SM13: Pediatric Speech Delays Can Be Managed if Caught Early

SCOTTSDALE, Ariz.—A small child who is having trouble talking, or isn’t talking at all, can be a big source of distress for parents, but early intervention can be effective, said a panel of experts here on Jan. 26 at the Triological Society Combined Sections Meeting. Click here to listen to the complete session on speech delay.

The experts also said it is important to distinguish between what is a problem and what isn’t—a task that might be difficult when the scenario is presented by worried parents—and to understand what helps and what might not be worth trying.

Risk Factors

Carla Zimmerman, PhD, an Arizona speech pathologist in private practice, said that speech delay should be thought of in two ways—how a child produces speech sounds and difficulty with the content of messages and vocabulary. Girls generally outpace boys in speech by only a few months, so a lag in a boy’s speech shouldn’t be chalked up simply to a gender difference, she said.

“Late talkers,” or kids who don’t start talking until they are between 18 and 30 months of age but seem to understand well, will frequently outgrow the problem; about 35 to 60 percent will go on to be normal talkers, Dr. Zimmerman said. “The problem is, we don’t know who those kids are,” she added.

Risk factors of speech delay include minimal babbling as an infant, a history of ear infections, limited consonant sounds, failure to link pretend ideas and actions together when playing, failure to imitate words, use of mostly nouns and few verbs, trouble playing with peers, a family history of communication delay or learning problems, mild comprehension delay for the child’s age and the use of few gestures to communicate. If a child has a limited vocabulary for his or her age and any of the risk factors, it’s best to consult with a speech pathologist, said Dr. Zimmerman. “There is a window of development for children, and if we catch the children early enough that they’re still in that window of potential learning, we can get a lot more bang for our buck,” she said.

Ankyloglossia

Ankyloglossia doesn’t affect speech unless it’s very severe, Dr. Zimmerman said. Panelists said that the decision to recommend and perform frenulectomy can be a touchy subject.

Moderator Kenneth Grundfast, MD, chairman of otolaryngology-head and neck surgery at Boston Medical Center, said he’ll typically just do the procedure rather than argue with a neonatologist about its merits, but if the child is two to three years old and will require general anesthesia, he’ll usually try to talk the parents out of it, with mixed success.

Other Underlying Variables

In some cases, the problem can be larger than a speech delay—it could be linked with autism. “If you see a child who has difficulty with social relationships … communication issues, any repetitive behaviors or overly restricted interests, there’s a really good chance that this child is going to fall within the autism spectrum,” Dr. Zimmerman said.

Julie Wei, MD, asscociate professor of otolaryngology-head and neck surgery at the University of Kansas Medical Center in Kansas City, said that when she gets cases of suspected speech delay, she ascertains the nature of the problem and assesses risk factors. When it comes to assessing the hearing, especially in toddlers, she likes using distortion product otoacoustic emission and tympanometry, she said. “That gives you very frequency-specific information in this age group, when generally cooperation is not there or just the speech awareness threshold is not as informative,” she said. “We’ve been utilizing that with success.”

Peter Weisskopf, MD, head of the neurotology section at the Barrow Neurological Institute in Phoenix, said that unilateral hearing impairment usually isn’t a barrier to speech, as long as the adults caring for the child know about it. Simple steps, such as making sure the child’s good ear is situated toward the storyteller at story time, can work well. There are other, more involved measures available, such as hearing aids and bone conduction, but he said those steps should not be considered automatic. “I think it’s very important to think a little about the social consequences…versus what we already know, which is that a lot of these kids do really, really well,” he said.

Genetics can have a hand in speech delay as well, said Scott Manning, MD, chief of otolaryngology at Seattle Children’s Hospital. Chromosome 22q11 deletion is the most common deletion syndrome. It’s marked by expressive speech delay by about one year of age, in addition to chronic middle ear effusions; anxiety, depression, ADHD or autism; and sometimes velo-cardio-facial syndome, a genetic condition involving heart defects, facial appearance effects and a lack of or underdevelopment of the thymus and parathyroid glands. Fluorescence in situ hybridization (FISH), which, in Dr. Manning’s state of Washington, doesn’t require insurance pre-authorization, can be used to test for the deletion. “We need to have a low threshold for doing that test for chromosome 22q11 deletion,” Dr. Manning said.

Mosaic Trisomy 21, present in 1 to 2 percent of trisomy 21 patients, is another genetic defect to watch out for. Its phenotype varies but is often present with speech delay. “It’s our job to make these diagnoses early,” he said, “when, developmentally, we can benefit better from speech therapy.”