Cervical Lymphadenopathy in Children

This guideline applies to children up to their 16^th birthday.

In scope: suspected cervical lymphadenopathy

Out of scope: strongly suspected or confirmed diagnosis of a congenital neck abnormality, please follow the Congenital neck lumps in Children guideline

Introduction

Neck lumps are common in children and have a broad differential diagnosis, typically categorised into congenital, reactive (infective or inflammatory) and neoplastic. Although the majority are due to benign self-limiting disease, they usually generate a lot of parental anxiety.

Overview of local referral pathways for cervical lymphadenopathy in children

If penicillin allergy, avoid flucloxacillin and use an alternative antibiotic.

Red Flag Features

Infant under 6 months
Rapid progressive growth
Associated B symptoms
- fever, night sweats, weight loss etc
Hepatosplenomegaly
Firm/rubbery consistency.
Skin tethering or ulceration
Supraclavicular fossa
Greater than or equal to 3cm

Investigations prior to referral

If red flag features, consider blood tests and initiate early discussion with the Paediatric Consultant on-call:

FBC with film
LDH
C-Reactive Protein (CRP)
EBV CMV Toxoplasmosis serology

Indications for neck ultrasound:

A focal neck mass persistently enlarged greater than 2 cm for more than 6 weeks.
A midline neck mass.
A palpable neck mass in infants under 6 months of age.
Suspected congenital or developmental neck lesions – to characterise and direct further management following paediatric or ENT referral.
Acute lymphadenitis which fails to respond to medical therapy – to assess for abscess formation and the need for further intervention.

Be aware that ultrasound cannot reliably differentiate between reactive and malignant lymph nodes and should not be used as a screening tool to ‘exclude malignancy’.

If there are red flag features or suspected abscess formation see referral process below.

Management Optimisation

In a well child with no red flag features, base initial management on whether there are signs of infection.

Infection suspected:

Prescribe Flucloxacillin for 2 weeks (use alternative antibiotic if penicillin allergic).
Review at 48-72hr – if no improvement, or concerned about abscess formation, contact same-day paediatric first on-call.
Review at 2 weeks – if lump has resolved, reassure and provide patient information. If it is persistent, arrange neck ultrasound.

No signs of infection:

Lump less than 2 cm : Reassure and provide patient information. Consider re-review of nodes between 1.5cm-2cm and discuss if enlarging or any worrying features.
Lump greater than 2cm: Review at 6 weeks:
- Resolved – reassure and provide patient information. Small, morphologically normal lymph nodes may persist and remain palpable for many months due to a lack of subcutaneous fat, superficial site and relative size of the neck.
- Greater than 2cm in absence of red flag features – arrange neck ultrasound.
- Persistent with red flag features – consider blood tests and initiate early discussion/referral with the Paediatric Consultant on-call.

Advice and Guidance

If benign congenital mass demonstrated on neck ultrasound, seeking ENT Advice and Guidance is an option. See the Congenital neck lumps in Children guideline for further information.

Direct radiological queries to the Radiology advice email: rch-tr.GPRadiologyEnquiries@nhs.net

Referral

Same-day care

Systemically unwell child with massive lymphadenopathy
Suspected or confirmed abscess formation

Arrange same-day assessment via Paediatric first on-call.

Paediatric Suspected Cancer

Neck lump in the context of red flag features
Neck ultrasound demonstrates worrying features

In hours, 09:00 to 21:00 Monday to Friday, call the Paediatric Consultant Advice Line: 07973 742812

Outside of these hours, discuss with the on-call Consultant Paediatrician via RCHT switchboard.

See the RMS guideline on Paediatric Suspected Cancer.

Supporting Information and References

For professionals:

Referral guidance for suspected cancer in children and young people: a supporting resource for NG12

BMUS: Paediatric Neck Lump Guidelines

Australian Journal of GP – Paediatric Neck Lumps

NHS Brighton and Sussex University Hospitals – Paediatric Lymphadenopathy and Lymphadenitis

For patients:

RCPCH – Lymphadenopathy

Page Review Information

Review date	16 January 2025
Next review date	16 January 2027
GP speciality lead	Dr Laura Vines
Contributors	Dr Shama Goyal, Consultant Paediatrician Mr Venkat Reddy, ENT Consultant Surgeon Ms Aileen Lambert, ENT Consultant Surgeon Dr Kate McGraw-Allen, Paediatric ST4 Dr Claire Keaney, Consultant Radiologist