Examination of Lymph Nodes in Children

Introduction to Lymph Node Examination in Children

Lymph node examination is a crucial component of the pediatric physical exam. It provides valuable insights into a child's immune system and can help identify various pathological conditions.

Lymph nodes are part of the body's immune system and act as filters for foreign particles.
In children, palpable lymph nodes are common and often represent a normal response to local or systemic infections.
However, significant lymphadenopathy can be a sign of serious underlying conditions, including malignancies.

Pediatricians must be proficient in examining lymph nodes to differentiate between benign reactive lymphadenopathy and potentially serious conditions requiring further investigation.

Anatomy of Lymph Nodes in Children

Understanding the anatomy of lymph nodes is essential for accurate examination and interpretation of findings.

Major Lymph Node Groups:

Cervical (anterior and posterior chains)
Submental and submandibular
Occipital
Preauricular and postauricular
Supraclavicular
Axillary
Epitrochlear
Inguinal

Note: In children, the most commonly enlarged nodes are found in the cervical region, often related to upper respiratory infections.

Lymphatic Drainage Patterns:

Scalp and face drain to cervical and preauricular nodes
Oral cavity drains to submandibular and submental nodes
Upper extremities drain to axillary and epitrochlear nodes
Lower extremities drain to inguinal nodes

Understanding these drainage patterns can help identify the source of infection or inflammation when lymphadenopathy is present.

Examination Technique for Pediatric Lymph Nodes

A systematic approach to lymph node examination ensures thorough assessment and accurate findings.

General Principles:

Ensure good lighting and a comfortable position for both the child and examiner
Use warm hands to avoid startling the child
Explain the procedure to the child and caregiver to reduce anxiety

Step-by-Step Examination:

Inspection: Observe for any visible swellings or asymmetry in lymph node regions
Palpation: Use fingertips to gently palpate each lymph node group
- Start with cervical chains, moving systematically to other regions
- Use a circular motion with light to moderate pressure
- Compare bilateral lymph node groups for symmetry
Assessment: For each palpable node, evaluate:
- Size (measure in millimeters)
- Consistency (soft, firm, hard, rubbery)
- Mobility (fixed or freely mobile)
- Tenderness
- Overlying skin changes (erythema, warmth)

Tip: In infants and young children, examining during sleep or while feeding can facilitate a more thorough examination.

Normal vs Abnormal Findings in Pediatric Lymph Nodes

Normal Findings:

Palpable nodes up to 10mm in diameter in cervical and inguinal regions
Soft, mobile, and non-tender
Bilateral and symmetrical enlargement

Abnormal Findings (Red Flags):

Size > 2cm in cervical region or > 1cm in other regions
Hard, fixed, or matted nodes
Significant tenderness or overlying skin changes
Persistent enlargement for > 4-6 weeks
Supraclavicular lymphadenopathy (always concerning)
Generalized lymphadenopathy (involvement of ≥ 2 non-contiguous regions)

Note: The presence of any red flag findings warrants further investigation, including imaging studies and possible biopsy.

Differential Diagnosis of Pediatric Lymphadenopathy

Consider the following categories when evaluating lymphadenopathy in children:

1. Infectious Causes:

Viral (e.g., EBV, CMV, HIV)
Bacterial (e.g., Streptococcus, Staphylococcus)
Mycobacterial (e.g., tuberculosis, atypical mycobacteria)
Parasitic (e.g., toxoplasmosis)

2. Autoimmune Disorders:

Juvenile idiopathic arthritis
Systemic lupus erythematosus
Kawasaki disease

3. Malignancies:

Lymphoma (Hodgkin and Non-Hodgkin)
Leukemia
Metastatic solid tumors

4. Other Conditions:

Sarcoidosis
Storage diseases (e.g., Gaucher disease)
Drug reactions

Remember: The age of the child, associated symptoms, and examination findings guide the differential diagnosis and further management.

Documentation of Lymph Node Examination in Pediatric Patients

Accurate and comprehensive documentation is crucial for monitoring changes over time and facilitating communication between healthcare providers.

