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Richard A. Bermudes, MD, psychiatrist, chief medical officer, BrainsWay; associate physician, University of California Davis.

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.

“It’s not just about screen time—it’s about context,” says Richard A. Bermudes, MD, on guiding conversations in pediatric well care visits.

Richard Bermudes, MD, on discussing screen use and time at well care visits

 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.

Study finds lean mass and fitness protect against anxiety and depression, while visceral adiposity increases risk in children aged 8-11.

Body composition and fitness linked to anxiety and depression in preadolescent children

Nicotine poisoning can include confusion, vomiting, and loss of consciousness. 

FDA wants nicotine pouch manufacturers to use child-resistant packaging

Certain dietary fats trigger neutrophilic asthma by activating lung immune cells independent of obesity, study findings show.

Dietary fats linked to neutrophilic asthma through lung inflammation pathways

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Dr Jon E. Grant talks about the genetics, neurobiology, and cognitive processes of body-focused repetitive behaviors, which include trichotillomania, skin picking, and other behaviors.

Treating Patients with Trichotillomania and Other Related Behaviors

**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

pregnancy may increase the risk of type 1 diabetes in offspring, according to findings from a large prospective cohort study in Denmark published in the 

Journal of Epidemiology & Community Health

Researchers evaluated data from 67,701 mother-child pairs enrolled in the Danish National Birth Cohort (DNBC) between 1996 and 2002. The study excluded mothers with preexisting diabetes or implausible dietary reports. Maternal diet was assessed at approximately 25 weeks of gestation using a comprehensive 360-item food frequency questionnaire. An empirical dietary inflammatory index (EDII) score was calculated to quantify the inflammatory potential of each participant’s diet, with higher scores indicating a more proinflammatory dietary pattern.

Over an average follow-up period of 17.6 years, 281 children (0.42%) were diagnosed with type 1 diabetes. The investigators observed a statistically significant association between maternal EDII score and the risk of type 1 diabetes in offspring. Each SD increase of 1 in the EDII score was associated with a 16% increased risk (adjusted HR, 1.16; 95% CI, 1.02–1.32) of type 1 diabetes diagnosis during childhood or adolescence.

“A low-grade inflammatory state secondary to an altered immune cell profile, which triggers proinflammatory pathways, is increasingly acknowledged as a critical early-life factor influencing offspring health,” the authors wrote.

The EDII score was derived using reduced rank regression. It was weighted based on associations between specific food group intake and circulating C-reactive protein concentrations, using data from a similar Nordic cohort. Diets high in red or processed meats, low-fat dairy, pizza, french fries, margarine, and savory snacks were associated with higher EDII scores. Conversely, higher intake of alliums, tomatoes, whole grains, fruits, vegetables, tea, and dark meat fish contributed to lower (anti-inflammatory) EDII scores.

Higher EDII scores were also associated with other maternal characteristics such as younger age, higher body mass index (BMI), smoking beyond 12 weeks of pregnancy, lower alcohol consumption, shorter breastfeeding duration, and lower socioeconomic status. However, total energy intake did not significantly differ across EDII quintiles.

Notably, the observed association between a proinflammatory diet and type 1 diabetes remained robust after adjusting for multiple potential confounders, including maternal age, BMI, smoking status, socioeconomic status, breastfeeding duration, and energy intake. Additional analyses indicated that gluten intake during pregnancy was also independently associated with elevated type 1 diabetes risk in offspring (HR per 10 g/day increase, 1.36; 95% CI, 1.09-1.71). In contrast, continued smoking during pregnancy was associated with a reduced risk (HR, 0.47; 95% CI, 0.31-0.72).

“Of particular note is the fact that 3 factors during midpregnancy, a proinflammatory dietary pattern, gluten, and smoking, seemed to independently predict the child’s risk of type 1 diabetes,” the authors stated. “This suggests that midpregnancy may be a critical period during which the fetus is particularly susceptible to maternal lifestyle influences in relation to the individual’s later risk for developing type 1 diabetes during childhood or adolescence.”

While the findings support the role of fetal programming in the development of autoimmune disease, the authors acknowledge limitations. As an observational study, causality cannot be established. Additionally, the child’s own diet postnatally was not assessed, and residual confounding from unmeasured factors remains possible.

Nevertheless, the study adds to a growing body of evidence linking maternal dietary exposures during pregnancy to long-term metabolic and immune outcomes in children. The authors concluded that further studies are warranted to replicate these findings and elucidate underlying biological mechanisms.

