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 Maturation delay Paediatrics4). OME = otitis media with effusion. Environment TORCH = toxoplasmosis, rubella, cytomegalovirus, Deprivation and and herpes simplex. neglect Selective mutism
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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 delay: Otological 1998; 2(9): 1–184. • Genetic syndromes • TORCH infections 2, National Institute for Health and Care • Prematurity/ Conditions predisposing to OME: Excellence. Otitis media with effusion in under hypoxia Craniofacial abnormalities, 12s: surgery. CG60. 2008. https://www.nice.org. Cerebral palsy • Neonatal jaundice for example, • Maternal Down’s syndrome, cleft palate uk/guidance/cg60 (accessed 13 Oct 2017). Meningitis hypothyroidism Sensorineural: 3. Leung AK, Kao CP. Evaluation and Neurological • Ototoxic drugs Conductive/sensorineural: management of the child with speech delay. • 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 assessment of children. BMJ 2013; 346: e8687. In multilingual children total words across of OME with appropriate intervention. all languages should be counted, and will Other causes that should not be missed 6. Beitchman JH. Summary of the practice parameters for the assessment and treatment often compensate for the perceived delay.5 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 enhanced potential outcomes for the child common conditions such as OME. Observed 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; 72(4): 491–499. delay, which can be split into psychological, suffer from both conductive deafness 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 chronic otitis media with effusion. N Engl J Med speech delay may be multifactorial and a at 2 and 5 years.9 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? Clin Otol 2006; 31(6): 580. child with speech and language delay is effusion resolution. Hearing aids are a non- 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 Patient consent Up to 60% of children with speech delay do insertion within 2 years of the first,10 with a The case presented here is fictional and not require intervention and the problem mean number of grommet insertions per therefore consent was not required. resolves spontaneously by 3 years of age.1 child of 2.1.11 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 these children. Freely submitted; externally peer reviewed. Speech and language delay may be an Competing interests MANAGEMENT early presenting feature in children with Diagnosis of the underlying causation of global developmental delay, and provides The authors have declared no competing speech delay is the priority and guides a crucial early opportunity to intervene and interests. management. All children with suspected provide multidisciplinary support. Prompt Discuss this article speech delay should be referred for audiological assessment is essential in all Contribute and read comments about this audiometry to exclude hearing loss as this is children with speech and language delay to article: bjgp.org/letters a potentially reversible cause in the setting exclude reversible causes.
48 British Journal of General Practice, January 2018