Essential Elements to Document:

Location: Specify the anatomical region(s) where lymph nodes are palpable
Size: Measure and record in millimeters (e.g., 8mm x 10mm)
Number: Indicate if single or multiple nodes are involved
Consistency: Describe as soft, firm, hard, or rubbery
Mobility: Note if freely mobile or fixed to underlying structures
Tenderness: Record presence or absence of pain on palpation
Skin changes: Document any erythema, warmth, or other skin abnormalities
Symmetry: Note if bilateral lymph node groups are symmetrical or asymmetrical

Sample Documentation:

"Right anterior cervical chain with a single, mobile, non-tender lymph node measuring 12mm x 8mm. No erythema or warmth of overlying skin. Left anterior cervical chain without palpable lymphadenopathy. All other examined lymph node groups within normal limits."

Follow-up Plan:

Include a clear plan for follow-up or further investigations based on the examination findings:

Timeframe for reassessment
Indications for earlier review
Ordered investigations (e.g., blood tests, imaging studies)
Referrals to specialists if indicated

Viva Q&A

Q1: What are the major groups of palpable lymph nodes in a pediatric physical examination?

A: The major groups include cervical, axillary, supraclavicular, epitrochlear, and inguinal lymph nodes.

Q2: How do you differentiate between a lymph node and a lipoma on palpation?

A: Lymph nodes typically feel firm, mobile, and discretely shaped, while lipomas are soft, doughy, and less well-defined. Lymph nodes may be tender, whereas lipomas are usually painless.

Q3: What is the significance of finding a supraclavicular lymph node in a child?

A: Supraclavicular lymphadenopathy is concerning and may indicate malignancy, particularly lymphoma or metastatic disease. It warrants immediate further investigation.

Q4: How do you describe the size of a lymph node during examination?

A: Lymph node size is typically described in millimeters or centimeters. For consistency, use the longest diameter of the node. Some clinicians also use comparisons to common objects (e.g., pea-sized, grape-sized).

Q5: What is considered the upper limit of normal size for cervical lymph nodes in children?

A: In children, cervical lymph nodes up to 1 cm in diameter are generally considered normal. Nodes larger than this may warrant further investigation, depending on clinical context.

Q6: How does the lymph node examination differ between infants and older children?

A: In infants, lymph nodes are often more difficult to palpate due to subcutaneous fat. Examination should be gentle and may require distraction techniques. In older children, a more systematic approach can be used, similar to adults.

Q7: What characteristics of a lymph node suggest malignancy?

A: Suspicious characteristics include size >2 cm, firm or hard consistency, fixed/immobile, matted appearance, overlying skin changes, and persistent enlargement without signs of infection.

Q8: In which pediatric age group is generalized lymphadenopathy most common?

A: Generalized lymphadenopathy is most common in school-age children (5-12 years) due to frequent exposure to new antigens and infections.

Q9: What is the most common cause of cervical lymphadenopathy in children?

A: The most common cause is reactive hyperplasia due to viral or bacterial upper respiratory tract infections.

Q10: How do you differentiate between anterior and posterior cervical lymph nodes?

A: Anterior cervical nodes are located anterior to the sternocleidomastoid muscle, while posterior cervical nodes are behind it. The anterior nodes drain the mouth and pharynx, while posterior nodes drain the scalp and neck.

Q11: What is the significance of finding a Virchow's node in a child?

A: Virchow's node, an enlarged left supraclavicular lymph node, can indicate metastatic abdominal or thoracic malignancy. In children, it's rare but highly concerning when present.

Q12: How do you assess for fluctuance in a lymph node?

A: To assess for fluctuance, apply gentle pressure with two fingers. A fluctuant node will feel like fluid moving between your fingers, suggesting abscess formation.

Q13: What is the appropriate follow-up for a child with a single, small (<1 cm), mobile cervical lymph node?

A: If the child is otherwise well, reassurance and follow-up in 2-4 weeks is appropriate. Advise parents to return sooner if the node enlarges or if systemic symptoms develop.

Q14: How does cat-scratch disease typically present in terms of lymphadenopathy?

A: Cat-scratch disease typically presents with unilateral, regional lymphadenopathy, often in the axillary or epitrochlear area, corresponding to the site of the scratch. Nodes may become fluctuant.

Q15: What is the significance of finding epitrochlear lymphadenopathy in a child?

