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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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 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 revised labeling will warn that patients younger than 6 years taking these medications are at greater risk of weight loss. 

FDA revises labeling on extended-release stimulants for ADHD to include weight loss risk

A look back at the FDA submissions and regulatory decisions in the pediatric health care space from June 2025.

FDA news in pediatrics: June 2025

The updated labeling includes a new contraindication for patients with prior or active hepatic events. 

FDA notifies providers of safety-related changes to prescribing information of maralixibat, odevixibat

MNV-201 is being evaluated in phase 2 clinical trials for treatment of the ultra-rare, life-threatening mitochondrial disorder affecting children.

MNV-201 receives fast track, rare pediatric disease to treat Pearson Syndrome

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

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The infant who arrives for medical care after an apparent life-threatening event (ALTE) presents the pediatrician with a host of uncertainties

A pragmatic approach to apparent life-threatening events

**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

Octavio Ramilo, MD, joins us once again to discuss potential benefits of RSV vaccination beyond disease prevention, and to explain how to speak with patients about vaccines and uptake. 

Potential downstream benefits of RSV preventive measures, with Octavio Ramilo, MD

The FDA’s June 9, 2025, approval of clesrovimab (Enflonsia; Merck)

 to prevent respiratory syncytial virus (RSV) in infants could have potential ripple effects of RSV prevention—not only in reducing bronchiolitis and hospitalizations, but possibly even lowering the global burden of pneumonia.

“If we prevent RSV now with these monoclonal [antibodies] and maternal vaccine, and we have a pneumococcus vaccine, the potential to reduce the morbidity and mortality associated with pneumonia will be important,” said Octavio Ramilo, MD, chair of the Department of Infectious Diseases at St. Jude Children’s Research Hospital and investigator in the CLEVER and SMART trials.

According to Ramilo, RSV and pneumococcus remain the 2 primary drivers of childhood pneumonia globally. While notable progress has been made in combating diseases like diarrhea through vaccines such as rotavirus, pneumonia now stands as a top priority for pediatric health agencies worldwide.

WATCH MORE: Octavio Ramilo, MD, reacts to the FDA approval of clesrovimab for RSV prevention

“The big challenge for pediatric health is respiratory infection, pneumonia, and the 2 big players are RSV and pneumococcus,” Ramilo said. “Now we are beginning to have prevention of RSV with monoclonals and maternal vaccine, so this is really, really important.”

Ramilo also suggested that preventing RSV could lead to unexpected benefits, including a reduction in ear infections and overall antibiotic use, though only time will tell what these potential downstream benefits are, and how impactful they may be. 

“RSV also facilitates ear infections,” he said. “So maybe we can even have an effect there... and if we reduce ear infections, we also decrease antibiotic usage.”

He expressed optimism that the introduction of preventive measures such as nirsevimab and clesrovimab will be well received by families. He added that pregnant persons are often receptive to maternal immunizations when the benefits are clearly explained.

“Pregnant women will do whatever it takes to protect the baby,” Ramilo said. “That’s sometimes an easier conversation, one in these very small babies than other vaccines we give to kids... [but] families want to protect the babies.”

Ramilo stressed that communication about vaccine efficacy needs to be nuanced and tailored to parents’ specific concerns. In his experience, some parents require more personalized, evidence-based discussions.

“My experience has been that when they tell you they don’t feel the vaccine is good for them… we need to make an effort to understand the reason,” he said. “Sometimes you cannot address the complete answer in one session.”

Ramilo emphasized that even partial protection has clinical value.

“A flu vaccine could work 60% to 70% to prevent flu,” he said, “but can prevent 90% of hospitalizations. Distinguishing how good the vaccine is, and what the expectations are, is very important.”

Fitch J. FDA approves clesrovimab to protect infants during first RSV season. Contemporary Pediatrics. June 9, 2025. Accessed June 20, 2025. https://www.contemporarypediatrics.com/view/fda-approves-clesrovimab-to-protect-infants-during-first-rsv-season

Fitch J. Octavio Ramilo, MD, reacts to the FDA approval of clesrovimab for RSV prevention. Contemporary Pediatrics. June 10, 2025. Accessed June 20, 2025. https://www.contemporarypediatrics.com/view/octavio-ramilo-md-reacts-to-the-fda-approval-of-clesrovimab-for-rsv-prevention

John Browning, MD, highlights why pediatricians should feel comfortable prescribing recent non-steroidals, and what questions to ask patients in office. 

John Browning, MD, explains dermatological questions to ask, answer in primary care

John Browning, MD, Chief of Dermatology at Children’s Hospital of San Antonio and Organon Health Partner, encouraged pediatricians to feel confident initiating treatment for atopic dermatitis (AD) using steroid-free creams when evaluating patients during routine visits. 

