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Heather Boone, OMS-III, Rocky Vista University College of Osteopathic Medicine, Englewood, CO.

Articles

 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.

Explore the connection between recurrent lymphadenitis and tonsillectomy in children, highlighting diagnosis, treatment, and potential long-term complications.

Full case: A 12-year-old female with right-sided neck swelling

Physicians embrace AI scribe technology, reporting enhanced efficiency, reduced burnout, and improved documentation quality in clinical workflows.

Physicians give AI scribes  a thumbs-up

. 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.

The BeeLine trial is a placebo-controlled study designed to evaluate radiprodil’s impact on both seizure frequency and non-seizure symptoms associated with GRIN-NDD. 

Phase 3 BeeLine trial to evaluate radiprodil in GRIN-related neurodevelopmental disorder

Training tools and EHR prompts boosted pediatricians’ adherence to early peanut introduction guidelines in a new trial.

Simple interventions improve pediatrician adherence to peanut allergy prevention guidelines

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

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Coronavirus 2019 disease (COVID-19) is often mild, but can lead to cardiovascular harm. Ensuring the safe return to sports by affected children will be a necessity.

Return to sports for adolescents and children after recovery from COVID-19

**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?

 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, January 6 at 12:00 PM ET for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Amar Davé, MD, FAAP and Pahroul Davé, APRN

A boy aged 10 years presented to the outpatient office with a history of painful nodules on the plantar surface of his bilateral feet 8 to 10 hours after spending time in a hot tub. He was unable to bear weight or put on socks and shoes due to his pain. The photos were taken soon after the painful and red papules appeared. The lesions affected the whole plantar aspect of both feet. Over the following 4 days, the nodules became less painful and red. 

Medical advice was sought on the fifth day of symptoms, and by this time, the child was improving clinically. He was stable with subcutaneous, mildly painful, fleshy nodules mostly populating the medial arch of the foot. His remaining clinical examination results were within a normal range. Further questioning of the child’s mother revealed that other children exposed to the hot tub experienced painful feet but without lesions. 

Due to the patient’s improving symptoms and the self-limiting nature of the illness, no tests or labs were ordered as the child was not acutely ill. No peer consultations or specialists were utilized.

Click here for the full case presentation, differential diagnoses, and the correct patient diagnosis, in a separate article.

The photos in this case were taken soon after the painful and red papules appeared.

Can you diagnose this boy with painful nodules on his feet?

Subgaleal hemorrhage refers to the accumulation of blood between the periosteum of the skill and the aponeurosis.

 This type of soft tissue injury of the scalp in infants is often caused by shearing forces during vacuum or forceps delivery.

 It is a rare and potentially fatal condition in newborns, with risk of severe complications such as hypovolemic shock, coagulopathy, acute anemia, and even death, requiring early detection.

 Existing research indicates that subgaleal hemorrhage typically presents within the first 48 hours, most commonly occurring within the initial eight hours post-birth.

 However, this case report discusses a rare occurrence of delayed presentation of subgaleal hemorrhage in an otherwise normally developing 2-month-old female. Literature contains very few case reports addressing such delayed instances of subgaleal hemorrhage.

 This report highlights the need for timely diagnosis and treatment of subgaleal hemorrhage beyond the neonatal period by pediatricians and emergency department doctors due to its potential life-threatening nature and unique presentation.

A 2-month-old female was born after an uneventful pregnancy at 40 weeks’ gestation via vacuum-assisted vaginal delivery to a G2P1011 female. The patient’s APGAR scores were 7 and 9 at 1 and 5 minutes, respectively, at birth. No bleeding or other complications were reported during delivery. The newborn and mother were discharged two days after delivery without requiring NICU stay or interventions. The infant briefly developed a small soft palpable scalp swelling that resolved within days after delivery. The patient followed an otherwise uncomplicated growth progression since birth. She did exhibit mild reflux symptoms, which were managed with supportive care measures. Physical examination after delivery and subsequent exams revealed no abnormalities, including no signs of scalp swelling or injury.

At 8 weeks of age, the patient presented to the Emergency Department with a three-day history of new-onset scalp swelling. The parents decided to seek medical attention after the swelling became noticeably enlarged. Parents denied any changes in her mental status, vomiting, fevers, lethargy, irritability, or any other new concerns. She did have symptoms of gassiness and fussiness that were unchanged from baseline. No history of trauma was reported, and there were no concerning signs suggestive of nonaccidental trauma. The patient appeared well, with a soft, fluctuant palpable subcutaneous fluid collection overlying the parieto-occipital scalp, without crossing suture lines. The anterior fontanelle was soft and non-bulging, and there was no hemotympanum. The patient was initially diagnosed with cephalohematoma, thought to be related to the history of a vacuum-assisted delivery. At the time, head CT was discussed; however, it was thought mutually unnecessary given the patient's stable and otherwise asymptomatic condition. The patient was advised to follow up with her primary pediatrician.

Two days later, the patient was brought to the pediatrician’s office due to the increasing size of the swelling, with no other symptoms developing. The patient was referred for an outpatient urgent head ultrasound to evaluate for subgaleal vs other intracranial hemorrhage. However, due to delayed ultrasound availability, she was referred to the Emergency Department (ED) for urgent imaging.

In the ED, CT of the head was performed, which revealed subgaleal hemorrhage. The patient was admitted to the general pediatric floor for monitoring and further workup. Neurosurgery consultation was undertaken, with recommendations made for close observation with no immediate need for surgical intervention. A spine ultrasound was recommended due to a noted sacral hair tuft as well.

