as long as they are well washed with antiseptic
solution *, dried with paper towels and peeled
Tomato sauce, prepared and used within 2 hours or kept in the refrigerator for up
to 24 hours
Condiments
Oils for dressings should be stored in a cool and dark place, and in a tightly closed
obscured bottle.
Butter (if used raw, preferably in single portion) should be stored covered in
refrigerator.
Pasteurized mayonnaise and ketchup (in small quantities and if tolerated) should be
used in single portion packet
Desserts and Beverages
Puddings should be prepared (also the pasteurized type available on market) and
consumed immediately.
Jams and honey (pasteurized), the icicles and ice cream, milk and cocoa-based
drinks must be the single portions ones and consumed once opened.
Soft drinks and other beverages must be consumed immediately after opened, or
closed, returned to the refrigerator and consumed within a few hours.
Clean thoroughly the top surface of soda cans before pouring the contents into a
glass
Dietary supplements given by doctors or dietitian may be, in powder to be
consumed freshly prepared, or in liquid to be consumed immediately after opening.
Packaging of powdered supplements should be stored tightly closed, in a cool and
dry place, and for no longer than three weeks
45
Remember:
To never use homemade canned food (jam, vegetables in oil or pickles)
To personally check the appearance, smell and taste of the food being served
To pay particular attention to the eventual presence of mold on the food being
prepared/served
To prefer the purchase of pasteurized processed foods (sauces, dessert)
available on market rather than the semi-fresh canned food, stored in the
refrigerator.
While shopping for groceries, to buy frozen products and fresh produce for last,
and place them in special insulated containers
To check the expiration date on the food packaging
To check the integrity of the food packaging
To control the overall aspects of the food being served
2. Personal hygiene procedures
Wash your hands thoroughly with liquid soap and warm running water for at least
15''. Rinse well under running water and dry with paper towels
Make sure the patients wash theirs hands thoroughly before every meal
After handling eggs, poultry and vegetables, wash your hands again before
performing any other cooking duties
3. Cleaning and Disinfection of Surfaces and Utensils
Always wash thoroughly and disinfect frequently cloths, sponges, etc...
Provide regular cleaning of the refrigerator to keep it in optimal hygienic
conditions, and periodically check the temperature (never exceeding 4 ° C)
46
Carefully clean anything that may come into contact with food (work surfaces,
kitchen utensils and containers)
The dish washing is preferably carried out with a dishwasher
Avoid cross contamination between cooked and raw foods:
- not using the same unwashed utensils
- Placing raw (especially eggs, poultry and vegetables) and cooked food in
different areas of the refrigerator and possibly in airtight containers
Poultry must be prepared and handled on a specially reserved cutting board or
surface
Always use a clean spoon for tasting
All food must be well-cooked. It is crucial that all parts of the food, especially
meat and vegetables, are brought to a temperature not lower than 70-75 ° C (8085°C for poultry). This is easier if you make small portions. Consume foods within
1-2 hours of cooking
When possible, it is advisable to use the pressure cooker
Grab the glasses from the base, cups from the handles, and plates from the
border, to prevent contamination
47
Dip. Ematologia-Oncologia Pediatrica
SS Trapianto di Midollo
Direzione Sanitaria
Servizio di Dietologia
Feeding of patients undergoing high-dose therapy and hematopoietic stem
cell transplantation (HSCT)
Hygienic standards for food selection, preparation,
handling and cooking
Food
group
Dairy
Products
Allowed
foods
 Pasteurized semi skimmed
milk
 UHT Milk
 Lactaid Milk (Zymil o
Accadi)
 Packaged ice-cream and
sorbet
 Packaged ice pop
 Cocoa milk beverages
 Pasteurized packaged
cheeses like mozzarella
and ricotta
 Sliced cheese
 Parmigiano Reggiano o
Grana Padano
 Hard cheese Emmental
type
 Pasteurized butter
48
Forbiden
foods
 Non-pasteurized milk
Fresh cheeses
 Flavoured and spicy
cheeses
 Fermented “blue” cheeses
(gorgonzola, Roquefort,
etc.)
