EDITORIALSection Editor: Diane D. Davey

Promoting FNAs in Children:Kid’s Love StickersJohn J. Buchino, M.D.*

In 1994, Geisinger, Silverman, and Wakely stated “Withregards to diagnostic cytopathology, children have beensorely neglected . . .” This seems to be particularly true inthe use of fine-needle aspiration (FNA) in pediatrics. Why,despite at least three monographs on the subject and numer-ous published studies confirming the validity and utility ofFNA in children, is the use of FNA not more widespread?1–5

I believe that there are several reasons.Although malignancies are the second most common

cause of death in children over one year of age, they accountfor less than 3% of specimens seen by pediatric patholo-gists. Furthermore, the types of malignancies that occur inchildren do not lend themselves to screening by exfoliativecytology. Therefore, pediatricians tend not to think of cy-tology as a diagnostic tool.

Because exfoliative cytology is not used much in pediat-rics, pediatric pathologists generally have little experienceand/or expertise in cytopathology beyond their time in train-ing. (The one exception to this is the examination of spinalfluids for leukemic cells). Understandably, they becomeapprehensive at the suggestion that they re-learn cytology,especially when the demand for the service is relatively low.This has led to one of life’s little ironies. That is, childrenare much more likely to be able to obtain an FNA at ageneral hospital where there is a cytopathologist accus-tomed to performing FNAs rather than at a children’s hos-pital where there are only pediatric pathologists.

However, general cytopathologists often are not particularlyanxious to perform FNAs on children. While they may be quiteadept at the procedure in adults, the prospect of dealing with acrying, squirming four-year-old is not cause for rejoicing.There is also the recognition that the differential diagnosis ofpediatric lumps and bumps is somewhat different than that foradults. And with that recognition is an appropriate concern formisdiagnosis once a specimen is obtained.

So, can or should anything be done to change the snail-pace utilization of FNA in pediatrics? From my biased view,there are several things that can help improve the currentstate of affairs.

Those in academics should attempt to publish FNA re-lated articles in pediatric clinical journals. Hopefully, thiswill cause pediatricians to think of FNA as a routine pro-cedure that should be available to their patients. Similarly,cytopathologists should offer to give pediatric grand roundson the utility of FNA at their related institutions.

In centers that have a separate children’s hospital, cyto-pathologists should make themselves available to pediatricpathologists to consult on both the performance and inter-pretation of FNAs. By the same token, pediatric patholo-gists should avail themselves of the expertise of their cyto-pathology colleagues. This is particularly true of trainingprograms. Pediatric pathology and cytopathology fellow-ships should include experience in pediatric FNAs. In eithercase, if the training institution does not offer adequateexposure to pediatric FNA, consideration should be given tosending the fellow to an institution that does.

For those who are apprehensive about dealing withchildren, there are publications that address the use ofvarious techniques that help alleviate several potentialproblems.6 Certainly, speaking to the child directly, aswell as to the parent, helps put the child at ease. I havefound it very useful to spend a few minutes talking to thepatient about topics other than the procedure, eg., sports,school, friends. For kids under 6 –7 years old, we oftengive them a sticker of a popular cartoon character prior tothe procedure. Most kids love these stickers and we’llgive them more when the procedure is finished. It’samazing how stickers will help the child forget about theprocedure.

Parents are an important part of the equation for a suc-cessful FNA in a child. Generally, they are quite anxiousabout their child having an unknown mass lesion. There-fore, it is critical that the parents be given a full explanationof the procedure, the alternatives, the risks, and the benefits.They also need to have an opportunity to have any questions

Kosair Children’s Hospital, MD, Departments of Pediatrics and Pathol-ogy, University of Louisville, Louisville, Kentucky

*Correspondence to: John J. Buchino, MD, Kosair Children’s Hospital,Departments of Pediatrics and Pathology, University of Louisville, P.O.Box 35070, Louisville, KY 40232. E-mail: johnbuchino@louisville.edu

© 2001 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 25, No 3 151

answered. Having been provided with that information,most parents are very appreciative of the pathologist per-forming the FNA. I have received positive feedback bothfrom the parents directly as well as via the referringclinician.

I have found it to be helpful to use assistants that aretrained to deal with children undergoing procedures. Themost likely candidates are nurses from the pediatric emer-gency room or pediatric phlebotomists. If you performFNAs on both adults and children, it is best to have aspecified block of time set aside for the children. Finally,more and more hospitals have dedicated sedation teamssupervised by the anesthesiology department. These teamscan be of great service for the child who is particularlydifficult to control.

Cytopathologists should help promote the value of FNAsin children. This may take persistence. But remember, kidslove stickers—so be one!

References1. Geisinger K, Silverman J, Wakely P. Pediatric cytopathology. Chicago:

American Society of Clinical Pathologists; 1994. p 1–361.2. Buchino JJ. Cytopathology in pediatrics. Karger, Basel; 1991.3. Vielh P., Howell L.P.: Guides to Clinical Aspiration Biopsy Pediatrics.

Igaku-Shoin, New York, 1993.4. Howell L, Russell LA, Howard PH, Teplitz RL. The cytology of

pediatric masses: a differential diagnostic approach. Diagn Cytopathol1992;8:108–115.

5. Buchino JJ, Jones VF. Fine needle aspiration in the evaluation ofchildren with lymphadenopathy. Arch Pediatr Adolesc Med 1994;48:1327–1330.

6. Buchino, J.J., Lee H.K.: Specimen Collection and Preparation in Fine-Needle Aspirations in Children. Am J Clin Path 1998;104:54–58.

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