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When to Worry: Neck Lumps, Bumps, and Enlarged Lymph Nodes in Kids · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Okay. Oh, I've been making the peanut butter sandwiches, by the way,
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bringing those and fruit instead of getting fast food, except for occasionally.
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Just FYI. You're trying your best. Yes.
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We know nobody's perfect. Yes. Although the place I took my daughter yesterday,
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it's this Mediterranean place they have. Have you seen?
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It's like, it looks like fruit, but it's actually a cake with chocolate and
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lots of stuff in it. So like mango, apple, a giant strawberry.
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People were in line waiting to buy these, what looks like fruit,
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but it's not at all fruit.
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Wow, they're trying to fool us. Yeah, and it's very, it's viral,
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I guess, is what my daughter said.
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Okay, I want to know about this place. Okay. I'm Holly Wehment,
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and this is Pediatrics Now, brought to you by the Department of Pediatrics at
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UT Health San Antonio and University Health.
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Today, we're talking about a scenario that pediatric practitioners frequently encounter, children,
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adolescents, and young adults who present with a new lump, bump,
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or an enlarged lymph node, and the challenge of knowing when to reassure,
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when to observe, and when to refer.
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Joining me back on the show today is pediatric oncologist with UT Health San
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Antonio and University Health, Dr.
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Shafka Shah, who has more than 20 years of experience.
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Dr. Shah, thank you so much for being here today back on Pediatrics Now. It's my pleasure.
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So when a child presents with a lump or bump, what features help you distinguish
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between something that's likely reactive versus something that raises concerns for malignancy?
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So this is actually a very common scenario for general practitioners.
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It's truly estimated in the lifetime of a child that 90% of children will have
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some lumps in their neck at some point.
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And in many cases, you can identify a recent infection or an illness of some
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kind that the child has had.
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So they may have had an ear infection.
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Maybe they've had strep throat.
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Maybe they've had a viral illness
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and have had fevers, respiratory symptoms, a little bit of a cough.
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If that history and examination supports a recent infection,
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in most situations the lymphadenopathy that you can feel in the neck is going
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to be related to that infection.
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So timing is obviously very important.
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If you are noticing all these respiratory symptoms and a fever and are palpating
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the neck and you feel a few lymph nodes, usually that's something that you can
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treat the infection, observe if it's a virus,
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offer antibiotics if it's a bacterial infection that you suspect,
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and reevaluate the child in a couple of weeks.
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Shafgad, that's great information. Let's talk about size, firmness, fixation.
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So those are all important features to note when you're examining the child.
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Typically, you'll feel one or two lymph nodes.
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They may be on both sides if it's a viral illness, or one side perhaps if it's
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related to an ear infection.
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They're usually fairly small, less than two sonometers, so less than the size of your finger.
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And they typically move. So if you can move them around very easily and they're
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not described as being extremely firm, rubbery.
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Or matted, those would be adjectives that would describe lymph nodes that may
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not be just related to an infection.
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And what is the, can you tell us the measurement again? So usually,
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depending upon the location in your body, anything over two centimeters would
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be considered abnormal.
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Granted, some patients that have infections, they may have pretty significant
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lymphadenopathy in their neck, and it may become two sonometers and then it may go away.
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So it would be more concerning if it was persistently enlarged.
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Now, in very young children, even one sonometer might be considered abnormal
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and it would be something that you would want to follow up on if it's,
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you know, a child under five years of age.
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In other locations, such as in the supraclavicular area, which sits just above your clavicle,
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That is a location where it's uncommonly associated to be with an infectious
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origin, but could be related to a process going on in the chest.
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So that raises a suspicion of something perhaps more serious than a typical
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viral respiratory infection or an ear infection.
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So then is it time to get an x-ray, a chest x-ray?
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So lymphadenopathy in the supracavicular area, you have to take very seriously.
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And you would want to go ahead and send the child for a chest X-ray,
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looking for possibly an infection or possibly even a mass in the chest.
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What about if it's the size that you mentioned or less than that,
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and it's not getting bigger?
