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Clean hands, for everyone, matter most. A 2024 guideline for children with cancer says many old restrictions can go: children can keep pets, go to school even when their white count is low, keep plants and swim, unless they have a PICC line. Still avoid building sites and digging in soil, bath toys that hold water, cleaning pet litter or cages, and ill visitors. Transplant units are stricter.
For children with cancer on curative treatment as outpatients (not after stem cell transplant), the Dutch Children's Oncology Group guideline (2024, GRADE, endorsed by the Children's Oncology Group in March 2025) makes hand hygiene for patients, carers and staff a strong good practice statement; recommends school or kindergarten attendance irrespective of neutropenia unless a classmate has a serious contagious disease such as varicella (strong, very low); suggests keeping domestic pets (weak, very low) but not letting children clean litter boxes or cages (weak, expert); suggests swimming irrespective of neutropenia (weak, very low) but not with a non-tunnelled line such as a PICC (strong, expert); recommends against reservoir bath toys (strong, very low) and public warm bubble baths (weak); suggests against chlorhexidine bathing or wipes (weak, very low); allows indoor plants (strong, expert); and, following ASCO/IDSA, recommends avoiding prolonged contact with environments high in fungal spores such as construction, demolition, gardening or digging (strong). It advises against crowded places and public transport with neutropenia during viral seasons (weak, expert).
For HCT recipients the CDC/IDSA/ASBMT guideline (2009) is stricter: no plants or flowers in hospital rooms (DIII), avoid gardening, soil and plants while immunosuppressed (CIII), avoid construction areas, screen visitors and keep symptomatic visitors away (BIII), vaccinate VZV-susceptible contacts (AIII), and do not ask patients to part with pets but avoid reptiles, chicks, exotic and young or ill animals, with someone else changing cat litter.
Why: Hands carry most of the germs that cause infection at home and on the ward; this matters more than any restriction on activities.
“Proper hand hygiene should be performed by patients, caregivers, and medical personnel (STRONG recommendation, GOOD PRACTICE STATEMENT).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, GOOD PRACTICE STATEMENT
Why: Visitors can bring in infections that are mild for them and serious for someone with no white cells.
“All visitors should be screened for symptoms of infection: fever, rash, vomiting, diarrhea, upper respiratory symptoms, or conjunctivitis, and should not be allowed to visit a HCT recipient while they are symptomatic (BIII).”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · BIII
Why: Chickenpox can be severe in people with weak immunity; protecting those around them reduces exposure.
“Health care workers (HCWs), family members, household contacts, and visitors who are healthy and do not have a reported history of varicella infection or who are VZV-seronegative should receive VZV vaccination before being allowed to visit or have direct contact with an HCT recipient (AIII).”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · AIII
Why: These places put large amounts of mould spores into the air, which can cause serious lung infection when neutrophils are low.
“We recommend that children with cancer and neutropenia should avoid prolonged contact with environments that have high concentrations of fungal spores (i.e., construction or demolition sites, exposure to soil through gardening or digging, household renovation) (STRONG recommendation, ASCO and IDSA guideline [21]).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, ASCO and IDSA guideline
Why: School matters for a child's life and learning, and the infection risk from attending is small; chickenpox in the class is the exception to discuss with the team.
“We recommend allowing children with cancer to attend school or kindergarten irrespective of neutropenia (unless someone in their class or group has a contagious disease with potential severe consequences, e.g., varicella zoster) (STRONG recommendation, VERY LOW quality evidence).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, VERY LOW quality evidence
Why: Pets help a child's wellbeing and no study found they raise infection; cleaning up after them is the task with the most germs and is easy to hand to someone else.
“We suggest allowing to keep domestic pets in the households of children with cancer (WEAK recommendation, VERY LOW quality of evidence).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · WEAK recommendation, VERY LOW quality of evidence
Why: Swimming was not linked to more infection in children with tunnelled lines; a PICC carries a higher infection risk and the panel advises against it.
“We strongly believe children with cancer with a non-tunneled central venous catheter such as PICC line should not swim (STRONG recommendation, EXPERT opinion).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, EXPERT opinion
Why: Water trapped inside bath toys grows Pseudomonas, and such toys have been linked to infections and an outbreak on a children's cancer ward.
“We recommend against the use of bath toys that have a reservoir (in which water can be retained) or bath toys that cannot be dried thoroughly (STRONG recommendation, VERY LOW quality of evidence).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, VERY LOW quality of evidence
Why: Studies in children with cancer did not show it adds anything to normal washing, and it is a burden.
