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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

 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.

The CRL issued by the FDA to Regeneron for extended EYLEA HD dosing to 24 weeks cited no safety or efficacy concerns.

FDA issues CRL for aflibercept 8 mg extended dosing for all indications

Krystina Way is a dedicated and experienced Board Certified Behavior Analyst (BCBA) and Licensed Behavior Analyst (LBA) based in Houston, Texas. With a strong educational foundation, Krystina holds a Bachelor of Arts in Psychology from Texas A&M University and a Master of Education in Special Education with a concentration in Autism and Developmental Disabilities from the University of Texas.

Since entering the field of behavior analysis in 2013, Krystina has amassed a wealth of experience across various settings, including homes, schools, rehabilitation centers, ABA clinics, and community environments. Through this diverse background, Krystina has gained exposure to the wide range of autism symptomology.

Through her work at Blue Sprig Pediatrics, Krystina is particularly passionate about neurodiversity-affirming care, caregiver support services and training, and mentoring fellow clinicians to provide high-quality ABA services. Her commitment to these areas underscores her dedication to improving the lives of individuals with developmental disabilities and supporting the broader community of behavior analysts.

Find out how pediatricians play a crucial role in early autism diagnosis and how to advise families post-diagnosis.

The crucial role pediatricians play in early autism diagnosis and why it matters

The sBLA for dupilumab (Dupixent) was supported by data from the phase 3 LIBERTY-CUPID clinical program in patients with uncontrolled CSU. 

FDA approves dupilumab for chronic spontaneous urticaria in ages 12 and up

"Testing for viruses should be the standard of care to help guide therapy," stated Jon Matthew Farber, MD. 

Viral studies reduce antibiotic use in hospitalized febrile infants

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Authors

Monica S. Guirguis, DO, is a board-certified pediatrician with Orlando Health Physician Associates.

Full case: 2-month-old with scalp swelling

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

**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

Recent research detailed that a child was most likely to be killed in a mass shooting by a parent or family member vs a stranger or peer. Study investigator Stephanie Chao, MD, breaks down these data. 

Stephanie Chao, MD details relationships in mass shootings involving children

Stephanie Chao, MD, FACS, FAAP, associate professor of Pediatric Surgery at Stanford Medicine Children’s Health, has dedicated her research to understanding the true risks of firearm-related mass shootings involving children. Motivated by both her professional expertise and personal experience as a mother, Chao became concerned after her young daughter described an active shooter drill at school.

“She told me, ‘Well, the teacher said, in case there’s a bear outside, this is what we should do,’” Chao recalled. “I just thought that that was incredible in that the teacher had to create a story.” This experience led Chao to question the effectiveness of school-based active shooter drills and examine where the true threats to children exist.

Chao co-authored a recent study published in 

, which analyzed mass shootings involving child victims. The study defined pediatric mass shootings as incidents in which at least 4 people were killed, excluding the perpetrator, and at least 1 of the victims was under 18 years old.

Researchers reviewed 121 incidents between 2009 and 2020, which resulted in 308 child fatalities. The study found that 59.1% of these deaths were perpetrated by a family member, with parents alone responsible for 40.9% of all mass shooting deaths. In contrast, classmates accounted for just 6.8% of child fatalities.

“I was surprised by our findings,” Chao said. “We found in our study that 59% of mass shootings that involved children dying were committed by a relative, and 41% of those shootings were committed by a parent. Only a very small percentage, by comparison, was committed by a classmate.” 

Chao emphasized the role of pediatricians in addressing firearm safety. 

“I think pediatricians are really on the front lines with kids,” she said. “They see all the small booboos, they see the cold, but they also see the things that are the beginnings of lifelong trauma.” However, discussing firearm safety remains a challenge in clinical settings. Chao noted that even seasoned pediatricians find conversations about gun safety uncomfortable and difficult to fit into busy patient visits.

One of Chao’s ongoing research projects, PLEDGE, aims to bridge this gap by developing a school-based curriculum focused on gun safety, safe storage, and mental health awareness. 

“We are trying to create a common vocabulary that is nonpartisan,” she explained. “We need to know how to talk about it starting as children.”

Chao believes that treating firearm violence as a public health issue, rather than a political debate, is crucial for prevention. 

“Gun deaths in our country need to be treated as a public health problem, and the research needs to address it just like we do any other issue,” she said. “It’s not going to be a single solution. It’s going to be multifaceted.”

This month, a new initiative from The Ad Council called "Agree to Agree" was launched at Northwell Health's annual Gun Violence Prevention Forum. The initiative address firearm violence and is the first national cross-sector youth gun violence prevention campaign with a public health approach.

The initiative includes a series of PSAs that feature health care professionals speaking to clinicians about gun violence. Using the trusted relationships that providers have with their patients and families, the initiative aims to drive conversation about gun violence prevention.

1. Stephanie D. Chao, MD FACS FAAP. Stanford profiles. Accessed March 26, 2025. https://profiles.stanford.edu/stephanie-chao 

2. Emengo P, Strope JD, Sabapaty A, et al. Victim-Shooter Relationships in Mass Shootings Involving Child Victims. 

 Published online February 10, 2025. doi:10.1001/jamapediatrics.2024.6609 

3. The Gun Violence Prevention Forum. Northwell Health. Accessed March 26, 2025. https://preventgunviolence.com/ 

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 Wednesday, March 26, 2025 at 12:00 PM ET or later for the full case presentation, differential diagnoses, and the correct patient diagnosis. The full case will be presented as a separate article on our home page.

This case was presented by Ngozi I. Eboh, MD, FAAP, FHM, Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas

A 13-year-old female with a history of iron deficiency anemia presented with altered mental status preceded by 5 days of headache, vomiting, nausea, and worsening somnolence that was not responsive to flumazenil, naloxone, or ammonia salts. She had a Glasgow coma scale of 12 and was drowsy with no cranial nerve deficits, or other abnormal physical examination findings. Laboratory evaluation showed microcytic anemia (hemoglobin 7.7 g/dL and MCV (mean corpuscular volume):64.7, lymphocytosis, and mildly elevated liver enzymes [Aspartate Aminotransferase (AST) 52, Alanine Transaminase (ALT) 110] otherwise her electrolytes and kidney function were normal. 

Urine toxicology, Tylenol level, Salicylate level, alcohol level thyroid studies, iron studies, hepatitis panel were normal. Urine pregnancy and COVID tests were negative. Head computed tomography (Head CT) showed mild hydrocephalus, and brain magnetic resonance imaging (MRI) showed increased signal folia and compression of the lower portion of the fourth ventricle and foramen of Magendie. 

She then had an emergency external ventricular drain placed (EVD) by pediatric neurosurgery, and the team started her on high-dose steroids and intravenous immunoglobulin (IVIG). On the third day of admission, she developed new onset left-sided facial drooping, drooling, downbeat nystagmus, and difficulty following commands. An emergent subcortical craniectomy and decompression, duraplasty, and cerebellar biopsy were performed. A cerebellar biopsy was performed due to findings on brain MRI.

Click here for the full case presentation, differential diagnoses, and the correct patient diagnosis.

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

Case Studies

Poll: Can you diagnose this 13-year-old female with altered mental status?

 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. 

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.

Monica Guirguis, DO

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