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So you could perhaps watch that child a couple more weeks and see that child back.
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And most people would say somewhere between four and six weeks is when a typical
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reactive lymph node would be improving or be resolved.
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And during that interim, if you see the child back and the child is having perhaps
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new symptoms, maybe they're not feeling so well, they've been tired,
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maybe they've been running more fevers,
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you know, if there's a weight loss, if there's other concerning signs,
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then you would want to make sure that there isn't a sign of either a systemic
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infection or maybe perhaps, you know, sign of a leukemia or lymphoma type process.
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So resolution of the symptoms, you know, after four to six weeks is reassuring.
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If it, you know, if things are not improving and you don't have an explanation
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for those lymph nodes, then the next steps would be doing laboratory work and
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considering that chest X-ray and that ultrasound of the lymph node itself.
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What about a small lump at the base of the neck?
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So especially young children, we do see that at the base of the neck,
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the lymph nodes that sit in the occipital area, they drain the scalp.
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And so a common skin infection on the scalp, such as a tinea fungal infection,
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could easily drain and cause an enlargement of lymph nodes.
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Now, if that's the only location, you know, you could certainly observe it,
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make sure that there's no sign of infection on the scalp.
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See that patient back. And again, within the two, four-week period,
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if there's resolution, then you can be happy that that was just a reactive process.
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If not, then I think you have to consider further evaluation.
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So if it's getting smaller or completely gone, it was reactive.
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And then what if it doesn't hurt, though?
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Is that less concerning?
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So the pain may be associated with an infectious process.
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Typically, if it's an infection and an abscess is starting to form,
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that's when, you know, most patients will have significant tenderness.
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And so that would be a prompt that perhaps you need to do an ultrasound on that patient.
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And if the ultrasound tells you that there's some fluid filling in there,
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you know, perhaps that would be a question to ask a surgeon to go after and
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relieve the pressure in there and send fluid off for culture.
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That would be, you know, a very common scenario that we see in pediatrics.
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Painless lymph nodes, certainly as an infection is improving and going away,
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maybe a viral illness. You know, you may have some painless,
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but again, over several weeks, the lymph node size should be improving and should be resolving.
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So if it's painless and then getting maybe more fixed, more matted,
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more rubbery, you know, that's when you would be worried more about a neoplastic
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process or perhaps a chronic viral infection.
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And if there's no fever, though, is that more reassuring?
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Um, it could be reassuring if you, if you had a obvious infection in the throat,
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you know, maybe you saw an exudate or on your ear exam, you were convinced that
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there was a new effusion and the patient was having ear pain,
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you know, that lymph node and the fever could be all related to that infection.
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But if the, you know, fever initially went away and then comes back,
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then, you know, perhaps there would be another secondary reason for it.
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So that could be that abscess or could be a more neoplastic or rare infection
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that you have not treated appropriately.
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Shafka, before a patient is sent for biopsy, what baseline studies do you want
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clinicians to obtain, and why are those studies so important?
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So doing a biopsy in a child, you know, I think oftentimes will require some
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sedation and some guidance, and so it's
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not an easy thing to send like a three-year-old for a lymph node biopsy.
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So, you know, I think you have to be sure that you have a certain sense of what
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the differential diagnosis is.
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How seriously ill does the child look?
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You know, is this something that requires maybe a consultation with other providers,
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such as infectious disease or cardiology?
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If there's an unusual rash, here's a dermatologist indicated.
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It um sometimes children just are are ill appearing enough that it makes sense
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to go ahead and send them to a emergency room and have um,
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in a consultation with others as well. But if the child is otherwise well-appearing,
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is still eating well, has been able to go to school, and the lymph node is the only thing,
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left, and you haven't been able to sort out a great explanation for it,
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a good place to start would be a CBC differential and asking the pathologist
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to look at the cells under the microscope to make sure whether there are any
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unusual-looking cells or if the cells look,
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frankly, just reactive, like they are reacting to a viral illness or a bacterial
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process, that can be reassuring.
