Identifying and managing common childhood language and speech impairments

7th June 2015

Dear Sir

We very much enjoyed the excellent review by Reilly et al. on the identification and management of common childhood language and speech impairments.[1]

Although structural speech disorders were not the subject of this review, might we make an appeal that when assessing children with speech impairment, a routine element of that assessment should include visual examination of the hard and soft palate?[2]

An overt soft palate cleft or submucous cleft palate are both associated with a degree of bifidity of the uvula; being familiar with ‘normal’ palatal anatomy will enable the clinician to more readily identify ‘abnormal’ anatomy when it presents. Some degree of uvula clefting is seen in approximately 2% of school children, although only 0.3% will have an entirely bifid uvula (Figure 1).[3] If there is a suspicion that an underlying structural deficit is contributing to the speech disorder then referral to a specialist cleft lip & palate unit is advocated. Delayed diagnosis of palatal clefts is more likely to result in the development of Persistent Speech Disorder that is associated with poorer outcomes in education and employment.[4] Increasingly we are finding that a ‘missed’ diagnosis may have medicolegal implications.[5]

Therefore if you are in any doubt as to whether a bifid uvula may be contributing to a child’s speech impairment, an expeditious referral to a specialist cleft centre is warranted.

Yours faithfully

Mr. Marc C. Swan DPhil FRCS (Plast)
Consultant Plastic & Cleft Surgeon
Spires Cleft Centre, Oxford University Hospitals NHS Trust

Ms. Carrie Luscombe MSc
Principal Speech & Language Therapist
Spires Cleft Centre, Oxford University Hospitals NHS Trust

Mr. Timothy E. E. Goodacre FRCS
Consultant Plastic & Cleft Surgeon
Spires Cleft Centre, Oxford University Hospitals NHS Trust

References:

1. Reilly S, McKean C, Morgan A, et al. Identifying and managing common childhood language and speech impairments. Bmj 2015;350:h2318 doi: 10.1136/bmj.h2318[published Online First: Epub Date].
2. Stengelhofen J. Working with cleft palate. Bicester: Winslow, 1990.
3. Wharton P, Mowrer DE. Prevalence of cleft uvula among school children in kindergarten through grade five. Cleft Palate Craniofac J 1992;29(1):10-2; discussion 13-4 doi: 10.1597/1545-1569(1992)029<0010:POCUAS>2.3.CO;2[published Online First: Epub Date].
4. Felsenfeld S, Broen PA, McGue M. A 28-year follow-up of adults with a history of moderate phonological disorder: educational and occupational results. Journal of speech and hearing research 1994;37(6):1341-53
5. Swan MC, Pancewicz N, Sell D, Pinkstone M, Thorburn G, Morris P, Sommerlad BC, Kangesu L. The impact of late cleft palate repair on speech development: a retrospective analysis of 39 consecutive cases over a 20 year period. Presented at the Annual Scientific Meeting of the Craniofacial Society of Great Britain & Ireland 7th April 2014.