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Can you guess what condition Tiny Tim had? 

Tiny Tim: What the diagnosis?

Pregnant women infected with avian influenza face a 90% maternal and 86% infant mortality rate, underscoring the urgent need for pandemic preparedness and protection strategies.

High mortality rates linked to avian influenza during pregnancy

. 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.

This week the panel weighs in on monoclonal antibodies in this patient population as well as important overall takeaways about COVID-19 therapies. 

COVID-19 Roundtable: Prophylaxis for the immunocompromised

The indication is for patients 12 years and older hemophilia A with factor VIII inhibitors or hemophilia B with factor IX inhibitors.

FDA approves concizumab-mtci prophylaxis for hemophilia A and B 

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Dr Smith is an assistant professor in the Department of Pediatrics, McGovern Medical School, Houston, Texas.

An 8-year-old girl is admitted to the hospital with complaints of right ear pain, right leg pain, left arm pain, and fever after a week of worsening symptoms. 

Child’s ear pain progresses to leg pain, arm pain, and fever

**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

"Tapinarof comes in with that mixture of the short-term studies and longer-term studies intermittently, giving us a nice, effective alternative non-steroid for eczema across the ages." 

Lawrence Eichenfield, MD, talks tapinarof cream, 1%, nemolizumab FDA approvals for atopic dermatitis

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, recently highlighted significant advancements in the treatment of 

 FDA approvals of tapinarof cream, 1% (VTAMA; Organon)

 to treat AD in patients 2 years and older, as well as 

 to treat patients aged 12 years and up with moderate-to-severe AD in combination with topical corticosteroids (TCS) and/or calcineurin inhibitors (TCI), when disease is not adequately controlled with topical prescription therapies,

Speaking about recent FDA approvals, Eichenfield emphasized the importance of these developments for both patients and clinicians.

“This is the first approval for tapinarof for atopic dermatitis,” he stated. “We get [approval] from age 2 [years] upward through adults at the same time with the same formulation that we’ve had experience with in psoriasis.” 

Eichenfield noted that the safety profile for pediatric patients was favorable, with good tolerance and minimal absorption concerns. 

Click here for full approval details, including clinical trial data highlights, as well as additional commentary from John Browning, MD, FAAD, FAAP, a board-certified pediatric and adult dermatologist in San Antonio, Texas, and is an assistant professor at the Baylor College of Medicine, as well as the chief of Dermatology at the Children's Hospital of San Antonio.

“I think it’s exciting to get newer non-steroidals in our hands,” said Eichenfield. “We certainly have patients who are very concerned about topical corticosteroids, and also many patients where we can’t necessarily treat with just topical corticosteroids long term. So tapinarof comes in with that mixture of the short-term studies and longer-term studies intermittently, giving us a nice, effective alternative non-steroid for eczema across the ages.” 

In addition to tapinarof, he discussed the approval of nemolizumab, a novel biologic targeting interleukin-31 (IL-31), for patients aged 12 years and older.

“It’s a totally novel drug... IL-31 is an important layer in pathophysiology of AD,” Eichenfield explained. “I think this gives us another systemic biologic, and we’ll see how it plays out in terms of sequencing or relationship to other biologics. People have these stories of incredible responsiveness that seems to be different than with other biologic agents.” 

Click here for full nemolizumab FDA approval details, including clinical trial data highlights

1. Fitch, J. FDA approves tapinarof cream, 1% for atopic dermatitis patients 2 years and up. 

. December 16, 2024. Accessed December 19, 2024. https://www.contemporarypediatrics.com/view/fda-approves-tapinarof-cream-1-for-atopic-dermatitis-patients-2-years-and-up

2. Fitch, J. FDA approves nemolizumab to treat atopic dermatitis in patients 12 years and up. 

. December 16, 2024. Accessed December 19, 2024. https://www.contemporarypediatrics.com/view/fda-approves-nemolizumab-to-treat-atopic-dermatitis-in-patients-12-years-and-up 

"Tapinarof comes in with that mixture of the short-term studies and longer-term studies intermittently, giving us a nice, effective alternative non-steroid for eczema across the ages."

News

This week, our experts weigh in on treatments not specifically indicated for COVID-19 treatment, including metformin, and concerns around using medications in this way.

COVID-19 Roundtable: Considering off label therapies

During the earliest stages of the pandemic, and before the development of antivirals and other therapies, clinicians were struggling to find ways to treat their patients. As providers began to use off-label treatments, small studies began to surface around various therapies including hydroxychloroquine, the antimalarial therapy, and the antibiotic, azithromycin. One published paper found these 2 therapies used in combination could help reduce viral loads.


And while clinicians quickly realized these therapies were not reducing symptoms or mortality, both disinformation and misinformation was prevalent enough and making the therapies out to be wonder drugs. These therapies’ efficacy for COVID-19 treatment were debated on social media for too long. 


Just this week, that aforementioned paper about hydroxychloroquine and azithromycin was finally retracted.The paper had been published in the International Journal of Antimicrobial Agents back in 2020, and the lead author was Philippe Gautret of the Hospital Institute of Marseille Mediterranean Infection. In the paper, it was claimed that hydroxychloroquine was able to reduce virus loads in COVID-19 patients, and that used in combination with azithromycin was even more effective.


This year, there has been some studies looking at metformin as an off-label treatment for COVID-19. However, with limited data showing efficacy and potential adverse effects, the panel believes it better to prescribe FDA approved therapies. 

