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Jesse Hinckley, MD, PhD, Associate clinical professor, University of Colorado School of Medicine, Thomas Jefferson University; Nemours Alfred I. duPont Hospital for Children

Articles

. 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.

At PAS 2025, Jesse Hinckley, MD, PhD, presented data showing cannabis use sharply increases odds of depression and suicidal behavior in youth.

Youth cannabis use and depression, suicidal behavior, with Jesse Hinckley, MD, PhD

 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

 You can reach her at mpetronelli@mjhlifesciences.com.

New model refines prevalence estimates, reduces misdiagnoses compared to the current coding system.

Artificial intelligence improves accuracy in estimating child abuse

A recent study found reduced preterm birth, complications, and NICU use in large Tennessee Medicaid cohort.

Buprenorphine linked to improved outcomes for pregnant women with OUD and their infants

Jennifer Nestor, MD, fellow physician, NemoursAlfred I. duPont Hospital for Children.

Jennifer Nestor, MD, evaluated a digital stethoscope to validate pediatric breath sound recordings for potential machine learning algorithm development.

Validating a digital stethoscope for pediatric breath sounds, with Jennifer Nestor, MD

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The medicine cabinet can be a potential source of prescription drugs for teenagers to misuse. This article offers advice on discussing the hazards of such misuse with adolescents.

The adolescent and the medicine cabinet

**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

Shorter antibiotic courses for AOM and CAP in children proved effective across a pediatric health system, according to data presented by Elysha Pifko, MD.

Decreasing antibiotics for acute otitis media and community acquired pneumonia, with Elysha Pifko, MD

At the 2025 Pediatric Academic Societies (PAS) meeting in Honolulu, Hawaii, Elysha Pifko, MD, presented results of a quality improvement (QI) project aimed at reducing antibiotic duration for acute otitis media (AOM) and community-acquired pneumonia (CAP) across a large pediatric health care system. The initiative, titled 

“Decreasing Ambulatory Antibiotic Treatment Duration for Acute Otitis Media and Community Acquired Pneumonia within a Pediatric Integrated Healthcare System,”

 was implemented across 2 emergency departments (ED), 67 primary care (PC), and 3 urgent care (UC) sites in Delaware, Pennsylvania, and Florida. 

“This was a quality improvement project that we have been working on for quite some time, and I've had really remarkable success,” said Pifko, assistant professor of Pediatrics at Sidney Kimmel Medical College and Nemours Alfred I. duPont Hospital for Children. “This project is one of the first projects that really is enterprise-wide, meaning it's involving multiple different clinical care settings.”

The QI effort began as a pilot in the ED with an amoxicillin order panel for AOM. Following its success, a multidisciplinary team—including infectious disease specialists, pharmacists, nurses, and physicians—developed clinical pathways and order sets for both AOM and CAP. These tools standardized antibiotic choice and duration, guided by national recommendations favoring shorter treatment courses.

“We actually did in-person education for about 700 different providers… educating people about the order panels, order sets, the recommendations for these antibiotics and really [asked] 'what were our goals for the project,'” Pifko said.

From October 2023 to September 2024, data from 26,896 patients showed an increase in appropriate antibiotic duration from 51% to 83%, with no rise in repeat antibiotic prescriptions within 7 to 30 days—supporting the clinical effectiveness of shorter courses. Specifically, adherence rose from 59% to 81% for AOM and 39% to 72% for CAP. Average prescription durations decreased from 8.5 to 6.8 days for AOM and 7.6 to 6.0 days for CAP in eligible patients (1).

“Since shortening the course of recommended antibiotics, there's been no increase in those prescriptions… which really shows that these kids are still… being successfully treated,” Pifko noted.

A key success factor was monthly feedback reports to providers, which Pifko said “really can help sustain a change.”

 Elysha Pifko reports no relevant disclosures

Pifko E. Decreasing Ambulatory Antibiotic Treatment Duration for Acute Otitis Media and Community-Acquired Pneumonia within a Pediatric Integrated Healthcare System Abstract. Presented at: Pediatric Academic Societies 2025 Meeting; April 24-28, 2025. Honolulu, Hawaii.

News

 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, March 24, 2025 at 12:00 PM ET or later for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Muhammad Aamir Anees and Bernard A. Cohen, MD

Want more puzzler and dermatology cases? 

A healthy 9-year-old girl developed an asymptomatic eruption of discrete and confluent, 2 to 3 mm, hypopigmented papules in a linear pattern along the lines of Blaschko on the back of her left thigh and leg over the past 3 weeks. The lesions cleared without treatment 4 to 5 months later. 

Inflammatory linear verrucous epidermal nevus

on Monday, March 24, 2025 at 12:00 PM ET or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

Take your best guess and try to diagnose this 9-year-old girl's linear eruption on the back of her left thigh and leg. Stay tuned for the full case presentation and correct diagnosis! 

Case Studies

Poll: What's the diagnosis of this linear eruption on the leg of a 9-year-old girl?

 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.

This case was presented by Rutva Vora, BS; and Monica Guirguis, DO.

