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What Causes Enlarged Lymph Nodes in Kids? · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Mike Smith (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:07
  Mike.
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  And with me is Dr.
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  Lori Morgan, a physician in hematology and oncology at Children's Mercy.
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  Today, we'll discuss lymphadenopathy, one of the most common yet anxiety-provoking
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  concerns in pediatric practice.
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  So Dr.
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  Morgan, welcome to the show.
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  I want to start off, you know, lymphadenopathy is one of the most
• 0:30
  common concerns in pediatric practice.
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  Can you first just run through what are some of the causes
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  that we should remember?
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  Dr. Lori Morgan:
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  Absolutely.
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  And thank you for having me today.
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  The far and away most common cause of lymphadenopathy in children is
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  infection, because our lymph nodes are comprised of immune cells.
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  And so, during an infection, they're going to enlarge as the
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  immune system mounts a response.
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  Host: Yeah, and that's where we kind of see the lymph nodes and the
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  lumps and the soreness and that kind of stuff on physical exam, right?
• 1:07
  Dr. Lori Morgan:
• 1:07
  Exactly.
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  Host: Yeah.
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  So, how long is it then, you know, for a general pediatrician—how long
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  is it reasonably to observe a child with some reactive lymphadenopathy
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  before getting really worried about it and moving on to the next steps?
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  Dr. Lori Morgan:
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  I think it can be a few contributing factors.
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  So, in addition to the timeframe, one of the most important pieces
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  is what is happening, if anything, to any nodes that we're seeing.
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  And so, if we see a child one day and their nodes are one centimeter
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  and then, a week later, they're two centimeters, that's a pretty remarkable
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  amount of growth in just one week.
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  Conversely, if a child has nodes that are there and they're not getting larger or
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  even getting smaller, and it's been a few weeks, they could continue to be watched.
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  So, I would say that it's a combination of the course of
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  the nodes and the overall time.
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  Host: You know, years and years ago, Dr.
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  Morgan, when I was doing some pediatric rotations in medical school
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  and learning more and more about the physical exam of a child, I came
• 2:18
  across a couple lymph nodes once.
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  And, you know, I got excited.
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  I found something, told my attending, and the attending was like, "Oh, we
• 2:25
  don't worry about those lymph nodes."
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  Are there any areas in the body that are just lymph nodes are so common
• 2:31
  that we don't really work them up?
• 2:33
  Dr. Lori Morgan:
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  I don't know that there's an area where I wouldn't work up a worrisome lymph
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  node, but where I do see them most commonly when they seem to be associated
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  with infection is in the neck, the jaw, so the submandibular, the submental,
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  the cervical nodes are quite common.
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  And a lot of times when kids come in, especially really thin kids, these nodes
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  just pop out, and they might look more significant than they actually are.
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  Host: How often does the parent find the node and then come into you?
• 3:10
  Dr. Lori Morgan:
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  I think that is the most frequent person to find the node because it's the parents
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  who are looking at their kids every day, if they're younger, giving them baths.
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  Sometimes in teens, older children, they might be the one to find
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  it, but it's typically someone in the family who notices it.
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  Host: So, what characteristics help you to distinguish between a benign lymph node
• 3:37
  versus something a little more serious?
• 3:40
  Dr. Lori Morgan:
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  One of the components that we talked about earlier, which is the course
• 3:43
  of the lymph node over time, is one of the most important pieces.
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  So if there's a lymph node that is progressively getting larger,
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  that is a worrisome lymph node.
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  If it's staying the same or even getting smaller, that's very reassuring.
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  And then, the physical exam is the other piece that's very helpful
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  for me when I'm considering someone who's seeing me for lymphadenopathy.
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  So, the size of a node, if it is greater than two centimeters, I
• 4:14
  start to worry a little bit more.
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  And then, the characteristics of the node on exam.
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  Worrisome findings would be a node that is firm, a node that is not mobile in
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  that it's fixed to the tissue below it.
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  And then also, a node that is nodular or has an irregular shape, unlike that sort
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  of rubbery, smooth, bean-shaped node that we tend to see in benign lymphadenopathy.
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  Host: How does pain play a role here?
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  Do you often find that the nodes that worry you the most maybe don't have pain?
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  Dr. Lori Morgan:
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  I think that if a node is painful, we could move a little bit towards
• 5:01
  the benign spectrum in our thinking.
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  A lot of times nodes that are painful, for example, those that a child might have
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  concurrent with a strep infection, they tend to be more in the benign category.
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  So yes, a painless node falls towards the side of the spectrum
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  that leans towards malignancy.
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  A painless node in and of itself, though, does not define malignancy
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  Host: Right.
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  So, when you are evaluating a patient and you feel there is some lymph nodes that
• 5:36
  are suspicious, what's your next move?
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  What are you going to do?
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  Dr. Lori Morgan:
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  So, the next thing that I want to do is get some imaging to get an understanding
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  of how many nodes are involved, where are they, and what are the characteristics.
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  And so, the best next step for imaging that I like is an ultrasound.
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  If someone's seeing me in the clinic for nodes that are noticeable, it
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  means they're likely on the surface or in a place that the ultrasound
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  can reach as opposed to being somewhere deep in the abdomen.
