The document outlines the examination and characteristics of lymphadenopathy in children, including normal lymph node sizes by region and indications for further investigation, such as size and specific lymph node locations. It describes the examination process step-by-step, emphasizing the need to check vital signs, assess growth parameters, and conduct thorough palpation of all relevant lymph node groups. Various causes of lymphadenopathy are also detailed, along with physical characteristics of pathological nodes, to help determine underlying health conditions.

1. Lymphadenopathy

2. • Lymph nodes reach the largest total lymph node mass at the age of
about 8–12 years and start to get reduced with atrophy after
adolescence. Therefore, in young children, 2 cm in the neck, 1 cm in
the axilla, and 1.5 cm in the inguinal region are normal values, and
they do not require investigation.
• Epitrochlear and supraclavicular lymph nodes need further
investigation, as they may be related to malignancy, even if they are 0.5
cm or less in size.

3. Examination
• INTRODUCE YOURSELF AND DO PROPER EXPOSURE
• OBSERVE FOR 30 SECONDS

4. Observe for
• Do the preliminary observations of whether the child appears well or
unwell.
• Check the growth parameters of head circumference, weight, and
height.
Unwell children may have infective or infiltrative conditions. For
example, children with Kawasaki disease are remarkably irritable.
Underweight children may have immune deficiencies, chronic
diseases, or malignancy. Overweight children may have hidradenitis
suppurativa (axillary adenopathy in the obese).

5. • Note any pallor (e.g. ALL), ecchymoses, purpura or petechiae (e.g.
ALL, AML).
• Scan the skin; children with atopic dermatitis often have
lymphadenopathy.
• Stand back and look for any asymmetry in the head and neck, and
quickly scan for goiter.

6. Approach the child
Check the vital signs
fever and tachycardia may accompany infective or infiltrative
diagnoses; BP may be elevated with certain tumors and connective
tissue disorders with renal involvement or decreased with sepsis or
Addison disease; pulse pressure may be widened in hyperthyroidism;
respiratory rate may be elevated with infective or infiltrative conditions.

7. Examine all the lymph node groups

8. Cervical lymph nodes
• Begin beneath the chin (submental lymph nodes), then move
posteriorly beneath the jaw (submandibular lymph nodes), move
upwards at the angle of the mandible (tonsillar and parotid lymph
nodes), and examine anterior (preauricular lymph nodes) and behind
the ears (posterior auricular lymph nodes).

9. • Palpate the posterior border of the sternocleidomastoid (posterior
cervical chain) to the mastoid process, then down the anterior border
of the sternocleidomastoid (anterior cervical chain) to the clavicle.
• Perform palpation over the occipital protuberance (occipital lymph
nodes).

10. • Instruct the patient to tilt their head (bring their ear towards their
shoulder) on either side and palpate at the back of the posterior
border of the clavicle inside the supraclavicular fossa (supraclavicular
and infraclavicular lymph nodes).

11. If the finding is cervical nodes only, the head and neck need to be examined
thoroughly.
o The ears, nose, and throat must be examined with the auroscope, including
carefully inspecting the teeth and gums.
o If any teeth appear carious, then wear gloves to palpate them for tenderness.
o Look at the external aspects of the eyes, for conjunctivitis (which can occur
with Kawasaki disease, Parinaud's oculo-glandular syndrome [with
preauricular lymphadenopathy] or leptospirosis), and for Horner's syndrome,
which can occur with neuroblastoma.
o Inspect and palpate the scalp for infected areas (hiding under the hair, such
as tinea capitis or a kerion).

12. Check epitrochlear lymph nodes
1.Using your corresponding hand, grasp the wrist of the side to be
examined (i.e., right to right).
2.Grasp behind the olecranon process with your opposite hand's
fingers. Palpate the inside aspect of the arm immediately above
the medial epicondyle of the humerus with your thumb over the
crease of the elbow.
3.Look for lymphadenopathy, which can be caused by metastatic
melanoma in the arm, or diseases that cause generalized
lymphadenopathy.

13. axillary nodes
oWhen inspecting the right axilla, take the patient's right
forearm in your right hand and advise them to relax it
completely, letting you support their weight. This relaxes
the axillary muscles.
oThe left hand should then be used for palpation. When
examining the left axilla, the procedure is reversed.
oThe axilla should be examined for lymph nodes in the
pectoral (anterior), central (medial), subscapular
(posterior), humoral (lateral), and apical groups.

14. Inguinal and subinguinal lymph nodes
o Request the patient to remove their pants and underwear to
reveal the inguinal region.
o Tell the patient to lie flat on the bed.
o Examine the area for any noticeable swellings or abnormalities.
o Assess the horizontal group of superficial inguinal lymph nodes by
immediately palpating inferior to the inguinal ligament (anterior
superior iliac spine and pubic tubercle).

15. For any palpable lymph node access
o Site: evaluate the lymph node's location in relation to other anatomical
structures.
o Size: evaluate the size of the lymph node.
o Shape: evaluate the lymph node's borders to determine if they feel
regular or irregular.
o Consistency: decide if the lymph node feels soft, hard, or rubbery.
o Tenderness: take note of if the lymph node is tender on palpation.
o Mobility: evaluate if the lymph node feels mobile or is tethered to
other local structures.
o Overlying skin changes: notice any overlying skin changes such as
erythema.

