Haematology and Oncology Department M.F. Hematopoietic Stem Cell Transplantation Istituto G. Gaslini - Genova

PEDIATRICS HEMATOPOIETIC STEM CELL TRANSPLANTATION

To parents of childrenwho 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 page 05The admission page 07Hygiene standards to be observed on the ward page 07Hospital room page 09Parental support page 10Rules for patients and visitors page 11A typical day in the ward page 13Visiting Rules page 15School service page 15The Psychologist page 16Religious Assistance page 16 Cultural mediators page 17Theodora Foundationpage 17Family’s accommodation page 18Useful phone numberpage 19 Medical records office page 20Complaints office page 20Bar – Bank - ATM page 21Volunteering associations page 22Hygiene and oral care page 27General standards for nutritional care page 31Guidelines for Food safety page 43Hygienic Standards for the Selection, Preparation,      Handling and Cooking of Foods page 48

RULES FOR ENTERING IN HSCT WARD :

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)

A – RELATIVES

EntryRules

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

The most essential hygiene care to be observed is frequent HAND WASHING, which should be done in the following situations: before entering the room

PERSONAL HYGIENE CARE

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!!

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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.

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:

LINENS

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YELLOW BIOBOX diapers or biological material;

BLACK BAG food, waste, paper, etc.

WHITE BAG for laundry.

WASTE

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.

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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.

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

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BEHAVIORAL STANDARDS IN THE HOSPITAL FOR PATIENTS AND

VISITORSBe 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

It is recommended that parents in assistance do not visit hospitalized children in other rooms.

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

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Children will be asked to wear special masks if they were to leave the department to perform external procedures and / or examinations.

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.

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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.

A TYPICAL DAY IN THE WARD

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 bedOn 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.

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07.00: starts the cleaning of the rooms and the ward by the janitorial staff

09.00/12.00: during the school year, there are nursery school teachers in the ward (identified by the badge),

11.30 (approximately): water is handed over for lunch (dinner)

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).

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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!!!!!

12.00 (approximately): lunch time

VISITING RULESIt 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 - UTCSEIstituto G. Gaslini - Largo G. Gaslini 5 16148 GENOVA

SCHOOL SERVICEThe 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.

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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.

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.

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.

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 MEDIATORSOur 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.

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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.

ACCOMMODATION FOR THE FAMILY

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Gaslini Institute ’s phone operator 01056361 Secretary –Medical offices 0105636405 FAX 0103777133 

TRANSPLANTATION UNIT 01056365070105636508

DAY HOSPITAL 01056366820105636551

FAX 0105636421 HOMECARE 0105636665 A.B.E.O. 0103073659 CALL CENTER (hotel availability) 01020041 PUBLIC RELATIONS OFFICE 0105636328  RAILWAY 147888088ALITALIA 147865641TIRRENIA (Ferry-boat) 0102758041RADIO TAXI 0105966

Useful phone numbers

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MEDICAL RECORDS OFFICEThe 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 OFFICEAdults 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.

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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

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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.

ASSOCIAZIONI

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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.itc/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.

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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.itPostbank 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: 010/6018961www.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 BAMBINOVia Maddaloni, 1/8, Genova Tel. 010. 591232

c/c postale 26873166Bank 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.–ONLUSAssociazione Regionale Ligure Affiliata alla Federazione Emofilici

V.le Centurione Bracelli 142r 16142 GENOVA Fax 010/868541www.arlafeliguria.it

e.mail: info@arlafeliguria.itPostbank 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)-ONLUSP.zza S .Matteo15/1, Genova Tel .010/8681370 Cell.334 3446288

www.makeawish.it e-mail: info@makeawish.itBank 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.

Rinsing with Chlorhexidine 0, 2% at least 4 times daily especially after meals.

Use of toothbrush if, allowed.

Plenty of rinsing with saline solution

The CURE PROTOCOL provides different levels of oral care

Benzydamine (Tantum) 50%

Benzydamine (Tantum) 50%

Gel Clair

1.

2.

3.

It is recommended the use of lip balms.

Once the mucositis abates, patients should return to normal oral care.

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GENERAL RULES FOR NUTRITIONAL

SUPPORT

Dip. Ematologia-Oncologia Pediatrica Direzione SanitariaSS Trapianto di Midollo 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. 

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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 post-transplantation 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)

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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

Dip. Ematologia-Oncologia Pediatrica Direzione SanitariaSS Trapianto di Midollo 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.

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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.

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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

First stepIn 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

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.

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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 brothBiscuits 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

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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)

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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).