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And other tests that may be helpful would be an LDH, liver function,
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kidney functions, those would be reassuring.
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And to tell you that there isn't organ involvement in this patient,
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doing a SED rate or a CRP to look for signs of inflammation may be helpful.
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If they're very high, then you might be more concerned and want to reach out
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to some of your colleagues to make sure you're not missing anything.
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Those things are very important. However, if you're to the point where you're
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very concerned and you think the child needs to have a surgical procedure,
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a chest x-ray is extremely important because if there's lymph nodes in the neck,
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there may be enlarged lymph nodes in the chest.
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And if you're going to sedate the child and there's a chest mass,
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that could lead to an airway emergency.
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So a chest x-ray would be, I think, ideal.
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And most anesthesiologists, I think, if they were involved in the case,
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would want to have a chest x-ray
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before sedating a child with significant lymphadenopathy in the neck.
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Shavka, this is also helpful. Are there situations where biopsy should be delayed
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or avoided based on initial results? I know you touched on, especially in young
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children, sedation would be needed.
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So, you know, I think, you know, for a pediatrician, they're not the ones that are doing the biopsy.
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So they're either going to be calling their pediatric surgeon or maybe sending
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the patient to the emergency room.
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So there will be plenty of opportunity to kind of discuss the case with other
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people and bounce ideas off of them. And I think that's something that is valuable.
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I think for children who are kind of in the school age range,
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they may be getting exposed to viruses like EBV or CMV.
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You know, those infections can be associated with lymphadenopathy and fever.
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And so perhaps sending titers and blood work to rule out those viruses would be helpful.
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Talking to the parents and making sure there, you know, perhaps there was some
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other exposure that could have led to an infection.
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You know, we have a lot of families that have ranches and the children are out
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and may have been exposed to, you know, infections perhaps from other animals or the dirt,
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mycobacterial infections or couch scratch disease, toxoplasmosis.
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All these infections are associated with lymphadenopathy.
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And so sitting back and asking about some new cats in the family, perhaps,
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you know, getting exposures like that sorted out can perhaps offer you some
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other tests to do if you're in a situation where you're not 100% certain as to what the next step is.
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Would cat scratch disease, would there be other symptoms or could it be just a lump?
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It could really just be a lump. Many children will have some fever around the
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time that they're developing the lymphadenopathy, but oftentimes the fever is
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not very high by the time the lymphadenopathy is discovered.
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They can also have some changes in the liver and the spleen that are very characteristic
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on imaging, so an ultrasound might be helpful with that.
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But typically, you can get a history of exposure, perhaps, with a kitten,
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typically, that has been scratching the child.
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Oftentimes, children hold young animals at their neck line, and it's easy to get a scratch.
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And so if you have that kind of clear history, I think sending titers for cat
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scratch would be helpful.
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Is it important, Shafka, to treat cat scratch disease? Yes, yes.
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You'll have definitely resolution of the symptoms much faster.
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So you would want to have antibiotics on board.
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Can you tell us, Shafka, can you walk us through the pros and cons of fine needle
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aspiration versus excisional biopsy in pediatric patients with enlarged lymph nodes?
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So this is an issue that comes up for us all the time.
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I mean, we accept patients from all over the South Texas area.
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And so some children may have already come from a primary care practice that,
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you know, perhaps did all the lab work, didn't get an answer,
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didn't have a clear-cut infection, and the lymph nodes are still enlarged a month later.
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They've gone ahead and done a chest X-ray and an ultrasound.
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And maybe even in radiology, a little fine needle was obtained.
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And many times, I would say about half the time, the information from the fine
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needle is fairly limited.
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So I think if you're in a situation where, you know, you really are thinking
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more of abscess and infection, a fine needle is a reasonable next step.
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And, you know, sometimes you can coach young children to get those performed
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without full-on anesthesia.
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However, if you're really a little bit more concerned and you're thinking about
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more of a rare infection or possibly a malignancy, you're going to need more
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tissue in order to establish that diagnosis.
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So it would be important to go ahead and remove the lymph node in its entirety.