Hematology was consulted to evaluate for an underlying bleeding disorder due to delayed presentation with no apparent trauma. Initial workup performed during hospital stay revealed normal platelet count, normal PT of 10.5 seconds, normal PTT of 28.5 seconds, normal fibrinogen of 204, normal VWD panel of 105% VWF activity, 143% VWF ag, FVIII 108%, and normal VWF act/ag ratio of 0.7. Functional FXIII of 104% was also normal. Stable hemoglobin levels (>7mg/dL) throughout the admission precluded the need for blood transfusion.

She remained clinically stable during admission with regular neuro checks and close head circumference measurements. Upon discharge, parents were advised to follow up with hematology and neurosurgery as well as their primary care provider. 

The patient has been cleared by the outpatient neurosurgical team as there were no concerns regarding increased intracranial pressure or the progression of the hematoma. Additionally, a spine ultrasound showed no evidence of spinal cord tethering. It is of note that on subsequent visits, the swelling was thought to in fact represent cephalohematoma vs subgaleal hematoma, with cephalohematoma thought more likely.

Comprehensive bleeding disorder workup by the outpatient hematology team has remained negative, with only a repeat Von Willebrand disease (VWD)panel pending. There is a presumption of an increased risk of bleeding, and it is acknowledged that the patient may require surgery or invasive procedures if symptomatic or not resolving, although this is thought unlikely. However, close monitoring is deemed essential for ongoing assessment of potential bleeding risks. (

Subgaleal hemorrhage is a life-threatening condition, which usually presents immediately after birth, most often following a vacuum or forceps assisted delivery. This report discusses an atypical case of delayed presentation subgaleal hemorrhage (vs cephalohematoma) in a 2-month-old female. It highlights the importance of recognizing and appropriately managing subgaleal hematomas in infants, including in the event of a delayed presentation.

The patient discussed in this report did not present with scalp swelling until 2 months of age. Despite remaining stable throughout the course of her life and hospitalization, the patient continues to carry an increased presumed risk of bleeding. Therefore, collaboration among pediatricians, emergency physicians, neurosurgeons, and hematologists/oncologists is crucial for a comprehensive assessment and appropriate follow-up care for addressing the complexities of delayed-onsetsubgaleal hematomas.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists . Prevention, detection, and management of subgalealhaemorrhage in the newborn C-Obs 28. East Melbourne (Australia): The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2009. https://ranzcog.edu.au/wp-content/uploads/Subgaleal-Haemorrhage.pdf

Plauché WC. Subgaleal hematoma. A complication of instrumental delivery. 

Colditz MJ, Lai MM, Cartwright DW, Colditz PB. Subgaleal haemorrhage in the newborn: A call for early diagnosis and aggressive management. 

. 2015;51(2):140-146. doi:10.1111/jpc.12698

Ditzenberger, G. R. (2016). Subgaleal hemorrhage. Newborn and Infant Nursing Reviews, 16(1), 36-38. https://doi.org/10.1053/j.nainr.2015.12.006

A rare case of delayed subgaleal hemorrhage in a 2-month-old highlights the need for timely diagnosis and management in pediatric care.

Full case: 2-month-old with scalp swelling

In a large observational cohort study conducted at Kaiser Permanente Northern California (KPNC), the long-acting monoclonal antibody nirsevimab was found to be highly effective in preventing respiratory syncytial virus (RSV)–associated lower respiratory tract disease (LRTD) in healthy term infants during the 2023-2024 RSV season. The study findings also demonstrated a significant reduction in RSV-related health care utilization among immunized infants.

The study included 31,900 healthy term infants born between April 1, 2023, and April 30, 2024. Among them, 15,647 (49.1%) received nirsevimab. Infants were excluded if they were born preterm, had high-risk conditions, or were born to mothers who received an RSV vaccine during pregnancy. The primary outcomes were the incidence of polymerase chain reaction (PCR)–confirmed RSV LRTD and the number of medical encounters associated with RSV LRTD.

There were 35 first episodes of RSV LRTD (6.10 per
1000 person-years [PY]) among nirsevimab-immunized infants compared with 462 episodes (58.51 per 1000 PY) among nonimmunized infants. Nirsevimab was associated with an adjusted effectiveness of 87.2% (95% CI, 81.7%-91.1%; 

 < .001) against RSV LRTD. The adjusted effectiveness against hospitalized RSV LRTD was 98.0% (95% CI, 85.1%-99.7%;

 < .001). For any PCR-confirmed RSV episode, regardless of LRTD diagnosis, the adjusted effectiveness was 71.0% (95% CI, 65.3%-75.8%; 

Among immunized infants who developed RSV LRTD, there were fewer total medical encounters (mean, 2.14 per episode) compared with nonimmunized infants (mean, 2.69 per episode). Linear regression showed that immunized infants had 0.86 fewer encounters per episode (95% CI, −1.36 to −0.36; 

Nirsevimab-immunized infants also had significantly lower odds of hospitalization (OR, 0.11; 95% CI, 0.01-0.85; 

 = .035) and emergency department visits (OR, 0.30; 95% CI, 0.13-0.67; 

The findings were consistent across sensitivity analyses, including exclusion of cases occurring within 2 or 7 days post immunization and those involving infants who received nirsevimab at 8 months or older. Nirsevimab was not associated with protection against PCR-confirmed influenza (

 = .67), suggesting minimal residual confounding.

Nirsevimab reduced RSV-related illness by up to 98% and lowered the amount of hospitalizations and health care use among healthy term infants in a real-world study.

Christopher S. Snyder, MD, FACC, FAAP

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