anna catalina aniag-dimalanta, md. to present a case of 31 month old male patient with speech delay...

CASE PRESENTATION

Anna Catalina Aniag-Dimalanta, MD

OBJECTIVES

To present a case of 31 month old male patient with speech delayTo discuss the approach to diagnosis of a patient with speech delay

GENERAL DATA

RC.31 month oldMale

CHIEF COMPLAINT

“He speaks mostly in jargons and cannot speak

well.”

HISTORY OF PRESENT ILLNESS

Mother noted delay in language development Started babbling at 8 mos. Old First real word at 1 year old At 2 years old, slow vocabulary acquisition

Speaks mostly in jargonCan say a few words with articulation difficultiesTurns when name is calledPoints to needs; points to picturesFollows 2-step commants

HISTORY OF PRESENT ILLNESS

At 2 years and 7 months old, Still speaks in jargonVocabulary was limited to less than

50 words Speaks fast but words cannot be

understoodSpeech is only 25% intelligible(+) pointing and hand leadingPlays with other children

REVIEW OF SYSTEMS

No fever, no weight loss, no trauma No cough, colds No cyanosis, tachypnea, difficulty of

breathing No vomiting, diarrhea, abdominal

distention No dysuria, no hematuria No bipedal edema, weakness of

extremities No seizures, no alteration in sensorium

BIRTH HISTORY

Full termDelivered via CS to a 40 y/o mother and

a 56 y/o fatherG2P2 (2002) at SLMC. BW 6 lbsUnremarkable perinatal and maternal

historyNewborn Screening normalHearing screening passed both ears

Feeding History

Breastfed for 6 months Semisolids started at 6 months Now has 3 meals and 2 snacks in a

day Bottle feeds (7 oz bottles x 4/day) Dislikes vegetables Can feed independently using a

spoon Eats at the dining table Typical meal duration: 20 mins

PAST MEDICAL HISTORY

(+) Bronchial asthma- admitted when he was 1 ½ yrs old, and then at 2 yrs old

FAMILY HISTORY

(+) hypertension- maternal grandfather

No neurologic/ developmental problems

Family History

MOTHER Shy as a child Average student Finished 2nd yr

college then went into modeling

Now a stay-at-home mom

Has a 19 yr old son from a previous relationship

FATHER French; based in

France Slow to warm up to

others Average student Engineer Has 2 children from

previous marriage

Personal and Social History Primary caretaker: Mother Lives with mother and 19 year old half-

brother Parental involvement: Speaks with the

father through the computer. Patient and mother were based in France but came home because of older brother.

Usual activities: Stays home and plays. Exposed to TV 4-6 hrs/day. Rarely reads books.

Developmental History

Gross motor: Roll over at 3 months Sits without support at 8 months Walks with one hand held at 12 months Walks alone at 14 months Runs at 18 months


Fine motor: Reaches for objects at 6months Holds bottle at 8 months Drinks from cup at 18 months

Personal-Social Social smile at 2-3 months Waves bye bye at 9 months Plays with other children at 18 months


Language: Babbles at 8 months First word: mama at 1 yr old Obeys simple commands at 12 months Says “mama” and “dada” discriminately at 14

months

DEVELOPMENTAL MILESTONES

GROSS MOTOR: can walk, run, and jump without difficulty

FINE MOTOR: can write using his fist and consistently writes with right hand. Can write in scribbles.

PERSONAL-SOCIAL: can initiate play with other kids. Can imitate adult activities and can do pretend play

LANGUAGE: speech is 25% intelligible; cannot combine 2 words in a sentence; speaks in jargons; can say few words, with articulation difficultiesFollows 2 step commands; turns when name is called; (+)protoimperative and proteodeclarative pointing

SELF HELP: can communicate toileting needs; eats with a spoon; can remove some shoes and shorts, needs help with shirt; can wear shorts

Physical Examination

Awake, Not in DistressAfebrile; HR 94 RR 20 WT 14 kg (zscore: 0-2) Ht 92 cm (zscore: 0-2) Pink palpebral conjunctiva, Anicteric scleraeMoist lips and buccal mucosa; No tonsillopharyngeal congestion, No cervical lymphadenopathyNo retractions, good air entry, Clear breath soundsAdynamic precordium, AB 4th LICS MCL, No murmursNondistended abdomen, normoactive bowel sounds, non-tender, no organomegalyFull and equal pulses

Neurologic Exam

GCS 15, alert, awakeCranial nerves intactMotor:5/5 in all extremitiesSensory: withdraws to touch and painReflexes: normoreflexive (-) Babinski, (-) ClonusNo signs of meningeal irritation

M-CHAT

PEDS – Path B (1 predictive concern: Expressive Language and articulation

MCHAT – PASS Brigance – FAIL ( Total Score: 68/100;

Delay Cutoff Score: <72 Advance Cutoff score: >83)

Brigance Self-help- below Average Brigance Social Emotional - Average

IMPRESSION

t/c Language Delay

Language Delay

No universally accepted definition of “language delay” in developmental conditions.

“Delay”- Catch up will occur Approximately 60% will catch up by 4

years of age

American Academy of Pediatrics, Developmental and Behavioral Pediatrics

R.G. Voigt, M.D. 2011

Language Disorder

Specific Language Impairment (SLI): impairment in the ability to understand and/or use words in context, both verbally and nonverbally



Language Disorder

Receptive Disorders Expressive Disorders Mixed Receptive and Expressive



Red Flags for Delayed Language DevelopmentAGE MILESTONE

6 months No cooing responsively

10 months No babbling

12 months No basic gesturing like waving bye-bye

18 months No words other than mama, dadaNo pointing to what he wants

24 months <50 wordsNo 2-word phrases

36 months No 3-word sentences<75 % intelligibilityAmerican Academy of Pediatrics, Developmental and Behavioral

PediatricsR.G. Voigt, M.D. 2011

Causes of Language Delay

Auditory(Hearing loss) Mental Retardation Autism Spectrum Disorder Learning Disorder

Hearing Loss Can have a devastating impact on language,

social, and learning abilities if not detected Delayed development of speech is a universal

symptom of hearing impairment Hearing testing- Auditory Brainstem Response

Testing



Mental Retardation Intellectual disability A disability characterized by significant

limitations in both intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills



Autism Spectrum Disorder ASDs are a heterogenous group of

neurodevelopmental disorders without an identified unifying pathological or neurobiological etiology.

Can cause severe and pervasive impairment in thinking, feeling, language, and ability to relate to others



Identification and Evaluation of Children With Autism Spectrum Disorders

C.P.Johnson, et.al. PEDIATRICS Volume 120, Number 5, November 2007

Autism Spectrum Disorder severe social skills deficits and

restricted, repetitive, and stereotyped patterns of behavior, interests, and activities are core features of all ASDs

significant language delays are characteristic of only AD and PDD-NOS.

Learning Disorders DSM-IV-TR states that learning disorders

are diagnosed “when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence”.



Plans

Referral to a Developmental Pediatrician

For hearing testing Language enhancement exercises at

home Observe closely his learning,

development, and behavior

THANK YOU!

anna catalina aniag-dimalanta, md. to present a case of 31 month old male patient with speech delay...

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