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Meet the Editors

Andrew Faniku, MD, pediatric hospitalist at Scott & White Healthcare.

Articles

Can you diagnose this newborn with a rash?

. 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.

The AAP stated public health and trauma care should address "needs of injured children across the continuum of care."

AAP policy: Developing trauma systems that provide optimal care

Michael Haller, MD, professor and chief, Pediatric Endocrinology, University of Florida.

Michael Haller, MD, discusses inhaled insulin’s safety, off-label use, and future role in easing type 1 diabetes management for children.

Michael Haller, MD, discusses safety and use for inhaled insulin in T1D

Get caught up with Contemporary Pediatrics! This list helps you navigate our top stories from the week, all in one place.

FDA approvals for NCFB, CKD; adolescent vaccine coverage, and more

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

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Authors

Timothy Tramontana, MD, medical and biochemical geneticist, Cleveland Clinic Foundation.

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

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

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

This case was presented by Umer Muhammad, MD; Neil Copeland, MD; and John Bishara, DO

A 23-month-old girl presented with a 3-day history of cough, rhinorrhea, and increased work of breathing. Initially, she was treated for bronchiolitis at an urgent care center, where a nasopharyngeal swab identified adenovirus. Despite initial treatment, the patient's condition worsened, and she required oxygen supplementation via nasal cannula for oxyhemoglobin desaturation. Her hypoxemia further deteriorated, necessitating an increase in oxygen supplementation (

On physical examination, the patient showed signs of respiratory distress. A chest x-ray (CXR) revealed opacities in the right middle and lower lobes. The patient's condition improved with supportive care, and she was discharged after several days in the hospital. 

However, 9 months later, due to recurrent wheezing, she was referred to the pulmonary service for further evaluation. A follow-up CXR, taken 3 months after the initial infection, demonstrated complete opacification of the right hemithorax, with a mediastinal shift to the right, as well as collapse of the right upper and middle lobes. 

Below, take your best guess at diagnosing this patient

Congenital pulmonary adenomatoid malformation (CPAM) 

website on Wednesday, July 23, at 3:00 PM EST or later for the full case presentation, differential diagnosis, 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.

News

Case Studies

Puzzler poll: Diagnose this 23-month-old with cough and rhinorrhea

Richard J. Wong, DO, and Tyra Bryant-Stephens, MD, outline strategies for controlling asthma as kids head back to school.

Tyra Bryant-Stephens, MD, Richard Wong, DO, break down asthma in the classroom

Asthma remains one of the leading causes of school absenteeism and a top chronic illness among children in the United States, according to the CDC.

 As the school year begins, pediatricians can play a crucial role in preparing families to manage asthma in the classroom and beyond. 

“Children at school face several challenges in making sure that their asthma stays under good control, as compared to being at home,” said Richard J. Wong, DO, pediatric pulmonologist, Phoenix Children’s. Limited access to rescue therapies, lack of an asthma action plan, or even stigma can all contribute to flare-ups.

Transitions from summer to school can also affect medication adherence. “A common challenge we see is that getting ready for a busy school day can make it difficult for families to remember to give the morning dose of medication,” said Tyra Bryant-Stephens, MD, medical director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia.

Age can influence management. Younger children rely on school staff to recognize symptoms, while adolescents may underreport symptoms and skip controller medications. “This can lead to an overreliance on short-acting β agonists,” Wong noted. 

Bryant-Stephens recommended that at the start of the year, pediatricians review an asthma action plan, ensure children have inhalers and spacers for both home and school, and verify insurance coverage for extra supplies. She outlined 5 key steps: discuss triggers, review provider needs, complete the school checklist, use control medications consistently, and ensure medication refills are available.

School nurses can be valuable partners in care, though availability varies. “We need to consider them part of the health care team,” said Bryant-Stephens. “They are allies in keeping children in school.”

Pediatricians can also share practical tips directly with children, such as pacing before and after exercise and restarting allergy medications before the school year to reduce triggers. “It is important to make sure enough refills are always present…and to encourage the use of spacers,” Wong added.

With clear communication, preparation, and collaboration between families, schools, and providers, children with asthma can start the school year ready to learn, and breathe, more easily.

Managing asthma in schools. CDC. August 13, 2024. Accessed August 8, 2025. https://www.cdc.gov/school-health-conditions/chronic/asthma.html

Richard J. Wong, DO; and Tyra Bryant-Stephens, MD, outline strategies for controlling asthma as kids head back to school. 

Tyra Bryant-Stephens, MD; and Richard Wong, DO, break down asthma in the classroom

Q: In pediatric patients presenting with acute necrotizing encephalopathy (ANE), what early clinical and imaging findings should raise suspicion for ANE, and how can timely recognition alter management and prognosis?

When a child presents with sudden-onset encephalopathy in the midst of a viral illness—particularly with fever, seizures, or altered mental status—ANE should be on the radar. It is rare, but it progresses quite quickly and can be devastating. Seizures are common, and many children show dramatic neurologic decline within even a day or two of initial infectious symptoms.

Imaging is key to diagnosis and, in addition to the clinical picture, reflects the defining feature. MRI of the brain typically shows prominent bilateral lesions in the thalami—often considered the hallmark finding of ANE. A subset of these patients has a specific pattern called trilaminar necrosis of the thalami, and if that is seen, the diagnosis is ANE. These thalamic lesions in general are critical because the thalamus is the brain's central relay station, or switchboard, and is highly implicated in disorders of consciousness. ANE lesions may also be seen in the brainstem, cerebellum, and white matter, and often show restricted diffusion or hemorrhagic changes. These findings, especially when paired with elevated liver enzymes, normal ammonia, low platelets, and high cerebrospinal fluid protein, are strong diagnostic clues.