A: Epitrochlear lymphadenopathy is uncommon and may indicate systemic disease such as lymphoma, sarcoidosis, or infections like cat-scratch disease. It warrants further investigation.

Q16: How do you differentiate between reactive and malignant lymphadenopathy on physical examination?

A: Reactive nodes are usually tender, mobile, and soft to firm. Malignant nodes tend to be hard, fixed, non-tender, and may be associated with constitutional symptoms. However, definitive diagnosis often requires further testing.

Q17: What is the appropriate technique for examining inguinal lymph nodes in a child?

A: Examine with the child supine and relaxed. Use the pads of your fingers to palpate along and below the inguinal ligament. Note size, consistency, and any tenderness.

Q18: In a child with cervical lymphadenopathy, what associated symptoms would suggest infectious mononucleosis?

A: Fever, fatigue, pharyngitis, and possible splenomegaly in addition to cervical lymphadenopathy (particularly posterior cervical) are suggestive of infectious mononucleosis.

Q19: What is meant by "shotty" lymphadenopathy?

A: "Shotty" lymphadenopathy refers to multiple small, firm lymph nodes that feel like shotgun pellets under the skin. This is often a normal finding in children.

Q20: How does Kawasaki disease affect lymph nodes, and which nodes are typically involved?

A: Kawasaki disease can cause acute, non-suppurative cervical lymphadenopathy. Typically, at least one lymph node is >1.5 cm in diameter, usually unilateral and in the anterior cervical chain.

Q21: What is the significance of finding a Sister Mary Joseph node in a child?

A: A Sister Mary Joseph node is an enlarged periumbilical node. In children, as in adults, it can indicate metastatic intra-abdominal or pelvic malignancy and requires urgent investigation.

Q22: How do you assess for matted lymph nodes, and what is their significance?

A: Matted nodes feel like a cluster of fixed, inseparable nodes. They can be assessed by attempting to move individual nodes within a group. Matted nodes may indicate chronic inflammation, granulomatous disease, or malignancy.

Q23: What is the appropriate management for a child with bilateral, small (<1 cm) inguinal lymph nodes?

A: Small, bilateral inguinal nodes are often normal in children. If the child is otherwise well and there are no concerning features, reassurance and routine follow-up are appropriate.

Q24: How does HIV infection typically affect lymph nodes in children?

A: HIV can cause persistent generalized lymphadenopathy (PGL), defined as enlarged lymph nodes in two or more non-contiguous sites for more than 3 months, excluding inguinal nodes.

Q25: What is the significance of finding a Delphian node in a child?

A: A Delphian node is a palpable lymph node above the thyroid isthmus. In children, as in adults, it can indicate thyroid or laryngeal malignancy and warrants further investigation.

Q26: How do you differentiate between tuberculous and non-tuberculous mycobacterial cervical lymphadenitis in children?

A: Tuberculous lymphadenitis often involves multiple nodes and may have systemic symptoms. Non-tuberculous mycobacterial lymphadenitis typically affects a single node or group, is unilateral, and lacks systemic symptoms. Definitive diagnosis requires further testing.

Q27: What is the appropriate technique for examining axillary lymph nodes in a child?

A: Have the child relax their arm. Support their elbow and slowly lower the arm while palpating the axilla with your other hand. Feel for nodes in the central, lateral, and apical groups.

Q28: In a child with cervical lymphadenopathy, what features would suggest a need for immediate imaging?

A: Immediate imaging should be considered for rapidly enlarging nodes, nodes >3 cm, supraclavicular nodes, nodes associated with mediastinal widening on chest X-ray, or if there's concern for a deep space neck infection.

Q29: How does Kikuchi disease (histiocytic necrotizing lymphadenitis) typically present in terms of lymphadenopathy?

A: Kikuchi disease typically presents with tender cervical lymphadenopathy, often unilateral and posterior. Nodes are usually 1-2 cm in size and may be associated with fever and night sweats.

Q30: What is the significance of finding a Ruviere's node in a child?

A: Ruviere's node is the most superior node in the internal mammary chain. Enlargement of this node in a child could indicate intrathoracic malignancy or infection and warrants further investigation.