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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.

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

Weekly review: MMR vaccination decline, more COVID-19 vaccine changes, and more

Aaron Milstone, MD, MHS, pediatric infectious disease specialist, Johns Hopkins Children’s Center; professor of Pediatrics, Johns Hopkins University School of Medicine. 

Aaron Milstone, MD, emphasizes the need for better recognition and prevention of Staphylococcus aureus infections in neonatal intensive care units. 

Renewed focus into Staphylococcus aureus risk in infants, with Aaron Milstone, MD

The authors noted that comparisons between PDA management strategies is crucial for informing optimal approaches to the PDA.

Transcatheter and surgical PDA yield comparable respiratory results in very preterm infants

 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.

Six-month results from the phase 2 VLA1553-221 trial aligned with initial data and demonstrated immune response at day 180 among patients aged 1 to 11 years. 

Six-month IXCHIQ chikungunya vaccine data demonstrates sustained antibody levels

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

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Children with epilepsy can usually achieve seizure control, but not always with the first medication prescribed. General pediatricians can learn from a child neurologist&s approach to this problem.

Tough seizures: When the first anticonvulsant fails

**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.

This case was presented by Giridhar Guntreddi, MD FAAP, FAPHM; Achuth Jayasankar Kondoor, Taylor Boske, Neelima P. Theella, MD, and Jayasree Vasudevannair, MD MPH FAAP. 

A healthy 12-month-old girl presented with one small skin lesion over the right heel (Image 1) for one month. On examination, her right lateral heel showed a round, white, pearl-like, hard, tiny lesion with a smooth appearance without any redness or itching. The patient's mother denied any pain, swelling, itching or fever. No significant travel, bites, heel stick injuries were reported in the history. No systemic symptoms suggested any underlying systemic diseases. The infant is closely monitored at subsequent well visits and re-checked. After 3 months, the child showed full resolution of the skin lesion over the heel area (Image 2).

Below, take your best guess at diagnosing this patient.

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.

News

Case Studies

Diagnose this infant with an asymptomatic pearl-like nodule on the heel

 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! 

Poll: What's the diagnosis of this linear eruption on the leg of a 9-year-old girl?

Since it was approved on July 17, 2023, nirsevimab (Beyfortus; Sanofi and AstraZeneca), has been a welcome tool for pediatric providers to fight against respiratory syncytial virus (RSV) disease in neonates and infants entering, or born during, their first RSV season. Backed by strong safety and efficacy data, the monoclonal antibody has been celebrated by providers and agencies alike, with over 6 million infants immunized.

On May 29, 2025, real-world, sustained durability data and additional efficacy data were announced at the 43rd Annual Meeting of the European Society for Pediatric Infectious Diseases (ESPID) in Bucharest, Romania, according to a press release from Sanofi.

Key data points included sustained efficacy and protection against hospitalizations due to RSV-associated lower respiratory tract infection (LRTI), as the antibody reduced hospitalizations by 82.7% through 6 months (180 days) compared to no intervention. Additionally, nirsevimab was associated with a 69% reduction in RSV hospitalizations in Spain following a nirsevimab-only immunization program.

Sustained nirsevimab efficacy for 6 months 

The 82.7% reduction sustained through 6 months was based on data from the ongoing phase 3b HARMONIE study, an open-label, parallel arm, randomized, controlled study conducted in France, Germany, and the United Kingdom. The study, published in 

, included 8057 infants who were randomly assigned to the nirsevimab group (n = 4038) or the standard care group (n = 4019). Infants are aged 12 months or younger and born at a gestational age of at least 29 weeks. Participants are assigned to receive a single intramuscular dose of nirsevimab (50 mg for children <5 kg or 100 mg for children ≥5 kg) or standard of care (no RSV prophylaxis) before their first RSV season.

