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Elizabeth Reichert, PhD, pediatric and adolescent psychologist, Stanford Medicine Children’s Health; co-director, Stanford Parenting Center.

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.

Psychologist Elizabeth Reichert, PhD, encourages primary care providers to use validation and connection to support mental health during routine visits.

Managing mental health between specialist visits with Elizabeth Reichert, PhD

Aleece Fosnight, PA-C, urology specialist at Aeroflow Urology.

Hydration, timed voiding, and limiting bladder-irritating foods can help kids manage incontinence, says Aleece Fosnight, PA-C, in this Q+A interview.

Aleece Fosnight, PA-C, discusses bladder control issues and associations with food

 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.

Among adolescents aged 13 to 17 years, coverage with 1 or more Tdap dose increased from 89% to 91.3% from 2023 to 2024, respectfully. 

Adolescent vaccination coverage improves for Tdap and MenACWY; HPV rates remain unchanged

Richard Auchus, MD, PhD, professor of pharmacology and internal medicine, University of Michigan.

Screenshot 2025-07-31 at 12.04.54 PM.png

Richard Auchus, MD, PhD, discusses how crinecerfont is improving CAH care and easing the transition from pediatric to adult management.

Richard Auchus, MD, on how crinecerfont is changing CAH treatment

Contemporary Pediatrics connects pediatricians with peer-reviewed articles, guideline updates, and practice strategies for real-world clinical application.

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**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

Manufacturer MannKind as submitted a supplemental Biologics Application to the FDA for its inhaled insulin Afrezza.

Michael Haller, MD discusses inhaled insulin and Afrezza data for type 1 diabetes

On August 6, 2025, MannKind Corporation submitted a supplemental Biologics License Application to the FDA for its inhaled insulin Afrezza for a pediatric population indication, with a decision expected early in the fourth quarter of 2025, according to a financial report from the company.

The filing was based on data from the INHALE-1 study, led by Michael Haller, MD, MS-CI, lead author of the study and professor and chief of Pediatric Endocrinology at the University of Florida. The study evaluated the safety and efficacy of the inhaled insulin regimen as a replacement for rapid-acting meal insulin in children with type 1 diabetes (T1D). It included 230 patients aged 4 to 17 years, who were randomized to either inhaled insulin or rapid-acting analogue for meals, with a primary outcome of change in A

According to a press release from the American Diabetes Association's 85th Scientific Session, where data were presented at the June meeting in Chicago, findings indicated that inhaled insulin is safe and effective in children with T1D. Full study results, including a safety extension, have been submitted for presentation at a medical meeting sometime in the second half of 2025, according to MannKind.

"The primary outcome essentially showed non-inferiority of inhaled insulin compared to rapid-acting injected insulin," stated Haller in the video above. "This finding is slightly qualified by the inclusion of 1 patient who was highly non-adherent to their insulin regimen and was assigned to the inhaled insulin group. Including this patient in the analysis resulted in a non-significant p-value for non-inferiority. However, in a sensitivity analysis excluding this non-adherent [patient], the inhaled and injected insulin groups showed nearly identical outcomes in terms of hemoglobin A

Currently, Afrezza is being prescribed off-label for the pediatric population, with the adult population being the only FDA-approved indication for the inhaled insulin. Now, with a filing submitted to the federal agency, Afrezza is one step closer to a proper label pediatrics. 

"The field has long been in search of more rapid-acting insulins—truly rapid insulins—that can more physiologically cover meal excursions and corrections and reduce risk for post-meal hypoglycemia," added Haller. "In terms of injectable insulins, we've made some progress by manipulating the insulin structure so it gets into the bloodstream faster, but again, it's just not fast enough."

"Essentially, this is a biomaterial technosphere that gets bound to regular human insulin," Haller explained of Afrezza. "So, it's your non-manipulated insulin, and then, when it's inhaled into the lung, these particles dissociate, and the insulin is absorbed very rapidly through the lung blood vasculature, allowing the insulin to reach peak levels within 15 or 20 minutes. So, much closer to the way a human pancreas that's working should work. Because of that, it really can provide more optimal meal coverage, safer control of hyperglycemic corrections, and it's much better for athletes in terms of not having hypoglycemia associated with insulin dosing." 

Haller added that until there is a wider shift in how T1D treatment is looked at, utilization rates, even among adults, could be lower compared to other T1D insulin options. 

"It's been successful in adults, although it remains fairly underutilized, I would say, just because the paradigm hasn't shifted so that people think of using inhaled insulin as a first option. Everybody still kind of assumes we have to use injected," he said. "Current pediatric use is off-label, and myself and many others are prescribing it that way. Lots of pediatric medicine is off-label, unfortunately."

MannKind Corporation reports second quarter 2025 financial results and provides business update. MannKind Corporation. Press release. August 6, 2025. Accessed August 7, 2025. https://investors.mannkindcorp.com/news-releases/news-release-details/mannkind-corporation-reports-second-quarter-2025-financial 

Inhaled insulin shown as a safe and effective replacement for standard-of-care in children with type 1 diabetes. American Diabetes Association. Press release. June 22, 2025. Accessed August 7, 2025. https://professional.diabetes.org/sites/dpro/files/2025-06/ADA_InhaledInsulinPressRelease_FINAL.pdf

Manufacturer MannKind has submitted a supplemental Biologics Application to the FDA for its inhaled insulin Afrezza. 

News

Michael Haller, MD, discusses inhaled insulin and Afrezza data for type 1 diabetes

Richard J. Wong, DO, and Tyra Bryant-Stephens, MD, outline strategies for controlling asthma as kids head back to school.

