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Discover the latest in pediatric infectious diseases with Infectious Insights, a new podcast series hosted by expert Tina Tan, MD, FIDSA, FPIDS, FAAP.

Introducing Infectious Insights, a new pediatric infectious disease podcast

. 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.

 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.

A new study aimed to determine mental health resilience in preterm-born children and identify modifiable factors associated with resilience. 

Improving mental health outcomes in children born preterm

According to research from 2021 to 2023, approximately 50% of adolescents who vaped had tried to quit in the last 12 months. 

Exploring vaping cessation methods among adolescents

Childhood cardiovascular health is crucial for lifelong benefits, enhancing cognitive, metabolic, and mental well-being while reducing disease risks.

Ideal cardiovascular health in childhood linked to lower chronic disease risk in adulthood

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

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A baby presented to you at 8 months has episodes of vomiting and has experienced rapid deceleration of weight velocity since 4 months.

Vomiting, failure to thrive in a breastfed infant

**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

 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.

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

News

Case Studies

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

 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, 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

A double-blind, placebo-controlled crossover trial led by researchers at the University of California San Diego School of Medicine found that purified cannabidiol (CBD) may be safe and tolerable in boys with autism spectrum disorder (ASD) and severe behavior challenges, but its efficacy in reducing core behaviors remains inconclusive. The study was published in the 

Journal of Autism and Developmental Disorders

 and represents the first controlled clinical trial evaluating the effects of purified CBD in this population.

“CBD was safe and well-tolerated in boys with severe autism and behavioral problems—participants were able to take the drug without difficulty and there were no serious adverse events,” the authors reported.

The trial enrolled 39 boys aged 7 to 14 years with confirmed diagnoses of moderate to severe ASD and persistent aggressive, self-injurious, and/or stereotyped behaviors. Participants were randomized to receive either eight weeks of oral CBD (up to 20 mg/kg/day) followed by eight weeks of placebo, or vice versa, separated by a four-week washout period. Epidiolex, a purified plant-derived CBD oral solution, was used as the study medication.

Primary outcomes included scores from the Repetitive Behavior Scale–Revised (RBS-R), the Child Behavior Checklist (CBCL), and the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). While both treatment groups showed improvement, the differences between CBD and placebo were not statistically significant on primary endpoints.

“While no significant differences were found between CBD and placebo on broad measures of behavior, clinician impressions suggested that approximately two-thirds of participants showed evidence of clinical improvement with CBD,” the study team wrote.

Blinded clinician observations indicated that 68% of children who completed the full 20-week study experienced behavioral improvements during the CBD phase. Reported improvements included reductions in aggression and hyperactivity as well as increased verbal communication in approximately 30% of participants. The placebo group also demonstrated marked improvements, underscoring the strong placebo effect observed in the study.

The researchers noted that the mean improvement in RBS-R scores was approximately twice as large in the CBD group compared with placebo (Cohen’s d = –0.44 vs –0.22), although this difference did not reach statistical significance (p = .095). Similar trends were seen in CBCL outcomes.

Plasma concentration analysis confirmed adequate systemic exposure to CBD and its active metabolite, 7-hydroxy-CBD. No tetrahydrocannabinol (THC) or related compounds were detected in any participant. Adverse events were generally mild and evenly distributed between the CBD and placebo phases. No serious adverse events were attributed to the study drug.

Of note, concomitant use of medications such as antipsychotics, alpha-2 agonists, and selective serotonin reuptake inhibitors was associated with lower CBD plasma levels and may have influenced outcomes. Sensitivity analyses accounting for these medications revealed stronger effects of CBD in participants not receiving behavior-modifying drugs.

While the authors emphasized the trial’s limitations, including small sample size, limited treatment duration, and the heterogeneity of autism, they concluded that purified CBD may hold therapeutic value for a subset of autistic children with severe behaviors.

“Our results underscore the importance of rigorous, controlled trials in evaluating the efficacy of novel treatments for autism,” the authors stated. “A study utilizing the same placebo-controlled and blinded approach but with a larger number of children, more targeted objective measures, and controlling for other medications used may be able to more definitively answer the question of whether CBD reduces problem behaviors in children with autism.”

The trial was funded by the Ray and Tye Noorda Foundation and the Wholistic Foundation. Epidiolex and placebo were provided by GW Pharmaceuticals (now Jazz Pharmaceuticals), which had no role in the study design, conduct, or analysis.

University of California San Diego. Research alert: CBD might help children with autism, but more research needed. June 23, 2025. Accessed July 10, 2025. https://www.eurekalert.org/news-releases/1088388

Trauner D, Umlauf A, Grelotti DJ, et al. Cannabidiol (CBD) Treatment for Severe Problem Behaviors in Autistic Boys: A Randomized Clinical Trial. 

Journal of autism and developmental disorders

. Published online Winter 2025:10.1007/s10803-02506884-y. doi:https://doi.org/10.1007/s10803-025-06884-y

A clinical trial found CBD was safe and well-tolerated in autistic boys, with some showing behavioral improvements, though placebo effects were strong.

Cannabidiol demonstrates safety, mixed efficacy for severe behavior problems in boys with autism

This case was presented by Giridhar Guntreddi, MD FAAP, FAPHM; Achuth Jayasankar Kondoor, Taylor Boske, Neelima P. Theella, MD, and Jayasree Vasudevannair, MD MPH FAAP. 

A healthy 12-month-old girl presented with one small skin lesion over the right heel (Image 1) 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, 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 re-checked. After 3 months, the child showed full resolution of the skin lesion over the heel area (Image 2).

Below, take your best guess at diagnosing this patient.

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? 

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

 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.

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

Donald Novak, MD

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