speech delay in toddler - Nursing Case Study

Pathophysiology

• Primary mechanism: Neurological - Brain maturation or injury can impact speech development. Neurological disorders like cerebral palsy or muscular dystrophy affect muscle tone and coordination required for speech, while others like autism spectrum disorder can affect comprehension, expression, and social use of language.

• Secondary mechanism: Hearing loss - Chronic otitis media or congenital hearing loss can hinder speech development. Lack of auditory input can lead to delayed speech or language skills as auditory feedback is essential for the child to learn and correct their speech.

• Key complication: Psychosocial impact - Chronic speech delay can lead to frustration, social withdrawal, and self-esteem issues in toddlers. It may also impact their academic performance as they age, leading to secondary emotional and behavioral difficulties.

Patient Profile

Demographics:

3 years old, male, not applicable for occupation

History:

• Key past medical history: Frequent ear infections, premature birth at 32 weeks with a low birth weight, diagnosed with Autism Spectrum Disorder at 2.5 years old.

• Current medications: No current medications

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Significant speech delay, unable to communicate verbally beyond a few simple words

• Key symptoms: Limited vocabulary, difficulty combining words into sentences, frustration due to inability to communicate, lack of social interaction, repetitive behaviors, difficulty with changes to routine, and occasional tantrums. Also, frequent ear infections which may contribute to hearing problems impacting speech development.

• Vital signs: Temperature: 99°F, Pulse: 132 bpm (elevated), Respiratory rate: 26 breaths per minute (elevated), Blood Pressure: 105/70 mmHg, Oxygen Saturation: 96%

Section 1

Change in patient status:

Over the course of the next few weeks, the toddler's behavior noticeably changed. His tantrums became more frequent and violent, often triggered by minor changes in routine or inability to express his needs. His frustration was evident in these episodes, often leading to self-harming behaviors such as banging his head against the wall or biting his own hands. The child also showed signs of regression in his previously acquired skills. For instance, he stopped using the few words he knew and relied more on non-verbal forms of communication such as pointing or tugging.

The toddler also started exhibiting signs of sensory sensitivities. He was often overwhelmed by loud noises, leading to excessive crying and heightened anxiety. He also developed a strong aversion to certain textures of food and clothing, refusing to eat or wear anything that he found uncomfortable. His parents reported that he had a reduced appetite and was losing weight. His vitals showed a slight increase in temperature to 99.8°F, pulse of 140 bpm, and respiratory rate of 28 breaths per minute. His weight decreased by 2 pounds within a month, which is concerning for a child of his age and developmental stage.

These changes in the child's behavior and physical health indicate an exacerbation of his Autism Spectrum Disorder symptoms, coupled with potential sensory processing difficulties. It also raises concerns about his nutritional status and overall physical health. The need for a comprehensive neurodevelopmental assessment and sensory profile has become more urgent to guide the next steps in his care and management.

Section 2

Change in Patient Status:

In the following days, the toddler's condition continued to deteriorate. He began showing increased signs of fatigue, with no improvement in his appetite or weight. His tantrums escalated to a point where he would injure himself, leading to minor bruises and cuts. His sleep pattern also changed significantly; he had difficulty falling asleep, often waking up multiple times throughout the night, resulting in increased irritability and heightened anxiety levels during the day. His temperature spiked to 100.2°F, pulse increased to 155 bpm, and his respiratory rate escalated to 35 breaths per minute. The toddler's weight continued to decrease, losing another pound within a week.

The parents reported a new behavior of the toddler repetitively arranging his toys in a certain pattern and becoming highly agitated if the pattern was disrupted. He also displayed a fixation on certain objects, refusing to let them out of his sight. Additionally, he exhibited a new aversion to light, squinting or closing his eyes in bright environments. These behaviors, combined with his increased physical symptoms, indicate a significant exacerbation of his condition. These symptoms suggest that the toddler's Autism Spectrum Disorder and sensory processing difficulties have intensified, necessitating a re-evaluation of his current management plan. The child's deteriorating physical condition also implies possible underlying health issues that need immediate attention.

