AIMS Acute infectious cervical lymphadenitis (AICL) is a common diagnosis in paediatric emergency departments. No prior studies have established a link between presenting features of AICL and the need for surgical drainage. Early identification of patients likely to require drainage may facilitate appropriate specialty involvement and timely intervention. METHODOLOGY A single-year retrospective chart review at a tertiary paediatric centre was performed. All patients presenting with AICL were included. Demographic data, clinical features and in-hospital management was assessed using univariate and multivariate statistical analysis. RESULTS Eighty-three patients were included. The mean age was 4.4 ± 3.1 years; 41 (49%) patients were female; 11 (13%) were of Aboriginal or Torres Strait Islander origin, and 18 (22%) were transferred from rural centres. Common presenting features included fevers (58%), reduced neck range of motion (45%) and a fluctuant neck mass (21%). Surgical drainage was required for 26 (31%) patients, with nine (35%) undergoing drainage within a day of admission. Surgical drainage was more common in younger patients (2.8 vs 5.2 years, p<0.001), those transferred from rural centres (38% vs 14%, p=0.01), patients presenting with fluctuant neck lumps (41% vs 12%, p=0.006) and children with longer symptom duration (9 vs 3 days, p=0.01). Lower haemoglobin levels at presentation were associated with an increased need for surgical drainage (106 vs 115 g/L, p=0.03). CONCLUSION At our centre, factors such as younger age, rurality, presence of a fluctuant neck mass, longer symptom duration and low haemoglobin predicted the need for drainage of AICL. These results may aid in early identification of children requiring surgical intervention for AICL.