Recognizing ANE early matters. Prompt diagnosis allows for early intensive care support and initiation of immunotherapy. In our US multicenter case series of influenza-associated ANE, early steroid use may be linked to better outcomes. Delays in recognition and treatment can lead to cerebral edema and herniation, which unfortunately can result in death within the first week of illness—actually within the first few days in most fatal cases.

Q: How should pediatricians approach the risk of ANE in children with recent viral infections—particularly influenza or COVID-19—and what additional considerations apply if there is a known familial 

 variant or other genetic predisposition?

Most children who get the flu or other common viruses recover without complication—but a very small subset may develop ANE, particularly with influenza A (and especially, as our data suggest, the H1N1/2009 strain). Pediatricians should be extra vigilant during peak respiratory virus season (eg, October-March, though cases have been observed outside this window) when a child with recent infection starts showing neurologic symptoms like confusion, lethargy, seizures, or focal neurologic deficits. We know that vaccination is key in helping prevent severe illness with influenza, and our findings suggest that vaccination may be one factor in preventing ANE. Only a small percentage of patients with ANE in our series were vaccinated, much lower than the national rates of influenza vaccination in children.

In some cases, there are genetic associations that predispose children to ANE. The most well characterized of these is a gene called 

 variants are at higher risk for familial ANE, which can recur with future viral illnesses. In families with 

 variants, individuals who carry a problematic change, also known as a pathogenic variant in the gene, may have about a 40% lifetime risk of ANE. It is important to remember that this pathogenic variant is very rare in the general population, but it’s not uncommon among people who develop ANE. As mentioned, there are other genes in addition to 

 that can be associated with an increased risk of ANE. This makes family history particularly important—if a sibling or parent has had unexplained encephalopathy, genetic testing should be performed for all first-degree family members. In our opinion, if there is suspicion for ANE, broad genetic testing should be done as soon as possible (eg, whole-genome sequencing). If you are encountering a case post hospitalization, we maintain that a referral to a geneticist should be done for all cases of ANE, regardless of family history.

There are no formal guidelines for managing children with 

 variants, but some clinicians recommend early antiviral and steroid treatment during febrile illnesses, and prioritizing influenza vaccination for these children and their households.

In light of our national data collection and analysis, for any child with ANE (genetic or sporadic), we strongly endorse early intensive care, alongside immunomodulatory (eg, intravenous pulse-dose corticosteroids, plasmapheresis, tocilizumab, etc.) and antiviral (eg, oseltamivir) therapy. Because most children in our national case series of influenza-associated ANE had not received the seasonal influenza vaccine, we also strongly recommend annual influenza vaccination.

Q: What are the current recommendations for acute management of ANE in children, and when should pediatricians consider initiating or referring for immunomodulatory treatments such as steroids, intravenous immunoglobulin, or plasmapheresis?

While there is no universal treatment protocol for ANE, most experts agree on starting high-dose intravenous steroids as early as possible. Other treatments like intravenous immunoglobulin, tocilizumab, and plasmapheresis are also often used, but data remain limited on the efficacy of the myriad of possible immunotherapies. What is clear is that early recognition and prompt treatment are critical.

Any child suspected of having ANE should be referred emergently for high-acuity medical attention. Nearly all patients with ANE will require management in a pediatric intensive care unit. These children often need airway protection, watchful neurocritical care, and sometimes intracranial pressure monitoring. Emergency and critical care providers should be wary of cerebral edema and take concrete steps to lower intracranial pressure as indicated. Pediatricians should not wait for confirmatory imaging or labs to initiate care or transfer to a pediatric intensive care unit with the capacity to further manage children with ANE—time is brain.

Q: For survivors of ANE, what are the key neurologic and developmental concerns pediatricians should monitor long term, and how can they coordinate multidisciplinary care to support recovery and function?

When children survive ANE, recovery can be long, grueling, and complex. Many are left with challenges like spasticity, movement disorders, seizures, or cognitive delays. In our US case series encompassing the 2023-2024 and 2024-2025 influenza seasons, approximately 60% of the children followed beyond 3 months had moderate to severe disability. Nearly half regained the ability to walk independently, and 40% had returned to school. Another way of thinking of this is that a fair percent of survivors do, in fact, recover to some degree, and many recover quite significantly. While this is a critical illness with high morbidity and mortality, early recognition and immediate treatment may help improve outcomes. And for survivors, that long-term recovery will require rigorous support.

This makes close, ongoing follow-up essential. Pediatricians can play a key role in coordinating multidisciplinary care, including neurology, physiatry, rehabilitation, nutrition, and educational support. Many children will need 504 or individualized education plans, physical and occupational therapy, and neuropsychological assessments and support.

Lastly, of course, it is also important to support families through this process. ANE is traumatic, and the path forward can be overwhelming. Helping families access services—while setting realistic but hopeful expectations—can make enormous differences in long-term outcomes.

Influenza-Associated Acute Necrotizing Encephalopathy (IA-ANE) Working Group, Silverman A, Walsh R, et al. Influenza-associated acute necrotizing encephalopathy in US children. 

. Published online July 30, 2025. doi:10.1001/jama.2025.11534

Uyeki TM. Pediatric influenza-associated acute necrotizing Encephalopathy-gaps need to be addressed. 

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.

Timothy Tramontana, MD

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