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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

The indication approved is for children aged 6 years and older who weigh at least 45 kg (99 lbs) for the preventive treatment of episodic migraine. 

FDA approves fremanezumab-vfrm for migraine prevention in children aged 6 years, older

Elizabeth Reichert, PhD, pediatric and adolescent psychologist, Stanford Medicine Children’s Health; co-director, Stanford Parenting Center.

Psychologist Elizabeth Reichert, PhD, encourages primary care providers to use validation and connection to support mental health during routine visits.

Managing mental health between specialist visits with Elizabeth Reichert, PhD

 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.

Though intensive nurse home services did not change outcomes in this South Carolina study, authors noted more research is needed on a larger scale to determine influence on adverse outcomes. 

Study: Intensive nurse home services did not reduce adverse outcome likelihood

Andrew Silverman, MD, MHS, is a child neurology resident at Stanford.

The authors of a recent study on flu-linked necrotizing encephalopathy in children give a deep dive into their findings and the biggest takeaways from the study.

Q&A: A deep dive into influenza-associated acute necrotizing encephalopathy

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

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Authors

Molly Wilson-Murphy, MD, is an assistant physician in the Department of Neurology at Boston Children's Hospital and instructor of Neurology at Harvard Medical School.

**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

Bite injuries are a significant problem in the United States. Discriminating between human and animal bites and identifying those associated with child maltreatment is essential. Approximately 250,000 human bites and several million animal bites occur annually.

 There was also a reported increase in animal bite injuries during the COVID-19 pandemic.

 Despite their frequency, it can be challenging to distinguish between types of bites. There are also few detailed images and descriptions of cutaneous findings of human and animal bites in the literature. 

Additionally, though such injuries occur in various ways, pediatric providers must consider the possibility of child maltreatment. In the COVID-19 pandemic, there was also a documented increase in child abuse–related injuries.

 Though bite wounds are a less common cutaneous finding in child abuse,

 both human and animal bites may result from nonaccidental trauma or neglect. 

In the poll below, try to identify what caused this bite mark on the palm of a 16-year-old boy

Thank you for taking this Contemporary Pediatrics puzzler poll

Visit ContemporaryPediatrics.com on Wednesday, August 6, 2025, at 12:00 PM ET or later for many more bite examples in the pediatric population and how to distinguish between common animal bites and human bites.

"This [case] was prompted by the increases in child abuse and animal bite injuries during the COVID-19 pandemic, with the need to add to the limited descriptions of cutaneous findings of bites in the literature," wrote the authors of this case.

Bula-Rudas FJ, Olcott JL. Human and animal bites. 

. 2018;39(10):490-500. doi:10.1542/pir.2017-0212

Dixon CA, Mistry RD. Dog bites in children surge during coronavirus disease-2019: a case for enhanced prevention. 

. 2020;225:231-232. doi:10.1016/j.jpeds.2020.06.071

Kovler ML, Ziegfeld S, Ryan LM, et al. Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic. 

. 2021;116(Pt 2):104756. doi:10.1016/j.chiabu.2020.104756

Kos L, Shwayder T. Cutaneous manifestations of child abuse. 

. 2006;23(4):311-320. doi:10.1111/j.1525-1470.2006.00266.x

Despite their frequency, it can be challenging to distinguish between types of bites. Can you identify the source of this bite mark? 

News

Case Studies

Puzzler poll: Can you identify this bite? 

 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 Wednesday, May 7, 2025 at 12:00 PM Eastern Time or later for the full case presentation, differential diagnoses, and correct patient diagnosis.

This case was provided by Akash Deswaney, MD, Neil Copeland, MD, and John Bishara, DO.

An 18-day-old female presented to the ED with concerns of apnea, cyanosis, and decreased feeding. The mother reported intermittent cyanosis of the lips, pale-appearing skin, and suspected apnea episodes. Since birth, Mom states patients had retractions since birth, which the PCP reassured her was normal periodic breathing. She had nasal flaring and grunting a couple of days after discharge from the nursery. Mom has noticed she breathes quickly, in the 60s or 70s at times.

Initial vitals in the ED showed hypoxemia, tachypnea, and fluctuating oxygen saturations were between 65-100% on room air. A chest X-ray is shown (

Click here for the full case presentation, differential diagnoses, and 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. 

Diagnose this 18-day-old female with apnea, cyanosis, decreased feeding concerns

Richard Auchus, MD, PhD, highlights data showing that crinecerfont use in children with CAH can improve metabolic outcomes. 

Crinecerfont demonstrates improvements in weight-related outcomes in children with CAH

Twelve-month findings from the Phase 3 CAHtalyst Pediatric trial presented at ENDO 2025 demonstrated that treatment with crinecerfont (Crenessity; Neurocrine Biosciences) led to improvements in weight-related outcomes for children with classic congenital adrenal hyperplasia (CAH) when combined with glucocorticoid therapy.

