14:48 PM

475 - Fever in Children, Hearing Aid Primer, Learning How to Grieve

Take 3 – Practical Practice Pointers©

From the Literature

1)    Ibuprofen and Acetaminophen for Fever in Children


Despite a recognition that fever can be a valuable host defense against infection, both parents and physicians still have some “fever-phobia.” As a result, recommendations to combine or alternate ibuprofen and acetaminophen are frequently given to parents of children with fever. Most international guidelines discourage this practice, and US guidelines note a lack of convincing evidence to support or refute the practice.

Researchers have undertaken a systematic review of the evidence behind this recommendation to see if combination/alternating therapy has any advantage over monotherapy in febrile children.

The review was fairly broad, including studies of febrile children 18 years of age and lower, in which one arm of the study was combined/alternating antipyretic therapy and which looked for outcomes related to fever such as at least 1-degree Celsius reduction in temperature and decreased discomfort as measured by validated scales. The review was otherwise performed according to Cochrane Collaboration methods and internationally recognized reporting standards.

Nine randomized controlled trials (RCTs) met inclusion criteria. Most were of low risk of bias, and the most common validity issue was lack of blinding. The definition of fever was usually 38 degrees Celsius, and the studies used a variety of methods for measuring temperature. Dosing of acetaminophen was usually 15 mg/kg/dose, but one study used 10 mg/kg/dose and one used 12.5 mg/kg/dose. Seven studies used 10 mg/kg/dose and 2 used 5 mg/kg/dose. All the medications were given orally.

For combined therapy vs. a single medication, there was no difference in proportion of children remaining febrile at 1 hour, but at 4 hours, fewer children in the combined group remained febrile (3 studies, relative risk (RR) 0.18, 95% confidence interval (CI)

0.06 to 0.53, number needed to treat (NNT) approximately 5). At 6 hours, 1 study showed a similar effect (RR 0.1, 95% CI 0.01 to 0.71, NNT approximately 3). Mean temperature was significantly lower by 0.29 degrees Celsius at 1 hour in the combined group, but not different at 4 or 6 hours.

For the alternating therapy groups vs. single agents, there were fewer children remaining febrile at 6 hours in the alternating group (3 studies, RR 0.3, 95% CI 0.15 to 0.57, NNT approximately 9). Discomfort scores favored the alternating therapy group at days 1, 2 and 3. There were no significant adverse events noted from either combined or alternating therapy. The authors concluded, based on relatively few studies per outcome and significant heterogeneity in most analyses, that the overall quality of evidence was too low to support combined or alternating antipyretic therapy.

John’s Comments:

The clinical significance of these results overall is questionable. The discomfort index used in the alternating therapy studies was originally developed for cognitively impaired children; its applicability in the setting of fever in cognitively normal children is questionable, and we’re not given the minimum clinically significant difference to assess the study results. In an otherwise healthy child, treating fever with monotherapy is probably sufficient, but we can reserve combination/alternating antipyretics for children with a febrile seizure history or other reason to be more concerned. We should be cautious with ibuprofen use in the setting of dehydration in the febrile child to avoid acute kidney injury.


·         Trippella G, Ciarcià M, de Martino M, Chiappini E. Prescribing Controversies: An Updated Review and Meta-Analysis on Combined/Alternating Use of Ibuprofen and Paracetamol in Febrile Children. Frontiers in Pediatrics. 2019;7. Link

From the FDA and the Literature

2)   Hearing Aid Primer


According to data from the National Institute on Deafness and Other Communication Disorders (part of NIH), 13% of persons in the US aged > 12 have hearing loss in both ears, based on standard hearing examinations. Additionally, about 2% of adults aged 45 to 54 have disabling hearing loss. The rate increases to 8.5% for those aged 55 to

64. Nearly 25% of those aged 65 to 74 and 50% of those who are 75 and older have disabling hearing loss. It is estimated that almost 29 million US adults could benefit from using hearing aids.

This problem has taken on an even greater sense of urgency as a recent meta-analysis showed that the usage of hearing restorative devices by participants with hearing loss was associated with a 19% decrease in hazards of long-term cognitive decline.

Furthermore, usage of these devices was significantly associated with a 3% improvement in cognitive test scores that assessed general cognition in the short term.

As of October 17, 2022, an FDA ruling allowing the sale of OTC hearing aids for anyone age > 18 without a medical exam, prescription, or professional fitting went into effect While it is anticipated this change will create greater innovation, competition, and affordability, in the short run it could also create more confusion as companies try to determine how to market and price hearing aids and consumers try to educate themselves about the many options available. While it is still recommend patients be evaluated by an audiologist if there is a concern about significant hearing loss, the use of smartphone self-test apps (also available on the computer) such as Mimi or SonicCloud using pure-tone audiometry can provide a basic sense of hearing acuity.

Presently, there are 4 main types of hearing aids:

·         Behind-the-ear (BTE) models where sound is delivered into the ear canal via a thin, hollow tube or via a wire and speaker bud that tucks into the ear canal.