“We suggest not to use chlorhexidine bathing or other bath wipes as it does not seem to have an added value to basic hygiene measures (WEAK recommendation, VERY LOW quality of evidence).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · WEAK recommendation, VERY LOW quality of evidence
Why: The risk from having plants in the house is very small, provided the child does not handle the soil.
“We strongly believe that indoor flowers or plants at home should be allowed (STRONG recommendation, EXPERT opinion).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · STRONG recommendation, EXPERT opinion
Why: Crowds at those times raise the chance of catching a respiratory virus; outside those times crowds and public transport are allowed with hand hygiene.
“We believe that it is not advisable for children with cancer with neutropenia to use public transport or visit crowded places when there is a higher incidence of viral infections and thereby a higher chance of getting infected (WEAK recommendation, EXPERT opinion).”
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · WEAK recommendation, EXPERT opinion
Why: Exercise helps children through treatment; a low platelet count raises the risk of bleeding from a knock or fall.
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · WEAK recommendation, EXPERT opinion
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.
For children with cancer outside transplant, the Dutch Children's Oncology Group guideline (2024), endorsed by the Children's Oncology Group, is the only evidence-graded guideline on daily-life restrictions and sets the standard: hand hygiene first, school regardless of neutropenia, pets, indoor plants and swimming allowed (not with a PICC), and a short list of exposures to avoid (construction and soil, reservoir bath toys, public bubble baths, cleaning litter or cages, crowds during viral seasons when neutropenic). Most of its recommendations rest on very low quality evidence or expert opinion, which the panel says openly. For transplant recipients, the CDC/IDSA/ASBMT guideline (2009) remains the reference and is stricter: no plants or flowers in hospital rooms (DIII), avoiding gardening and soil while immunosuppressed (CIII), visitor screening (BIII) and restrictions on certain animals. The two guidelines differ on plants, and the transplant guideline's restrictions are graded mainly on expert opinion (III).
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · Children's Oncology Group 2025 · CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 · ASCO and IDSA, Journal of Clinical Oncology 2018
Where it differs: No plants or dried or fresh flowers in hospital rooms during conditioning or after transplant; avoid gardening, soil and plants while on immunosuppressive therapy, or wear an N95 mask and gloves if continuing; avoid construction areas; do not adopt young, ill or stray animals, reptiles, chicks or exotic pets; someone other than the patient changes cat litter daily for the first 6 months.
Evidence: Graded mainly on expert opinion: plants and flowers in rooms DIII, gardening and soil CIII, reptiles BII, litter boxes BIII; the guideline notes plants and flowers have not conclusively caused mould infection.
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009
Where it differs: Transplant centres house patients at highest risk of mould infection in rooms with HEPA-filtered air and, when such rooms run short, use portable HEPA filters; laminar air flow rooms are not recommended for new builds.
Evidence: HEPA filtration AIII and room allocation BIII; laminar air flow DII because it has not shown an overall survival benefit.
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009
Where it differs: Where Dutch practice previously discouraged it, children with an external tunnelled line may swim if the site and dressing can be cleaned and dried and there is no needle in a port; a tight shirt can hold the line against the body.
Evidence: One retrospective cohort found no significant difference in infection between swimmers and non-swimmers; the recommendation is weak, very low quality.
Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Hand hygiene by patients, carers and staff | STRONG recommendation, GOOD PRACTICE STATEMENT | Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 |
| School or kindergarten irrespective of neutropenia | STRONG recommendation, VERY LOW quality evidence | Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 |
| Avoid environments high in fungal spores when neutropenic | STRONG recommendation, ASCO and IDSA guideline | Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 |
| Keep domestic pets | WEAK recommendation, VERY LOW quality of evidence | Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 |
| No plants or flowers in hospital rooms after HCT | DIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
| Avoid gardening, soil and plants while on immunosuppressive therapy after HCT “Patients should be advised to avoid gardening, soil, and plants while receiving immunosuppressive therapy (CIII).” | CIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
| Water-retaining bath toys should not be used by HCT recipients “Water-retaining bath toys should not be used by immunocompromised HCT recipients and candidates as they have been associated with an outbreak of Pseudomonas aeruginosa in a pediatric oncology ward (DII)” | DII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
| Do not routinely advise HCT recipients to part with their pets “HCT physicians should advise recipients and candidates undergoing conditioning therapy of the potential infection risks posed by pet ownership; however, they should not routinely advise HCT recipients to part with their pets, with limited exceptions.” | not graded in the sentence; reptiles BII, juvenile and stray animals BIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
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