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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.

Current prevention strategies include 2 injectables for infants and young children, namely palivizumab and nirsevimab.

RSV prophylaxis: Palivizumab, nirsevimab, and more

Research shows that nearly 80% of foster children have at least 1 significant mental health need. 

Pediatricians and foster care: A vital role

MD, executive director, Positive Development; associate clinical professor, Department of Psychiatry, UCSD School of Medicine; co-chair, Disaster and Trauma, American Academy of Child and Adolescent Psychiatry. 

Joshua Feder, MD, highlights the need for psychiatry to better integrate sensory processing research into care strategies beyond autism.

Joshua Feder, MD, on broadening the role of sensory integration in psychiatry

Akash Deswaney, MD, Charleston Area Medical Center, Department of Pediatrics.

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

Diagnose this 18-day-old female with apnea, cyanosis, decreased feeding concerns

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**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 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 (

 poll! Be sure to visit ContemporaryPediatrics.com on Wednesday, May 7, 2025 at 12:00 PM Eastern Time or later for the full case presentation, differential diagnoses, and correct patient diagnosis.

News

Case Studies

The FDA and the US Department of Health and Human Services (HHS) has announced a plan titled "Operation Stork Speed" aimed at expanding options for safe, reliable, and nutritious infant formula, according to a press release from the federal agencies.

Actions include beginning the nutrient review process and increased testing for heavy metals and other contaminants. The agencies are calling on companies to develop new infant formulas and "clarify opportunities to help inform consumers about formula ingredients," stated the agencies. 

"The FDA is deeply committed to ensuring that moms and other caregivers of infants and young children and other individuals who rely on infant formula for their nutritional needs have confidence that these products are safe, consistently available, and contain the nutrients essential to promote health and wellbeing during critical stages of development and life,” said Sara Brenner, MD, MPH, acting commissioner of the FDA, in a statement. 

"Whether breastfed, bottle fed or both, the rising generation must be nourished in a way that promotes health and longevity over the course of their lives, added Brenner. 

According to a list provided by the FDA and HHS, the agencies stated they will use longstanding and newly granted authorities to uphold safety, nutritional adequacy, and resilience of infant formula and formula supply. The FDA is, according to the press release:

Starting the nutrient review required by law by issuing a Request for Information in the coming months to start the first comprehensive update and review of infant formula nutrients by the FDA since 1998

Increasing testing for heavy metals and other contaminants in infant formula and other foods children consume

Extending the personal importation policy

Encouraging companies to work with the FDA on any questions regarding increased transparency and clearer labeling

Communicating regularly with consumers and industry stakeholders as significant developments occur to ensure transparency, including information regarding nutrients and health outcomes

Collaborating with the National Institutes of Health and other scientific bodies to address priority scientific research gaps regarding short- and long-term health outcomes associated with formula feeding in infancy and childhood across the lifespan

"The FDA will use all resources and authorities at its disposal to make sure infant formula products are safe and wholesome for the families and children who rely on them," said Robert F. Kennedy, Jr., secretary of HHS, in a statement. 

Bobbie launches first USDA organic whole milk infant formula in US

Bobbie Labs has announced the planned launch of Bobbie Organic Whole Milk Formula, which the company bills as the first and only USDA Organic Whole Milk 

FDA approves Surgifort human milk-based fortifier for term infants after gastroschisis surgery

The FDA has approved the first human milk-based nutritional fortifier indicated for term infants, with the approval of Prolacta Bioscience's Surgifort, according to a press release from the company.

The human, pasteurized fortifier is indicated for term infants at or older than 37 weeks, following corrective surgery for the gastrointestinal disorder gastroschisis.

1. HHS, FDA Announce Operation Stork Speed to Expand Options for Safe, Reliable, and Nutritious Infant Formula for American Families. FDA. Press release. March 18, 2025. Accessed March 18, 2025. https://content.govdelivery.com/accounts/USFDA/bulletins/3d78943

2. Campbell P. Bobbie launches first USDA organic whole milk infant formula in US. 

. March 10, 2025. Accessed March 18, 2025. https://www.contemporarypediatrics.com/view/bobbie-launches-first-usda-organic-whole-milk-infant-formula-in-us 

3. Fitch, J. FDA approves Surgifort human milk-based fortifier for term infants after gastroschisis surgery. 

. February 25, 2025. Accessed March 15, 2025. https://www.contemporarypediatrics.com/view/fda-approves-surgifort-human-milk-based-fortifier-term-infants-gastroschisis-surgery 

The federal agencies are encouraging companies to develop new infant formulas and clarify opportunities to inform consumers about formula ingredients.  

FDA, HHS announces plan to enhance quality, safety of domestic infant formula

A new study has found a statistically significant relationship between air lead concentration and infant mortality, highlighting the ongoing risks posed by industrial emissions even in developed countries like the United States. The research, conducted by economists from Carnegie Mellon University, Boston College, and Hunan University, provides the first causal estimates of airborne lead’s impact on infant mortality in settings with modern medical care and at contemporary exposure levels.

“Although many studies have examined the adverse effects of lead on children’s cognitive and behavioral outcomes, few have analyzed the effect of exposure to lead on infants’ health, so we know little about the extent of harm to infants’ health from airborne lead,” said Karen Clay, professor of economics and public policy at Carnegie Mellon’s Heinz College and the study’s lead author.

