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A large population-based study found that first-trimester tetracycline exposure does not elevate the risk of major congenital malformations, though specific risks for nervous system and eye anomalies warrant further research.

Major congenital malformations not linked to first trimester tetracycline use

. 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.

Currently, there are no treatments for the serious, rare pediatric disease. 

Gildeuretinol for Stargardt disease receives Rare Pediatric Disease, Fast Track Designations

From 2017-2018, antiviral treatment of hospitalized children with influenza ranged from 70%-86%. In the 2023-2024 season, it was less than 60%.

Antiviral treatment for hospitalized influenza pediatric patients declining

Paul Kruszka, MD, MPH, FACMG, chief medical officer of GeneDx, joined us to provide background of whole genome sequencing and its benefits. 

Background on whole genome sequencing and review of the GUARDIAN study

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For several days, a 9-year-boy has had painful swelling on the top and left side of his forehead, bilateral eye swelling, intermittent fever, and nasal congestion. He was seen in the office 4 weeks earlier, after he had hit his left eye on a school desk. At that time, he presented with a left retro-orbital headache, nasal congestion and discharge, and intermittent fever.

Young Boy With Painful Swelling of the Eye and Forehead

**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

David Turkewitz, MD, explains how getting involved in the community to advocate for SUID awareness can make a difference in outcomes for the infant population.

Quick watch: Advocating and community involvement to decrease SUID

David Turkewitz, MD, medical director of Newborn Nurseries at Allegheny Health Network in Pittsburgh, Pennsylvania, joined 

 to advocate for community involvement for pediatricians regarding sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID) awareness.

He underscored the importance of advocacy for awareness SUID, and encourages providers to get involved in their communities to further decrease the risk of SUID.

, Turkewitz emphasized the critical role of pediatricians in educating families about strategies to prevent SIDS and SUID, and highlighted key aspects from the 2022 guidelines from the American Academy of Pediatrics.

Click here to watch this video interview.

Just bringing up safe sleep in the newborn nursery and these strategies, and bringing it up in the office isn't enough.When we started in 1970s to 1980s, 1 in 250 babies, that's an extraordinary number in otherwise well developed, rich countries, were dying sleep-related deaths. Now, because of all the things that I've discussed, the rate is about 1 in 2500.You can say, "Boy, that's terrific, that's tremendous, that's a 10-fold risk reduction," but tell that to any parent whose baby dies an unexpected deaths. One death is too much, and we know that it's really not enough for us to give this message in the newborn nursery. It's not enough, while it's important that the pediatrician mention this at every visit in the first year of life, pediatricians should be involved with community organizations that further promote, because we know the more ways this message get can get out, we know that it's more likely that we're going to be able to overcome some of these social determinants and several factors [and] barriers that currently exist out there in terms of promoting these safe seek strategies. 

David Turkewitz, MD, explains how getting involved in the community to advocate for SUID awareness can make a difference in outcomes for the infant population. 

News

H. Westley Phillips, MD, joined us to provide clinical pearls regarding the early identification of drug-resistant epilepsy patients in the primary care setting. 

Identifying drug-resistant epilepsy patients in primary care

Drug-resistant epilepsy remains a critical challenge in pediatric care, with far-reaching implications for patient outcomes. “If a patient fails two medications, the likelihood that the next medication will result in seizure freedom is less than 5%,” stated H. Westley Phillips, MD, pediatric neurosurgeon-scientist and epilepsy researcher at Stanford Medicine Children’s Health, in this 

interview. As Epilepsy Awareness Month brings this issue to the forefront, Phillips explained how primary care providers can help identify these patients for early referral and advanced interventions.

“We have very recent data demonstrating that the time from diagnosis of epilepsy to surgical evaluation can be upwards of 16 years,” Phillips emphasized. This delay often prevents patients from accessing effective options like epilepsy surgery. 

To facilitate early detection, Phillips encouraged pediatricians to maintain a high index of suspicion during routine visits. He explained, “A quick referral to the pediatric neurologist if there are concerns about seizures can help diagnose a seizure that may not look like a stereotypical, generalized tonic-clonic seizure, but something more focal.” 

Once a diagnosis of epilepsy is established, pediatricians play an ongoing role in monitoring treatment efficacy. “If a patient has trialed multiple medications and are still having seizures, it is worthwhile to bring up to that patient and patient's family if there has been a discussion about epilepsy surgery,” Phillips said. He noted a disconnect in the understanding of surgical evaluations and their efficacy for drug-resistant epilepsy. 

“For cases of surgical resection or ablation, we’re talking about seizure freedom rates in the 60% to 70%, and with neuromodulation, which has greatly expanded the number of patients eligible for surgery, we’re talking about a conservative estimation of about 50% reduction in 50% of patients,” Phillips explained. 