16. Examine the skin for any local lesions (such as herpetic infections [HSV I
or II, HVZ], cat-scratch disease's papular lesions on hands/ fingers
[Bartonella henselae], any inflamed areas, reddened, cellulitic, or
purulent from staphylococcal or streptococcal infection; any
generalized rash [rubella classically causing suboccipital
lymphadenopathy; Kawasaki disease can have many types of rash; SLE
causes a malar rash]) or discoloration over the nodes themselves
(purplish discoloration classic for MAIS).

17. • Examine the chest for any evidence of asthma (for underlying Churg–
Strauss syndrome, or diffuse pulmonary Langerhans cell
histiocytosis) or histoplasmosis (from inhaling fungal spores,
Histoplasma capsulatum).
• Examine the abdomen for hepatosplenomegaly (Malignancy
[neuroblastoma, lymphoma], ALL/AML, Toxoplasmosis, CMV,
Connective tissue disorders, HIV, EBV, Syphilis).

18. Examine the musculoskeletal system looking for: skeletal tenderness at
the sternum, clavicles, ribs, pelvis, tibiae (tibial infiltrates); joint
tenderness; swelling; or decreased range of movement (ALL, AML, JIA).

19. A brief list of typical causes for typical locations of nodes
• Cervical:
1. oropharyngeal/scalp infection (viral [usual URTI pathogens, EBV, CMV, HSV, HHV-6],
streptococcus, staphylococcus, mycobacteria [TB, MAIS]).
2. cat-derived: cat-scratch disease; toxoplasmosis.
3. Kawasaki disease.
4. Dental caries (an infectious dental hard tissues, decalcification of inorganic parts of the
tooth, then a breakdown of the organic matrix, dietary carbohydrate-modified, saliva-
regulated).
• Supraclavicular:
1. (a) left side: intraabdominal malignancy; (b) right side: intra-mediastinal malignancy or
infection.
2. Lymphoma.
3. TB.
• Epitrochlear:
1. hand or arm infection.
2. Cat-scratch disease.
3. Lymphoma

20. • Axillary:
1. arm or chest wall infection or malignancy.
2. Animal-related: cat-scratch disease; brucellosis.
3. Lymphoma/leukemia.
• Abdominal:
1. malignancy.
2. TB.
3. Mesenteric adenitis from Yersinia enterocolitica, group A streptococcus or
measles.
• Inguinal:
1. lower limb suppurative infection.
2. Perineal/Genito-urinary/venereal infection.
3. Malignancies (rhabdomyo- and non-rhabdomyosarcoma; Hodgkin's and non-
Hodgkin's lymphoma, neuroblastoma).
• Popliteal: foot or leg infection.

21. Physical characteristics of pathological nodes
•
Acute inflammation (acute lymphadenitis) causes a red, hot, tender, swollen lymph node. In
addition, there may be secondary torticollis (wry neck) due to reflex spasm of adjacent muscles,
especially the sternocleidomastoid muscle, such that any movement of the neck is painful,
whether active or passive.
• Acute lymph node abscess presents as a red, hot, tender swollen node that can fluctuate has
been enlarging over a few days, and may point, and then discharge pus. These are often seen in
children between 6 months and 3 years of age.
• Atypical MAIS (subacute) lymphadenitis causes swollen nodes with purple skin discoloration
overlying them, with low-grade inflammation. They tend to be soft, they may be matted, and
they are often not tender. In addition, there can be an underlying collar-stud, 'cold' abscess
(although cold means normal body temperature). These typically present in a 1–2-year-old child
for 1–2 months. If a lymph node drains spontaneously or develops a fistulous tract, this infers a
MAIS infection, particularly if it takes a few weeks to form, whereas a fast-developing abscess
that drains suggests either staphylococcus aureus or streptococcus pyogenes.

22. •
Reactive hyperplastic nodes present with swelling are non-tender and can be up to 3 cm in
length, although if nodes of this size are noted, excisional biopsy is often the management plan if
these are present for 4–6 weeks. Reactive hyperplasia typically occurs with common upper
respiratory tract infections.
• Neoplastic (malignant) diseases typically cause rubbery, firm, or stony nodes, usually neither
tender nor discolored. Lymphoma and chronic leukemias tend to cause firmer nodes than
leukemia. However, hemorrhage within such a node can cause tenderness and/or discoloration;
immunologic stimulation and certain malignancies can also cause tenderness, so the presence or
absence of tenderness is not very discriminatory.
• Malignant nodes can be shotty and discrete in early stages, becoming fixed to underlying
structures or matted together when the diagnosis is made.
o Primary lymph node tumors, often in cervical nodes, include Hodgkin's and non-Hodgkin's
lymphoma.
o Again, secondary lymph node tumors in cervical nodes include neuroblastoma, thyroid tumors, or
nasopharyngeal tumors.