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

Poll

 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.

Try to diagnose this patient with 3 days of right-sided neck swelling.

Poll: Can you diagnose this 12-year-old female with right-sided neck swelling?

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

Lori Handy, MD, MSCE, addresses rising vaccine inquiries, emphasizing informed decisions that balance risks and benefits for children's health and safety.

Understanding the risks and benefits of current immunization practices

. 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 once-daily, steroid-free cream can be used anywhere on the body for treatment, and for any duration, according to Arcutis.

FDA approves roflumilast cream 0.05% for atopic dermatitis for children aged 2 to 5 years

Kari Allan, PharmD, BCPS, BCPPS, Children’s Hospital Colorado and the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora, CO.

Combination vaccines enhance childhood immunization by reducing the number of shots, improving adherence, and potentially increasing overall vaccination rates. 

Combination vaccines: Can fewer shots mean better outcomes? 

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

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Authors

Neil Cella, MD, HCA HealthONE Rocky Mountain Children’s at Presbyterian St. Luke’s, Pediatric Emergency Medicine, Denver, CO.

**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 July 23 at 3:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis. 

This case was presented by Umer Muhammad, MD; Neil Copeland, MD; and John Bishara, DO

A 23-month-old girl presented with a 3-day history of cough, rhinorrhea, and increased work of breathing. Initially, she was treated for bronchiolitis at an urgent care center, where a nasopharyngeal swab identified adenovirus. Despite initial treatment, the patient's condition worsened, and she required oxygen supplementation via nasal cannula for oxyhemoglobin desaturation. Her hypoxemia further deteriorated, necessitating an increase in oxygen supplementation (

On physical examination, the patient showed signs of respiratory distress. A chest x-ray (CXR) revealed opacities in the right middle and lower lobes. The patient's condition improved with supportive care, and she was discharged after several days in the hospital. 

However, 9 months later, due to recurrent wheezing, she was referred to the pulmonary service for further evaluation. A follow-up CXR, taken 3 months after the initial infection, demonstrated complete opacification of the right hemithorax, with a mediastinal shift to the right, as well as collapse of the right upper and middle lobes. 

Below, take your best guess at diagnosing this patient

Congenital pulmonary adenomatoid malformation (CPAM) 

website on Wednesday, July 23, at 3:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

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

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Case Studies

Puzzler poll: Diagnose this 23-month-old with cough and rhinorrhea

Then visit our website on August 20 at 12:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

This case was provided by Andrew Faniku, MD, pediatric hospitalist at Scott & White Healthcare.

A 21-year-old primigravida female presented to the hospital in preterm labor, with an otherwise uneventful pregnancy except for a febrile illness after exposure to family members with measles a week prior.

She reported having fever, cough, conjunctivitis, and a rash that started on her face and spread to her trunk, consistent with measles. Her fever and symptoms had mostly resolved, except for her lingering rash that began six days earlier. In the delivery room, she still had fresh excoriation marks on her arms. She had not received any MMR vaccines.

Six hours after admission, the patient delivered a female infant via spontaneous vaginal delivery at 35 weeks’ gestation. The baby weighed 2410 grams, which was approximately the 50

 percentile for her gestational age. The baby had mild respiratory distress after delivery and briefly required supplemental oxygen via blow by during transitioning. Apgar’s of 8 at 1 minute and 9 at 5 minutes was given at delivery. The baby subsequently improved and was allowed to room in with mother without the need for NICU admission. Nursing staff noticed a rash on the baby’s back. 

 website on Wednesday, August 20 at 12:00 PM EST or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

Can you diagnose this rash in a newborn?

 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?

C. Buddy Creech, MD, MPH, director of the Vanderbilt Vaccine Research Program

 discussed emerging trends in vaccine research and development during a presentation at the American Academy of Pediatrics (AAP) 2025 National Conference and Exhibition.

Advances in monoclonal antibodies and mRNA platforms

Creech noted that monoclonal antibodies are gaining traction for preventing respiratory infections in early life. “I think you can look at the success of RSV monoclonal with nirsevimab and now claustrovimab to be able to prevent respiratory infections early in life by giving a long-acting monoclonal,” he said. He also observed that parents often show “a lot less hesitancy around giving a monoclonal antibody than we do an active vaccination.”

