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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.

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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: New AAP guidance, FDA COVID vaccine updates, and more

Adolescents from socioeconomically deprived families reported more eating disorder symptoms, highlighting disparities in risk and diagnosis.

Family socioeconomic position linked to eating disorder symptoms in adolescence

Piero F. Mejia, MD, is a pediatric pulmonary fellow at Johns Hopkins Hospital.

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AAP updates guidance on screening for mental, emotional, and behavioral problems in children

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As fall approaches, one of the biggest questions is: Can children return to school and be in classroom environments that assure health and well-being for all? Here's how practitioners can help.

Safe return to school: Part 2

**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

Vaccination coverage among kindergartners in the United States declined during the 2024-2025 school year while exemption rates rose, according to new findings from the CDC. Data from states and the District of Columbia showed decreases in coverage for all routine childhood vaccines compared with the previous year. Most states also reported year-over-year declines in protection against illnesses such as measles, polio, and varicella.

Click through the slideshow above to see vaccination numbers from the CDC for the 2024-2025 school year.

Alongside the drop in immunization rates, more kindergartners entered school with exemptions from 1 or more required vaccines. Exemption rates increased in a majority of states, with a growing number surpassing the 5% mark. These changes come as public health officials continue to raise concerns about declining community protection and rising vulnerability to outbreaks in schools and communities. 

"I was speaking with some colleagues at the CDC yesterday, and this is really terrible," Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief of 

and attending physician in the Division of Infectious Diseases at Ann & Robert H. Lurie Children’s Hospital of Chicago, told 

"It is a true indicator of the increase in vaccine hesitancy and antivaccination beliefs. The goal should be for all health care providers to work to find a way to slow down the number of infants and children not being vaccinated so that we can protect them against vaccine-preventable diseases," said Tan. "These diseases continue to circulate in the community, and being unvaccinated will place them at significant increased risk for getting the vaccine-preventable disease and possibly developing severe disease and complications." 

As families prepare for the start of a new school year, ensuring children are up to date on vaccinations remains a key public health priority, said 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, in a 

. Handy explained that linking vaccines to the school calendar has long been an effective way to prevent outbreaks of contagious childhood illnesses such as measles and polio. These diseases often spread quickly in classroom settings among children encountering their first exposures.

“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.

Lori Handy, MD, on importance of vaccine catchup before the school year

Handy noted that school-entry requirements serve as an important checkpoint, especially for families who may have missed routine care. 

“It is a nice pause to say, 'Let’s look back: Have you missed anything? Do we need to catch you up?'” she said.

"We need to be strong advocates for the patients whom we are privileged to provide care for," Tan added. 

Vaccination coverage and exemptions among kindergartners. CDC. July 31, 2025. Accessed August 1, 2025. https://www.cdc.gov/schoolvaxview/data/index.html

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

. July 17, 2025. Accessed August 1, 2025. https://www.contemporarypediatrics.com/view/lori-handy-md-importance-vaccine-catch-up-before-school-year 

New CDC data show fewer kindergartners are fully vaccinated as exemption rates increased during the 2024-2025 school year.

News

CDC: Kindergarten vaccination decreases, exemptions increase 

As families prepare for a new school year, pediatricians are essential in helping parents navigate immunization schedules and school requirements and ensuring vaccine confidence.

Aligning vaccinations with the start of a new school year

For parents with children attending school, there is no shortage of to-do lists, ranging from back-to-school clothes shopping to meeting teachers and learning bus schedules. The tail end of summer also serves as an excellent opportunity for parents to ensure their children are caught up with all necessary and recommended vaccines before kicking off another year of learning or perhaps the child’s first year in the classroom. Understandably, parents may not have vaccines in their minds, with so many other responsibilities circulating in the late summer to early fall months. That is where the ever-expanding role of the pediatrician can once again come in and make a difference. 

Using back-to-school season as a vaccine reminder 

Beyond reminders of upcoming vaccines, pediatric primary care providers can also equip parents with tools that help them better understand when and why vaccines are given at certain ages. Plenty of vaccine recommendation tools exist, such as the CDC's full vaccine schedule or the more parent-oriented Vaccine Education Center website, created by Children’s Hospital of Philadelphia (CHOP).

 These resources can be invaluable in the various local communities nationwide, where school vaccine mandates vary by state for certain vaccines. Although they might add one more item to check off on a parent’s hectic schedule in the lead-up to a new school year, vaccine requirements and reminders are essential to protect children in the halls. Using the school year as a benchmark reminder has been a long-standing tradition. 

“I think it is important to go back in history to understand how we even linked vaccines to the school year,” said Lori Handy, MD, MSCE, associate director of the Vaccine Education Center and attending physician in the Division of Infectious Diseases at CHOP. “This is related to earlier vaccines—measles vaccine, polio vaccine—where we had diseases that spread heavily in schools. Groups of young children, 5 or 6 years old, were getting infections for the first time and spreading something highly contagious to their classmates. So school time 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,” said Handy. 

Millions of children missed out on 1 or more vaccinations in the 3 years after the COVID-19 pandemic for various reasons, including service disruptions, a strained health care system, or a lack of vaccine confidence, according to a report from UNICEF. The April 2023 report stated that 67 million children missed a vaccine in this time frame, and although 5 years have passed since the first COVID-19 cases appeared, some children could still be playing catchup.

