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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Speech, language and hearing assessment

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Acute loss or disruption of communication

Sudden slurred, absent or disordered speech can reflect stroke, seizure, encephalitis, intoxication, metabolic disturbance or airway and bulbar disease rather than developmental delay.

Action: Use ABCDE, check glucose and obtain an exact onset and last-known-well time. New dysarthria, aphasia, facial asymmetry, weakness, ataxia, altered consciousness or severe headache needs immediate paediatric neurological and emergency imaging assessment; follow the local paediatric stroke or seizure pathway where relevant. Drooling with inability to swallow, stridor, choking or aspiration requires urgent airway and feeding-safety management. Treat suspected meningitis, encephalitis, poisoning or hypoglycaemia promptly. Do not send an acutely changed child to a routine speech-and-language waiting list.

Synopsis

Distinguish speech, language, communication, fluency, voice and hearing concerns, identify urgent neurological or safeguarding presentations, select age-appropriate audiology and speech-language assessment, and coordinate early support without waiting for diagnostic certainty.

  • Define the concern: speech is sound production, language is understanding and formulation, pragmatic communication is social use, fluency is flow, and voice is quality or resonance.
  • Assess receptive language separately from expressive language; a child who speaks little may understand well, while fluent speech can conceal poor comprehension.
  • A passed newborn hearing screen does not exclude unilateral, mild, acquired, fluctuating, progressive or auditory-neuropathy-spectrum hearing loss.
  • First-line assessment combines developmental and communication history, multi-setting observation, ear and oral examination, formal audiology and speech-and-language therapist assessment when indicated.
  • Choose hearing tests by developmental ability, not age alone: visual reinforcement audiometry for many infants, play audiometry for preschool children and pure-tone audiometry for cooperative older children.
  • Otoacoustic emissions test cochlear outer-hair-cell function; automated auditory brainstem response tests neural pathway activity; neither alone describes everyday functional hearing.
  • Tympanometry assesses middle-ear mechanics and supports diagnosis of effusion but is not a hearing-threshold test.
  • For suspected otitis media with effusion, NICE formal assessment includes otoscopy, hearing testing and tympanometry.
  • Reassess bilateral OME with hearing loss after 3 months; intervene earlier when hearing difficulty significantly affects daily living, communication or development.
  • Bilingual or multilingual exposure does not cause language disorder. Assess every language with trained interpreters and culturally appropriate methods.
  • Refer early and provide communication support while assessment proceeds; augmentative and alternative communication supports language and does not prevent speech development.
  • Treat the functional access problem: improve hearing, interaction, education, environment and communication rather than chasing a single test score.

Key red flags

Loss of previously established words, comprehension, social communication or motor skill is developmental regression and requires prompt paediatric or neurological assessment.

Sudden speech change, dysarthria, facial weakness, ataxia, seizures or altered awareness requires emergency assessment rather than developmental surveillance.

No response to sound, marked asymmetry, progressive hearing difficulty, persistent unilateral tinnitus or vestibular symptoms needs formal audiology and cause-specific review.

Persistent or recurrent otorrhoea, mastoid tenderness, post-auricular swelling, systemic illness or facial weakness requires urgent ENT or paediatric assessment.

Coughing, choking, wet voice, recurrent chest infection, prolonged meals or weight faltering suggests unsafe swallowing and needs prompt feeding and aspiration assessment.

No babble or communicative gesture around 12 months, no meaningful words by about 18 months or no spontaneous two-word phrases by about 24 months is a prompt for assessment, not a threshold for passive waiting.

Poor shared attention, reduced response to name, repetitive behaviour or rigid sensory patterns requires wider developmental and autism-focused assessment as well as hearing evaluation.

Investigation priorities

01
First-line: integrated developmental and communication historyFirst stepFirst line

Define domain, onset, trajectory, regression, languages, functional impact, hearing and medical context across settings.

02
Reference standard: comprehensive audiological assessmentReference standard

Estimate ear-specific hearing thresholds and type of loss using developmentally appropriate behavioural and objective measures.

Management branches

Initial assessmentDefine domain and urgency

A child is not communicating as expected or hearing is questioned.

  1. Determine whether change is acute or regressive and assess swallowing, neurological, infectious, ENT and safeguarding red flags.
  2. Take a multi-language developmental and medical history, observe spontaneous communication and examine ears, mouth, growth and neurology as indicated.
  3. Arrange formal audiology and SLT or wider developmental referral according to the pattern while starting practical communication support.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG127 suspected neurological conditions in childrenUK urgency and referral recommendations for speech change, regression, hearing concerns and related neurological features.
  • UK newborn hearing screening programme operational guidanceCurrent national screening pathway and limitations of newborn screening.
  • NICE NG233 otitis media with effusionFormal assessment, 3-month reassessment, hearing support and treatment recommendations.
  • NHS newborn hearing testParent-facing UK explanation of the screen, methods and follow-up.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

Injury patterns, sexualised language, fear, neglect, family concern or communication barriers increasing vulnerability must trigger safeguarding enquiry and accessible disclosure support.