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Articles

With 1 in 7 adolescents worldwide diagnosed with mental health disorders, emerging research suggests that diet is a powerful yet often overlooked therapeutic tool. 

Brain food: Nutrition's critical role in teen mental health

. 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.

Walker and Harris emphasize the importance of early hearing loss detection, screening, and intervention to support optimal child development.

Camille Walker, Sacheen Harris discuss hearing loss, screenings, and testing in primary care

The PANDAS/PANS questionnaire is based on symptoms and comorbidities described in the literature and is a self-report completed by parents of children younger than 18.

New questionnaire effectively screens for PANDAS/PANS

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! 

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

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Authors

A previously healthy 16-year-old female patient presents with intermittent pleuritic chest pain and shortness of breath. The night before her symptoms started, she hit her chest on a door after a "fainting" episode.

Pleuropulmonary blastoma in an adolescent

**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. 

 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.

News

Case Studies

At the 2025 NAPNAP Conference in Chicago, Jessica Spruit, DNP, CPNP-AC, FAANP, discussed the AAP's first clinical practice guideline on opioid prescribing. 

Discussion: AAP's opioid for acute pain clinical practice guideline with Jessica Spruit, DNP

At the 2025 NAPNAP National Conference on Pediatric Health Care in Chicago, Illinois, Jessica Spruit, DNP, CPNP-AC, FAANP, discussed the American Academy of Pediatrics' (AAP) first clinical practice guideline (CPG) on "Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." The guideline seeks to balance effective pain management with opioid safety and addresses disparities in pediatric pain treatment.

“This is actually a brand new guideline. It's the first of its kind. The AAP really took this on with the intention of promoting appropriate prescribing of opioids,” Spruit stated.

“We know that in the setting of an opioid crisis, certainly there's reason for all of us as clinicians to be cautious and thoughtful about the way we utilize and prescribe opioids in our practice," Spruit added. "But what we also worry about is that some pain is inadequately managed as a consequence of regulations and kind of pulling back on the utilization of those medications which do have a long track record of beneficial use. So it’s all about the thoughtful and appropriate prescribing, and this guideline provides some guidance to promote that.”

The guideline emphasizes a multimodal approach to pain management, urging clinicians to combine non-opioid medications and non-pharmacologic therapies when treating acute pain. According to the CPG, opioid monotherapy should not be used for children and adolescents. Instead, opioids should only be used in combination with other pain management strategies.

Spruit highlighted another significant recommendation:

“The other thing that really stood out to me, which had a really high grade in the quality of evidence, was regarding the disposal of opioids following utilization of that prescription. Excess opioids should be disposed of, and if we provide that education with the mode of disposing it, [such as] talking about DEA take back events, using those mail return envelopes, that's all really helpful in promoting adherence to those recommendations for the families we serve.”

A major concern addressed in the guideline is the risk of opioid misuse among adolescents.

“I think recognizing that opioids are in our communities [is important]. We know that when adolescents report that they've misused an opioid or used it in a way that it was not intended, they've often gathered those leftovers from family and friends,” Spruit noted. “I think that even if you're not prescribing it, being aware of the fact that children, adolescents, and families, have access to these medications and that their proper storage, utilization, and disposal is really important.” 

The CPG underscores this issue by recommending that PHCPs educate caregivers on directly observed medication administration and safe storage.

While the guideline does not ban opioid use outright, it sets clear restrictions on certain medications. 

“So within the guideline, there isn't a specific case that says opioids as a class should not be used. It does suggest that it should never be used as a single therapy. So you should never, when trying to manage pain, only prescribe an opioid,” Spruit clarified. “And there is some guidance regarding restrictions related to codeine and Tramadol, which pediatric providers are likely very familiar with but there is nothing within the guideline that states opioids should never be utilized.” 

The guideline explicitly advises against prescribing codeine and tramadol for children under 12 years and for adolescents with conditions like obesity, obstructive sleep apnea, or severe lung disease. It also recommends prescribing immediate-release opioid formulations at the lowest effective dose for age and weight, with an initial supply of five days or fewer, "unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days," according to the CPG.

“I just think that all of us who are committed to relieving pain in children and keeping children and families safe from the risks of opioids can refer to this document as the first of its kind, and keep an eye out," Spruit said. "The AAP provided some guidance regarding additional research that's necessary, gaps in the evidence, and I think we all have an important responsibility in contributing to filling those gaps and enhancing the guidelines in future editions.”

1. Van Damme D, Madded M, Spruit J. Pediatric clinical guidelines update. Presented at: NAPNAP. March 10-13, 2025. Chicago, Illinois. 

2. Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. 

 November 2024; 154 (5): e2024068752. 10.1542/peds.2024-068752 

Bobbie Monaco, MSN, CPNP-PC, provided a recap of her NAPNAP session regarding period poverty, and called for continued advocacy and awareness in the United States and globally. 

Addressing period poverty with Bobbie Monaco, MSN, CPNP-PC

At the 2025 NAPNAP National Conference on Pediatric Health Care in Chicago, Bobbie Monaco, MSN, CPNP-PC, a pediatric nurse practitioner with the Children’s Hospital of Philadelphia (CHOP) Care Network in Pottstown, Pennsylvania, addressed the critical issue of period poverty and menstrual equity in her session, “Breaking the Cycle: Addressing Period Poverty, Promoting Equity and Fostering Sustainability in Menstrual Health," presented at the 

NAPNAP National Conference on Pediatric Health Care

Monaco has been involved in addressing period poverty and menstrual equity since 2015, drawing from her global health work. 

“I suddenly thought about what girls were doing for their periods. When I asked, I was told they were using cardboard, staying home, participating in transactional sex, using mattress stuffing, or even using round stones that they placed in their vaginas as a plug. I thought, ‘Wow, I need to do something about this,’” she said. 

Although she initially saw period poverty as a global issue, the COVID-19 pandemic shifted her focus to the United States. 

“I found that the statistics here were staggering. In 2023, one in four girls missed school or work because they could not afford or did not have access to period products,” Monaco explained. 

Despite growing awareness, many states still classify period products as luxury items. 

Until 2020, when the COVID CARES Act was passed, individuals could not use health savings accounts (HSAs) or flexible spending accounts (FSAs) to purchase menstrual products. Advocacy efforts have led to increased access in schools, but widespread availability remains a challenge.

“We need to speak up in our communities, learn what is happening locally, and determine how we can help. We must contact our local and state representatives to make them aware of this issue in our clinics, communities, and schools.”

Beyond accessibility, menstrual health is also impacted by product safety and sustainability. 

“A research study published last year examined 18 different brands of pads and tampons—both organic and non-organic—available in the United States. The study found levels of lead and arsenic in all of the products, exceeding the levels allowed in fabrics that touch the skin,” Monaco said.

Monaco also pointed out the potential risks of these toxins coming into contact with mucous membranes, highlighting the need for further research on their long-term effects. 

The environmental impact of disposable menstrual products is also significant.

“Pads are composed of 90% plastic and break down into microplastics that enter our waterways and landfills. Every tampon and pad ever used is still in a landfill today, as they take 500 to 800 years to decompose,” she stated.

Monaco emphasized that providers play a vital role in breaking the stigma surrounding menstruation. 

“We must normalize conversations about menstruation, making it a common topic rather than one that elicits giggles or discomfort.” 

She encouraged primary care providers to routinely discuss menstruation during adolescent visits, asking not only about cycle regularity and pain but also about the types of menstrual products used.

“Are these products working for them? Have they considered reusable options? Do they have access to them? Do they need help? I have found that by opening this dialogue, girls and mothers return year after year to share how they have made changes. If we do not initiate these conversations, the opportunity for education is lost.”

According to Monaco, NAPNAP is in the process of creating a position statement to address period povert and period equity, with and aim to be published this year.

Monaco B. Breaking the Cycle: Addressing Period Poverty, Promoting Equity and Fostering Sustainability in Menstrual Health. Presented at: NAPNAP. March 10-13, 2025. Chicago, Illinois. 

Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN, comments on the ongoing measles outbreaks and encourages advocation for vaccines and accurate information. 

  Measles outbreaks: 223 cases reported in Texas

Measles cases have continued to increase this week in both Texas and New Mexico, according to each state's respective health department agencies.

As of March 11, 2025, the number of measles cases in Texas has reached 223, all reported since late January. Of these, 29 patients have been hospitalized. In February, a school-aged child who lived in the Texas outbreak area, was vaccinated, and had no underlying health conditions died of measles, the first death in the United States related to the highly contagious disease in a decade.

Later, on March 6, 2025, the New Mexico Department of Health (NMDOH) reported that a resident of Lea County had died. The health agency stated the individual was unvaccinated and had tested positive for measles after death.

As of March 11, 2025, NMDOH reported 33 cases of measles, including a new case in Eddy County, the first reported outside of Lea County.

 Of the 33 cases currently reported, 27 are among those who have not been vaccinated and 5 among with an unknown vaccination status.

Emma Batchelder, MD

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