A 2-month-old female was born after an uneventful pregnancy at 40 weeks’ gestation via vacuum-assisted vaginal delivery to a G2P1011 female. The patient’s APGAR scores were 7 and 9 at 1 and 5 minutes, respectively, at birth. No bleeding or other complications were reported during delivery. The newborn and mother were discharged two days after delivery without requiring NICU stay or interventions. The infant briefly developed a small soft palpable scalp swelling that resolved within days after delivery. The patient followed an otherwise uncomplicated growth progression since birth. She did exhibit mild reflux symptoms, which were managed with supportive care measures. Physical examination after delivery and subsequent exams revealed no abnormalities, including no signs of scalp swelling or injury.

At 8 weeks of age, the patient presented to the Emergency Department with a 3-day history of new-onset scalp swelling. The parents decided to seek medical attention after the swelling became noticeably enlarged. Parents denied any changes in her mental status, vomiting, fevers, lethargy, irritability, or any other new concerns. She did have symptoms of gassiness and fussiness that were unchanged from baseline. No history of trauma was reported, and there were no concerning signs suggestive of nonaccidental trauma. The patient appeared well, with a soft, fluctuant palpable subcutaneous fluid collection overlying the parieto-occipital scalp, without crossing suture lines. The anterior fontanelle was soft and non-bulging, and there was no hemotympanum.

Bleeding disorder (e.g. Von Willebrand Disease)

Can you diagnose this patient? Take our poll and find out! Then check back for the full case, differential diagnosis, and correct diagnosis.

Diagnose this 2-month-old with scalp swelling

Joshua Feder, MD, emphasizes that sensory play is most effective when rooted in relational strategies that support autistic children in daily environments.

Sensory play for children with autism, with Joshua Feder, MD

Pediatricians and caregivers can better support children with autism by rethinking sensory play not as a standalone tool, but as a relationship-driven strategy integrated into daily life, according to Joshua Feder, MD, executive director of Positive Development and associate clinical professor in the Department of Psychiatry at UC San Diego School of Medicine. 

“Sensory play is not about just getting a bunch of sensory toys, right?” said Feder. “It’s really something that needs to be integrated into the holistic approach to the child.” He explained that understanding a child’s sensory profile—how they process external and internal stimuli—can help caregivers reduce overwhelm and support connection and communication.

Many children, Feder noted, are brought in for evaluation because of issues like irritability or perseveration, which may be misattributed to behavioral problems rather than sensory sensitivities. “What I really get concerned about is when people jump to medication for irritability, when many times those problems that the kids are having, have to do with their sensory experience,” he said. “They may be irritable because of the light in the room or the sound… or they may be inattentive because they’re not responding to their sensory environment.”

He encouraged clinicians to explore sensory factors before prescribing medication, particularly in cases involving irritability or attention issues. Feder added that interoception—awareness of internal sensations—is often overlooked but critical, and that cataloging sensory responses can guide targeted support.

“Once you understand all those different sensory differences, you can start to figure out, 'well, how do I help the child do better?'” he said. “Either pay attention to the things that [the child] otherwise wouldn’t… or help them to learn to tolerate the things that are in their environment that are very difficult.”

For families facing long wait times for evaluations and services, Feder emphasized the value of daily, mindful interaction. “If you can help people to be mindful and curious about the child’s experience… you can think about what might be helpful to the child to expand their world a little bit and their tolerance,” he said.

While professional guidance from trained occupational therapists or developmental specialists is ideal, he added, “you can do that through your own play, your own relationship.”

This week, the FDA and the US Department of Health and Human Services announced several new measures to phase out all petroleum-based synthetic dyes from the United States' food supply.

According to a press release from the federal agencies, 6 steps will be implemented over the coming weeks and years. The actions are: 

Establishing a national standard and timeline for the food industry to transition from petrochemical-based dyes to natural alternatives.

Initiating the process to revoke authorization for 2 synthetic food colorings—Citrus Red No. 2 and Orange B—within the coming months.

Working with industry to eliminate 6 remaining synthetic dyes—FD&C Green No. 3, FD&C Red No. 40, FD&C Yellow No. 5, FD&C Yellow No. 6, FD&C Blue No. 1, and FD&C Blue No. 2—from the food supply by the end of next year.

Authorizing 4 new natural color additives in the coming weeks, while also accelerating the review and approval of others.

Partnering with the National Institutes of Health (NIH) to conduct comprehensive research on how food additives impact children’s health and development.

Requesting food companies to remove FD&C red No. 3 sooner than the 2027-2028 deadline previously required.

The deadline for red No. 3 was announced on January 15, 2025, by the FDA to remove the color additive from food and ingested drugs.

, a 2022 petition cited various data including 2 studies that demonstrated cancer in laboratory male rats that were exposed to high levels of FD&C red no. 3. The FDA noted the way the dye causes cancer in male rats does not occur in humans, and that claims that the "use of red no. 3 in food and ingested drugs puts people at risk are not supported by the available scientific information," wrote the agency at the time of the announcement.

Red No. 3 specifically gives certain foods and drinks a signature, bright red color often found in candy, cakes, and cupcakes, as well as cookies, frosting, icing, and ingested drugs, among other foods.

"The FDA is asking food companies to substitute petrochemical dyes with natural ingredients for American children as they already do in Europe and Canada,” said FDA Commissioner Marty Makary, MD, MPH, in a statement. "We have a new epidemic of 

One step will be a partnership with the National Institutes of Health to research how food additives impact children's health. 

Jessica B. Calihan, MD, MS

Articles

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