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:
- https://www.cclg.org.uk/sites/default/files/2025-02/cclg-referral-guidance-april-2021.pdfh
- https://www.bmus.org/media/resources/files/BMUS_Paediatric_Neck_Lump_Guidelines.pdf
- Australian Journal of GP – Paediatric Neck Lumps
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 |