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And that's when we usually consult with our pediatric surgeons who are very
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good at understanding what we're trying to do.
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And our ENT surgeons as well also understand that, you know.
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If they're going to go in there, they may as well get whatever lymph node is abnormal.
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So we can get sufficient tissue to either rule in a malignant process or rule out.
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If you don't have enough material, when we see these patients,
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we often end up having to do a second procedure.
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Which has delayed the diagnosis, unfortunately. So in pediatrics,
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we definitely err more on the side of taking the entire lymph node out.
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If we have run through, you know, the four-week period and we don't have a great
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explanation, the lymph nodes are still abnormal in size or perhaps getting more matted.
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The child is not, you know, looking 100% well.
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You know, I think you will get much more information by removing the entire lymph node.
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And then the pathologist can go ahead and do all the tests that they need in
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order to give us the best answer.
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And sometimes in my experience, the answer turns out to be cat scratch disease,
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which is great because that's something that the child will recover from. Yes.
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But it can be difficult to make, you know, diagnosis, sometimes the blood work
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is not, you know, 100% sensitive.
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So, you know, in the best of stories, you know, you help make a diagnosis through
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appropriate testing that the pathologist can complete.
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But in other situations, if you are thinking of some kind of a cancerous malignant process,
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there's a lot of tests that the pathologist will need to do in order to figure
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out not just the diagnosis, but the subtype and any other biological features
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that will help us decide what the best therapy is for that child.
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Shafka, as we know, steroids are commonly prescribed for upper respiratory infections
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with enlarged lymph nodes.
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What should clinicians keep in mind before starting steroids in these patients?
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So this is also another scenario that we run into because, you know,
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obviously many children have allergies and asthma, especially here in San Antonio.
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There's a lot of allergies year-round, it seems.
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And, you know, they're going to their PCPs all the time with cough and can be
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difficult to sort out whether, you know, the child is having an exacerbation
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of their respiratory illness from their baseline or if this is a new viral illness.
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And, you know, I think if they have especially a croupy cough or wheezing on
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exam, oral steroids may be prescribed.
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And I think, unfortunately, if the child has more of a malignant process,
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the steroids can actually help treat, you know, the lymphoma and the lymph nodes
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will go away temporarily and you will have masked what's actually happening in the child.
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So I think most pediatricians are fairly sensitive to that.
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I think we run into that more when we have the older teens, adolescents perhaps,
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that are going to urgent care.
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You know, in those situations, oftentimes adult providers are seeing those patients
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and they're much more likely to use steroids for, you know, for example,
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a bronchitis or something like that.
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So most pediatricians will think twice
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before they use steroids in a child especially if
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they don't have a great history of asthma and you know it's not in an age range
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where they expect to see croup you know they would consider doing that chest
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x-ray making sure they're not missing something going on in the chest a pneumonia
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or other infectious process or a chest mess per se so I think,
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It's wise to really consider what the guidelines are for treatment of these
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respiratory infections.
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And, you know, if there's true airway issue, we obviously want everyone to use
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the steroids if it's indicated.
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So, but, you know, typically that kind of a child should, you know,
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be seen in the emergency room where it can be monitored and make sure that they're improving.
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Or they may need other kinds of treatments in addition to the steroids.
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So I know steroids can make you feel better fairly quickly, and they can make some symptoms go away.
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And so we definitely see that from time to time where a lymphoma was brewing.
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You know, the patient was given steroids for a persistent cough.
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And, you know, a couple weeks later, they're worse, and the chest X-ray is done,
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and there's obviously a big mediastinal mass at that time.
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So, you know, I think, you know, trying to put it all together and making sure
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whatever treatment that you're justifying appropriately is my best advice.
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And, you know, obviously trying
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to make sure the child is being seen by somebody that knows them well.
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So someone that can say, yeah, this kid every winter, he ends up wheezing.
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And, you know, no matter what aerosols we give him, he's going to end up having
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an exacerbation. and need the steroids.
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I mean, I think that's a situation where the pediatrician knows that child and
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feels that he can be more confident in using that as a treatment strategy.
