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Lea Widdice, MD, is director of the Adolescent Medicine Fellowship and associate professor at the University of Cincinnati Department of Pediatrics in Cincinnati, Ohio.

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.

Lea Widdice, MD, details her recent presentation at PAS 2025 on OTC STI testing within pediatrics.

Uncovering the pediatrician's role in OTC STI testing, with Lea Widdice, MD

. 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.

Stealth BioTherapeutics' CEO stated, "We hope to gain more information on the revised action date in the coming days." 

Elamipretide to treat Barth syndrome sees FDA target action delay

The human FcRn-blocking monoclonal antibody is indicated for gMG patients aged 12 years and older. 

FDA approves nipocalimab-aahu to treat generalized myasthenia gravis

“Tamarah Westmoreland, MD, Pediatric surgeon, Nemours Children’s Health, Orlando, Florida; Professor of surgery, University of Central Florida College of Medicine”

A PAS 2025 study by Mazar and Westmoreland shows Zika virus can eliminate both local and distant tumors in neuroblastoma mouse models.

Zika-based therapy for metastatic neuroblastoma with Tamarah Westmoreland, MD and Joseph Mazar, PhD

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Can you determine what's causing this baby's nasal congestion, runny nose, cough, and noisy breathing?

Overheard: Wheezing from a healthy 4-month-old

**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 Advances in Pediatric Pneumonia Management

Emerging research in pediatric pneumonia management was highlighted by Jillian Cotter, MD, MSCS, assistant professor at the University of Colorado School of Medicine in Denver, Colorado, during a presentation at the 2025 Pediatric Academic Societies (PAS) Meeting.

"The most emergent evidence that we have over the last five to 10 years has really focused on antibiotic duration for kids with pneumonia," Cotter said. Multiple placebo-controlled randomized trials have shown that shorter antibiotic courses—specifically five days—are noninferior, and in some cases superior, to longer regimens of seven to ten days. Cotter explained, "They see kids reach their clinical response similar times, so fever, duration, resolution of symptoms, and have similar adverse events associated with the antibiotics with fewer days of antibiotic therapy."

Despite most of the robust evidence stemming from outpatient studies, hospitals such as the University of Colorado have extrapolated these findings to the inpatient setting. "We are doing 5 days, and we've updated our internal clinical pathways to recommend 5 days for kids hospitalized with uncomplicated pneumonia, and have had really great adoption from that," Cotter noted.

Diagnostic challenges persist in pediatric pneumonia. Unlike urinary tract infections, where direct bacterial detection is possible, pneumonia lacks a definitive diagnostic test. Cotter commented, "There's no great diagnostic tool to say whether you have pneumonia, yes or no, or whether you have a bacteria or a virus." Tests such as procalcitonin and respiratory viral panels have limitations. Procalcitonin-guided algorithms have produced mixed results and have not seen widespread adoption in pediatric settings. Similarly, respiratory pathogen panels have not significantly altered clinical management due to concerns about co-infection and colonization.

Emerging technologies, including inflammatory marker panels and cell-free DNA sequencing, offer promise but also face limitations. Cell-free DNA assays have shown improved pathogen detection and faster diagnosis, yet specificity remains a concern, complicating the distinction between colonization and true infection.

Antibiotic stewardship remains central to improving outcomes. "Antibiotic stewardship is always thinking about ways to reduce antibiotic exposure to kids," Cotter emphasized. Strategies include prioritizing narrow-spectrum agents, minimizing duration of therapy, and favoring oral over intravenous routes whenever possible to reduce adverse events, maintain gut microbiome integrity, and lower healthcare costs.

As new diagnostic and therapeutic evidence continues to emerge, clinicians must balance evolving research with careful clinical judgment to optimize care for children with pneumonia.

Pfizer Inc (Ongoing) (Products/Services: Research Support, including clinical trials & the principal or named investigator).

Cotter J. Putting the 'Pnew' in Pneumonia. Presentation. Presented at: Pediatric Academic Societies 2025 Meeting; April 24-28, 2025. Honolulu, Hawaii.

"We've updated our internal clinical pathways to recommend 5 days for kids hospitalized with uncomplicated pneumonia," Cotter noted.

News

Jillian Cotter, MD, MSCS, on recent advances in pediatric pneumonia management

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

In a session at the 2025 Pediatric Academic Societies Meeting in Honolulu, Hawaii, Jesse Hinckley, MD, PhD, presented findings linking cannabis use to major depressive disorder and suicidal behavior among adolescents, drawing from a secondary analysis of the National Comorbidity Survey—Adolescent Supplement (NCSA).

"Both trends have been on the increase or on the rise over the last decade or so," Hinckley explained, citing growing concerns over cannabis legalization and the lagging pace of related scientific research. Hinckley is as associate professor at the University of Colorado School of Medicine. He emphasized the importance of studying cannabis use given its increasing prevalence among youth and the significant associations found between cannabis use, depression, and suicidality.

