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Cervical Lymphadenopathy in Children

 

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

It applies solely to patients with suspected cervical lymphadenopathy. In patients with a 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

  • Patient age < 6 months
     
  • Rapid progressive growth
     
  • Associated B symptoms
    • fever, night sweats, weight loss etc
  • Hepatosplenomegaly
     
  • Firm/rubbery consistency.
     
  • Skin tethering or ulceration
     
  • Supraclavicular fossa
     
  • =/>3cm
     
  • Petichiae/ unexplained bruising or pallor
     
  • Known family TB contact

Investigations

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 Ultrasound

  • A focal neck mass persistently enlarged > 2 cm for > 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

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

 

Infection suspected:

  • Prescribe Flucloxacillin for 7-10 days (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  the end of the antibiotic course – if lump has resolved, reassure and provide patient information. If it is persistent, arrange neck ultrasound.

 

No signs of infection:

  • Lump <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 > 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.
  • > 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.


 

Supporting Information and References

For professionals:

 

For patients:

 

Page Review Information

Review date

6 May 2025

Next review date

6 May 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 ST5

Dr Claire Keaney, Consultant Radiologist

Daniel Hearsey, Advanced Specialist Clinical Pharmacist, RCHT