This article was originally published by our sister publication 

1. BMJ Group. ‘Inflammatory’ diet during pregnancy may raise child’s diabetes type 1 risk. News release. Eurekalert. July 1, 2025. Accessed July 9, 2025. https://www.eurekalert.org/news-releases/1089224?

2. Noorzae R, Bjerregaard AA, Halldorsson TI, et al. Association between a pro-inflammatory dietary pattern during pregnancy and type 1 diabetes risk in offspring: prospective cohort study. 

. Published online July 7, 2025. doi:10.1136/jech-2024-223320

A proinflammatory maternal diet during pregnancy was linked to a 16% higher risk of type 1 diabetes in offspring, a Danish cohort study finds.

News

Pro-inflammatory diet during pregnancy tied to diabetes in children

Obtaining a psychosocial history from adolescents can pose a challenge for even the most experienced clinicians. Yet this is arguably the most important part of the routine adolescent health care visit. For example, motor vehicle accidents, as well as homicides and suicides, each account for several thousand young adult deaths annually, with alcohol being a factor in many of these fatalities.

 In addition, nearly 2000 adolescents die every year from an unintentional opioid overdose, mostly attributable to the widespread availability of illicitly manufactured fentanyls.

Sexually transmitted infections, pregnancy, eating disorders, and abuse/neglect are also associated with significant adverse sequelae in youth.

 Perhaps most striking is that the vast majority of these occurrences are preventable. Implementing a comprehensive, organized approach to understand a patient’s strengths and risks can be challenging in a busy practice. This article aims to illustrate how this can be accomplished using the HEADS FIRST Checklist (

) as a quick, concise, and easy-to-use screening tool for meeting the comprehensive health care needs of adolescents and young adults.

Several interview instruments exist to elicit a psychosocial history from adolescents.

 The HEADS FIRST Checklist is structured to offer pediatric practitioners a more streamlined, up-to-date approach to this important topic. It is especially notable that our checklist can be further differentiated from other methods by featuring specific questions about abuse, body image, and gender identity. For more than 30 years, the HEADS FIRST Checklist has been used as a clinical and undergraduate and graduate medical teaching tool at our institution to address sensitive topics that comprise the major causes of morbidity and mortality in adolescents and young adults. The checklist has been modified and updated numerous times since it was initially published in 

 This method highlights the importance of getting into adolescents’ heads first, to connect with them meaningfully and genuinely, in an effort to reduce risk-taking behaviors. We also use the word “first” as part of the acronym to heighten awareness that the psychosocial history should be considered the most important component of the routine adolescent checkup and even more important than the physical examination itself.

It is preferable to identify teens at risk proactively rather than reactively. The annual health checkup provides an excellent opportunity to accomplish this goal. Although it is ideal to identify psychosocial issues early, issues in the HEADS FIRST categories may also present with medical symptoms at an acute or sick visit, including during a hospitalization. There is no substitute for a carefully performed psychosocial history, especially when underlying risk factors or behaviors may not be readily apparent or disclosed. This is particularly true when topics are seen as stigmatized, too personal, or taboo. Clinicians must initiate conversations addressing these sensitive topics, just as we ask about headaches, chest pain, rashes, etc. The psychosocial history is equally important for youth with disabilities or chronic medical conditions as they face similar challenges as their healthier peers. Furthermore, they must deal with the effects of their underlying disorder as an added stressor.

Basic clinical approach to the HEADS FIRST history

The HEADS FIRST topics are interrelated, and problems in one area may be closely linked to issues in other areas. Because of this, in practice, the topics on the checklist may flow conversationally; the checklist is not meant to be used strictly in order. The questions can be sequenced in accordance with the flow of the interview at the practitioner’s discretion. Topics that the examiner perceives to be especially sensitive for an individual patient can be reserved for later in the conversation as deemed appropriate. We proceed with clear, direct, focused trigger questions (Figure) and follow up with open-ended questions.

Though it has been shown that patients and their parents expect the topics listed in the HEADS FIRST Checklist to be discussed as part of routine adolescent health care,

 patients’ readiness to answer certain questions on the HEADS FIRST Checklist varies. Practitioners who care for adolescents are accustomed to adjusting the medical history to the developmental level of their patients and should tailor the timing of this interview to individual patient needs. The HEADS FIRST screening tool addresses deeply personal, complex, intertwined, and potentially anxiety-provoking or stigmatized topics. Fostering a mutually respectful, strengths-based conversation is the most important element of implementation. It must be stressed that trust and respect are not automatic and must be earned by both the clinician and the patient. In our office, starting at the 11- or 12-year visit, we meet with the patient and parents together to review the general medical history, discuss any concerns, and address privacy. In some cases, it may be pertinent to weave some of the HEADS FIRST topics into the history of the present illness while the parents are still in the room.We then excuse the parents (assuring them of private time with the clinician if desired) and meet with the patient alone in the exam room, unless the patient desires the presence of others.