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Fat meat or fishGround beef, hamburgerMolluscsCold cuts of any sort (except lean cooked ham)Raw or undercooked eggsCereals and whole-grain baked goodsFocaccia Acid fruits or with small seeds (* citrus, strawberries, figs, kiwi)Fibrous vegetables (artichokes, cabbage and alike, fennel, non-mashed legumes) and not explicitly allowedMushrooms and trufflesTap water and non-bottled beveragesUnpasteurized mayonnaise and foods that contain it (e.g., potato salad, sandwiches, etc)Non pasteurized and non single-portioned creams and saucesNon processed stuffed cakes, whipped cream or ice creamPre-made food and pastryPre-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 

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 productsSoft fermented cheeseYogurtRaw fish and meat

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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, well-cooked): 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

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Dip. Ematologia-Oncologia Pediatrica Direzione SanitariaSS Trapianto di Midollo 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)

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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 allowedCooked meat should be stored in the refrigerator for no longer than 12 hoursHam must be packed in single portions 

Eggs must be washed with antiseptic solution * (boiled for 10 minutes or well-cooked 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 tomatoesVegetables 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 peeledTomato 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)

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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 (80-85°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 Direzione SanitariaSS Trapianto di Midollo 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

Allowed foods

Forbiden foods

Pasteurized semi skimmed milkUHT MilkLactaid Milk (Zymil o Accadi)Packaged ice-cream and sorbetPackaged ice popCocoa milk beverages

Pasteurized packaged cheeses like mozzarella and ricotta

Sliced cheeseParmigiano Reggiano o Grana Padano

Hard cheese Emmental typePasteurized butter

Non-pasteurized milk Fresh cheesesFlavoured and spicy cheesesFermented “blue” cheeses (gorgonzola, Roquefort, etc.)Cheeses such as taleggio or camembert or brieYogurt Non-pasteurized butter

Dairy Product

s

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All types of meat (poultry, beef, pork, rabbit, lamb, etc...), preferably lean cuts, but especially well doneLean cooked ham

All types of well cooked fishOctopus, squid, cuttlefish, etc.Tuna or other canned fish

Smoked salmon and tuna in vacuum packagingHard-boiled eggs

Well cooked omelette with vegetables prepared in the oven

Brodo di carne sgrassato

All meat and fish undercookedEggs not cooked properly

Meat or fish stew prepared or pickled, but not cooked nor packed

Shellfish of all kindsSalami sausages of all kinds

Meat and other Protein

Sources

All types of flour 0 or 00 bread, crackers, breadsticks, biscuits, sliced toastsBiscuitsBreakfast cereals (refined grain only)Wheat flour dough pastaNon stuffed fresh PastaRicePolenta Well done Pizza

Bread and other whole grain productsMuesli or other breakfast cereals with added nuts, raisins, etc.

Bread, pasta, cereals and other Baked

Goods

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Fresh fruit thoroughly washed and peeledCanned fruit in syrup

Pasteurized fruit juices

Jam and fruit jelly single portionPasteurized packed fruit single portion

Fruit compoteDry fruit compote

Fruit not washed properly

Dried fruitsFigs and kiwi Walnuts, almonds and other seedsCoconut

Fruits and Juices

Vegetable brothHomogenized Vegetable Vegetable soups

Boiled, steamed or stewed vegetablesCooked tomato sauceWell washed and peeled tomatoesMashed vegetables, if toleratedCooked garlic and other flavorings, if tolerated

Raw vegetablesFibrous vegetables (artichokes, fennel)Garlic, Cucumber, bell-pepperCabbage, broccoli, etc.Soybeans

Vegetables

Extra virgin olive oilSeed oilsPasteurized butter single portionPasteurized Mayonnaise preferably light, and ketchup single portion

Sauces containing raw eggs or fermented cheese

Non pasteurized butterVinegarSauces and packed condiments, opened for more than 24 hours

Condiments

Non-carbonated mineral waterIce made (mineral water)Pasteurized juicesDrinks available on the market Cola-based drinks (preferably without caffeine) diluted with mineral waterRehydration drinks like Gatorade

Tea or other infusions made with boiled waterIced tea single portion packagesPasteurized chocolate milk, single portion

Tap waterNon pateurized fruit juicesBeverages and pasteurized juices opened for more than 24 hours (even when refrigerated)

Beverages

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Processed snacks foods like cookies, cakes (without cream)Homemade pies or cakes (without cream), pies, jam tarts, tarts with stewed fruitProcessed ice cream, sorbets and processed packed iciclesSingle-portion puddingsProcessed packaged fruit jelliesProcessed non mint hard candy

Dolci porzionati con creme Torte farcite con creme e panna Artisanal non-processed ice creamNon single-portioned puddingsHome-made candiesPanna cotta Bavarian, frozen desserts or sweets with raw eggs (tiramisu, etc)Cream spread

Desserts

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 pizzaSaffron for cooking risotto, etcPasteurized single-portioned honeyDietary products and supplements in powder or liquid

Pre-made sandwiches and other pre-made take-awaySpices

Other foods