 Cheeses such as taleggio
or camembert or brie
Yogurt
 Non-pasteurized butter
 All types of meat (poultry,
beef, pork, rabbit, lamb,
etc...), preferably lean
cuts, but especially well
done
 Lean cooked ham
Meat and other
Protein Sources
 All types of well cooked
fish
 Octopus, squid, cuttlefish,
etc.
 Tuna or other canned fish
 All meat and fish
undercooked
 Eggs not cooked properly
 Meat or fish stew
prepared or pickled, but
not cooked nor packed
 Shellfish of all kinds
 Salami sausages of all
kinds
 Smoked salmon and tuna
in vacuum packaging
 Hard-boiled eggs
 Well cooked omelette
with vegetables prepared
in the oven
 Brodo di carne sgrassato
Bread, pasta,
cereals and
other Baked
Goods
All types of flour 0 or 00
bread, crackers,
breadsticks, biscuits,
sliced toasts
Biscuits
Breakfast cereals
(refined grain only)
Wheat flour dough pasta
Non stuffed fresh Pasta
Rice
Polenta
Well done Pizza
 Bread and other whole
grain products
 Muesli or other breakfast
cereals with added nuts,
raisins, etc.
49
 Fresh fruit thoroughly
washed and peeled
 Canned fruit in syrup
 Pasteurized fruit juices
Fruits and
Juices
 Jam and fruit jelly single
portion
 Pasteurized packed fruit
single portion
 Fruit not washed properly
 Dried fruits
 Figs and kiwi
 Walnuts, almonds and
other seeds
 Coconut
 Fruit compote
 Dry fruit compote
 Vegetable broth
 Homogenized Vegetable
 Vegetable soups
Vegetables
 Boiled, steamed or stewed
vegetables
 Cooked tomato sauce
 Well washed and peeled
tomatoes
 Mashed vegetables, if
tolerated
 Cooked garlic and other
flavorings, if tolerated
 Raw vegetables
 Fibrous vegetables
(artichokes, fennel)
 Garlic, Cucumber, bellpepper
 Cabbage, broccoli, etc.
 Soybeans
Condiments
Beverages
 Extra virgin olive oil
 Seed oils
 Pasteurized butter single
portion
 Pasteurized Mayonnaise
preferably light, and
 ketchup single portion
 Sauces containing raw
eggs or fermented cheese
 Non-carbonated mineral
water
 Ice made (mineral water)
 Pasteurized juices
 Drinks available on the
market
 Cola-based drinks
(preferably without
caffeine) diluted with
mineral water
 Rehydration drinks like
Gatorade
 Tea or other infusions
made with boiled water
 Iced tea single portion
packages
 Pasteurized chocolate
milk, single portion
 Tap water
Non
pateurized
fruit
juices
 Beverages
and
pasteurized juices opened
for more than 24 hours
(even when refrigerated)
 Non pasteurized butter
 Vinegar
 Sauces and packed
condiments, opened for
more than 24 hours
51
Desserts
Other foods
 Processed snacks foods
like cookies, cakes
(without cream)
 Homemade pies or cakes
(without cream), pies, jam
tarts, tarts with stewed
fruit
 Processed ice cream,
sorbets and processed
packed icicles
 Single-portion puddings
 Processed packaged fruit
jellies
 Processed non mint hard
candy
 Dolci porzionati con creme
 Torte farcite con creme e
panna
 Artisanal non-processed
ice cream
 Non single-portioned
puddings
 Home-made candies
 Panna cotta
 Bavarian, frozen desserts
or sweets with raw eggs
(tiramisu, etc)
 Cream spread
 Non-spicy olives
(processed). Keep
refrigerated after
opening for up to 96
hours, or used to prepare
cooked sauces or pizza.
 Capers to prepare cooked
sauces or pizza
 Saffron for cooking
risotto, etc
 Pasteurized singleportioned honey
 Dietary products and
supplements in powder or
liquid
 Pre-made sandwiches and
other pre-made take-away
 Spices