According to the study investigators, the primary outcome was the incidence of hospitalizations because of RSV-associated LRTI up to 180 days after administration of the monoclonal antibody. The median age at randomization was 4 months (IQR 1.0 - 7.0; range 0.0 - 12.0), and 52.1% of participants were male. At up to 180 days, 12 of 4038 infants in the nirsevimab group and 68 of 4019 infants in the standard care group were hospitalized for RSV-associated LRTI. These data corresponded to a nirsevimab efficacy of 82.7% (95% CI, 67.8 - 91.5 [

"The 6-month data from HARMONIE show [nirsevimab's] protection exceeded the typical 5-month RSV season," said Thomas Triomphe, executive vice president of Vaccines at Sanofi, in a statement. "This is important because half of infant RSV hospitalizations occur in older babies born before the RSV season begins. These data demonstrating high, sustained efficacy, combined with real-world public health impact data, underscore how BEYFORTUS provides proven protection against the number one cause of lower respiratory tract disease in all infants.”

According to late-breaking data presented at ESPID, from the REACH observational study, RSV hospitalizations were reduced by 69% in Spain after a nirsevimab-only immunization program was targeted to all infants. The real-world analysis was performed on the LOGEX RTI Observatory

 run by health care analytics company LOGEX, and used administrative and microbiology data from multiple hospital sites across Spain and the United Kingdom. 

With data collection going through May 2025, current results were reflective of 3 consecutive RSV seasons from June 2022 through the end of March 2025. No RSV prevention program was in place for the 2022-2023 RSV season. 

More on overall RSV hospitalization rates 

In early May 2025, the Centers for Disease Control and Prevention's 

published RSV-associated hospitalization data from a pair of surveillance networks among infants aged 0 to 7 months, which revealed that hospitalizations were estimated to be 28% and 43% lower in the 2024-2025 RSV season compared to pre-COVID-19 RSV seasons.

The reduced hospitalization rates align with a 

, which detailed high uptake in the preventive measures, as well as positive outcomes. In the 

 study, results demonstrated that 64% of eligible pregnant individuals received the RSV vaccine and 70.1% of eligible newborns received nirsevimab. These administrations resulted in an overall RSV protection that exceeded 80% during a majority of the study period months, highlighting the real-world adoption of the interventions that were approved in 2023. 

1. Fitch J. Nirsevimab-alip FDA approved to prevent RSV in neonates, infants. Contemporary Pediatrics. July 17, 2023. Accessed May 29, 2025. https://www.contemporarypediatrics.com/view/nirsevimab-alip-fda-approved-to-prevent-rsv-in-neonates-infants

2. Beyfortus public health advantage bolstered by first real-world comparison of infant vs maternal RSV immunization programs. May 29, 2025. Accessed May 29, 2025. https://www.news.sanofi.us/2025-05-29-BEYFORTUS-R-public-health-advantage-bolstered-by-first-real-world-comparison-of-infant-vs-maternal-RSV-immunization-programs

3. Munro APS, Drysdale SB, Cathie K, et al. 180-day efficacy of nirsevimab against hospitalisation for respiratory syncytial virus lower respiratory tract infections in infants (HARMONIE): a randomised, controlled, phase 3b trial. 

Lancet Child Adolesc Health. 2025. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(25)00102-6/fulltext

4. Fitch, J. Infant RSV hospitalization rates 28%, 43% lower this season vs pre-COVID seasons. Contemporary Pediatrics. May 9, 2025. Accessed May 29, 2025. https://www.contemporarypediatrics.com/view/infant-rsv-hospitalization-rates-28-43-lower-this-season-vs-pre-covid-seasons

New phase 3b durability data revealed nirsevimab reduced RSV hospitalizations in infants by 82.7% through 180 days vs no intervention. 

Nirsevimab demonstrates sustained efficacy in reducing RSV hospitalizations through 6 months

This case was presented by Rutva Vora, BS; and Monica Guirguis, DO.

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 3-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.

Bleeding disorder (e.g. Von Willebrand Disease)

Diagnose this 2-month-old with scalp swelling

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 (

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

Eric Kossoff

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