D: Conclusion(s) of evidence (pediatric oncology patients)

 * The letter refers to the specific GRADE assessment described in section C1.

**Social restrictions evaluated were related to indoor public places, outdoor public places, friends visiting at home, daycare centers, kindergarten, and school beyond kindergarten.

C: Results in pediatric and adult oncology patients 
C1. Evidence in pediatric oncology patients

In our literature search, one study was included for this clinical question. Tramsen et al (2016) (11) performed a retrospective cohort study, including children with acute myeloid leukemia treated accordingly AML-BFM 2004, between 2004 and 2010 in Germany, Austria, Switzerland and the Czech Republic. They reported about a survey about anti-infective measures. In total, 37 hospitals completed a survey about anti-infective measures. The survey included questions about restriction in social contacts, pets at home, and food.
Social restrictions evaluated were related to indoor public places, outdoor public places, friends visiting at home, daycare centers, kindergarten, and school beyond kindergarten. Restrictions were categorized as always restricted (2 points), restricted under certain circumstances (1 point) or never restricted (0 points).

For the social restrictions, Tramsen (2016) reported a median score of 9 (range 7-12) for a score with six items and consequently the highest possible score of 12. For the unadjusted analysis, a higher restriction in social contact score was associated with an increased incidence of bacteremia (IRR 1.21, 95% CI 1.07-1.37, p=0.003).
However, when the results were adjusted for gender, age, weight groups, risk stratification and antibiotic prophylaxis, restriction of social contacts was not significantly associated with the risk of infection. Namely, for fever of unknown origin, an IRR of 0.99 was reported (95% CI 0.92-1.08, p=0.9); for bacteremia an IRR of 1.15 was reported (95% CI 0.99-1.33, p=0.066); for pneumonia an IRR of 0.99 was reported (95% CI 0.77-1.28, p=0.96) and for gastroenteritis an IRR of 0.94 was reported (95% CI 0.73-1.21, p=0.63).

Table 11: Study characteristics Tramsen 2016

*or possible risk factor group, or intervention group

Table 13: Outcomes Tramsen 2016 – Restriction in social contact (school and kindergarten)

G: GRADE: Grade quality assessment restriction in social contacts: design is retrospective cohort study, inconsistency not serious, indirectness not serious, imprecision serious, publication bias unlikely, downgraded 1 level because of serious risk of bias (selection bias low, attrition bias low, detection bias low, reporting bias unclear, confounding bias high, other bias low).

C2. Additional recommendations guidelines (adults)
From our search for existing relevant guidelines, no additional guidelines were included for this clinical question.

B: Clinical question, search and selection

B1: Clinical question:
What is the effect of social restrictions (regarding risk of infections) on infections (prevalence and infectious complications) and other outcomes in children with any type of cancer and/or after stem-cell transplantation?

P =      Children (aged 0-18 years) with any type of cancer and/or after stem-cell transplantation receiving anti-cancer treatment with curative intent
I = Social restrictions regarding risk of infections (i.e. restriction in school attendance, kindergarten, visiting zoo or farm, pets, swimming (whirlpool, sauna visits), being in crowded places, public transport, intimacy, flowers, or other author defined social restrictions)
C = (No social restrictions)
O = Severe or mild infections (prevalence and infectious complications), quality of life, anti-cancer treatment-related complications (adjustments in therapy or delay), costs, mortality, event-free survival

B2: Literature search and study selection
For the complete methodology of this guideline development and the search strategy, we refer to pages 18-23.
Of 6038 unique citations identified in the literature search, one study with pediatric oncology patients (Tramsen, 2016 (11)) was included. Evidence was extracted and assessed using the GRADE methodology.