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  And what the ultrasound can do is show whether or not the architecture of the
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  lymph node has been maintained, if it has its fatty hilum, or if it looks like
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  it's more disorganized inside where we might be more concerned for a malignancy.
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  Host: And so, when you're doing the ultrasound, how often does that turn
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  into a biopsy right then and there?
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  And if that's often, how do you explain that to the family?
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  Dr. Lori Morgan:
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  Typically, when I see someone for lymphadenopathy, I like to set
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  expectations once I have a sense of their history and physical
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  of the possible next steps.
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  And so, I will always counsel them that we're getting the ultrasound.
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  And depending on what that shows, these are the steps we might take.
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  We might do nothing and I never see you again.
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  We might do nothing and I'll see you next week for another exam,
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  or we might go towards a biopsy.
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  Host: And if you feel like you want to move to some other exams, what are those?
• 7:16
  Dr. Lori Morgan:
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  So when considering the course of a lymph node, one of the pieces that can be
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  really helpful is having some continuity in the person who's examining the node.
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  Because if I evaluate a child and I'm the one who is palpating those lymph nodes, I
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  have a good sense of what they feel like.
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  So if I see them in another week or another two weeks and I'm the one who is
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  doing the exam again, I can tell what I think any changes might be versus having
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  different clinicians evaluating them.
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  So, I really like having that consistency.
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  Host: Yeah.
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  What about other physical exam findings that you kind of put together with
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  what you're thinking about this node?
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  You know, maybe you're suspicious about this node.
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  Are there some physical exam findings then that help you decide to move
• 8:06
  forward to imaging, et cetera?
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  Dr. Lori Morgan:
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  I think one finding that I pay very close attention to is the abdominal
• 8:13
  exam because I want to feel if there is any enlargement of the liver
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  or spleen, in which case I would, without a doubt, move on to imaging.
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  And then, I also try to palpate all of the lymph node chains that I'm
• 8:29
  able to on exam, so under their arms, in the inguinal region, and so on.
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  Because if I'm able to palpate enlarged nodes in more than one
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  chain and, in particular, above and below the diaphragm, that moves
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  me a little bit closer to imaging.
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  Host: Are there any labs that you often recommend in these situations?
• 8:50
  Dr. Lori Morgan:
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  Yeah.
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  So with labs, I'm looking for signs of cell breakdown and
• 8:56
  electrolyte abnormalities.
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  So, we look at the LDH to see if it's elevated, a sed rate if it's elevated.
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  It's not specific, but it gives us a sign into what might be happening.
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  And then, we also look for elevated uric acid and electrolytes that would
• 9:16
  go along with tumor lysis syndrome.
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  And then, of course, we love getting CBCs.
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  And with the CBC, I'm looking for any signs of marrow disruption.
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  So, that would be extremes in the white blood count, very high or very
• 9:31
  low, along with a low hemoglobin, low neutrophil count, or a low platelet count.
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  Host: So Dr.
• 9:38
  Morgan, what advice would you like to give primary care providers
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  about balancing, you know, the reassurance with early identification
• 9:47
  of what could be serious disease?
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  Dr. Lori Morgan:
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  I think what primary care providers can do is have this long-standing
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  relationship with their parents and families so that they're able to navigate
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  some of these conversations that might be a little bit scary for families
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  or even a lot scary for families.
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  So, I think being reassuring that infection is the most common cause
• 10:14
  of lymphadenopathy in children.
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  But if we're concerned, let's bring you back in a week, let's bring you back in
• 10:20
  two weeks, and these are the things that I would want you to call me for in between.
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  So, the most important piece being maintaining evaluations of the
• 10:30
  patient and letting them know that they are being followed and that
• 10:34
  this issue is being taken care of.
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  Host: You know, Dr.
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  Morgan, as a specialist in the field of hematology, oncology, is
• 10:42
  there anything that you're really excited about in terms of innovation?
• 10:46
  Dr. Lori Morgan:
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  Oh, absolutely.
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  I think that I am living at a time of leukemia lymphoma treatment that
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  has enormous potential to change the face of how we treat children
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  with these types of cancers.
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  Only a couple of years ago, we had a breakthrough in our standard
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  treatment for our most common type of leukemia, which is an immunotherapy
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  as opposed to chemotherapy.
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  We are seeing and will continue to see more and more incorporation of
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  immunotherapy using the immune system to fight cancer as opposed to these
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  very toxic chemotherapies that we've been using for so many decades.
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  And I'm thrilled to be able to practice in a time where we
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  are actively seeing that shift.
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  I think it's very exciting and, more importantly, very inspiring.
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  Host: Fantastic.
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  I love it.
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  Listen, I'm on board.
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  I think immunotherapy, the body has great defenses, right, Dr.
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  Morgan?
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  We just got to learn how to use it better, utilize it, right?
• 11:57
  Dr. Lori Morgan:
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  Yes.
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  Host: Yeah.
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  I think that's fantastic.
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  Thank you so much for coming on today.
• 12:01
  This has been great information.
• 12:03
  Hey, don't forget, you can claim your CME credits after listening to this
• 12:06
  episode by visiting cmkc.link/cmepodcast
• 12:13
  and clicking the Claim CME button.
• 12:17
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• 12:24
  This is Pediatricists in Practice, a CME podcast.
• 12:28
  I'm Dr.
• 12:28
  Mike.
• 12:29
  Thanks for listening.