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. 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.

Articles

Tezepelumab received FDA approval for CRSwNP in patients 12 years and older, supported by strong phase 3 data.

FDA approves tezepelumab for CRSwNP in patients 12 years and up

Kathryn Xixis, MD, Associate professor of Pediatrics, University of Virginia

At CNS 2025, Kathryn Xixis, MD, highlighted the growing adoption of EPAs and outcomes-based learning in pediatric neurology.

Kathryn Xixis, MD, on developing EPAs for child neurology training

 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.

Indication expansions include hidradenitis suppurativa for patients 12 years and up, as well as for patients with uveitis aged 2 years and older. 

FDA expands adalimumab-aaty's pediatric indications to include hidradenitis suppurativa, uveitis

Peace Madueme, chief, Cardiology, Nemours Children’s Hospital, Orlando, Florida

In our second interview with Peace Madueme, MD, he explains the types of conditions that frequently appear on ECGs, which are aiding routine sports physicals in youth athletes in Florida.

Using ECGs to identify heart conditions in youth athletes, with Peace Madueme, MD

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

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The infant who arrives for medical care after an apparent life-threatening event (ALTE) presents the pediatrician with a host of uncertainties

A pragmatic approach to apparent life-threatening events

**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 September 24, 2025, at 3:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

Heather Boone, OMS-III; and Neil Cella, MD. 

A 12-year-old female with no significant past medical history presents to our Emergency Department with 3 days of right-sided neck swelling, which has progressively worsened. The patient notes some pain with chewing on the right side, which has led to decreased intake. The parents report no known fevers but note that other members of the family have recently been sick with a suspected viral illness. The family also reports that this is a recurrent issue that occurs 2 to 3 times a year and endorses that it began after her tonsillectomy procedure. They state that symptoms typically resolve after a course of antibiotics. She has been seen at an ENT clinic for these concerns in the past, with reportedly no solution. She has no other known medical diagnoses or surgeries and is not taking any medications. She lives with her parents and 3 siblings and is in 7th grade.

Her vital signs, including temperature, are within normal limits upon arrival. Physical exam is significant for an indurated, moderately-tender, swelling approximately 2 cm in diameter located anteroinferior to the mastoid process. An oral exam is unremarkable aside from reported dental discomfort elicited by right-sided bite testing. Some residual tonsillar tissue is noted. Upon consulting with the team, labs and imaging are ordered, including CBC, CMP, CRP/ESR, LDH, uric acid serum tests, and diagnostic ultrasound. The lab values demonstrate mild hemoconcentration (possibly due to living at high altitude) and a mildly elevated lymphocyte count. Ultrasound findings include limited images showing bilateral hypoechoic foci in the parotid gland and upper neck regions, and a broad differential is provided. Due to these nonspecific findings, a blood culture is ordered, which produces no growth.  

Below, take your best guess at diagnosing this patient

Try to diagnose this patient with 3 days of right-sided neck swelling. 

Case Studies

News

Poll: Can you diagnose this 12-year-old female with right-sided neck swelling?

article discussing how to obtain the psychosocial history from adolescents using the HEADS FIRST Checklist (

). Both articles illustrate how 1-sentence triggering questions can be used to conduct this interview. The first article outlines the basic clinical approach to gathering this information, whereas specific trigger questions, as suggested in the Figure, are explored in greater detail here. Techniques for sorting out the responses to determine whether intervention is required are also discussed here.

ome: The 3 leading sources of stress in an adolescent’s life are typically problems at home, at school, or with their friends. In many instances, teenagers struggling in these or other areas may be unable to open up to others. They often hope that the clinician will initiate discussions on such matters. Accordingly, we ask, “Are you having any problems with your family?” and then pause for their answer. If they say no, the examiner can move on to the next topic. If they say yes, we follow up with open-ended questions and explore their responses. It is important to be sensitive to the fact that seemingly minor or trivial concerns raised by the adolescent may be a “big deal” to them and/or their family members. The clinician should gently probe the adolescents’ concerns and determine whether additional guidance is indicated.

ducation: “Are you having any problems at school?” Once again, if they say yes, we explore their answer by asking them to tell us about those problems. If they do not attend school, then this question can address employment if they are employed. Academic expectations, study habits, and achievement may be points of contention between adolescents and their families. Pediatric practitioners are in an ideal position to uncover any underlying conditions that may be contributing factors. The COVID-19 pandemic’s effect on teenagers’ mental health must be considered “a given,” including feelings of loneliness, isolation, depression, anxiety, and fears about the future that may interfere with learning.