The provision of confidential health care, whenever possible, is an essential component of adolescent medicine.

 Recommendations for optimizing confidentiality practices and protections for adolescents and young adults within the pediatric practice setting are outlined per American Academy of Pediatrics (AAP) guidelines.

Practitioners must be aware of adolescent privacy laws in their state, as there is state-by-state variability in the legal rights for minors.

 If confidential care is not provided, adolescents may withhold information and not return for subsequent visits.

 Beyond legal rights and access to care, speaking with the adolescent alone supports their emerging autonomy and allows them to practice talking with their health care practitioner.

The physical examination is then performed in the presence of a chaperone, as indicated per AAP guidelines.

 In our practice, the HEADS FIRST questions are asked after the physical is completed. Obtaining the HEADS FIRST psychosocial screen in the exam room rather than externally (eg, online, at home, or in the patient waiting area) may help promote and preserve privacy. Confidentiality may be more difficult with previsit electronic questionnaires. Another challenge with written screens is that they cannot be adjusted to each patient’s educational and developmental level in real time.

When taking the HEADS FIRST history, it is suggested to begin with nonthreatening “buffer questions” on topics that are usually less sensitive and that teenagers enjoy talking about, such as their recreational habits and favorite activities. These questions focus the interview on the patient’s strengths and potential. A strengths-based approach, where adolescents are understood and appreciated as whole persons rather than a collection of risk behaviors, can mitigate shame and promote effective communication.

We have found it striking how most adolescents will answer most questions openly and honestly most of the time, even to a total stranger during the first visit. Even if they are unwilling or unable to disclose sensitive information at any one visit, by asking these questions, the examiner can demonstrate that the office is a safe, affirming place for further discussion when the patient is ready. Full disclosure is not always the goal. Once a relationship is fostered, the adolescent will disclose at their own pace. The clinician’s thoughtful review of the responses, willingness to listen, and ability to carry on a meaningful conversation will greatly enhance rapport with adolescents.

The HEADS FIRST Checklist is arranged in a concise, easy-to-remember format that is analogous to the traditional medical review of systems. One-sentence trigger questions are used to screen for any concerns in each of the 10 categories. Concerning responses are followed up by an open-ended question such as “Can you tell me about this?” The answers are dissected out, just as would be done with medical symptoms such as headaches or chest pain. High-risk behaviors and thoughts are then targeted for further action and counseling as indicated. If multiple concerns are uncovered, priority must be given to responses that could place the patient and/or others in immediate danger, such as thoughts of homicide or suicide. Less pressing issues can be addressed by scheduling follow-up visits. Positive reinforcement is also very important.

The second half of this 2-part article will expand on the basic clinical approach to taking the psychosocial history as described above. Early recognition of potentially harmful thoughts and/or behaviors must be considered crucial to obtaining timely intervention and an optimal outcome. Having a concise, organized approach to identifying adolescents at risk for serious illness, injury, and death is especially important in the busy practice setting. Part 2 will offer specific techniques that can be utilized to follow up on any positive responses to the 10 trigger questions listed in the HEADS FIRST Checklist. Suggestions for intervention, if needed, will also be presented.

Curtin SC, Tejada-Vera B, Bastian BA. Deaths: leading causes for 2020. 

WISQARS leading causes of death visualization tool. CDC. Accessed July 30, 2025. 

https://wisqars.cdc.gov/lcd/?o=LCD&y1=2023&y2=2023&ct=10&cc=ALL&g=00&s=0&r=0&ry=2&e=0&ar=lcd1age&at=groups&ag=lcd1age&a1=0&a2=199

Bonnie RJ, O’Connell ME, National Research Council and Institute of Medicine Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, eds. 

Reducing Underage Drinking: A Collective Responsibility

Tanz LJ, Dinwiddie AT, Mattson CL, O’Donnell J, Davis NL. Drug overdose deaths among persons aged 10-19 years - United States, July 2019-December 2021. 

. 2022;71(50):1576-1582. doi:10.15585/mmwr.mm7150a2

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. 

. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1

Eliner Y, Gulersen M, Kasar A, et al. Maternal and neonatal complications in teen pregnancies: a comprehensive study of 661,062 patients. 

Discover effective strategies for conducting psychosocial screenings in adolescents using the HEADS FIRST Checklist to enhance health outcomes.

Jon E. Grant, JD, MD, MPH

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