·         In-the-canal (ITC) models that are more difficult to see but historically have less power and fewer features than BTE models

·         In-the-ear (ITE) models where all components rest in the bowl of the outer ear

·         Rechargeable earbuds which look like conventional Bluetooth wireless earbuds and either cover or fit into the ear canal.

Hearing aids must be customizable to account for one’s unique hearing profile across the range of frequencies. Those labeled as “self-fitting” must be able to deliver results on par with a fitting from a hearing professional using a smartphone-based hearing test. Based on the results, an app automatically calibrates low-, medium- and high-frequency sound output for each ear. Other models offer a choice of preprogrammed settings that represent common hearing-loss profiles. These models may be less expensive, but they will not likely offer the same “customized” acuity.

According to Consumer Reports, features of hearing aids that are most desired (but may not be available yet on most OTC models) include rechargeable batteries, smartphone capabilities, tinnitus masking, automatic noise level adjustment, advanced microphone features, wireless connectivity to other devices, and the option of multiple program settings to optimize sound quality to a variety of environments. Other desirable features on higher end models include directional microphone, feedback suppression, and digital noise reduction.

Hearing aids are already being sold at most drug stores as well as many retailers, including Walmart, Best Buy, Sam’s Club, and Costco. Prices presently range from

$200-3,000, which overall is significantly less than the present prices when purchasing from an Audiologist. One important trade-off is that you won’t receive the same level of support and expertise that you would receive from an audiologist.

Mark’s Comments:

As the OTC hearing aid market is established, there will likely be many changes over the next few years in terms of both features and cost. It is important to remind our patients that while these devices can certainly help with hearing loss, even higher end models will not eliminate hearing loss and various models have their own strengths and shortcomings. Remember as well that Medicare Parts A and B do not cover the cost of hearing aids, including any fittings and hearing exams with the intended purpose of prescribing hearing aids. Depending on the plan, some Medicare Advantage plans offer hearing coverage. Given the potential market for more affordable devices, I wouldn’t be at all surprised if soon we’ll be getting “detailed” by hearing aid sales reps.


·         Sheng Yep Yeo B, et al. Association of Hearing Aids and Cochlear Implants With Cognitive Decline and Dementia: A Systematic Review and Meta-analysis. JAMA Neurol. Published online December 5, 2022. Abstract

·         US FDA. How to Get Hearing Aids. Current as of 11/18/22. Link

·         Consumer Reports. Hearing Aid Buying Guide. Last updated March 10, 2021. By subscription. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    When Did You Learn How to Grieve?


“When you compare losses, someone else’s may seem greater or lesser than your own, but all losses are painful.― Elisabeth Kübler-Ross, MD, Psychiatrist, author and pioneer in our understanding of dying and grieving

When did you learn how to grieve? Given my Swiss-Germanic roots on both sides of the family, my memory growing up is that grieving was not publicly expressed and if by chance it slipped out, was rather emotionally muted. This particular pattern was for the most part reinforced during both my medical school and residency training.

However, I was blessed with a few professional mentors and role models, particularly during my residency training, who encouraged us to not be afraid to explore our challenging emotions, including those around grief. One of those role models was a psychiatrist whose name is quite familiar to most, Elisabeth Kübler-Ross. Best known for her groundbreaking 1969 book, “On Death and Dying,” which first introduced her model outlining five stages of dying, she was a and pioneer in changing the way dying and grieving were viewed both in the medical community and in the population at large.

While she is best known for this model, she also did trailblazing work with children who were dying as well as with prisoners dying of AIDS at the height of the AIDS epidemic. In 1988, I was part of a group of resident physicians who had the opportunity to attend a private day-long workshop with Dr. Kübler-Ross at her farm and retreat center in Virginia. We spent much of the day exploring our own beliefs about death, dying, and loss, as well as analyzing the artwork from children who were dying, as art therapy played a significant role in her work with children (yes, way ahead of her time). I had never before considered death from a child’s perspective and was deeply inspired by the wisdom and beauty of the insights expressed in their art.

What I still remember most about this time was how moved I felt and the comfort I experienced while discussing death, dying, and grief in the presence of my colleagues – in being given permission, encouragement, and the “space” to tell our stories. That was a first. What was also a first was the realization that we were all carrying significant accumulated and unprocessed (and therefore unresolved) grief from our medical school and residency training, and each thought we were the “only one” who was struggling since grief and loss were rarely acknowledged let alone discussed. This experience started an important journey of discovery as I explored how and where grief manifests for me – a journey that continues to this day.

So, when did you learn how to grieve? If your answer, like many, is “I didn’t,” perhaps now is the time. It is quite likely that those with whom you work every day are also carrying much accumulated, unprocessed, and unresolved grief. What an opportunity to learn together! Next week, we’ll explore the many facets of grief, and better understand that the pioneering work of Dr. Kübler-Ross and others regarding death and dying was a doorway and invitation for exploration, not a destination, formula, or conclusion. As we continue this exploration, be sure to check in more often with your PeerRx partner and with yourself, as tender (even raw) memories and emotions may surface. And remember, no one should grieve alone.


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org