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Strict lists of banned foods (the 'neutropenic diet') do not prevent infections in trials, in children or adults, and they make eating harder. What matters is ordinary food safety: clean hands and surfaces, raw meat kept apart, fruit and vegetables washed, meat and eggs cooked through, and no unpasteurised milk or cheese, mouldy food or unsafe water. Transplant teams may differ.
The 2025 POGO guideline, endorsed by the Children's Oncology Group, reviewed 8 randomised trials and suggests that food restrictions not be routinely used to prevent infection in children with cancer (conditional, moderate quality) or after autologous or allogeneic HCT (conditional, low quality), with a good practice statement to follow safe food handling, storing, preparation and consumption as set by applicable health authorities. ASCO (2022) does not recommend neutropenic diets to prevent infection in adults during active treatment. Meta-analysis of 6 randomised trials (Ma 2022) found no reduction in infection (risk ratio 1.13, 95% CI 0.97 to 1.31) or mortality, and a 2025 systematic review of 5 trials in adults having high-dose therapy found no benefit and a tendency to worse nutritional status. One older trial in 153 adults with AML or high-risk MDS found fewer bloodstream infections with restrictions; the POGO panel judged it indirect for children.
The older CDC/IDSA/ASBMT HCT guideline (2009) still recommends a low-microbial diet before engraftment (CIII, noting evidence is lacking) and a food-safety diet after it until immunosuppression stops; its safe handling advice (separate raw meat, wash produce, cook meat to a measured internal temperature, refrigerate leftovers within 2 hours) is what most food safety teaching uses. The items safe handling advice agrees on everywhere are unpasteurised milk and cheese, undercooked eggs and meat, mouldy food and possibly contaminated water.
Why: Food poisoning germs such as Salmonella and Campylobacter can cause severe infection when white cells are low; the teaching works best before the first course.
“This review and education should be done before the conditioning regimen (ie, chemotherapy and radiation) begins (BIII).”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · BIII
Why: This is the measure every guideline agrees on; local advice fits local foods and water.
“Follow practices for safe food handling, storing, preparation and consumption outlined by applicable health authorities.”
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 · Good practice statement
Why: Six trials in people having chemotherapy showed no consistent drop in infections, and restrictions can harm eating, nutrition and quality of life.
“We suggest that food restrictions not be routinely used for the prevention of infections in paediatric patients with cancer (conditional recommendation, moderate quality evidence)”
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 · conditional recommendation, moderate quality evidence
Why: Two transplant trials found no benefit, though there are no trials in children after transplant.
“We suggest that food restrictions not be routinely used for the prevention of infections in paediatric autologous HCT and allogeneic HCT recipients (conditional recommendation, low quality evidence)”
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 · conditional recommendation, low quality evidence
Why: ASCO's review found neutropenic diets did not lower the risk of infection.
“Neutropenic diets are not recommended to prevent infection in patients with cancer during active treatment.”
Why: Raw meat is the commonest source of the germs that cause food poisoning; keeping it apart stops them reaching food that will not be cooked.
“Persons preparing food should always use separate cutting boards or wash the board(s) with warm water and soap between cutting different food items (AIII).”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · AIII
Why: Washing removes most of the soil and germs on produce, so fresh fruit and vegetables can stay in the diet.
“All fresh produce should be washed thoroughly under running water before serving (AIII)”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · AIII
Why: Colour is not a reliable guide; the temperature inside the meat is what shows germs have been killed.
“Persons cooking food for HCT recipients should follow established guidelines for monitoring internal cooking temperatures for meats, which is the only method for determining if meat has been adequately cooked (AII).”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · AII
Why: Germs multiply in food left at room temperature; prompt cooling and thorough reheating stop them.
“refrigerate leftovers within 2 hours of cooking (AII)”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · AII
Why: These are the foods that food safety guidance treats as risky everywhere; other foods, such as sushi, depend on local context.
“For some food items, safe food handling guidance should be consistent across jurisdictions, such as avoidance of unpasteurised milks and cheeses, undercooked eggs and meats, food with visible or introduced mould, and potentially contaminated drinking water.”
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Teach and follow ordinary food safety, and do not impose a restrictive neutropenic diet. For children with cancer and after transplant this is the POGO 2025 guideline endorsed by the Children's Oncology Group (conditional recommendations against routine food restrictions, moderate and low quality evidence, plus a good practice statement on food safety); for adults in active treatment it is ASCO 2022 (neutropenic diets not recommended). The older CDC/IDSA/ASBMT HCT guideline (2009) differs: it recommends a low-microbial diet before engraftment, while grading that CIII and saying evidence for its efficacy is lacking, and a food-safety diet after engraftment until immunosuppression ends. A randomised trial after HSCT in 222 adults (Stella 2023) found an unrestricted diet non-inferior to a protective diet, with higher patient satisfaction.
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 · Children's Oncology Group 2025 · ASCO, Journal of Clinical Oncology 2022 · CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · Blood Advances 2023 · Frontiers in Oncology 2022
Where it differs: Restricts the diet of transplant recipients before engraftment, then keeps a list of foods to avoid (raw sprouts, fresh salsa, berries, unroasted raw nuts, soft and mould-ripened cheeses, raw honey and others) for 3 months after autologous transplant and, after allogeneic transplant, until all immunosuppression stops and live vaccines can be given.
Evidence: The low-microbial diet is graded CIII, with the guideline stating that evidence for its efficacy is lacking; many of the individual food bans are graded EII. Later trials and the 2025 POGO guideline do not support routine restrictions.
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025
Where it differs: Many centres still use a neutropenic or low-bacterial diet as standard after HSCT; the 2025 Nutrients review cites a European survey of 2015 and 2016 in which over 90% of centres in 23 countries did so.
Evidence: Five randomised trials in 510 adults on high-dose therapy found no advantage on any endpoint and a tendency to worse nutritional status (Nutrients 2025); the Stella 2023 trial found an unrestricted diet non-inferior after HSCT.
Where it differs: Some leukaemia units restrict uncooked foods during induction chemotherapy for acute myeloid leukaemia.
Evidence: One randomised trial of 153 patients (median age 64) with AML or high-risk MDS reported fewer bloodstream infections with food restriction (14% against 29%); the POGO panel judged it indirect for children, and the pooled trials show no overall benefit.
Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025
| Recommendation | Grade, as printed | Source |
|---|---|---|
| No routine food restrictions in children with cancer | conditional recommendation, moderate quality evidence | Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 |
| No routine food restrictions in children after autologous or allogeneic HCT | conditional recommendation, low quality evidence | Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 |
| Follow local health authority food safety practices | Good practice statement | Pediatric Oncology Group of Ontario (POGO), eClinicalMedicine 2025 |
| Low-microbial diet for HCT recipients before engraftment “A low-microbial diet is recommended for HCT recipients prior to engraftment 771, 772, although evidence for its efficacy to prevent infection is lacking (CIII)” | CIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
| Review general food safety practices before transplant | AIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
| Pooled infection risk with a neutropenic diet across 6 randomised trials “The meta-analysis found that patients in the study group had similar results for the incidence of infection compared with the patients in the control group (risk ratio, 1.13; 95% CI, 0.97 to 1.31; P = 0.11).” | risk ratio 1.13, 95% CI 0.97 to 1.31 (meta-analysis, not a guideline grade) | Frontiers in Oncology 2022 |
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