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. He joined the brand in March of 2023 as an editor before being promoted to senior editor in January 2024. Fitch graduated from Youngstown State University in Youngstown, Ohio in 2020 with a degree in telecommunications and journalism. He started his career as a news and sports videographer before becoming an on-air sports anchor at the NBC-affiliated news station in Youngstown. Fitch briefly worked as a national content writer for a Chicago-based national television station before joining the 

team. He can be reached at: jfitch@mjhlifesciences.com.

Articles

According to a new study, racial and ethnic disparities were evident when counseling on nutrition, lifestyle, and weight among children with high blood pressure measurements. 

Racial, ethnic disparities exist when counseling on nutrition, lifestyle, and weight

Tina Tan, MD, FAAP, FIDSA, FPIDS, discusses the severity of the current respiratory virus season and stresses the importance of vaccinations to protect against influenza, COVID-19, RSV, and more. 

Tina Tan, MD, comments on a severe respiratory season, stresses timely vaccination

"My takeaway is that if medicine is needed, stimulants will be my first choice in this age group, regardless of whether the ADHD coexists with ASD."

ADHD with ASD and without it: Should they be treated differently?

Puzzler: 14-year-old with asthma, vomiting, and vape use presents with chest pain

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Research is shedding light on the mysteries of this distressing disorder, which isn&t as rare as you might think. Once the diagnosis is made, antiemetic and antimigraine drugs provide reasonably effective relief.

CME: New hope for children with cyclic vomiting syndrome

**Editor's Note** Please note that starting January 1, 2025, we will be switching to an online-exclusive publication process. This will allow us to publish case submissions quicker without having to deal with the variables that come along with print publication. All cases will still be eligible for print publication consideration, but publication in our print magazine is not guaranteed and will be up to the editor's discretion. 

Do you have a puzzling pediatric case that you’d like to share with the readers of 

We are looking for intriguing diagnoses that have stumped the experts—a diagnostic “Puzzler”—to help our physicians enhance their day-to-day practices. If you have such a story to tell, tell us.

Here’s what to do: Before you begin, we suggest that first you review the Puzzler 

https://www.contemporarypediatrics.com/case-studies

. Please note the specific style required for writing Puzzler manuscripts.

Next, prepare a draft of your case, including a summary of the presenting symptoms, a case overview, a 

table of the differential diagnosis (MANDATORY)

, and the special aspects of your case that qualify it as a Puzzler, and send it to us. Please note that the differential diagnosis table should also be discussed in the body text. We’ll review your draft and let you know what you need to add or revise before we send the manuscript to peer review for evaluation.

Puzzlers vary in length, and we suggest a minimum of 1,200 words up to a maximum of 2,000 words, but that is because of the complexity of some cases and whether some patients returned for many assessments before their diagnoses were determined. Also, some authors describe the pathophysiology of the differentials in great detail. Please also note no more than 3 authors are allowed per article.

What's most important is to show us the process that you used to analyze the case, including:

Why you decided to order certain tests and why you did not order others.

Peer consultations or why you elected to contact other specialists.

Lab values including vital signs or blood tests.

Labs and values if your patient was attended to in the emergency department or other hospital departments such as radiology or neurology.

Discussion related to the possible diagnoses.

Final diagnosis, treatment, prognosis, and follow-up.

Remember to indicate numbered citations within the body of the text and include a complete list of corresponding literature/references at the end of the manuscript. (Do not use any citation management programs or unlink them.) 

Limit references to 25. No references (unless it is a seminal study) can be older than 10 years.

We prefer primary research as references, but some cases are so obscure that authors will need to pull from a variety of sources. However, 

. Be advised that peer reviewers are adamant that the disease/disorder you describe was actually diagnosed and not determined by index of suspicion on the basis of ruling out various differentials. We use AMA11 as our publication style, which uses superscript citation numbers and a corresponding numbered reference list. Please create your citations and references in this style.  Check this recent article posted online at 

https://www.contemporarypediatrics.com/view/the-rx-of-adhd

 for examples of reference style. IMPORTANT NOTE WITH AMA 11TH EDITION: PLEASE PUT DOI OR WEBSITES/URLS AT THE END OF THE REFERENCE LINE.

When you send your draft manuscript, also 

. These image files must be high-resolution jpg or tiff files (minimum of 300 dpi) and as large in size as possible. We suggest a minimum of 7 horizontal inches. The images must be original photos with clear permissions to use, not images from copyrighted sources. Send as separate attachments with your e-mail submission; do not embed images into your manuscript document.

After we receive your manuscript, our editors and peer reviewers will review your draft and let you know if we accept your submission for publication. 

Puzzler is one of the departments for which we receive the most submissions, so it may be several months after submission before you receive feedback from us.

If we do accept your submission for publication, we will contact you with further instructions.