“We find that it is a significant rush for kids who have, for whatever reason, fallen behind. The summer months are a time when people make an increased effort to ensure that their kids are completely up to date,” Jesse Hackell, MD, FAAP, told 

Hackell is a retired general pediatrician and currently serves as chair of the Committee on Pediatric Workforce at the American Academy of Pediatrics (AAP). He is the immediate past president of NYS AAP–Chapter 3 and is cochair of the Pediatric Council of NYS AAP–Chapter 2 and NYS AAP–Chapter 3.

The change of environment from the outdoors and increased play time during the summer months to the confined spaces of hallways and classrooms during the fall is even more reason to encourage parents to ensure their children are up to date on immunizations.

“A number of viruses and illnesses circulate in greater numbers during the winter,” said Hackell. “If you add the presence of normal viruses to the close quarters and increased indoor time, we know it is a time when communicable diseases have an easier time spreading. There is a higher risk of the spread of diseases during the school year, which is another reason for making sure that everybody is current when they start school.”

Explaining requirements, recommendations to parents

As mentioned before, different states may have slightly different vaccine requirements, though it could be best practice to recommend beyond the scope of the school requirement. This is where the broader recommendations from the CDC, AAP, and other trusted sources come into play.

“To know the difference between the childhood immunization schedule, as recommended by the CDC, vs a school requirement is important. They are different,” said Handy. “As a pediatrician, I would focus on the recommended childhood schedule because those are the vaccines children need not just to go to school but also to exist in the world. You do not need a tetanus vaccine to be safe in a classroom, but as a 5-year-old, you need a tetanus vaccine to be safe playing in the dirt. As pediatricians, we want to ensure children receive the right vaccines to be healthy, and that means following the full immunization schedule.”

Navigating vaccines with parents in the current climate

Both Handy and Hackell acknowledged how vaccine hesitancy can play a role, especially in recent years, in whether parents choose to have their children vaccinated or how many of the recommended vaccines they want their children to receive. Recent changes in the federal government related to vaccine schedules, frameworks, and policies could be adding uncertainty for parents.

On July 7, 2025, the AAP, American College of Physicians, American Public Health Association, Infectious Diseases Society of America, Massachusetts Public Health Alliance, Society for Maternal-Fetal Medicine, and a pregnant physician announced a lawsuit against the US Department of Health and Human Services and its secretary, Robert F. Kennedy Jr, to “defend vaccine policy.”

The joint societies referenced the CDC’s May 27, 2025, pulling of its recommendation for routine COVID-19 vaccination among healthy individuals and pregnant women as well as the firing of 17 Advisory Committee on Vaccine Immunization members, who were then replaced by Kennedy-appointed personnel “who have historically espoused antivaccine viewpoints.”

Amid these changes, paired with misinformation on social media and other platforms that are in front of parents and children, experts recommend providers fall back on long-standing, reputable, and trusted sources, especially as parents explain their potential real concerns regarding vaccines.

“Both pediatricians and adult clinicians are taking a moment to think about what resource they want to use as their go-to,” added Handy. “For pediatricians, we want to stick to resources where the entire mission is keeping kids healthy. Organizations that share that mission include the AAP, the Vaccine Education Center, and the American College of Obstetricians and Gynecologists, [the last of] which focuses on maternal health and protecting newborns through maternal vaccination. If you encounter confusing or conflicting information elsewhere, fall back on these society resources that have hundreds of years of experience supporting children and healthy pregnancies.”

For parents who may be concerned about vaccination, it is important to thoroughly listen to their concerns and seek out the root of the issue while using the knowledge that parents are coming to you for: knowledge that will best protect their children.

“Our job is to address them, to build confidence in the parents about the vaccines, their safety, and their efficacy, to build confidence in the manufacturers and the pediatricians who administer the vaccines,” said Hackell. “We want to reassure parents that the reason for doing this is to benefit their children, to keep them safe and healthy, and to keep them in school.”

Handy agrees, advising her patients to ask their pediatricians these questions so they get information from a trusted source.

“What I have been saying most often is that in this moment of so much misinformation and changing information, the most trusted resource and the most trusted messenger is the child's pediatric provider,” said Handy. “Providers should own that role and embrace it. It takes work and time, but it is an important position to be in to help families navigate all this information and guide them to make good choices for their children.” 

All stock clips in video above courtesy of stock.adobe.com

Your child needs vaccines as they grow! CDC. June 20, 2025. Accessed July 9, 2025. https://www.cdc.gov/vaccines/imz-schedules/child-easyread.html

Age groups and vaccines. Children's Hospital of Philadelphia. Updated June 1, 2023. Accessed July 9, 2025. https://www.chop.edu/vaccine-education-center/vaccine-schedule/age-groups-and-vaccines

New data indicates declining confidence in childhood vaccines of up to 44 percentage points in some countries during the COVID-19 pandemic. Press release. UNICEF. April 20, 2023. Accessed July 9, 2025. https://www.unicef.org/press-releases/sowc_2023_immunization

ACIP updates: committee recommends clesrovimab for RSV, reaffirms routine influenza vaccination. 

. July 7, 2025. Accessed July 7, 2025. https://www.contemporarypediatrics.com/view/acip-updates-committee-votes-5-2-to-recommend-clesrovimab-to-protect-against-rsv 

Aligning vaccinations with the start of a new school year 

In November 2023, an otherwise healthy 11-year-old boy presented to the clinic with the chief concern 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 an ear, nose, and throat specialist for an episode of epistaxis, which was benign and resolved without requiring cauterization. His medical history was otherwise unremarkable, notable only for molluscum contagiosum at the age of 5 years 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, comprehensive metabolic panel, prothrombin time, and partial thromboplastin time. 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 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 his previous laboratory test results 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.

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.

Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP

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