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Speech and Language Delay in Children: a Case to Learn From

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Speech and Language Delay in Children: a Case to Learn From Clinical Intelligence Nicola Wooles, Joanna Swann and Emma Hoskison Speech and language delay in children: a case to learn from INTRODUCTION On follow-up at 2 years, 6 months, his Speech and language delay in children is vocabulary had expanded to >100 words, a common presentation to primary care and audiogram showed thresholds <20 dB either directly to the GP or through the in the normal range. health visitor, affecting approximately 6% of pre-school children.1 Young children, ASSESSMENT AND DIFFERENTIAL particularly those with speech delay, can DIAGNOSIS be difficult to examine. Differentiation Speech and language delay must be between an isolated pathology and those separated from variation in speech with concurrent global developmental delay development, and is defined by children is crucial. This article presents an example falling behind recognised milestones. of a common case, considers the learning Regression or loss of speech and language points, and highlights management are particularly concerning. principles. Initially, a history with a focus on identifying a cause for the speech delay CASE HISTORY should be taken, including pregnancy and A 2-year-old boy presented to primary birth history, developmental milestones, care with fewer words than his peers, and family history. and with difficulty in non-family members Aspects of the antenatal history that understanding him. On closer questioning may impact on newborn hearing must he had <10 words of speech. He was born at be explored. These include TORCH 39 weeks by normal delivery, not requiring interuterine infections (toxoplasmosis, special care baby unit, and passed his rubella, cytomegalovirus, and herpes newborn hearing screening. Review of his simplex) and maternal drug exposure. Personal Child Health Record (red book) Important aspects of the perinatal history showed consistent growth along centile include prematurity, hypoxia, birth trauma, lines, and other developmental milestones and neonatal jaundice. Newborn hearing attained. In the consultation room he played screening does not occur worldwide and appropriately, made good eye contact, and should not be assumed in births outwith followed instructions: identifying his nose the UK. General maternal health is useful, and ears when asked. On examination, he particularly for the exclusion of conditions had normal facies, and otoscopy revealed such as hypothyroidism. bilateral dull tympanic membranes. The child’s medical history should be N Wooles, MRCS(ENT), ST4 otolaryngology; Referral to audiology was made and age- covered, including conditions such as E Hoskison, MA, FRCS, ST8 otolaryngology, appropriate free-field hearing testing with meningitis, head trauma, and seizures, and Department of Otorhinolaryngology, Head and tympanometry performed. He had hearing exposure to ototoxic drugs. Developmental Neck Surgery, University Hospitals Coventry thresholds of 40 dB (mild-to-moderate milestones should be noted, including and Warwickshire, Coventry. J Swann, MBChB, > GPST2, Bridgeton Health Centre, Glasgow. hearing loss) with flat tympanograms social interactions with peers and family. Address for correspondence indicating a conductive loss in keeping with This is not only to explore the possibility Nicola Wooles, Department of otitis media with effusion (OME). of a global developmental delay/disorder Otorhinolaryngology, Head and Neck Surgery, For 3 months the child was actively and the possibility of an underlying Coventry CV2 2DX, UK. observed and then referred to the ear, psychological diagnosis, but may also E-mail: [email protected] nose, and throat consultant. With evidence highlight deprivation and neglect. Submitted: 12 March 2017; Editor’s response: of persistent conductive hearing loss, he It is important to enquire about any family 6 April 2017; final acceptance: 9 June 2017. ©British Journal of General Practice 2018; was offered hearing aids or grommets, history of hearing loss and speech delay 68: 47–48. in keeping with National Institute for including the possibility of consanguinuity, https://doi.org/10.3399/bjgp17X694373 Health and Care Excellence guidelines.2 which may point to metabolic or recessive His parents elected for grommet insertion. conditions. British Journal of General Practice, January 2018 47 Figure 1. Venn diagram demonstrating the different causes of speech and language delay (adapted from the Oxford Handbook of Psychological Paediatrics4). OME = otitis media with effusion. Maturation delay Environment TORCH = toxoplasmosis, rubella, cytomegalovirus, Deprivation and and herpes simplex. neglect Selective mutism REFERENCES Autism spectrum disorders 1. Law J, Boyle J, Harris F,et al. Screening for speech and language delay: a systematic Global developmental review of the literature. Health Technol Assess Otological delay: 1998; 2(9): 1–184. • Genetic syndromes 2, National Institute for Health and Care • TORCH infections • Prematurity/ Conditions predisposing to OME: Excellence. Otitis media with effusion in under hypoxia Craniofacial abnormalities, 12s: surgery. CG60. 