Palpable cervical lymph nodes (Paediatric Guidelines)

A focused history and examination is the most useful way to approach palpable nodes and determine the likely cause or need for further assessment. Often, further investigations or referrals are not required.

History

A focused history should include the following:

• The node: location, timeline, speed of growth, size over time, pain, redness
• Associated symptoms: fever, sore throat, cough, runny nose, ear pain, lumps elsewhere, rashes
• B symptoms and red flags: fever, weight loss, night sweats , fatigue, pruritus, bone pain, symptoms of mediastinal mass (e.g. shortness of breath, facial swelling, distended neck veins, chest pain)
• Past medical history, including: recent infections, previous malignancy, previous radiation therapy, conditions associated with increased cancer risk e.g. Down’s syndrome, Noonan syndrome
• Family history: thyroid cancer
• TB risk - travel history, contacts, vaccine status
• Assess the level of parental concern.
  night sweats are defined as ‘sweating so much that your night clothes and bedding are soaking wet, even though where you are sleeping is cool’ (3).

Clinical examination

A systematic approach to examination of the neck and node(s) should be taken, with clear documentation of:

• Location and distribution of palpable node(s)
• Accurate size of node(s)
• Consistency
• Mobility
• Tenderness
• Overlying skin changes

It can be useful to conduct serial examinations to assess how the node(s) changes over time.
It is also important to assess:

• The height and weight of the child
• General assessment – does the child look well or unwell?
• Ear, nose, throat and mouth (including mucous membranes, teeth and gums)
• Skin and scalp exam – for cradle cap eczema, petechiae, bruising, pallor
• Other lymph node sites – supraclavicular, axillae, inguinal regions
• Respiratory and cardiovascular
• Abdomen – masses, organomegaly (1)

Physiological

Commonly, palpable nodes are a normal physiological finding, as children have less subcutaneous fat and smaller necks relative to adults.

Benign reactive nodes

The most common cause of palpable cervical nodes is enlarged nodes as a response to infection; commonly an URTI, or systemic viral illness. Poorly controlled eczema is also a possible cause.

Infection

Lymph nodes may be a site for infection, including bacterial lymphadenitis, mycobacterium tuberculosis, atypical mycobacterium or cat scratch disease (Bartonella).

Inflammatory

Though uncommon, Kawasaki disease and PIMS-TS are possible causes of cervical lymphadenopathy. Also consider SLE and JIA.

Malignancy

Leukaemia, lymphoma, thyroid cancer and neuroblastoma may all be associated with cervical lymphadenopathy. Isolated cervical lymphadenopathy is, though possible, rarely a result of cancer.

Other

Alternative “neck lumps” like thyroglossal duct cyst, branchial cleft cysts or vascular anomalies (1).

1. Ruffle A, Beattie G, Prasai A, et al. Fifteen-minute consultation: A structured approach to the child with palpable cervical lymph nodes. Arch Dis Child Educ Pract Ed. 2022 Feb 17:edpract-2020-321378. doi: 10.1136/archdischild-2020-321378. Epub ahead of print. PMID: 35177487.
2. Cancer Research UK, 2022. ‘Children’s Cancer Statistics’. https://www.cancerresearchuk.org/health-professional/cancer-statistics/childrens-cancers. Accessed October 2022.
3. NHS, 2021. ‘Night Sweats’. Night sweats - NHS (www.nhs.uk). Accessed October 2022.
4. NICE, 2021. ‘Suspected cancer: recognition and referral’. Overview | Suspected cancer: recognition and referral | Guidance | NICE. Accessed October 2022.
5. Murray MJ, Ruffle A, Lowis S et al. Delphi method to identify expert opinion to support children's cancer referral guidelines. Arch Dis Child. 2020 Mar;105(3):241-246. doi: 10.1136/archdischild-2019-317235. Epub 2019 Aug 16. PMID: 31420330.
6. Kingston Hospital Charity, 2021. ‘Lymphadenopathy in Children’. https://kingstonhospital.nhs.uk/healthcare-professionals/paediatrics-referrals/lymphadenopathy-in-children/. Accessed November 2022.
7. NHS Healthier Together, 2022. Clinical Paediatric Pathways ‘Lymphadenopathy Pathway Table 1’. CS45385_NHS_Lymphadenopathy_Pathway_Acute_Hospital_Setting_Feb_18_final.pdf (what0-18.nhs.uk). Accessed November 2022.