“I believe that pediatricians should be very confident to prescribe a steroid-free cream. They should feel like they can and should do that when they see a patient,” Browning said. He noted that AD is often first observed during routine physicals or skin checks and emphasized that early, informed intervention can help prevent prolonged suffering or delays in care. 

“Having a safe, steroid-free cream at their fingertips is great,” Browning said. “And I think that they should all know about what’s out there, so that they can help their patients. Otherwise, those patients are going to suffer before they’re finally going to be seen by a pediatric dermatologist.”

Browning explained that many families presenting to pediatric care have already tried over-the-counter products, including low-potency corticosteroids or general moisturizers. He recommended pediatricians ask specific questions about past use: “What kind of moisturizer? Has it helped? Has it not helped?”

Given the chronic nature of AD, Browning noted that a recurrent pattern of flare-ups is common, especially following the discontinuation of hydrocortisone. 

“There may be a rebound flare when they finish using the hydrocortisone or other topical steroid,” he said. “There’s also some other characteristics with AD, such as a symmetric nature to it. In kids, we see the flexural surfaces, so the front of the arms, back of the legs, sometimes it’ll be the neck, and around the face and eyes.” 

Recognizing these locations and distribution patterns can help general providers distinguish AD from other rashes. Browning also recommended screening for co-occurring conditions.

“There may also be some co-morbid conditions with AD, such as allergic rhinitis, seasonal allergies, or maybe some food allergies or asthma. Those are also good things for them to ask about.” 

By incorporating these questions into the clinical encounter and staying informed on evolving nonsteroidal therapies, Browning said pediatricians can play a key role in initiating safe, effective treatment for children with eczema. 

In this video interview, Michael Daines, MD, explains phase 3 data for Panzyga (Octapharma) for pediatric acute- onset neuropsychiatric syndrome (PANS).

Discussing phase 3 data of Panzyga for PANS, with Michael Daines, MD

Michael O. Daines, MD, division chief of Pediatric Allergy and Immunology at the University of Arizona College of Medicine and principal investigator of the phase 3 trial evaluating Panzyga for pediatric acute-onset neuropsychiatric syndrome (PANS), emphasized the potential clinical benefit of the treatment despite narrowly missing its primary efficacy endpoint in a recent phase 3 study. 

"We chose a primary endpoint of something called a CY-BOCS, which is a validated scoring system for looking at OCD," said Daines. "There was a clinically relevant improvement in children that were treated with Panzyga in this study, but it did not reach statistical significance, because there was also some improvement in the placebo." 

The randomized, double-blind, placebo-controlled trial assessed the safety and efficacy of Panzyga (immune globulin intravenous, human - ifas) 10% in 71 pediatric patients aged 6 to 17 years with moderate-to-severe PANS. Participants received 3 infusions of Panzyga or placebo over 2 days every 3 weeks for a total of 9 weeks, followed by a double-blind, crossover extension period.

While CY-BOCS (Children's Yale-Brown Obsessive-Compulsive Scale) was selected as the primary endpoint because of the central role OCD symptoms play in diagnosing PANS, the improvement observed in the Panzyga group, though greater than in placebo, did not achieve statistical significance (

"Many times in clinical studies, when you start bringing kids in and observing them and looking at them and doing things with them, they get better just from being part of a clinical study," Daines noted.

However, the trial's secondary endpoint—the Clinical Global Impression-Improvement (CGI-I) scale—showed a statistically and clinically significant improvement (

"This is a broader tool that looks at essentially how sick the child is," said Daines. "It’s also going to include those minor criteria... and there was a clinically relevant and strongly significant improvement in the CGI in the children that were receiving treatment." 

Looking ahead, Daines highlighted the need for continued research, and pointed to the need for studies of other immune-modulatory treatments that may offer lower costs or improved safety, as well as the importance of identifying a biomarker for more efficient diagnosis. 

"There are a lot of diseases that don't have biomarkers... but because it is a relatively complex assessment... if we had a simple blood test or microbiome test... that could help us get to a diagnosis quicker," he added. 

Octapharma releases results for phase 3 superiority study of pediatric acuteonset neuropsychiatric syndrome. Octapharma. Press release. May 27, 2025. Accessed June 19, 2025. https://www.octapharma.com/news/press-release/2025/octapharma-releases-results-phase3-superiority-study-pediatric-acuteonset-neuropsychiatric-syndrome 

Pediatric dermatologist John Browning, MD, offers practical sun safety tips and guidance for selecting sunscreens, emphasizing the importance of choosing formulations that work for sensitive skin.

John Browning, MD, provides practical skincare reminders ahead of summer season

Pediatric dermatologist John Browning, MD, offers practical sun safety tips and guidance for selecting sunscreens, emphasizing the importance of choosing formulations that work for sensitive skin. 

Joshua L. Bonkowsky, MD, PhD

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