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But you do have to be careful because steroids are very powerful medications.
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And they can lower the immune system? They can if they are given for a long period of time.
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But I think in the setting of like an acute infection, we oftentimes will use
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some steroids to reduce the inflammation.
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So that's something that definitely, even for the infectious disease perspective,
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you know, would be considered rational in some scenarios.
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But you don't want to continue steroids for weeks on end. I mean,
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that would not be standard of care.
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You would definitely want to be speaking to, you know, pulmonologist,
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infectious disease specialist,
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maybe a, you know, immunologist, allergist to kind of see if there's potentially
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better treatment options than just the steroids.
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We have so many new medicines out there that we don't typically use lengthy
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courses of steroids anymore.
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Shavka, what advice do you have for clinicians who feel pressure to treat symptoms quickly.
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So that is a very challenging discussion that you have with the parents.
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I think we're definitely in an era where parents want to hear your rationale
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and they want to know what they should do if things aren't better in two days
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and parents have to miss work.
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You know, I think there have been better studies on, you know,
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the typical course of what a respiratory virus infection looks like.
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And so most patients will start to feel better in three or four days.
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And if they're not, then I would say, then you definitely need to see that child back.
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You know, perhaps it is more of a bacterial process that needs antibiotics.
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But even today, you know, guidelines for patients with uncomplicated ear infections
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do suggest just observing them, not necessarily rushing to antibiotics.
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As many of these infections are associated with viruses, that not every ear
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infection is a bacterial process.
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So I think the difficulty lies if we give antibiotics to every upper respiratory
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infection, you are going to definitely run into resistant organisms.
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And we know that there's a lot of research that has shown even a single dose
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of antibiotics can alter your normal bacterial fungal flora in your body.
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And that imbalance that's caused by inappropriate use of antibiotics could lead
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to rare, more difficult, challenging infections in the future.
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So, you know, we don't want to alter the flora of bacteria and fungi in our bodies unnecessarily.
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And we had a very, actually, insightful grand rounds recently by one of our
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infectious disease experts that talked about trying to decide exactly how many
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days of antibiotics is needed. So I think.
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We need to keep that in mind, that antibiotics do have side effects.
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And one of them is really causing an imbalance of the normal bacteria that live
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in your own mouth, your intestines, your skin.
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And disturbing that balance can potentially be risky in developing things like
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allergies and eczema, you know, other conditions.
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So I think as a pediatrician, you can sit and talk to your families.
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That every decision that you're making, you're trying to make it in the best
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interest of the child with the caveat that if things are not improving within
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a few days, then obviously you want to see that child back.
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And we'll try to run that grand rounds on pediatrics now.
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I think you're talking about the talk by Dr. J.B. Canty about antibiotics in the NICU.
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And he's been on the show several times, and that was a great talk. So, yes, yes.
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Shafka, at what point would you prefer a phone call rather than an electronic referral or a text?
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So, I think I just got a phone call about a week ago. And I know you freely
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give out your cell phone number to community pediatricians, which I love.
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I think that's so crucial.
26:00
And you see patients at our clinic in University Hospital, the pediatric oncology
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clinic I wanted to mention before we forget that.
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Yeah, so I'm on call about every six to seven weeks.
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And so during that week, I'll be fielding all kinds of phone calls from people out in the community.
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And it's nice to hear because, you know, some of them are former residents or
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they perhaps have worked with us in different settings. And so it's nice to see what they're up to.
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And so, you know, some of those people are pretty sharp. So if they're calling
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me, that already, you know, has my suspicion raised, you know,
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that sounds concerning. If such and such Dr.
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Bushman is calling me, that means that I probably should pay attention. Mm-hmm.
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I think, again, the characteristics of the lymph nodes are important.
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So if they're telling me that they're fixed, they're matted,
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they're actually not very tender, and the child's had them for several weeks
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already, I think that's a child that we want to try and work in within the week.
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If the child is having any respiratory symptoms or fever and is not looking
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well, you know, those children probably should go to the emergency room and
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not wait for us to assess. They probably need a test x-ray, blood work.
