History and Examination

History should include:

• Duration of lymph node
  • lymph nodes present for more than 6 months are very unlikely to be malignant pathology in young people
• Location
  • cervical lymph nodes are very unlikely to be malignant
• Pain, tenderness, redness
• ENT symptoms
• Fever
• Weight loss
• Pruritis
  • NB lymph nodes associated with eczema are very common, especially in younger children
• Fatigue
• Bone or joint pain
• Respiratory symptoms
  • it is particularly important to identify symptoms associated with mediastinal masses – stridor, recumbent cough
• Contact with tuberculosis (TB)
• Contact with pets or livestock
• Travel
• Family history
  • malignancy
  • HIV risk
  • TB
  • immunodeficiency
• Presence of isolated night sweats is not of concern

Examination

• General examination including:
  • height and
  • weight
• Look for:
  • pallor and
  • petechiae
• Examine skin for:
  • infection
  • infestation or
  • dermatitis
• Examine ear, nose and throat
• Examine for mediastinal mass listen for stridor and inspect neck and thorax for distended veins
• Palpate all lymph node groups:
  • cervical
  • supraclavicular
  • epitrochlear
  • axillary
  • inguinal
• Palpate abdomen for hepatosplenomegaly
• Examine testes for swelling

• Severe pallor
• Fever/signs of sepsis
• Unexplained bruising
• Unexplained bleeding
• Any signs or symptoms suggestive of mediastinal mass

Most lymph nodes need no investigation – Full blood count is rarely helpful.

Most enlarged lymph nodes require no treatment or investigation and simple reassurance is all that is required. Regular review is unlikely to be helpful, but a single review after 2-3 weeks is useful if a node is still enlarging.

Acute Bacterial Lymphadenitis

If the lymph node is red and/or tender, and/or there is a short history with signs of infection, give 10 days of oral co-amoxiclav and arrange review, If the swelling is particularly large or fluctuant, or the child is systemically unwell, consider referral acutely.

Refer as below referral section.

It is important to definitively tell the child and family that this is not cancer. It may be helpful to get the carers to self-examine as it is normal for everyone to have some palpable lymph nodes. Reassure the child and family that the lymph node may persist, and will get bigger and smaller with intercurrent infections, and that this is "the immune system doing its job".

Refer as emergency

• Red flag features refer immediately to acute paediatrics via the on-call team:
  • Severe pallor
  • Fever/signs of sepsis
  • Unexplained bruising
  • Unexplained bleeding
  • Any signs or symptoms suggestive of mediastinal mass

Suspected malignancy

Including those referred under the 2 Week Wait rule:
Refer urgently by telephone, direct to the Attending Paediatric Consultant available via Switchboard on Bleep 340 or out-of-hours to the Consultant Paediatrician on-call. They will then advise if admission or other course of action is needed.

If not to be admitted, the clinician taking the call will take details of the patient to ensure that an out-patient appointment is booked without delay.

These may include:

• Axillary, epitrochlear or supraclavicular lymph nodes of more than 1cm diameter
• Inguinal lymph nodes more than1.5 cm diameter
• All cervical lymph nodes more than 2 cm diameter which are either increasing in size or present for more than 2 weeks.
• In patients over 10 years refer all lymph nodes more than 1cm in any location, if present for more than 2 weeks and no obvious explanation
• Presence of worrying symptoms suggestive of haematological malignancy:
  • Pallor
  • Persistent fatigue
  • Unexplained fever
  • Unexplained persistent infection
  • Generalised lymphadenopathy
  • Persistent or unexplained bone pain
  • Unexplained bruising
  • Unexplained bleeding

If suspected acute bacterial lymphadenitis refer to acute paediatrics via the on-call team if not responded to oral antibiotics, systemic symptoms, fluctuant mass or very large (more than 5cm) swelling.

NICE suspected cancer

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2017