Tyra Bryant-Stephens, MD, Richard Wong, DO, break down asthma in the classroom

Asthma remains one of the leading causes of school absenteeism and a top chronic illness among children in the United States, according to the CDC. As the school year begins, pediatricians can play a crucial role in preparing families to manage asthma in the classroom and beyond. 

“Children at school face several challenges in making sure that their asthma stays under good control, as compared to being at home,” said Richard J. Wong, DO, pediatric pulmonologist, Phoenix Children’s. Limited access to rescue therapies, lack of an asthma action plan, or even stigma can all contribute to flare-ups.

Transitions from summer to school can also affect medication adherence. “A common challenge we see is that getting ready for a busy school day can make it difficult for families to remember to give the morning dose of medication,” said Tyra Bryant-Stephens, MD, medical director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia.

Age can influence management. Younger children rely on school staff to recognize symptoms, while adolescents may underreport symptoms and skip controller medications. “This can lead to an overreliance on short-acting beta agonists,” Wong noted. 

Bryant-Stephens recommended that at the start of the year, pediatricians review an asthma action plan, ensure children have inhalers and spacers for both home and school, and verify insurance coverage for extra supplies. She outlined 5 key steps: discuss triggers, review provider needs, complete the school checklist, use control medications consistently, and ensure medication refills are available.

School nurses can be valuable partners in care, though availability varies. “We need to consider them part of the health care team,” said Bryant-Stephens. “They are allies in keeping children in school.”

Pediatricians can also share practical tips directly with children, such as pacing before and after exercise and restarting allergy medications before the school year to reduce triggers. “It is important to make sure enough refills are always present…and to encourage the use of spacers,” Wong added.

With clear communication, preparation, and collaboration between families, schools, and providers, children with asthma can start the school year ready to learn, and breathe, more easily.

Managing asthma in schools. CDC. August 13, 2024. Accessed August 8, 2025. https://www.cdc.gov/school-health-conditions/chronic/asthma.html

Richard J. Wong, DO, and Tyra Bryant-Stephens, MD, outline strategies for controlling asthma as kids head back to school. 

 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 Giridhar Guntreddi, MD, FAAP, FAPHM; Achuth Jayasankar Kondoor; Taylor Boske; Neelima P. Theella, MD; and Jayasree Vasudevan Nair, MD, MPH, FAAP. 

A healthy 12-month-old girl presented with one small skin lesion over the right heel (

) for one month. On examination, her right lateral heel showed a round, white, pearl-like, hard, tiny lesion with a smooth appearance without any redness or itching. The patient's mother denied any pain, swelling, itching, or fever. No significant travel, bites, or heel-stick injuries were reported in the history. No systemic symptoms suggested any underlying systemic diseases. The infant is closely monitored at subsequent well visits and rechecked. After 3 months, the child showed full resolution of the skin lesion over the heel area (

Below, take your best guess at diagnosing this patient.

click here for the full case presentation, differential diagnosis, and 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

Diagnose this infant with an asymptomatic pearl-like nodule on the heel

Then, visit our website on July 9, at 12:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis. 

This case was provided by Drashti Patel, BS, BA, and Jyoti Budania, MD.

In November 2023, an otherwise healthy 11-year-old boy presented to the clinic with the chief complaint of testicular discomfort. He reported mild testicular pain that worsened with physical activity, and he denied the presence of dysuria, urinary urgency, or frequency. He was recently evaluated by ENT for an episode of epistaxis, which was benign and resolved without requiring cauterization. His medical history was otherwise unremarkable, notable only for molluscum contagiosum at5 years of age and a few episodes of streptococcal pharyngitis and otitis media.

His vital signs in clinic were within normal limits, and the only additional finding at this time was a nontender, nonpruritic, and nonpalpable petechial rash on the bilateral lower extremities. His mother observed that the rash appeared to fluctuate with his activity level, worsening during periods of increased stress or activity.

Given the presence of petechiae, an initial workup was initiated, including a complete blood count (CBC), comprehensive metabolic panel (CMP), prothrombin time (PT), and partial thromboplastin time (PTT). A point-of-care urinalysis performed in the clinic revealed traces of blood in the urine. The patient appeared well and did not show any other signs of illness. He was diagnosed with viral epididymitis while pending laboratory results. He was advised to remain hydrated and to return for follow-up if his symptoms persisted or worsened. His mother agreed with this plan and committed to closely monitoring his rash.

Over the following week, he returned to our clinic. His rash had progressed, spreading to his thighs, buttocks, and the distal shaft of his penis. All of his previous labs were within normal limits, and additional workup was initiated, including a platelet function assay and measurements of serum IgA, C3, and C4 levels, along with a repeat urinalysis.

Below, take your best guess at diagnosing this patient

Idiopathic thrombocytopenic purpura (ITP)

Now, click here for the full case presentation, differential diagnosis, and correct patient diagnosis. 

Thank you for taking this Contemporary Pediatrics poll! Want more puzzler case studies?

Can you diagnose this 11-year-old with a petechial rash?

Recent 24-week data from the ADmirable study reinforce the safety and efficacy of lebrikizumab-lbkz (Ebglyss; Eli Lilly) in adolescents and adults with moderate to severe 

 (AD), including individuals with pigmented skin tones. Findings were shared via an oral presentation from Eli Lilly at the Revolutionizing Atopic Dermatitis (RAD) conference and represent the latest update in ongoing efforts to evaluate treatment performance across diverse patient populations.

Lebrikizumab-lbkz, a biologic targeting IL-13 

Lebrikizumab demonstrated efficacy and safety in patients with skin of color and moderate to severe atopic dermatitis in the ADmirable trial. Trial investigator Andrew Alexis, MD, MPH, reacts. 

Aleece Fosnight, PA-C

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