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Making sure that their signs of inflammation are not getting worse.
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I think, you know, for a patient that is having any of those systemic issues,
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like their appetite is not good, they're losing weight,
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you know, those are concerning features for us in terms of a more systemic illness or malignancy.
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So, you know, those would be other signs that we would want to consider evaluation
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more readily, try to expedite them into our clinic.
27:45
Shafka, we hear a lot about patients getting lost between pediatric and adult
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systems. I know pediatric clinicians see this a lot.
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How does this affect oncology patients, particularly those between 18 and 25?
28:02
Yeah, so I would say most pediatric practices, you know, they start to have
28:07
these transition talks with the patients around 15,
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16, to try to encourage them and the parents to figure out where are they going
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to take them when the child turns 18, 19.
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And many practices, I know if the child has had a fairly complicated history,
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they may hold on to them a little bit longer.
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Or if they live in a part of the state where there are just not a lot of providers,
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they may, you know, hold on to them till 19, 20.
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You know, but honestly, around that age range, they oftentimes end up being
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seen by adult providers.
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And adult practice is very rapid fire.
28:45
They're so overwhelmed. A lot of times, you know, I feel like children transitioning
28:52
through those age ranges into teens and young adults, they oftentimes,
28:56
you know, may come across as a little bit shy.
28:59
They don't know how to present their symptoms well.
29:02
They probably don't want to go to the doctor, honestly, but their family is
29:06
telling them they should go to the doctor.
29:08
And we've definitely had some experience recently with a young man who was having
29:13
lymph nodes in the neck. And he just didn't have any insurance.
29:17
And his sister had been telling him, go to the doctor, go to the doctor.
29:21
And he was treated with a couple courses of antibiotics.
29:25
And then the doctor told him, look, it's just not getting better.
29:28
You have to go to the emergency room. And he was afraid to go to the emergency
29:31
room because he wasn't sure how he would pay for it.
29:35
He was working full time, a young 20-year-old man. But I'm glad he went.
29:41
And he ended up getting a chest X-ray and he had lymphoma in his chest.
29:46
So, you know, these are things that we see multiple times a year.
29:50
Unfortunately, I think it's hard for people in that age range to maintain insurance
29:56
once they're off their parents' plan and if they're not in college.
29:59
And so, you know, I would just say that as a parent myself, you know,
30:04
we do quite a bit of helping, trying to get our kids to the best health care providers that we can.
30:14
But, you know, I think at some point, you know, they will become independent.
30:18
And it's great if the pediatric practice has been kind of teaching them,
30:23
like, how to present themselves, how to call for an appointment.
30:26
You know, all these are real-world duties.
30:30
But a lot of kids these days, they would rather not have to make those phone calls.
30:36
They'd rather do things online. And I do worry that, you know,
30:41
when symptoms are not getting better, they don't get addressed in a speedy fashion,
30:47
you know, when they're on the adult side.
30:49
You know, I think when a practitioner calls me.
30:54
I'm fortunate in that we work with the PDER so closely here that I can ask the
31:00
PDER doctors to evaluate a patient that I'm concerned about.
31:04
And so I can have that discussion directly with the ER, and I'm happy to do
31:09
that if it seems like a situation that's already been lingering for a while
31:14
and I don't want any further delays.
31:16
Maybe it's a Friday and the young adult can't come to our clinic for a few more days.
31:24
You know, I think I'll cash in a few favors at that point.
31:29
Shafka, it's such an honor to talk to you today. If pediatricians take away
31:34
just one message about evaluating lymphadenopathy and avoiding missteps before
31:40
referral, what would you want that to be?
31:43
What I would say is that if at all possible, it is great to follow up with the patient.
31:49
So if it's a patient that you are convinced is that you're infection,
31:54
you're going to give them antibiotics and you know the mother will call you
31:57
if things are not better, fine.
32:00
Don't call her two weeks later. But if it's a family that you do worry about,
32:04
the parents work all the time and, you know, the kid looks a little bit sicker,
32:09
I would say give them a phone call in a few days or a week.
