Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Lori Morgan, a physician in hematology and oncology at Children's Mercy. Today, we'll discuss lymphadenopathy, one of the most common yet anxiety-provoking concerns in pediatric practice.

So Dr. Morgan, welcome to the show. I want to start off, you know, lymphadenopathy is one of the most common concerns in pediatric practice. Can you first just run through what are some of the causes that we should remember?

Dr. Lori Morgan: Absolutely. And thank you for having me today. The far and away most common cause of lymphadenopathy in children is infection, because our lymph nodes are comprised of immune cells. And so, during an infection, they're going to enlarge as the immune system mounts a response.

Host: Yeah, and that's where we kind of see the lymph nodes and the lumps and the soreness and that kind of stuff on physical exam, right?

Dr. Lori Morgan: Exactly.

Host: Yeah. So, how long is it then, you know, for a general pediatrician—how long is it reasonably to observe a child with some reactive lymphadenopathy before getting really worried about it and moving on to the next steps?

Dr. Lori Morgan: I think it can be a few contributing factors. So, in addition to the timeframe, one of the most important pieces is what is happening, if anything, to any nodes that we're seeing. And so, if we see a child one day and their nodes are one centimeter and then, a week later, they're two centimeters, that's a pretty remarkable amount of growth in just one week.

Conversely, if a child has nodes that are there and they're not getting larger or even getting smaller, and it's been a few weeks, they could continue to be watched. So, I would say that it's a combination of the course of the nodes and the overall time.

Host: You know, years and years ago, Dr. Morgan, when I was doing some pediatric rotations in medical school and learning more and more about the physical exam of a child, I came across a couple lymph nodes once. And, you know, I got excited. I found something, told my attending, and the attending was like, "Oh, we don't worry about those lymph nodes." Are there any areas in the body that are just lymph nodes are so common that we don't really work them up?

Dr. Lori Morgan: I don't know that there's an area where I wouldn't work up a worrisome lymph node, but where I do see them most commonly when they seem to be associated with infection is in the neck, the jaw, so the submandibular, the submental, the cervical nodes are quite common. And a lot of times when kids come in, especially really thin kids, these nodes just pop out, and they might look more significant than they actually are.

Host: How often does the parent find the node and then come into you?

Dr. Lori Morgan: I think that is the most frequent person to find the node because it's the parents who are looking at their kids every day, if they're younger, giving them baths. Sometimes in teens, older children, they might be the one to find it, but it's typically someone in the family who notices it.

Host: So, what characteristics help you to distinguish between a benign lymph node versus something a little more serious?

Dr. Lori Morgan: One of the components that we talked about earlier, which is the course of the lymph node over time, is one of the most important pieces. So if there's a lymph node that is progressively getting larger, that is a worrisome lymph node. If it's staying the same or even getting smaller, that's very reassuring.

And then, the physical exam is the other piece that's very helpful for me when I'm considering someone who's seeing me for lymphadenopathy. So, the size of a node, if it is greater than two centimeters, I start to worry a little bit more. And then, the characteristics of the node on exam. Worrisome findings would be a node that is firm, a node that is not mobile in that it's fixed to the tissue below it. And then also, a node that is nodular or has an irregular shape, unlike that sort of rubbery, smooth, bean-shaped node that we tend to see in benign lymphadenopathy.

Host: How does pain play a role here? Do you often find that the nodes that worry you the most maybe don't have pain?

Dr. Lori Morgan: I think that if a node is painful, we could move a little bit towards the benign spectrum in our thinking. A lot of times nodes that are painful, for example, those that a child might have concurrent with a strep infection, they tend to be more in the benign category. So yes, a painless node falls towards the side of the spectrum that leans towards malignancy. A painless node in and of itself, though, does not define malignancy

Host: Right. So, when you are evaluating a patient and you feel there is some lymph nodes that are suspicious, what's your next move? What are you going to do?

Dr. Lori Morgan: So, the next thing that I want to do is get some imaging to get an understanding of how many nodes are involved, where are they, and what are the characteristics. And so, the best next step for imaging that I like is an ultrasound. If someone's seeing me in the clinic for nodes that are noticeable, it means they're likely on the surface or in a place that the ultrasound can reach as opposed to being somewhere deep in the abdomen. And what the ultrasound can do is show whether or not the architecture of the lymph node has been maintained, if it has its fatty hilum, or if it looks like it's more disorganized inside where we might be more concerned for a malignancy.