 A sudden decline in academic performance is a red flag that something may be amiss, including the onset of a physical condition or an acute stressor (eg, bullying, ostracization, change in teachers or schools, family concerns, death of a close friend or relative, or substance use).

buse: The purpose of screening for abuse on a routine basis is to prevent ongoing distress and/or injury to the patient and potentially others (eg, siblings). This topic should be incorporated into the annual health supervision visit per current American Academy of Pediatrics (AAP) guidelines.

 No subject is more sensitive, nor more important, than this. In-person or online bullying, sex trafficking of adolescents, and the Me Too movement have shed new light on this serious problem of longstanding duration. We have been screening for abuse in our office since the early 1990s at the suggestion of a third-year medical student. We simply ask, “Has anyone ever abused you by their actions or their words?” If the patient says yes, we ask if it was verbal, emotional, physical, or sexual abuse. We then gently probe the adolescent’s perception regarding any form of abuse that they have experienced and proceed with appropriate guidance or additional help as indicated.

rugs: The AAP recommends universal screening for drug use in pediatric primary care settings.

 There are many ways to obtain this history described in the literature, such as the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) substance abuse screening test.

 Our trigger question is “Ever use e-cigs, tobacco, alcohol, marijuana, opioids, or other drugs to relax or get high?” If the patient says yes, we ask about the duration, amount, and frequency of use for any drugs specified. We find it helpful to categorize the pattern of use as experimentation, self-medication to treat underlying psychiatric issues, addiction, or any combination of the above. Management varies with each category and must be individualized to meet the needs of each patient. It must be stressed that all patterns can have serious adverse sequelae, and it should not be assumed that casual drug use is always benign.

 Even first-time use can lead to a tragic event, and the craving induced by just one pill can lead to a life of dependency, especially with highly addictive substances such as opioids.

afety: We believe that “Do you wear a seatbelt regularly?” is the most important safety question generic to all adolescents. About half of young adult drivers and passengers killed in car crashes are unrestrained, and it is universally recognized that seatbelts can dramatically reduce the risk of death or serious injury.

 The routine checkup gives pediatric practitioners an ideal opportunity to reinforce the importance of consistent seatbelt use to their young adult patients as recommended by the AAP.

 More specific safety risk factors can be addressed as they are uncovered by responses to other questions on the HEADS FIRST Checklist. For example, parents/guardians of adolescents who have depression should be advised to keep any guns at home locked up and unloaded, with the ammunition inaccessible to their teenager.

riends: The special insight pediatric practitioners have into adolescent development should help determine the significance of any “yes” responses to the question, “Are you having any problems with your friends?” Understanding the nature of changing interpersonal relationships during adolescence is key to putting positive responses into proper context. For example, what may seem like a serious issue to some teenagers may be of little or no clinical significance to the examiner and vice versa. It must be stressed that the patient’s feelings should always be addressed and never be dismissed as inconsequential. Unresolved emotional pain and suffering may build up over time and reach a critical point in unpredictable ways. Of equal or even greater importance is that adolescents may act on impulse to resolve concerns, whether real or perceived. In some instances, this can have tragic consequences, such as suicide.

Peer pressure, magnified through social media, can be intense, with the need to belong and the desire for acceptance being overwhelming for some youth. This may sometimes lead to engagement in risk-taking behaviors as a desperate means to fit in. Some teenagers may begin to drift away from peers, suggesting potential isolation and the accompanying risks of depression, anxiety, or some other acute stressor. Many such concerns have been exacerbated by the COVID-19 pandemic, which has affected young people’s mental health disproportionately.

 Loneliness has also emerged as a particularly salient pandemic psychosocial outcome to understand.

 However, loneliness should not be equated with being a loner, as some adolescents engage in solitude by choice as a positive experience.

 Although not everyone needs a best friend, lack of a confidant or trusted friend is of particular concern for those who are struggling with depression and may be a risk factor for harming themselves or others.

mage: Self-image is a complex blend of how others view adolescents and how they feel about themselves. Routine screening for eating disorders and gender identity concerns is recommended by the AAP.

 We ask, “Do you have any questions or concerns about your looks, appearance, or gender identity?” Expect a wide range of answers from worries about a few small pimples to severely distorted body image. The latter may seem very real to the adolescent, just as the image we may see when looking into a carnival mirror. If their answer indicates concern about their body size and/or shape, follow-up questions to explore the possibility of an eating disorder should be asked. For patients who disclose body image concerns, we explain how powerful and all-consuming these feelings can be and that we are committed to seeking common ground by meeting them where they are at as a starting point to help them achieve health. Ignoring their perception can be counterproductive and may compromise the examiner’s credibility in the patient’s eyes.

