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Lori Handy, MD, MSCE, is an attending physician in the Division of Infectious Diseases, Children’s Hospital of Philadelphia; and associate director, CHOP Vaccine Education Center. 

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.

Lori Handy, MD, MSCE, highlights how pediatricians can better prepare families and systems for missed vaccines during the back-to-school rush.

Lori Handy, MD: Vaccine-only visits can help ease back-to-school gaps

Tyra Bryant-Stephens, MD, is a board-certified pediatrician; medical director, Asthma Prevention Program; chief health equity officer, Center for Health Equity, at Children’s Hospital of Philadelphia.

Tyra Bryant-Stephens, MD, encourages families to revisit asthma triggers, refill medications, and manage allergies to prevent avoidable complications.

Tyra Bryant-Stephens, MD, talks asthma reminders ahead of school year

 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.

Most youth with type 1 diabetes in sub-Saharan Africa lack autoimmune markers, suggesting a distinct, non-autoimmune form of insulin-deficient diabetes.

Non-autoimmune diabetes common in African youth with T1D diagnosis

Secretary Robert F. Kennedy, Jr. this week signed the ACIP's recommendation to remove the mercury-based preservative from all influenza vaccines. 

HHS to remove thimerosal from all influenza vaccines in the US

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

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A 3-week-old female presented to the emergency department with a 3-day history of a progressively enlarging, erythematous, seemingly painful lump on her back. 

Infant girl develops bulging sacral mass

**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

Lori Handy, MD, MSCE, emphasizes the role of school entry as a critical time for ensuring children are caught up on routine vaccinations.

 Lori Handy, MD on importance of vaccine catch-up before the school year

As families prepare for the start of a new school year, ensuring children are up to date on routine vaccinations remains a key public health priority, according to Lori Handy, MD, MSCE, associate director of the Vaccine Education Center and attending physician in the Division of Infectious Diseases at Children’s Hospital of Philadelphia.

Handy explained that the link between vaccines and the school calendar dates back to early immunization programs targeting highly contagious childhood diseases such as measles and polio. These infections were known to spread rapidly among young school-aged children, often encountering their first exposures in classrooms. 

“There was a way to link prevention to the age group that needed it the most, at the time they needed it the most, right when they were about to enter a crowded setting,” said Handy. 

Requiring vaccines prior to school entry allowed public health officials to strategically deliver protection at a time of heightened risk. But Handy said it also served another, often overlooked function: creating a universal checkpoint for children who may have had missed or inconsistent access to care. 

“For children who might have had intermittent medical care or missed opportunities for medical care, turning 5 [years old] became this moment to ensure that all children in the country are receiving the preventative measures they need,” she said. “It was a nice pause for all children to say, let’s look back: have you missed anything? Do we need to catch you up?” 

Handy emphasized the ongoing relevance of this system, particularly in households juggling the demands of multiple children or busy schedules that can result in missed appointments. 

“Parents may not realize they missed that 4-year-old visit. Maybe they have 3 or 4 kids, and it is hard to keep track of all the well care their children need,” Handy said. “So, it is a great time to pause and make sure children are protected and ready to enter a crowded setting where they can learn and not contract a new infection.” 

By treating the back-to-school period as a built-in reminder to review vaccination records, Handy said providers and parents alike can help ensure children start the academic year protected, prepared, and positioned to thrive.

Lori Handy, MD, MSCE, emphasizes the role of school entry as a critical time for ensuring children are caught up on routine vaccinations. 

News

Lori Handy, MD on importance of vaccine catch-up before the school year

Pediatric pulmonologist Richard Wong, DO, outlines how school environments can complicate asthma management for children across all age groups.

Richard Wong, DO, explains challenges children with asthma face in school

Before long students will be walking the hallways of schools across the nation, and children with asthma often face heightened risks and management challenges that differ significantly from their home environment, according to Richard Wong, DO, pediatric pulmonologist at Phoenix Children’s.

“At home, families can better control exposures and reduce triggers, but school presents a much more complex environment,” Wong said. “Respiratory viruses, allergens, exercise, and environmental exposures like air pollution all contribute to increased risk.” 