Section 3

Response to Interventions:

On re-evaluation, the toddler's pediatrician adjusted his management plan to include intensive behavioral therapy and a trial of pharmacological intervention. A selective serotonin reuptake inhibitor (SSRI) was introduced to manage his anxiety and repetitive behaviors. However, after a week, the toddler showed increased restlessness, irritability, and his self-injurious behavior escalated. His vitals remained unstable with a persistent fever of 100.4°F, pulse of 160 bpm, and an increased respiratory rate of 38 breaths per minute. His weight loss continued, with a further loss of half a pound.

Dietary interventions were also implemented, introducing high-calorie and nutrient-rich foods. However, the toddler showed increased resistance, leading to episodes of choking and aspiration, resulting in a cough and increased respiratory rate. Upon auscultation, crackles were noted in the lower lobes of both lungs, suggesting possible aspiration pneumonia. His oxygen saturation levels dropped to 92% on room air, indicating decreased oxygen supply. The toddler's worsening condition, despite the interventions, raised concerns for a more complex, underlying medical issue. It is clear that the toddler's situation requires a more comprehensive diagnostic evaluation to guide further management and interventions.

Section 4

Change in Patient Status:

Over the next several days, the toddler's condition worsened. He became increasingly lethargic and his level of consciousness decreased, becoming less responsive to stimuli. His vitals continued to fluctuate, with a persistent fever that spiked to 102.7°F, and his pulse increased to a concerning 178 bpm. His respiratory rate also increased to 44 breaths per minute, with a decreased oxygen saturation level of 88% on room air, despite supplemental oxygen. The toddler's decreased oral intake and continued weight loss of an additional pound raised alarms for potential malnutrition, further compromising his immune system.

New Diagnostic Results:

The pediatrician ordered a broad diagnostic panel, considering the complexity of the toddler's symptoms. A comprehensive metabolic panel revealed hypokalemia (potassium level of 2.8 mEq/L) and hyponatremia (sodium level of 125 mEq/L), potentially indicative of malnutrition. Further, a complete blood count reported a high white blood cell count of 18,000/mm3, suggestive of an ongoing infection, possibly aspiration pneumonia. A chest X-ray confirmed the suspicion of aspiration pneumonia with bilateral infiltrates. Genetic testing was also performed, revealing a mutation in the SHANK3 gene associated with Phelan-McDermid syndrome, a condition known to cause global developmental delay, including speech delay. The toddler's worsening condition and the new diagnostic findings highlighted the need for a redirection in management and intervention strategies.

Section 5

Response to Interventions:

Despite the intravenous administration of antibiotics for the aspiration pneumonia and the implementation of a high calorie, nutrient-dense diet to combat malnutrition, the toddler's status continued to deteriorate. His lethargy persisted and he developed a decreased level of consciousness. His Glasgow Coma Scale score dropped to 8, indicating a severe decrease in neurological function, and his Pediatric Early Warning Score (PEWS) increased from 4 to 7 over the course of 48 hours. The toddler's vitals remained unstable; the fever persisted at 102.3°F, his pulse had escalated to 185 bpm, and his respiratory rate was now 54 breaths per minute. His oxygen saturation levels continued to drop, now at 85%, even with high flow nasal cannula at 6 L/min.

The toddler's clinical picture was further complicated by the onset of seizures, likely associated with the SHANK3 gene mutation and Phelan-McDermid syndrome. The seizures were generalized tonic-clonic in nature, lasting for approximately 2 minutes at a time, and were occurring with increasing frequency. Despite administration of first-line antiepileptic drugs, such as levetiracetam, the seizures remained uncontrolled. Furthermore, the toddler's electrolyte imbalances, particularly the hypokalemia, were resistant to correction with IV potassium chloride, raising concerns for possible renal tubular dysfunction. These new developments emphasized the need for a multidisciplinary approach to the toddler's care, involving pediatric neurology and nephrology teams.