Send your submissions in Microsoft Word format to 

, via e-mail to mpetronelli@mjhlifesciences.com

Guidelines for PUZZLER, Contemporary Pediatrics

 poll. Take a look at the following case below. After reading through the description, choose a multiple choice answer and try to guess the correct patient diagnosis. 

 on Wednesday, January 29 at 12:00 PM ET for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Nicholas W. Kieran, MS and Annuradha Goel, MD.

A 14-year-old girl presented to her primary care office with 2 weeks of vomiting that began when she tried to eat breakfast. She said she was feeling well up until that point, but then developed sudden onset vomiting and constant, 7/10, non-radiating chest pain centrally located at about the level of the second rib that remained unchanged since onset and slightly worsened when trying to eat. 

She was able to take in liquids but vomited all food, despite having an appetite. She denied feeling the food get stuck in her throat and endorsed continued vomiting of meals within 2 minutes of eating. She denied blood in the vomit and denied any abdominal pain. 

Urination was unchanged, and stools, although infrequent because of a lack of eating, continued to have their normal consistency and color. The patient did endorse some mild shortness of breath. This started around the same time as the other symptoms, but did not find it very bothersome. Her last sexual encounter was 3 months prior to this visit, just prior to Nexplanon (etonogestrel implant) insertion. Her last menstrual period was 2months prior to the visit.

On review of systems, she did not endorse palpitations, syncope, lightheadedness. She had increased her vape use recently but did not disclose when she started or how much she vaped. She had no recent travel and had not identified any extremity swelling. She was unsure if she had lost weight but had not been trying to lose any.

website on Wednesday, January 29, 2025, at 12:00 PM ET or later for an article featuring the full case presentation, differential diagnosis, and correct patient diagnosis.

The patient had increased her vape use recently, but did not disclose when she started, or how much she vaped. 

News

Case Studies

14-year-old girl presents with chest pain, 2-week history of vomiting

 poll. Take a look at the following case below. After reading through the description, choose a multiple choice answer and try to guess the correct patient diagnosis.

on Monday, January 6 at 12:00 PM ET for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Amar Davé, MD, FAAP and Pahroul Davé, APRN

A boy aged 10 years presented to the outpatient office with a history of painful nodules on the plantar surface of his bilateral feet 8 to 10 hours after spending time in a hot tub. He was unable to bear weight or put on socks and shoes due to his pain. The photos were taken soon after the painful and red papules appeared. The lesions affected the whole plantar aspect of both feet. Over the following 4 days, the nodules became less painful and red. 

Medical advice was sought on the fifth day of symptoms, and by this time, the child was improving clinically. He was stable with subcutaneous, mildly painful, fleshy nodules mostly populating the medial arch of the foot. His remaining clinical examination results were within a normal range. Further questioning of the child’s mother revealed that other children exposed to the hot tub experienced painful feet but without lesions. 

Due to the patient’s improving symptoms and the self-limiting nature of the illness, no tests or labs were ordered as the child was not acutely ill. No peer consultations or specialists were utilized.

Click here for the full case presentation, differential diagnoses, and the correct patient diagnosis, in a separate article.

The photos in this case were taken soon after the painful and red papules appeared.

Can you diagnose this boy with painful nodules on his feet?

Based on recent reports, norovirus outbreaks in the 2024-2025 seasonal year is above the range reported from the 2012-2020 and 2021-2024 seasonal years.

Tina Tan, MD discusses the increased outbreaks of norovirus this year

Norovirus, one of the most contagious viruses, spreads easily through contaminated food, surfaces, and person-to-person contact. Tina Tan, MD, FAAP, FIDSA, FPIDS—editor in chief of 

, professor of pediatrics at Northwestern University’s Feinberg School of Medicine, Infectious Diseases attending at Lurie Children's Hospital of Chicago, and president of the Infectious Diseases Society of America—emphasizes the importance of preventive measures to reduce its transmission, particularly in environments like schools, daycare centers, and nursing homes, where it spreads rapidly. 

“Norovirus is a very transmissible virus, and most people pick it up because they come into contact with an infected individual, or they ingest food that is contaminated,” said Tan. Common culprits include fruits, vegetables like lettuce, and seafood such as oysters. Improper handling or inadequate washing of these foods increases the risk of outbreaks. 

Outbreaks are common and widespread. From August to December 2024 alone, the CDC’s Norovirus Sentinel Testing and Tracking (NoroSTAT) program reported 495 norovirus outbreaks, exceeding the range observed in most previous years. The most affected populations include young children, older adults, and individuals with weakened immune systems, who are at higher risk for severe symptoms such as dehydration. 

Parents often misattribute norovirus symptoms to other illnesses like the flu. “When you think about the symptoms of the norovirus, it’s usually fever, nausea, vomiting, diarrhea, abdominal pain. Some older individuals can also get body aches,” said Tan. She emphasized that many parents are unaware of the virus’s extreme transmissibility and the need for strict hygiene measures.