Wong noted that the start of the school year frequently correlates with a dramatic increase in asthma-related emergency department visits. “In one large metropolitan area, ER visits jumped by almost 46% after school resumed,” he said. “That pattern highlights how common and serious school-related asthma challenges can be.”

Beyond increased exposure, students may struggle with adherence to maintenance therapy due to more rigorous and unpredictable schedules that could lead to missed doses and decreased control of asthma symptoms. 

As school season approaches, now is a good time to remind parents of have inhalers stocked so children can have the resources they need to help control asthma. This time of year also serves as a good reminder to create an asthma action plan, as going without one can bring challenges for the child once school is back in session. 

In some cases, children don’t have timely access to rescue inhalers while at school. “Whether due to restrictive school policies, lack of an asthma action plan, or even bullying and stigma, some kids can’t or won’t get the help they need when they’re symptomatic,” Wong said. “This leads to increased flares and worsening control.”

Age is also a critical factor in how children manage asthma and how providers should tailor education and interventions. 

“Younger children, such as those in preschool or elementary school, may not have the ability to describe their symptoms,” Wong said. “They rely on adults—teachers and school nurses—to recognize what’s happening and intervene appropriately.”

Middle schoolers, on the other hand, begin to take more responsibility but may avoid treatment out of embarrassment. “They may hesitate to use their inhalers in front of friends, leading to untreated symptoms and avoidable complications,” he said. 

In high school, many teens are given full independence in managing their condition, which can create another set of issues. “Adolescents often feel like if they’re not having symptoms, their daily controller medication isn’t necessary,” Wong said. “That mindset can result in skipped doses and overuse of rescue inhalers, which sets the stage for serious asthma flares.”

Wong emphasized the importance of consistent education, communication, and support across all age groups to help children manage asthma safely—both at home and in the classroom. 

Silverman RA, Ito K, Stevenson L, Hastings HM. The Relationship of Fall School Opening and Emergency Department Asthma Visits in a Large Metropolitan Area. 

 2005;159(9):818–823. doi:10.1001/archpedi.159.9.818 

Pediatric pulmonologist Richard Wong, DO, outlines how school environments can complicate asthma management for children across all age groups. 

 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 9, at 12:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis. 

This case was provided by Drashti Patel, BS, BA, and Jyoti Budania, MD.

In November 2023, an otherwise healthy 11-year-old boy presented to the clinic with the chief complaint of testicular discomfort. He reported mild testicular pain that worsened with physical activity, and he denied the presence of dysuria, urinary urgency, or frequency. He was recently evaluated by ENT for an episode of epistaxis, which was benign and resolved without requiring cauterization. His medical history was otherwise unremarkable, notable only for molluscum contagiosum at5 years of age and a few episodes of streptococcal pharyngitis and otitis media.

His vital signs in clinic were within normal limits, and the only additional finding at this time was a nontender, nonpruritic, and nonpalpable petechial rash on the bilateral lower extremities. His mother observed that the rash appeared to fluctuate with his activity level, worsening during periods of increased stress or activity.

Given the presence of petechiae, an initial workup was initiated, including a complete blood count (CBC), comprehensive metabolic panel (CMP), prothrombin time (PT), and partial thromboplastin time (PTT). A point-of-care urinalysis performed in the clinic revealed traces of blood in the urine. The patient appeared well and did not show any other signs of illness. He was diagnosed with viral epididymitis while pending laboratory results. He was advised to remain hydrated and to return for follow-up if his symptoms persisted or worsened. His mother agreed with this plan and committed to closely monitoring his rash.

Over the following week, he returned to our clinic. His rash had progressed, spreading to his thighs, buttocks, and the distal shaft of his penis. All of his previous labs were within normal limits, and additional workup was initiated, including a platelet function assay and measurements of serum IgA, C3, and C4 levels, along with a repeat urinalysis.

Below, take your best guess at diagnosing this patient

Idiopathic thrombocytopenic purpura (ITP)

Now, click here for the full case presentation, differential diagnosis, and correct patient diagnosis. 

Thank you for taking this Contemporary Pediatrics poll! Want more puzzler case studies?

Can you diagnose this patient? Take our poll and find out! Then check back for the full case, differential diagnosis, and correct diagnosis.

Case Studies

Can you diagnose this 11-year-old with a petechial rash?

 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.

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! 

Ashley Mogul, MD

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