The second part of the “I” question concerns gender identity. In addition to “Do you have any concerns about your gender identity?”, one may simply ask, “What is your gender identity?” Only a few years ago, this topic was commonly overlooked or even considered off-limits by many pediatric practitioners. Now it should be considered a routine component of comprehensive adolescent health care.

 The regular checkup may be the only chance to identify adolescents who are struggling with gender identity and have no one in whom to confide.

Adolescents who identify as transgender or who express gender-diverse feelings should be cared for as per AAP recommendations.

 These youth are at disproportionate risk for adverse sequelae, including substance abuse, sexually transmitted infections (STIs), and mental health issues, including suicide.

It must be stressed that such health disparities are not inherent to transgender identity and are not inevitable.

 Furthermore, transgender identities and diverse gender expressions do not constitute a mental disorder.

 If a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the adolescent.

ecreation: It’s enjoyable to talk to teenagers about “What do you do for fun and exercise?” Again, this can be a good buffer question before getting into more sensitive areas. The answer to this question provides insight into their daily routines, helping to assess whether they are engaging in sufficient physical activity and/or spending too much time on sedentary activities, including too much screen time. Specific advice can be given when needed as per AAP guidelines, such as the importance of wearing a helmet while riding a bicycle, etc.

Online safety and cybersecurity strategies are also important topics for families to discuss.

 Especially for younger teenagers, anticipatory guidance should be provided about the dangers of sharing photos online, particularly nude photos, and talking with strangers. Harm reduction strategies, including setting limits, technology-free zones, providing alternatives, modeling healthy behavior, and maintaining open lines of communication, are also indicated if screen time is excessive, content viewed is inappropriate, or if use of social media is otherwise problematic.

exuality: We ask, “Have you ever had any sexual experiences or concerns?” If the patient does have a history of sexual experiences, we ask whether partners were boys, girls, or both, including whether partners were transgender. We ask what types of experiences they have had and whether the experiences were mutually consensual and respectful. Despite making up only a quarter of the sexually active population, adolescents account for approximately half of new STIs in the United States every year.

 Routine laboratory screening for common STIs is indicated for all sexually active adolescents as recommended by the CDC.

 Counseling and screening should be tailored to individual needs. It is important to determine whether there has been oral, genital, and/or anal contact so that screening for gonorrhea and chlamydia can be obtained at all sites of contact.

 Blood should be sent for HIV and syphilis testing as recommended per current CDC guidelines.

 A pregnancy test should be obtained for all patients with a uterus if there is concern for pregnancy. We stress the importance of consistent barrier protection for all forms of sexual contact. Contraceptive counseling should be offered for patients at risk of pregnancy, including the recommendation for dual-method contraception. We also discuss the availability and indications for emergency contraception with all boys and girls, regardless of their gender identity or sexual orientation, in case they or someone they know is the victim of sexual assault or an unexpected sexual exposure.

The most recent CDC STI guidelines suggest that practitioners consider opt-out chlamydia and gonorrhea screening (ie, the patient is notified that testing will be performed unless the patient declines, regardless of reported sexual activity, for adolescent and young adult women during clinical encounters).

 Cost-effectiveness analysis indicates that opt-out chlamydia screening among adolescent and young adult women might substantially increase screening, be cost saving, and identify infections among patients who do not disclose
sexual behavior.

hreats: We screen for threats of harm to self or others by asking, “Do you get depressed or upset easily?” If the patient answers yes, we ask him or her to “tell me about this” to get a sense of the severity of their thoughts and how they are coping with them. We specifically ask about thoughts of suicide, feelings of hopelessness, previous suicide attempts, or any history of self-inflicted injury such as cutting, burning, or abrasions. Such acts of self-harm are often not a suicide attempt but rather an attempt to feel better or to distract from painful emotions. However, any suicidal ideation or behavior must always be taken seriously and explored to determine whether the adolescent has a specific plan and whether they have the intent to attempt suicide. We additionally ask whether they have felt like hurting someone else. Adolescents who have active suicidal or homicidal ideation require immediate intervention by mental health experts, legal authorities, or both, along with parental involvement.

The fact that stress, anxiety, and depression are significant sources of morbidity and mortality for adolescents cannot be overstated. Accordingly, the US Surgeon General and AAP have declared a national mental health crisis among youth.

 This concern is underscored by the fact that nearly 10% of American high schoolers attempted suicide in 2023.

Explore effective techniques for gathering psychosocial histories from adolescents using the HEADS FIRST Checklist to enhance mental health interventions.

Joshua L. Bonkowsky, MD, PhD

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