32:13
And if things are not improving, lay hands on them again and decide if you want
32:17
to go ahead to the next step of
32:19
getting lab work and x-ray and potentially calling for help at that point.
32:25
I think it's very hard in a busy practice to do that,
32:28
but I know good pediatricians have staff trained appropriately to make those
32:33
follow-up phone calls and just checking in with the family and providing knowledge
32:39
to the parents that, you know, this would be the expected course.
32:42
In a week, things should be a lot better.
32:45
When you try to go and feel that lymph node under the ear of your child,
32:49
that should be significantly better.
32:52
But if things are not improving, then, you know, I think the next step,
32:56
perhaps it's a different course of antibiotics. Perhaps it's an ultrasound.
33:00
Perhaps it's waiting another couple of weeks if the child doesn't look that sick.
33:04
But I think it's wise to kind of make a reassessment at that point and see what
33:09
the next best choice is for that child.
33:13
And what about if it's staying the same size at the occipital area?
33:18
No, I think if it's staying the same size and there aren't any new lymph nodes,
33:22
and when you look at the child, you don't identify any source of infection,
33:27
I would probably just bring that child back in a few more weeks and evaluate him further.
33:32
It's pretty unusual for the occipital lymph node like that to be a sole area
33:38
where a malignancy can develop. It's typically more right, you know,
33:42
under the jaw and the anterior cervical, posterior cervical chain.
33:47
Shafka, is there anything else you want to mention that clinicians,
33:51
you want them to know before we wrap up? This has been so insightful.
33:55
No, I think one thing to remember is that, you know, we're talking quite a bit
34:00
about infections and perhaps malignancies.
34:03
But in the very young child, there may be congenital things like a cyst that's
34:08
got an infection, for example, along the neck might be a thyroid gland that's enlarged.
34:13
So sometimes, you know, I think in the day-to-day setting, we're so used to
34:18
seeing these lymph nodes and palpating the neck.
34:21
You know, I think sometimes we, you know, we need to slow down and just say,
34:25
hey, this is more of a midline lesion.
34:27
It's not to the side like most lymph nodes are. So if there's something different
34:30
about the presentation, especially in a younger child, you know,
34:34
it could be maybe a congenital lesion, a cyst of some kind.
34:38
And the next step for that evaluation would be that ultrasound.
34:41
And so that would be helpful in making an assessment.
34:44
So not everything is infection or lymphadenopathy associated with cancer.
34:49
So there's other things that could potentially present, especially in the younger child under two.
34:56
And one pediatrician was saying to me the other day that she sees so many lumps
35:01
and bumps in kids' necks all day long, it seems like. So it's very common.
35:06
It is very common. And really, the statistics would say about 90% of children
35:11
at some point will have some lymphadenopathy.
35:14
But only about, I think one article said, you know, maybe 1% to 3% are associated with a malignancy.
35:20
So most children will have something that is not cancerous.
35:25
And sometimes just an unexplained lump? It could just be that?
35:29
It could be. It could be a reactive lump, or it could be maybe a more unusual,
35:34
like a mycobacterial infection or something. And sometimes it does take excision
35:39
by a surgeon to remove it to make that diagnosis.
35:44
Dr. Shafka Shah with UT Health San Antonio and University Health,
35:48
thank you so much for being here again on Pediatrics Now.
35:52
It's my pleasure, and honestly, if there are any questions, we certainly would like to be contacted.
35:58
You know, these are young children, and we know how busy your practices are,
36:02
so we're happy to troubleshoot as needed.
36:04
So we'll include the contact information for our listeners in the South Texas area.
36:13
Don't forget to click on the link in this podcast for free credit that may include
36:17
CME, MOC, or ethics credit, depending on the topic or podcast.
36:22
Our sister podcast is Pediatrics Now for Parents. We'll have a shorter,
36:27
parent-friendly version on lumps and bumps.
36:30
That's also wherever you get your podcasts. I'm Holly Wehment,
36:35
and I'll see you next week.