Recommendations Summary

ONC: Neutropenic Dietary Precautions for Adult Oncology Patients 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Neutropenic Dietary Precautions for Adult Oncology Patients with Neutropenia (non-Bone Marrow Transplant)

  If an adult oncology patient has neutropenia, the registered dietitian nutritionist (RDN) should provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution. Research has not demonstrated the effectiveness of low-microbial diets.

  Rating: Fair
  Conditional

  ONC: Neutropenic Dietary Precautions for Adult Oncology Patients Undergoing Bone Marrow Transplant

  If an adult oncology patient is undergoing bone marrow transplant, the RDN should provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution. There is conflicting research regarding the effectiveness of neutropenic diets in the bone marrow transplant population.

  Rating: Weak
  Conditional

  • Risks/Harms of Implementing This Recommendation

    There are no potential risks or harms associated with the application of this recommendation.

  • Conditions of Application

    • The recommendation ONC: Neutropenic Dietary Precautions for Adult Oncology Patients with Neutropenia (non-Bone Marrow Transplant) applies to oncology patients with neutropenia
    • The recommendation ONC: Neutropenic Dietary Precautions for Adult Oncology Patients Undergoing Bone Marrow Transplant applies to oncology patients undergoing bone marrow transplant
    • Consider advance directives when planning nutrition intervention.

  • Potential Costs Associated with Application

    Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions including collaboration with other healthcare professional are essential for improved outcomes.

  • Recommendation Narrative

    Infectious complications are a major cause of morbidity and mortality. Therefore, it is important to measure the prevention of infection as an outcome in oncology patients (Zitella et al, 2006).

    The following evidence excerpts support the recommendations.

    ONC: Neutropenic Dietary Precautions for Adult Oncology Patients with Neutropenia (non-Bone Marrow Transplant)

    Guideline B5. Patients should receive dietary counseling regarding foods which may pose infectious risks and safe food handling during the period of neutropenia. Grade C. (August et al, 2009).

    Rationale

    • Although the effect of low-microbial or sterile diets on infection risk is unknown, neutropenic HCT patients should avoid foods that may contribute to an increased risk for infection
    • A descriptive survey of 120 institutions found that 78% utilized low microbial diets, but there were wide variations in the triggers used to order low microbial diets (e.g., white blood cell and neutrophil counts)
    • Eight studies of both pediatric and adult patients were included in the analysis of the role of diet and infectious risk in combination with other interventions such as isolator units and laminar airflow rooms
    • Some studies suggested a reduced incidence of infection in patients who received a sterile diet, while other studies indicated no difference or no additional benefit
    • It is difficult to make comparisons between the study groups because the dietary restrictions were not adequately described and because of variations in practice
    • More definitive research is needed on this topic. Until further research is available, it seems prudent to continue to provide dietary restrictions on high-risk foods during the period of neutropenia. Palatability of food choices in these anorectic patients should be considered.

    ONC: Neutropenic Dietary Precautions for Adult Oncology Patients Undergoing Bone Marrow Transplant

    Guideline: Low Microbial Diet for Neutropenic Patients Grade: EFFECTIVENESS UNLIKELY. (Zitella et al, 2006).

    • Most institutions recommend dietary restrictions to their patients with neutropenia,  even though there is little evidence to support the effectiveness of this practice. Avoidance of uncooked meats, seafood and eggs and unwashed fruits and vegetables are most commonly recommended
    • Inconsistencies in the literature and practice complicate and impact the result. Many of the studies related to diet include confounders, such as protected environments and differences in restrictions.
    • Further research is needed on the effectiveness of the neutropenic diet in preventing infection and what role diet plays in the institutional environment.

  • Recommendation Strength Rationale

    The Academy of Nutrition and Dietetics (AND) and the Oncology Expert Work Group concur with the American Society of Parenteral and Enteral Nutrition (ASPEN) Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer Treatment and in Hematopoietic Cell Transplantation and the ONS Putting Evidence Into Practice (PEP) guideline on Prevention of Infection and approved the following equivalency scale: External Guideline EAL Equivalency Rating.

    Evidence to support the recommendation is as follows:

    • Grade C (EAL Rating Equivalent: Fair)
    • Effectiveness Unlikely (EAL Rating Equivalent: Weak).

  • Minority Opinions

    None.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009 Sep-Oct; 33 (5): 472-500. doi: 10.1177/0148607109341804. No abstract available. PMID: 19713551.

    Zitella LJ, Friese CR, Hauser J, Gobel BH, Woolery M, O'Leary C, Andrews FA. Putting evidence into practice: Prevention of infection. Clinical J Oncol Nurs. 2006; 10(6): 739-750.