Richard Auchus, MD, PhD, professor of pharmacology and internal medicine at the University of Michigan, highlighted the metabolic risks these patients face. “Children with CAH have a high prevalence of obesity, as do adults with CAH, which places them at increased risk for cardiovascular disease,” he explained. "In adults, secondary to adrenal crisis, the second most common cause of death in CAH is cardiovascular disease. They have a significant metabolic risk, which begins developing in childhood due to prolonged exposure to the high doses of glucocorticoids traditionally necessary to manage the condition adequately."

The intention behind the trial was to determine whether adding crinecerfont—a CRF1 receptor antagonist—could lower adrenal androgens and allow for lower, more physiologic glucocorticoid doses. In the 28-week, double-blind period, androstenedione dropped by about 50% in the crinecerfont group, enabling an 18% glucocorticoid dose reduction, whereas dosing increased in the placebo group.

"In the crinecerfont group, BMI decreased following this period, whereas BMI slightly increased in the placebo group," said Auchus. "At the 28-week point, the placebo arm was crossed over into crinecerfont, and additional data presented showed that this transition resulted in reductions in androstenedione and 17-hydroxyprogesterone levels. This, in turn, allowed for glucocorticoid dose reduction and a subsequent decrease in BMI in the placebo group post-crossover."

According to a press release from Neurocrine Biosciences, pediatric patients on crinecerfont achieved reductions in BMI standard deviation scores (SDS) at Week 28, and these improvements were maintained through Week 52. For pediatric patients who were overweight or obese at baseline (~60%), a higher percentage on crinecerfont achieved at least a 0.2 reduction in BMI SDS compared to placebo. 

Auchus noted that after the placebo group crossed over to crinecerfont, they too experienced reductions in BMI and hormone levels, though, “At 12 months, the improvement in BMI was greater in those who had received crinecerfont from the start," he said. “Even modest excesses in glucocorticoids appear harmful over the long term,” and underscored the value of early intervention. 

Crinecerfont was approved by the FDA in December 2024

 for use in adults and children aged 4 years and older with classic CAH, based on data showing meaningful reductions in glucocorticoid dosing and serum androgen levels. Its mechanism targets adrenal androgen overproduction directly, helping reduce reliance on high-dose steroids.

Kyriakie Sarafoglou, MD, discusses crinecerfont FDA approval for congenital adrenal hyperplasia

“General pediatricians will encounter these patients… There is now an intervention that was not previously available,” Auchus added. “Evidence now shows that even small reductions in glucocorticoid dosing can significantly impact body weight and insulin sensitivity.” 

Neurocrine Biosciences presented one-year data from phase 3 CAHtalyst studies showing improvements in weight-related effects of glucocorticoid treatment at the 2025 Endocrine Society’s Annual Meeting. Neurocrine Biosciences. Press release. July 14, 2025. Accessed July 31, 2025. 

Ebert M. FDA approves Crenessity for treatment of classic congenital adrenal hyperplasia. Contemporary Pediatrics. December 13, 2024. Accessed July 31, 2025. https://www.contemporarypediatrics.com/view/fda-approves-crenessity-for-treatment-of-classic-congenital-adrenal-hyperplasia 

Richard Auchus, MD, PhD, highlights data showing that crinecerfont use in children with CAH can improve metabolic outcomes.

Richard Auchus, MD: Crinecerfont's positive weight-related outcomes in children with CAH

Suzanne Hollander, MS, RD, LDN and Timothy Tramontana, MD offer thoughts on the newly FDA-approved sepiapterin for PKU.

WATCH: Experts react to the FDA approval of sepiapterin to treat PKU

FDA approved PTC Therapeutics' sepiapterin (Sephience) 

to treat adult and pediatric patients with phenylketonuria (PKU). Sepiapterin is now the third FDA-approved medication for lowering blood phenylalanine (Phe) levels and can be used alongside a Phe-restricted diet to expand protein tolerance in individuals with sepiapterin-responsive PKU. 

"This is a really exciting time in PKU, with a new treatment coming out," said Suzanne Hollander, MS, RD, LDN, metabolic dietitian at Boston Children’s Hospital. "Sepiapterin is an oral Phe-lowering medication just recently approved for PKU in individuals of all ages. For individuals with PKU, historically, standard-of-care treatment has included a protein-restricted diet with low phenylalanine formula. More recently, there have been 2 Phe-lowering medications available on the market. These previous 2 medications and the diet do not always sustainably work for everyone to keep their Phe level within the target treatment range. That target treatment range is less than 360 µmol/L."

FDA approval follows the phase 3 APHENITY trial, in which sepiapterin demonstrated potential benefits such as increased dietary protein intake and reduced reliance on PKU-specific formula.

Suzanne Hollander, MS, RD, LDN; and Timothy Tramontana, MD, offer thoughts on newly FDA-approved sepiapterin for PKU.

Molly Wilson-Murphy, MD

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