Host: And so, when you're doing the ultrasound, how often does that turn into a biopsy right then and there? And if that's often, how do you explain that to the family?

Dr. Lori Morgan: Typically, when I see someone for lymphadenopathy, I like to set expectations once I have a sense of their history and physical of the possible next steps. And so, I will always counsel them that we're getting the ultrasound. And depending on what that shows, these are the steps we might take. We might do nothing and I never see you again. We might do nothing and I'll see you next week for another exam, or we might go towards a biopsy.

Host: And if you feel like you want to move to some other exams, what are those?

Dr. Lori Morgan: So when considering the course of a lymph node, one of the pieces that can be really helpful is having some continuity in the person who's examining the node. Because if I evaluate a child and I'm the one who is palpating those lymph nodes, I have a good sense of what they feel like. So if I see them in another week or another two weeks and I'm the one who is doing the exam again, I can tell what I think any changes might be versus having different clinicians evaluating them. So, I really like having that consistency.

Host: Yeah. What about other physical exam findings that you kind of put together with what you're thinking about this node? You know, maybe you're suspicious about this node. Are there some physical exam findings then that help you decide to move forward to imaging, et cetera?

Dr. Lori Morgan: I think one finding that I pay very close attention to is the abdominal exam because I want to feel if there is any enlargement of the liver or spleen, in which case I would, without a doubt, move on to imaging. And then, I also try to palpate all of the lymph node chains that I'm able to on exam, so under their arms, in the inguinal region, and so on. Because if I'm able to palpate enlarged nodes in more than one chain and, in particular, above and below the diaphragm, that moves me a little bit closer to imaging.

Host: Are there any labs that you often recommend in these situations?

Dr. Lori Morgan: Yeah. So with labs, I'm looking for signs of cell breakdown and electrolyte abnormalities. So, we look at the LDH to see if it's elevated, a sed rate if it's elevated. It's not specific, but it gives us a sign into what might be happening. And then, we also look for elevated uric acid and electrolytes that would go along with tumor lysis syndrome.

And then, of course, we love getting CBCs. And with the CBC, I'm looking for any signs of marrow disruption. So, that would be extremes in the white blood count, very high or very low, along with a low hemoglobin, low neutrophil count, or a low platelet count.

Host: So Dr. Morgan, what advice would you like to give primary care providers about balancing, you know, the reassurance with early identification of what could be serious disease?

Dr. Lori Morgan: I think what primary care providers can do is have this long-standing relationship with their parents and families so that they're able to navigate some of these conversations that might be a little bit scary for families or even a lot scary for families. So, I think being reassuring that infection is the most common cause of lymphadenopathy in children. But if we're concerned, let's bring you back in a week, let's bring you back in two weeks, and these are the things that I would want you to call me for in between. So, the most important piece being maintaining evaluations of the patient and letting them know that they are being followed and that this issue is being taken care of.

Host: You know, Dr. Morgan, as a specialist in the field of hematology, oncology, is there anything that you're really excited about in terms of innovation?

Dr. Lori Morgan: Oh, absolutely. I think that I am living at a time of leukemia lymphoma treatment that has enormous potential to change the face of how we treat children with these types of cancers. Only a couple of years ago, we had a breakthrough in our standard treatment for our most common type of leukemia, which is an immunotherapy as opposed to chemotherapy.

We are seeing and will continue to see more and more incorporation of immunotherapy using the immune system to fight cancer as opposed to these very toxic chemotherapies that we've been using for so many decades. And I'm thrilled to be able to practice in a time where we are actively seeing that shift. I think it's very exciting and, more importantly, very inspiring.

Host: Fantastic. I love it. Listen, I'm on board. I think immunotherapy, the body has great defenses, right, Dr. Morgan? We just got to learn how to use it better, utilize it, right?

Dr. Lori Morgan: Yes.

Host: Yeah. I think that's fantastic. Thank you so much for coming on today. This has been great information. Hey, don't forget, you can claim your CME credits after listening to this episode by visiting cmkc.link/cmepodcast and clicking the Claim CME button. If you enjoyed this podcast, please share it and check out the entire podcast library of topics that might be of interest to you. This is Pediatricists in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.