Paediatric Pathways

Cervical lymphadenitis / Lymph node abscess pathway for children presenting to hospital


Acute presentation of unilateral, red, hot, tender neck lump. Often associated with fever.

Differentials include:

  1. Infection
    • Bacterial lymphadenitis / LN abscess (more common in children <6 years of age)
    • Bartonella (Cat scratch)
    • Toxoplasmosis
    • TB / non-tuberculous mycobacteria (usually painless, non-tender)
    • Infected congenital cyst such as branchial cyst or lymphangioma
    • Consider mumps if parotid swelling
  2. Kawasaki disease
  3. Sternocleidomastoid tumour in neonates
  4. Malignancy (lymphoma, leukaemia)
  5. Severe eczema is the commonest cause of generalised lymphadenopathy



  • Stertor or stridor suggesting airway obstruction
  • Difficulty swallowing/drooling
  • Muffled speech
  • Torticollis (can occur in minor infections but potential sign of retropharyngeal infection)
  • Severe respiratory distress
  • Haemodynamic instability / sepsis (may require urgent source control)

URGENT senior review and ENT input


Evaluate severity of infection:
MILD = systemically well
MODERATE = previous antibiotic failure, systemically unwell or clinical signs suggestive of LN abscess (fluctuant mass).
SEVERE = presence of any red flags

If MILD infection, no investigations required.
If MODERATE / SEVERE infection, for FBC, CRP and blood culture +- throat swab
Consider USS if clinical signs suggestive of LN abscess. Urgent imaging (USS neck) if severe infection#. If retropharyngeal infection suspected, consider urgent CT neck.2
In severe cases, ensure airway secure before imaging.


MILD infection – manage with oral antibiotics as per local / national guidelines.

Choice of oral Abx as per local / national guidelines
Total duration of treatment = 7 days
Provide verbal and written safety netting information

In MILD infection, consider IVAbx if:

  • Oral Abx not tolerated/absorbed
  • No improvement despite ≥48 hours of adequate oral Abx (check dose and adherence). Incision and drainage may be required – consider USS.
  • Significant immunosuppression

Choice of antibiotic as per local empirical antibiotic guidelines


MODERATE infection – initially manage with IVAbx as per local empirical antibiotic guidelines. If clinical deterioration despite 24 hours IVAbx or persisting fever/no clinical improvement despite 48 hours IVAbx, arrange urgent USS. If collection, for ENT review and consider incision and drainage. Conservative treatment can be considered in children with small collections (<2.2cm) if no red flag features present.1,2
If development of red flags, for urgent ENT review and consider urgent CT neck.2 Ensure airway secure before imaging.

Consider ambulation4 on IVAbx from ED / assessment unit (admission avoidance) unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information
IV to oral switch when:

  • Clinically improving +- improving inflammatory markers
  • Apyrexial
  • If source control (I+D), then early IV to oral switch recommended.
  • Choice of oral Abx as per local / national guidelines. Total duration of treatment (IV+oral )= 7 days

If clinically deteriorating or remains pyrexial despite antibiotics, consider:

  • Deep seated infection requiring source control; ENT review +- imaging (USS)
  • Resistant organism – check risk factors and microbiology results
  • Non-infective pathology or unusual infection (consider differentials)
  • Seek ID/micro advice if complex infection


SEVERE infection – start IVAbx as per local / national guidelines

  • Urgent ENT review and consideration of source control (operative management)
  • If airway is compromised by swelling, consider emergency measures to secure it
  • If evidence of toxin mediated disease, consider adding an antitoxin antibiotic (i.e. clindamycin) and lower threshold for urgent drainage (source control).

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

  1. Luu TM, Chevalier I, Gauthier M et al. Acute adenitis in children: clinical course and factors predictive of surgical drainage. J Paediatr Child Health 2005; 41: 273-7.
  2. Georget E, Gauthier A, Brugel L et al. Acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children. BMC Ear Nose Throat Disord 2014; 14: 8.
  3. McMullan BJ, Andresen D, Blyth CC et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis 2016; 16: e139-52.
  4. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.

Access e-Learning course:

This course has been created to supplement the BSAC Paediatric Pathways site. The course follows the pathway for treating Lymphadenitis but does so through a case study. The aim of this course is to familiarise yourself with the pathway and how the pathways are put in place practically.

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