Hi, my name is Tiffany Munzer and I'm excited to share with you a case discussion on speech and language delay in a patient in a pediatric office. This case is developed in collaboration with my colleague, Dr. Ashley Dahl. So let's get started. So we're seeing a patient in clinic today, a 25 month boy named Aidan who presents to your clinic for a well child check. His mom and dad note that he can say about five words, mama, dada, ball, sis, and dog. They note he started babbling right around 7-8 months of age time period and he started pointing around 12 months of age. He speaks both English and Russian in his home environment and parents are wondering if they should be concerned about his level of language development. So to get into some of his prior history, you ask questions about his birth history. He was born prematurely at 33 weeks or about two months early, he was in the NICU for about two weeks just for help with feeding and growing, but otherwise had pretty unremarkable course, and he is discharged at around 35 weeks gestation age. His past medical history is notable for a history, four ear infections in the past six months which were treated with antibiotics. He lives at home with his mom, dad, 5-year-old sister. Mom is an engineer, and Dad is an interpreter, and Aidan attends a full-time daycare. Family denies any kind of psychosocial stressors like food insecurity or difficulty meeting their bills at the end of the month. With regard to his family history, his older sister had a history of speech delay, and there is no family history of autism, spectrum disorder, anxiety, depression, ADHD, or any kind of global developmental delay. So on your physical exam, you see a really well-nourished boy who's generally pretty happy and he's babbling pretty often. You hear him say mama a few times and parents respond appropriately to him and narrate the world around him. Then when you hand him a book, he points to all of the different animals in the pictures. He makes really good eye contact and turns his parents when he's upset and he's really easily comforted. On the rest of your physical exam, his head circumference, growth and vital signs, all are within the normal range. But on your ear exam, you note bilateral middle ear effusions. So should you be worried and are you worried? I think one of the red flags that we note at this visit is that he's really only speaking a few words at two years of age, even if you account for his prematurity, and subtract a couple of months and think of him more as a 23-month-old, he would still be behind for his age. At two years of age, most providers actually even stop correcting for prematurity. By two years of age, we really expect kids to have closer to about 200 words and to be able to string together at least two words into one sentence. There are some reassuring features though, like he's really pointing and babbling and really nicely engaged and socially motivated. So what could be going on for this two-year-old boy Aidan? We're wondering about whether or not you might have in isolated speech or language delay, and whether or not hearing impairment might also play a big role in his speech and language development. He's had these frequent episodes of acute otitis media, and then also a persisting middle ear effusion. Also on the differential includes autism spectrum disorder, but he's had really reassuring social engagement on his physical exam and nice use of gestures, which makes this differential diagnosis lower. Then also on the differential includes more of a global developmental delay and this is something that we would need to examine further with additional cognitive testing. What are the risk factors that Aidan might have? His prematurity itself is a risk factor for his language delay. Even late preterm infants are at greater risk for language delays compared to their non-preterm counterparts. Then, there's also a family history of language delay for Aidan. There's a really strong genetic overlay for language delay and twin studies show that identical twins have 67-96 percent chance of the other identical twin having also a language delay, and in fraternal twins, that risk is about 33-69 percent in fraternal twins. Then also his possible hearing loss due to his frequent ear infections add an additional layer of risk for Aidan. So what are some protective factors for Aidan? He has a very responsive and stable caregiving environment which is known to promote language development. The fact that he's actually in a bilingual household really shouldn't cause language delays of more than three months. So what are your next steps as a pediatrician? We'd like to refer for a hearing evaluation to rule out hearing loss and if he has continued hearing loss, we'd like to correct the underlying cause. So for Aidan, we'd like to place ear tubes for his middle ear effusion to help him promote his hearing and then if other hearing loss, we'd like to consider hearing aids. We'd like to refer for speech and language evaluation, and treat at the frequency of about once a week in speech therapy. Early intervention is a free public service and anybody can refer kids to early intervention, and they'll actually come to families homes and do a free evaluation and free speech therapy sessions if they're determined necessary. As a pediatrician, you could also refer for private speech therapy services, but payments for these services are really insurance-dependent. Lastly, you could consider referral to developmental behavioral pediatrics for further cognitive testing and further evaluation for any other developmental causes of language delay. So in terms of prognostic factors, we know that early intervention is so important and that children make really incredible gains and progress with speech therapy. That correcting and underlying hearing loss can really improve speech and language acquisition significantly. Each child's trajectory though, is going to be a little bit different depending on their environmental input and genetic risk, and children in the future who have language delays might have more difficulties with reading and writing in school age. So that concludes our section. If you'd like to learn a little bit more about what we talked about today, these are the references that we used. Thank you so much for your time.