2008. https://www.nice.org. • Neonatal jaundice for example, Cerebral palsy uk/guidance/cg60 (accessed 13 Oct 2017). • Maternal Down’s syndrome, cleft palate Meningitis hypothyroidism Sensorineural: 3. Leung AK, Kao CP. Evaluation and • Ototoxic drugs Neurological management of the child with speech delay. Conductive/sensorineural: • head trauma Am Fam Physician 1999; 59(11): 3121–3128. 4. Tasker R, McClure R, Acerini C, eds.Oxford handbook of paediatrics. Oxford, Oxford University Press, 2008. 5. Bellman M, Byrne O, Sege R. Developmental of OME with appropriate intervention. assessment of children. BMJ 2013; 346: e8687. In multilingual children total words across all languages should be counted, and will Other causes that should not be missed 6. Beitchman JH. Summary of the practice 5 parameters for the assessment and treatment often compensate for the perceived delay. include global developmental delay and of children and adolescents with language and Examination should be global, observing psychiatric disorders such as autism learning disorders. J Am Acad Child Adolesc behaviour but with a focus on otoscopy, spectrum disorder, both of which will Psychiatry 1998; 37(10): 1117–1119. which may provide instant diagnosis of require a multidisciplinary approach with 7. Fenson L, Dale PS, Reznick JS,et al. Variability common conditions such as OME. Observed enhanced potential outcomes for the child in early communicative development. Monogr Soc Res Child Dev 1994; 59(5): 1–173. or formal neurological assessment of fine if support and treatment are offered earlier. 8. Mandel EM, Doyle WJ, Winther B, Alper CM. and gross motor skills may highlight a Ultimately these children will require input The incidence, prevalence and burden of OM global development delay, with head from a child development centre. in unselected children aged 1–8 years followed circumference a useful adjunct. Children with craniofacial abnormalities, by weekly otoscopy through the ‘common cold’ There are multiple causes of speech for example, Down’s syndrome, may season. Int J Pediatr Otorhinolaryngol 2008; suffer from both conductive deafness 72(4): 491–499. delay, which can be split into psychological, neurological, and otological (Figure 1). There and development delay, which will be 9. Zielhuis GA, Straatman H, Rach GH, van den Broek P. Analysis and presentation of data on is a known association between confirmed confounded if not treated. the natural course of otitis media with effusion speech and language delay and psychiatric In the case described the child was in children. Int J Epidemiol 1990; 19(4): 1037– disorders such as autism spectrum disorder, suffering from speech delay secondary to 1044. with up to 50% occurring concurrently.6 OME. This is the commonest cause of hearing 10. Gates GA, Avery CA, Prihoda T, Cooper JC In syndromic children, especially impairment in the developed world8 and is Jr. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of those with craniofacial abnormalities the reversible. OME has two peaks of incidence 9 chronic otitis media with effusion. N Engl J Med speech delay may be multifactorial and a at 2 and 5 years. The current treatment 1987; 317(23): 1444–1451. multidisciplinary approach with multiple strategy for OME is grommet insertion 11. Daniel M, Vaghela H, Philpott C,et al. Does referrals required. after a recommended 3-month period of the benefit of adenoidectomy in addition to One of the challenges in assessing a watchful waiting2 to allow for spontaneous ventilation tube insertion persist long term? effusion resolution. Hearing aids are a non- Clin Otol 2006; 31(6): 580. child with speech and language delay is that the order of learning and speech and surgical alternative but are generally seen language acquisition is fixed, but there is as socially unacceptable. Twenty-five per significant variation in timings described.7 cent of children will require further grommet 10 Patient consent Up to 60% of children with speech delay do insertion within 2 years of the first, with a The case presented here is fictional and not require intervention and the problem mean number of grommet insertions per 1 11 therefore consent was not required. resolves spontaneously by 3 years of age. child of 2.1. This emphasises the recurrent It is therefore important to undertake an nature of OME and the importance of close Provenance individualised approach to each child. follow-up for
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