One crucial preventive step is proper handwashing, as hand sanitizers are ineffective against norovirus.

“We know with this particular virus that the hand sanitizers do not work against it. You actually have to do soap and water to basically get rid of this particular virus,” Tan explained. Cleaning contaminated surfaces and washing laundry in hot water are additional measures that families should adopt. 

Despite these recommendations, some individuals neglect basic food safety, a lapse exacerbated by potential misinformation on social media promoting risky practices like consuming raw milk.

“People are a little bit less likely to wash their fruits and vegetables very carefully,” noted Tan, underscoring the need for pediatricians to educate families about foodborne risks and proper hygiene practices. 

By following simple but essential steps—washing hands with soap and water, cleaning surfaces thoroughly, and ensuring food is prepared safely—families can significantly reduce their risk of norovirus infection. 

Fitch, J. CDC: 2024-2025 seasonal norovirus outbreaks up from previous years. 

. January 9, 2025. Accessed January 24, 2025. https://www.contemporarypediatrics.com/view/cdc-2025-seasonal-norovirus-outbreaks-up-previous-years

Epinephrine nasal spray (neffy; ARS Pharmaceuticals) could soon be on the shelves of various school nurses offices in the United States for use in emergency situations.

The potential comes from a program called neffyinSchools, recently launched by ARS Pharmaceuticals. According to an announcement from the pharmaceutical company, eligible K-12 schools, both public and private, in the United States have the opportunity to receive 4 single-use doses of neffy 2 mg for emergency use treatment of type I allergic reactions (included anaphylaxis) in adults and children who weigh 66 lbs (30 kg) or more.

Schools could receive neffy at no cost via the School Health Corp. SHConnect platform. If schools do not already have this platform, they may be asked to subscribe for a fee.

Neffy was approved by the FDA for the above indication on August 9, 2024, to become the first nasal spray to treat anaphylaxis. The approval provided an option for those with needle phobia, a fear that is so great in some patients that it could prevent receipt of a potentially life-saving care, according to the CDC.

The single-dose nasal spray is administered into 1 nostril, with potential of a second dose administration if there is no improvement in symptoms, or if symptoms worsen.

“I think this [treatment] will just float way to the top as soon as it becomes an option and people are aware of it, and there are a number of reasons why," Russell Libby, MD, founder and president of the Virginia Pediatric Group and an assistant clinical professor of Pediatrics at the George Washington University School of Medicine and Health Sciences, 

"The first reason, to me, is that it is needle-free and it is a stable solution. When you look at EpiPens, you have a real narrow window of temperatures where it stays stable," said Libby. "Sometimes it can become impotent, but more often, the potency just diminishes.” 

Type 1 allergic reactions can be caused by foods, insects, medication, exercise, or other unknown causes, and they can happen quickly. ARS noted in the announcement that approximately one-quarter of anaphylactic reactions in schools are among those with previously undiagnosed allergies.

"School nurses play a pivotal role in the health and wellbeing of students," said Kenneth Mendez, President and CEO of the Asthma and Allergy Foundation of America in a statement.

"Unexpected allergic reactions can happen at any time – including during the school day – so it is crucial to have epinephrine readily available to administer by nurses and other trained school officials," added Mendez. "The 

inSchools program will help schools to obtain epinephrine free of cost. This positions schools to be ready to provide emergency treatment for severe allergic reactions."

Schools that are interested in applying to the program can do so at neffy.com/community-programs. 

On January 13, ARS announced that a supplemental new drug application filed with the FDA for a 1 mg dose among those who weigh 33 to 66 lbs has been assigned a prescription drug user fee act date of March 6, 2025 for potential expanded approval.

If approved, product availability is expected in the second quarter of 2025. 

Click here for more on neffy, as well as initial FDA approval details and commentary.

1. ARS Pharmaceuticals Launches neffyinSchools Program Providing Free Life-Saving Needle-Free Epinephrine For Emergency Use to Eligible K-12 Schools. ARS Pharmaceuticals. Press release. January 21, 2025. Accessed January 22, 2025. https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-launches-neffyinschools-program-providing

2. Fitch, J. 2024’s critical needle-free approvals for pediatric anaphylaxis, influenza. 

. December 26, 2024. Accessed January 22, 2025. https://www.contemporarypediatrics.com/view/2024-s-critical-needle-free-approvals-for-pediatric-anaphylaxis-influenza

3. Fitch, J. PDUFA date set for neffy 1 mg for children who weigh 33 lbs or more. 

. January 13, 2025. Accessed January 22, 2025. https://www.contemporarypediatrics.com/view/pdufa-date-set-for-neffy-1-mg-for-children-who-weigh-33-lbs-or-more

Eligible schools have the opportunity to receive 2 cartons of epinephrine nasal spray for use in emergency situations to treat type I allergic reactions, including anaphylaxis.

B.U.K. Li

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