The study used U.S. Toxic Release Inventory (TRI) data on lead emissions to determine the effect of air lead concentration on infant mortality. The researchers employed an innovative approach by using annual variations in fugitive lead emissions—those that escape from industrial processes into the air—and wind speed near reporting plants to estimate local ambient lead concentration. This method allowed them to isolate the causal effect of lead exposure on infant mortality while controlling for other pollutants.

The findings indicate that higher concentrations of lead in the air led to an increase in infant mortality in both the first month and first year of life, suggesting that both in utero and postnatal exposure play a role. In particular, higher lead levels were linked to increased deaths due to low birthweight, sudden unexplained infant death (SUID), and respiratory and nervous system causes.

The study’s estimates suggest that declines in fugitive lead emissions alone prevented 34 to 59 infant deaths per year, with economic benefits ranging from $380 million to $670 million annually. Expanding the scope to include all TRI-reported reductions in air lead concentrations, the researchers estimate that approximately 241 infant deaths were prevented per year, amounting to $2.7 billion in economic benefits annually.

Edson Severnini, associate professor of economics at Boston College and coauthor of the study, emphasized the implications of their findings. “Back-of-the-envelope calculations indicate that declines in fugitive lead emissions prevented 34 to 59 infant deaths per year, generating benefits of $380 million to $670 million annually,” he stated.

The research also sheds light on potential mechanisms underlying these effects. Previous studies have linked lead exposure to damage in neurological development, potentially disrupting sleep and arousal mechanisms, which could contribute to conditions such as sudden infant death syndrome (SIDS), a subset of SUID (Lyngbye et al., 1985; Clay et al., 2025). In addition, animal studies have shown that lead exposure weakens the immune system, which may increase vulnerability to respiratory illnesses.

Despite significant progress in reducing lead exposure from gasoline and paint, industrial emissions continue to contribute to elevated air lead levels. “In the United States, industrial firms and the aviation industry still emit hundreds of thousands of pounds of lead into the air,” noted Xiao Wang, assistant professor of economics and trade at Hunan University and coauthor of the study. “Our new estimates can inform investments in reducing air lead emissions and soil cleanups.”

The findings contribute to a growing body of research on the health impacts of lead exposure and reinforce the need for continued efforts to reduce industrial lead emissions. The study suggests that stricter air quality regulations and targeted remediation efforts could yield significant public health benefits, particularly for vulnerable infant populations.

1. Carnegie Mellon University. Infant mortality tied to concentration of lead in air. Eurekalert. February 25, 2025. Accessed February 27, 2025. https://www.eurekalert.org/news-releases/1074938

2. Clay KB, Severnini E, Wang, X. The Hidden Toll of Airborne Lead: Infant Mortality Impacts of Industrial Lead Pollution (February 2025). NBER Working Paper No. w33447. 

A study finds air lead exposure increases infant mortality, linking emissions to low birthweight, SUID, and respiratory issues, urging stricter regulations.

Higher air lead concentration linked to increased infant mortality

On March 18, 2025, Bavarian Nordic A/S announced the US commercial launch of its recently approved Chikungunya Vaccine, Recombinant (Vimkunya) for use in individuals aged 12 years and older, according to an announcement from the vaccine company.

Bavarian received approval for the virus-like particle (VLP) vaccine on February 14, 2025, making it the first VLP single-dose, pre-filled syringe for chikungunya among the indicated age group. Prior to this approval, the only FDA approved vaccine for chikungunya prevention,

, was indicated for individuals aged 18 years and older.

“The commercial availability of VIMKUNYA™ in the U.S. underscores our commitment to addressing emerging health threats and safeguarding communities nationwide,” said Lee Ann Kimak, vice president, Commercial for North America at Bavarian Nordic, in a statement.

“As the first virus-like particle single-dose, pre-filled syringe chikungunya vaccine, Vimkunya provides a crucial new tool to help protect at-risk individuals traveling to regions where the virus is spreading," Kimak added.

Approval of Vimkunya was based on 2 phase 3 clinical trials that enrolled over 3500 healthy individuals aged 12 years and up.

"Primary endpoints were met in the phase 3 trials, with results showing that 21 days after vaccination, Vimkunya induced neutralizing antibodies in up to 97.8% of individuals vaccinated and demonstrated a rapid immune response starting to develop within [1] week," Bavarian Nordic stated.

According to the company, the vaccine was well-tolerated and adverse events were mild or moderate. 

Over the last 20 years, the mosquito-borne disease caused by the chikungunya virus has emerged in several regions in Africa, Asia, and the Americas, stated Bavarian Nordic. Since discovery, the virus has been identified in over 110 countries, with data on confirmed transmission in more than 50 countries in the last 5 years.

Presentation of chikungunya typically includes acute symptoms such as fever, rash, fatigue, headache, and severe joint pain.

Ixchiq was approved on November 10, 2023, as the world's first approved vaccine for chikungunya, in individuals aged 18 years and older who are at an increased risk of exposure to the virus.

Prior to approval on February 14, 2025, the only FDA approved vaccine for chikungunya protection was indicated for 18 years and up.

Noah Christian, MD

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