“I don't think there's an overwhelming amount of data that would support it. With metformin, there were two studies together that pretty much showed it wasn't effective,” said Michael Curulewski, PharmD, BCPS, BCIDP, BCGP infectious diseases and antimicrobial stewardship pharmacist, Endeavor health, Northwest Community Hospital. “One thing to keep in mind is anytime that we use an off-label therapy or a therapy that's not supported by a large amount of data, [or even] the safety profile is a major one for me—because a lot of the medications are not benign. Metformin, for example, we have to watch out for patients who have renal dysfunction, IV contrast exposure, and drug-drug interactions. So, without that data to support it, I would say I don't routinely endorse or recommend off-label therapies.” 



This is episode 3 of our 4-part series. Check back for the last episode next week. 

Click here to view episodes 1 and 2 of this roundtable series

1. O’ Grady C. Infamous paper that popularized unproven COVID-19 treatment finally retracted. 

December 17, 2024. Accessed December 17, 2024. https://www.science.org/content/article/infamous-paper-popularized-unproven-covid-19-treatment-finally-retracted

Nathan Kuppermann, MD, MPH, explains the different quartiles of the pediatric emergency department readiness scale, and why the top tier is so crucial for pediatric patients. 

Understanding pediatric ED readiness: Quartiles, disparities, and cost

Nathan Kuppermann, MD, MPH, executive vice president and chief academic officer at Children’s National Hospital, emphasized the critical importance of pediatric readiness in emergency departments (EDs) and its potential to significantly improve outcomes for children. 

“If you look at the topic of pediatric readiness, [it’s a] super important issue. The lay public will think that every emergency department is the same,” Kuppermann said. “However, their ability and preparedness to care for children is quite variable.” 

Kuppermann noted that freestanding children’s hospitals, such as Children’s National, represent the highest levels of readiness, prepared to manage any pediatric emergency. Conversely, most children—approximately 85%—receive care in community EDs, where readiness levels vary widely, stated Kuppermann. Previous research categorized these EDs into 4 quartiles of preparedness, with significant differences in outcomes based on readiness level. 

“They involve things like having a pediatric emergency care coordinator, making sure that they have protocols in place, [and] that all the tube sizes and equipment are ready for neonates all the way to adolescents,” Kuppermann said. “On average, it would cost the United States [$11.84] per child per year to raise all emergency departments to the high level of readiness.” 

That figure was part of the results demonstrated in a study published in early November 2024 in 

, conducted by Kuppermann, Craig Newgard, MD, MPH, et al.

According to results from the study, of the 7619 child deaths that occur annually after ED presentation, 2143 (28.1%; 95% CI, 678-3608) were preventable through universal high ED pediatric readiness, with population-adjusted state estimates ranging from 0 to 69 pediatric lives per year.

Kuppermann also underscored the role of high readiness in reducing health inequities. A recent study—led by Kuppermann's colleague Peter Jenkins, MD, MSc—demonstrated that as pediatric readiness improves, racial and ethnic disparities in care diminish.

“Raising to the highest bar of pediatric readiness not only improves outcomes for children, [but] it also serves to diminish or decrease inequities of care,” said Kuppermann. 

The cohort study found that of 633,536 children treated in 586 EDs across 11 states, the mortality of Black children was greater than that of White children at all quartile levels of readiness. This was observed among individuals with acute medical emergencies, but not traumatic injuries.

"Increased readiness was associated with decreased mortality overall, and it decreased most for Black children with acute medical emergencies," wrote Jenkins, Kuppermann, et al, according to study results.

In conclusion, Kuppermann urged systemic changes to ensure all EDs meet the highest readiness standards.

“It’s not very expensive," he said. "We can certainly afford it in this country, and we certainly owe it to the children of this country and their families to make sure that every ED meets that highest standard.”

1. Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. 

 2024;7(11):e2442154. doi:10.1001/jamanetworkopen.2024.42154

2. Jenkins PC, Lin A, Ames SG, et al. Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity. 

 2023;6(9):e2332160. doi:10.1001/jamanetworkopen.2023.32160

Nathan Kuppermann, MD, MPH, explains the different quartiles of the pediatric emergency department readiness scale, and why the top tier is so crucial for pediatric patients.

Greg Forlenza, MD, offers practical advise for primary care providers regarding continuous glucose monitors and automatic insulin delivery systems. 

Screening for diabetes in primary care and CGM, AID advice for providers

video interview, Greg Forlenza, MD, a pediatric endocrinologist at the Barbara Davis Center for Diabetes at the University of Colorado, joined us to discuss screening in primary care for type 1 diabetes, as well as some practical clinical pearls for navigating continuous glucose monitors (GCM) and automated insulin delivery (AID) systems. 

“Five or 6 years ago, testing type 1 diabetes antibodies was very expensive, very difficult to do. Only a handful of centers would do it, and you couldn’t generally get it covered," said Forlenza. "Within the last, really, 3 or 4 years, it’s moved to a lot of commercial labs are doing standard type 1 diabetes antibody panels, and the antibodies are inexpensive and reliable.”

Forlenza highlighted that advancements in screening have enabled earlier detection of diabetes stages, allowing for more proactive care. “We’re having patients that are detected at earlier stages of diabetes—stage 1, which is antibody positive, you know, asymptomatic. Stage 2, antibody positive, mild glycemic abnormalities. Stage 3 is the stage where people are familiar with that’s symptomatic. And so we’re seeing more and more people identified at that stage.”

Holly D Smith, MD

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