By fostering collaboration between pediatricians, neurologists, and epilepsy specialists, Phillips believes medicine can rise to meet this challenge.

“All of medicine I consider a team sport. I think epilepsy, maybe more so, or just as much as any other aspect of medicine, really relies on the team," said Phillips.

A discussion of tips and recommendations general providers can use when evaluating ADHD in pediatric patients.

ADHD treatment clinical pearls for primary care providers

Pediatricians play a vital role in the management of attention-deficit/hyperactivity disorder (ADHD). 

“You are America’s ADHD providers,” said Rakesh Jain, MD, MPH, clinical professor of psychiatry at Texas Tech University School of Medicine. “I know you didn’t sign up for it, but ADHD is in your practice, and 80% to 90% of all patients with ADHD in America are being taken care of by you.” 

Jain highlighted the approval of clonidine hydrochloride (ONYDA XR, Tris Pharma), a new extended-release liquid formulation of clonidine. “We’ve got once-a-day formulation that’s liquid and can be used as a monotherapy in appropriate patients, or if your patient’s currently on a stimulant, we don’t have to settle for suboptimal control of symptoms,” he explained. “We certainly can, in appropriate situations, consider augmentation therapy.” 

For pediatricians managing ADHD, Jain emphasized several practical tips to improve outcomes and workflows. He encouraged routine screening for ADHD as early as possible to address symptoms before they escalate. “It’s so much easier to catch ADHD and treat it in its early stages than when it’s catastrophic, meaning the child is being kicked out of school or [they have] failing grades,” he said. Screening tools like the Vanderbilt Assessment Scale remain valuable for identifying cases early. 

Jain also recommended gathering input from multiple sources to get a complete picture of a child’s challenges. “Definitely get input from the teachers,” he said. “This triangulation of information is important.” 

While medications like stimulants have long been the cornerstone of ADHD treatment, Jain urged pediatricians to consider behavioral therapy first. “Medications are not first line, not immediately,” he said. “If you don’t see what you’re needing for that child’s sake, or the adolescent’s sake, within, say, 6 to 8 weeks of behavioral therapy, then it’s important to consider medications.”

For clinicians, seeing improvements in patients with ADHD can be profoundly rewarding. “When a kid or an adolescent gets better and they see that innate intelligence and abilities flourish, I've got to tell you, that feeling is the reason why I continue being excited about being a clinician,” Jain concluded.

The availability of ONYDA XR offers pediatricians an additional tool to optimize ADHD care, empowering them to tailor treatment to their patients' needs.

, Jain explained the the once-a-day oral solution's make-up in more detail. Click here to watch.

A discussion of tips and recommendations general providers can use when evaluating ADHD in pediatric patients. 

ADHD treatment: Clinical pearls for primary care providers

Brittany Bruggeman, MD, highlights the importance of newer, easier-to-use glucagon formulations in treating severe hypoglycemia in patients with type 1 diabetes.

New glucagon formulations simplify emergency treatment for type 1 diabetes patients

Brittany Bruggeman, MD, a pediatric endocrinologist at the University of Florida and type 1 diabetes (T1D) physician scientist, highlighted crucial advancements in diabetes management, particularly regarding the use of glucagon for severe hypoglycemic events. 

Bruggeman emphasized the critical importance of having glucagon readily accessible for patients with T1D. “Glucagon is what I like to think of as the EpiPen of diabetes, and so it's very important that everybody with T1D, or even type 2 on insulin, has glucagon immediately available to them,” she said during an interview at the 

2024 American Academy of Pediatrics National Conference & Exhibition.

Recent developments in glucagon formulations have made it much easier to administer, especially in emergency situations. Bruggeman noted that older versions required users to mix a powder and liquid before injection, a process that could be confusing and time-consuming. “What we used to have to do is mix a powder and a liquid together before injecting the person with glucagon, which made it really tough for people in the lay public to know how to use this, and even, like school nurses and things, had to have special trainings,” she explained.

However, new formulations of glucagon have simplified the process, making it more accessible to non-medical personnel. “Now there's a formulation that is a nasal spray, and so literally, you just spray the powder into the person's nose,” Bruggeman said, highlighting how this change has improved usability. Additionally, there are now shelf-stable liquid versions of glucagon that function similarly to an EpiPen, allowing for a quick injection without needing to mix anything. 

Bruggeman stressed the importance of awareness among healthcare professionals and the public regarding these advancements. “It's really important that the lay public, pediatricians, [and] everyone knows about glucagon, and that if someone with T1D is on insulin, they need to have access to this in order to treat them if they had a severe hypoglycemic event,” she said.

Brittany Bruggeman, MD, highlights the importance of newer, easier-to-use glucagon formulations in treating severe hypoglycemia in patients with type 1 diabetes. 

Cameron Symonds, DO

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