The role of mRNA technology, widely recognized during the COVID-19 pandemic, is still evolving. “Now I think the question is, will that type of technology be suitable for everything that we want to do? Is it best used for some viruses or some pathogens over others? And I think we’re really too early to tell,” Creech said.

Creech emphasized the importance of adjuvants in enhancing immune responses and reducing antigen amounts needed for protection. “Adjuvants are really incredibly helpful for us, and we’ve used them in vaccines for over 100 years,” he said. While aluminum remains the most common adjuvant, new options are emerging. “One of the things that we should be seeing in the next few years…are novel adjuvants that aren’t aluminum-based, but take advantage of our understanding of the immune system, like little droplets of oil inside water,” Creech explained. He highlighted the Novavax COVID-19 vaccine as an example, which used a derivative from the Chilean soap bark tree.

Creech also stressed that adjuvant safety is always assessed as part of the full vaccine. “We never study a vaccine, get a safety profile for it, and then add an adjuvant. That never happens. We always study the whole package together,” he said.

Combination vaccines and parental concerns

Regarding combination vaccines, Creech said that combining antigens is pursued carefully. “If we could combine every single childhood vaccine into one vaccine, well we probably wouldn’t do it. That’s just a lot of vaccines to slam into one injection,” he said. Instead, combinations are designed based on compatibility and dose schedules. Safety is less of a concern when antigens have already been given simultaneously, but “the efficacy concerns are a little bit more when we put them in the same needle.”

He acknowledged parents’ growing interest in spacing out vaccines despite the need for more injections. Pediatricians, he said, must balance efficiency and effectiveness while addressing parental preferences.

Creech pointed to oral and intranasal vaccines as an important frontier, citing rotavirus and nasal influenza vaccines as key examples. “It turns out the first time you see a germ that dictates how you will respond to that germ for maybe the rest of your life,” he said. This principle, he noted, supports research into nasal pertussis, influenza, and COVID-19 vaccines. “I think that mucosal delivery of vaccine is going to be one of the next big frontiers within vaccinology.”

Creech concluded by underscoring the importance of transparency and communication with parents as new vaccines and technologies are introduced. “We want to really be able to communicate how these new vaccines come to market and all of the rigor that goes into testing them,” he said. He stressed that flexibility and trust-building will be critical in addressing vaccine hesitancy: “If we can get that balance right, I think we’ll find a lot of success.”

C. Buddy Creech, MD, discusses the future directions in vaccinology

Creech CB. New Technologies and New Vaccines for Prevention of Pediatric Infectious Diseases. Presentation. Presented at: American Academy of Pediatrics 2025 National Conference & Exhibition. September 26-30, 2025. Denver, Colorado.

C. Buddy Creech, MD, MPH, highlights advances in mRNA, monoclonals, adjuvants, and mucosal vaccines, stressing safety and parent communication.

Thomas Crawford, MD, discusses recent data for apitegromab for SMA, as well as overall developments in the field. 

Thomas Crawford, MD, talks advancements for spinal muscular atrophy treatment

The pivotal phase 3 SAPPHIRE trial has provided the strongest evidence to date that apitegromab, an investigational myostatin inhibitor, can improve motor function in children with spinal muscular atrophy (SMA) who continue to experience weakness despite standard survival motor neuron (SMN)-targeted therapies.

SAPPHIRE enrolled 188 patients aged 2–21 years with nonambulatory type 2 or type 3 SMA across 48 hospitals in the U.S. and Europe. All participants were already receiving nusinersen or risdiplam. The primary analysis focused on children aged 2–12 years. At 12 months, patients treated with apitegromab achieved a least squares mean 1.8-point improvement on the Hammersmith Functional Motor Scale–Expanded (HFMSE) compared with placebo (0.6 vs –1.2; 95% CI, 0.30–3.32; 

WATCH MORE: Thomas Crawford, MD, highlights improved motor function with apitegromab for spinal muscular atrophy

Neil Cella, MD

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