In the study, adolescents with lifetime cannabis use had 2.07 times higher odds of mild or moderate major depressive disorder (MDD) and 3.32 times higher odds of severe MDD compared to non-users (

, 95% CI = 2.31-4.75). "We could see that using cannabis was also associated with not just the prevalence, but also the severity of major depressive disorder," Hinckley said. Further analysis demonstrated that lifetime cannabis use was associated with a 6.90 times higher odds of lifetime suicide attempt, even after controlling for major depression (

, 95% CI = 4.67-10.19). "When we looked at lifetime suicide attempt after accounting for whether or not they had a major depressive disorder, those who had used cannabis in their lifetime were 6.9 times more likely to have attempted suicide," Hinckley stated.

Importantly, the study also explored the impact of frequency of cannabis use. Adolescents who used cannabis three to four days per week or more had an 8.7 times higher odds of attempting suicide, and even less frequent users (less than monthly) had a 4.9 times higher odds of suicide attempt compared to non-users. "When we look at what we can colloquially call like that dose effect, whereas exposure goes up, the outcome goes up, that lets us know that, 'oh, maybe there really is something here,'" Hinckley noted. "If you lecture these kids, they've been lectured by so many people, they kind of just shut it off," he said. Instead, Hinckley recommends using motivational interviewing techniques to "help them bring those 2 things back together" and increase awareness about the risks.

The findings underscore the critical need for pediatricians and mental health providers to screen for cannabis use when assessing suicidality risks in adolescents. "Having active substance use problems is one of the things that can help distinguish those who have suicidal thoughts from those who will then act on those thoughts," Hinckley concluded.

Hinckley J, Mikulich-Gilbertson SK, He JP, et al. Cannabis Use Is Associated With Depression Severity and Suicidality in the National Comorbidity Survey—Adolescent Supplement. 

Hinckley J. Cannabis use and suicidal behavior in youth. Hot Topic Symposia session. Presented at: Pediatric Academic Societies 2025 Meeting; April 24-28, 2025. Honolulu, Hawaii.

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

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

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

A recent study led by Jennifer Nestor, MD, fellow physician at Nemours Alfred I. duPont Hospital for Children, evaluated the effectiveness of digital stethoscope technology in recording pediatric breath sounds for clinical and educational use. The poster, titled “Validation of a Digital Stethoscope for Recording and Identification of Pediatric Breath Sounds to Aid in Development of a Machine Learning Algorithm,” was presented at the 2025 Pediatric Academic Societies meeting in Honolulu, Hawaii.

The project emerged from Nestor’s experience during her fellowship, which coincided with a national albuterol shortage amid a surge in pediatric respiratory illnesses. “We were working with a week’s worth of albuterol nebulized therapy for our patients, and trying to sort of be really judicious about where we were using the therapy,” Nestor said.

Faced with limited resources and high patient volume, Nestor and her colleagues saw an opportunity to explore how digital auscultation could optimize bedside decision-making. The prospective observational study recorded breath sounds from children younger than 18 years using EkoCore digital stethoscope technology. Recordings were captured from up to 10 positions and classified in real time by the bedside clinician. These same recordings were later assessed independently by five expert listeners, blinded to original classifications.

“There is no gold standard [for pulmonary auscultation],” Nestor explained. “The gold standard is the trained professional who’s listening to the patient at the bedside and hearing specific things.”

The study’s primary aim was to assess interrater and intrarater reliability using Cohen’s kappa and Fleiss' kappa to evaluate agreement between bedside and remote listeners. “My kappa values all fell within the fair to moderate agreement range,” Nestor said, citing background noise and extraneous patient movement as factors impacting classification accuracy.

Despite these challenges, the technology showed promise. Interrater agreement between the bedside recorder and majority classification of all listeners was moderate (k = 0.43), while all individual comparisons showed fair agreement. 

“No difference in agreement based on age, gender, respiratory support or nebulizer use” was observed, and even conditions like bronchiolitis and respiratory failure showed only slight agreement, according to the study. 

“My hope… is that we work on the technology for cleaning up some of the breath sounds and see if that can push us from that fair to moderate agreement into more of the substantial to almost perfect agreement classification,” Nestor said. Nearly all study participants consented to breath sound storage, which may contribute to the creation of the first pediatric database for machine learning development in pulmonary auscultation. “Ultimately… depending on what we’re able to do with the technology, [this] may lend itself to the development of that algorithm,” Nestor added.

Nestor J, Slamon N, McMahon K, et al. Validation of a Digital Stethoscope for Recording and Identification of Pediatric Breath Sounds to Aid in Development of a Machine Learning Algorithm​. Poster. Presented at: Pediatric Academic Societies 2025 Meeting; April 24-28, 2025. Honolulu, Hawaii.

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

 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?

 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.

The photos in this case were taken soon after the painful and red papules appeared.

Bradley Robinson, MD

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