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Lymphadenopathy (Benign) - Draft

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Overview

Benign reactive lymphadenopathy is very common in childhood, and not of concern. Palpable benign lymph nodes may remain present for many months without regressing completely, which is normal.

Please see Management of Lymphadenopathy in children in Primary Care guidelines produced by Bristol Children's Hospital.

Cervical Lymphadenopathy

The total mass of lymphoid tissue increases during development and is up to twice that of adults during puberty. As a result, cervical lymphadenopathy is common and may be found in more than one third of otherwise healthy children. Observation and reassurance without investigation is usually appropriate for the well appearing child with cervical lymphadenopathy
Most cases are benign and self-limiting however the differential diagnosis is broad:

Viral upper respiratory tract infection is the most common cause of cervical lymphadenopathy in children. These enlarged "reactive" nodes may persist for weeks to months.
Acute bacterial lymphadenitis is characterised by enlarged nodes, which are tender, usually unilateral and may be fluctuant.

Characteristics of benign lymphadenopathy

Small mobile lymph nodes that often wax and wane in size with intercurrent infections.
Usually cervical, in anterior or posterior triangle and or occipital region.
Generally well child.
Not associated with any concerning systemic symptoms

Red Flags

The BRHC guidelines advise that referral to secondary care using the USC/2WW pathway should be considered if children have lymphadenopathy associated with any of the following red flags:

History

Weight loss
Fevers/profuse night sweats
Systemic symptoms
Breathlessness
Bone pain/limp

Examination

Lymph node > 2cm
Pallor
Hepatosplenomegaly
Axillary or supraclavicular lymph nodes
Lymph node increasing rapidly in size
Lymph node with abnormal consistency (hard/matted or non-mobile).

If a child has potentially concerning lymphadenopathy, please examine the whole body and describe the size and location of the nodes in the ‘clinical details’ section of the USC/2WW referral form, plus any associated symptoms.

Management in Primary Care

If there are no red flags and a child is otherwise well then blood tests, imaging or referral is usually not required. In most cases, all that is needed is reassurance and safety-netting advice to parents.

The BRHC guidelines give advice on when to consider investigations in primary care and when to consider referral.

Blood tests should only be considered as indicated and advised in the guidelines.

Imaging such as USS for lymphadenopathy is rarely appropriate and imaging requests on ICE are very likely to be rejected.

Advice and Guidance

Consider requesting Paediatric advice & Guidance if you need further advice on the need for investigations or referral.

Referral

If there are red flags then use the Children & Young People – USC (2WW) referral route.

If there are no red flags and referral is indicated then please refer to general paedatrics via eRS - please include details of how referral guidelines have been followed and include results of investigations if a referral is made.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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