“His glands are swollen,” said a mom recently in clinic. Warily she measured my reaction and added, “Will you look at them?”
And look I did. Her toddler giggled as I felt the chains of lymph nodes that run up and down the neck in parallel lines. He’d had a cold for a few days, and in her ministrations, his mom felt something that had gotten her attention. Sure enough, on the right I felt a Rice Krispie-sized series of lumps along the area under his jaw. This “lymphadenopathy” –as it is termed– was enough to convince his mom something terrible was going on.
But was it? Why do lymph nodes swell up? When should you worry about it?
To answer these questions, one has to understand a little bit how lymph nodes work.
Lymph nodes are sentinels of the network of glands and ducts that run in parallel to our blood vessels. Lymph nodes circulate lymph, a clearish fluid laden with proteins and immune cells that tag and package potentially troublesome materials (bacteria, viruses) to the lymph node. There, legions of white blood cells and antibodies neutralize any potential threat to the body.
When there is a persistent or significant amount of inflammation in one area, (say, the scalp due to ringworm), the lymph nodes in that region respond by increasing the number of immune cells to address the problem. Within hours to days, one or more lymph nodes may recruit extra immune support and double, or even triple in size. Hence, Mr Ringworm could have a few pea-sized benign ‘reactive’ nodes behind his ears due to the rash on his head. That in itself isn’t such a bad thing…and in fact, a slightly enlarged node or two could be busy making someone better.
The size of normal lymph nodes varies across the lifespan. Newborns have itty bitty lymph nodes that are difficult to feel. From infancy through puberty, it is commonplace to find normal but seemingly impressively sized lymph nodes all over the place. Thereafter, nodes shrink to a smaller size from adolescence into adulthood. In younguns, normal nodes of up to 2 cm in size (think chick pea) can be found in the groin area, or ½ cm to 1 cm sized (grain o’ rice) individual nodes along the sides of the neck or armpit (careful, that tickles!). By contrast, nodes of 2 cm or larger might be considered abnormal in adults. When lymph nodes are bigger than 2-2.5 cm anywhere on the body of a child (or if they are ever felt over the collarbone), the suspicion rises that something abnormal might be going on.
Happily, the vast majority of cases of swollen lymph nodes are a consequence of a short-lived, annoying-but-not-dangerous phenomena. Colds, rashes, canker sores…that sort of thing. As a provider, a careful review of a child’s history and physical exam help us figure out goes a long way in figuring it all out.
Location and Duration. Providers will ask where the large nodes are noted (one side, or both? Just the neck or elsewhere?) and how long they’ve been swollen or painful. (days? weeks?)
Sick contacts or exposures. Have kids been around who are sick that make nodes swell up, such as mononucleosis (aka “mono”), strep throat, or flu? Other entities should be asked about: Any canker or viral cold sores (herpes), insect bites (tick, mosquito) or animal bites (cats, dog)? For teens, are they sexually active (Gonorrhea, syphilis, for example)? Any recent travel to places with potentially exotic, node-inflaming illnesses (plague in the US Southwest, or say, TB from developing countries)?
Other symptoms matter. Throat, dental or ear pain, rashes, swollen joints, weight loss, or fever of any duration may be key to clinching the diagnosis behind a swollen lymph node. In light of the history, a healthcare provider will assess a child’s overall appearance. Well-appearing kids with illness of a brief duration are reassuring. Kids with fever, fatigue, dehydration, pain or severe discomfort may merit a more thorough evaluation including labwork, or imaging studies. When things are looking complicated (which, again, is rare), a relevant specialist may be consulted, such as an infectious disease doctor, surgeon, or hematologist/oncologist.
When a swollen node is found, one must determine its location, size, and consistency. Further, tweaking and palpating the node assesses if there is tenderness, if it affects more than one gland, and if the lump is a lymph node at all. The trifecta of inflammation for a node known medically by the Latin Rubor, Dolor, Calor (Redness, Pain, & Heat). Ironically, the nodes themselves may become infected, reddened and sore. Lymphadenitis, as this is called, may require antibiotics, and in rarer cases, drainage of abscesses, or collections of pus.
While big nodes are most often due to run-of-the-mill infection or inflammation, cancer–the C word–bears mention. A deeper worry may furrow the brow of parents with kids with large nodes that something worse–something cancerous–is going on. I urge any parent to voice these concerns upfront, to avoid feeling dismayed if the provider ‘doesn’t say anything about it.’ More than likely, a clinician will have this in mind, but may rule it out as they proceed with their evaluation. Fortunately, leukemia, lymphoma or other malignancies are relatively rare. These entities may produce unusual symptoms such as unexplained nosebleeds, funky bruising, weight loss and fever for more than a week. Of course, if any parent has such a concern, I recommend they consult their health care provider pronto–for the peace of mind, if nothing else!
And so, all around the world this week, parents will stumble across or perseverate over BB-sized glands in their young child’s neck or groin. Those neck nodes are likely due to a cold, patch dry skin, or those big groin nodes because their child walks barefoot, outside. Hopefully, having a sense of what is normal (that kids have big nodes!) and what is typical (most big nodes return to usual size in 4-6 weeks!) will dispel the alarm. Treatment of swollen glands–if any at all–will depend on whatever is causing them to grow large.
If those big nodes linger, or, if they run with fever or great discomfort, or if you are in doubt, you can always get your charges checked out, right? You node it.
Nice photo above by Bernard Hudson, from a tick bite, BTW(click pic to link)
cartoon below by me.