Your child is a real go-getter; maybe they’re a straight-A student or a star athlete. Lately, though, they have trouble breathing during very inopportune times, like before a test or a big track meet. You have seen their primary care doctor and you have seen a pulmonologist. Maybe they are put on an inhaler, but it doesn’t seem to be working like you hoped. So what’s going on?

Have you heard of vocal cord dysfunction? Well, there is a new name for it: exercise-induced laryngeal obstruction (EILO) and inducible laryngeal obstruction (ILO). That’s a mouthful.

Whenever there’s a “trigger” (i.e. exercise, stress, certain odors), the vocal cords narrow and it feels like you can’t get a good breath in no matter what you try to do. It isn’t life-threatening because your vocal cords are actually still open, but they aren’t open enough to fill your lungs. It’s scary. Your child is panicking and now you are, too.

What are the symptoms of EILO/ILO?

• Chest/throat tightness
• Difficulty inhaling
• Noisy breathing
• Shortness of breath

That sounds an awful lot like asthma, doesn’t it? You’re right; EILO/ILO and asthma sound very similar, but there are a few differences. Let’s compare the two:

You have ruled out asthma with your physicians and ruled in EILO/ILO. 

What do we know about EILO/ILO?

Onset can occur at any age, but most commonly, EILO and ILO are diagnosed in 12 to 18-year-olds.

It is most prevalent in our young athlete population and it can lead to anxiety about playing sports because of the fear of not being able to breathe. The same thing can happen around stressful situations like an upcoming AP history test or a choir performance.

Speech Therapy

What can be done to help these kids get back into their sports, extracurriculars, and high-demand classes? Speech therapy and/or physical therapy is the answer! And it’s all about breath.

With speech therapy, we look at how the child is breathing and teach them a variety of strategies to make their breathing more efficient.

We work on rescue breathing techniques that will blow the airway open during an active EILO/ILO episode as well as preventative breathing strategies that will keep the airway open during exercise or stressful activities. We also focus on diaphragmatic breathing or belly breathing, so the child can optimize the amount of air they are getting into their lungs at rest and during physical activity.

With physical therapy, we can look at the athlete’s movement patterns, posture, endurance, and strength that may be impacting their breathing. Oftentimes, stiffness or weakness through the trunk and core changes a person’s breathing pattern, causing them to have difficulty controlling their breath (especially during high-intensity activities).

This can lead to increased fatigue, tension around the neck and/or shoulders, and EILO symptoms. Another area of focus is cardiovascular endurance training to avoid the feeling of “hitting a wall” during exercise.

Through guided exercises, improvements can be achieved by reducing compensations or our body’s way of cheating through movements, training the proper muscle groups, and supporting proper muscle use and form during athletic movements.

What is the common goal? To give the child the skills they need to get back to the activities they love. If your child is experiencing any of these symptoms, reach out to their primary physician to discuss a potential referral to an ENT (otolaryngologist) or pulmonologist for further diagnostic testing.

All children learn to babble and talk at different times. Before you know it, they can read their favorite book or tell you what they want for their birthday. But, when they can't tell you what they want to eat for breakfast or the daycare teacher can't understand what they say, parents need somewhere to turn.

At Cook Children's Rehabilitation Services, our speech language pathologists (SLPs) are highly skilled and experienced in children's communication development. They work with parents to help empower their children to achieve their goals.

We have about 40 SLPs who serve our patients in our medical center and outpatient clinics. They have expertise in:

• Feeding/dysphagia
• Speech/language skills
• Augmentative and alternative communication
• Hearing loss
• Autism
• Traumatic brain injury and so much more!

As we celebrate Better Speech and Hearing Month this May, Jonathan Suarez, Rehabilitation Services clinic lead, and Suzanne Bonifert, Rehabilitation Services manager, provide answers to commonly asked questions about speech and hearing.

What can I do to get my child to speak more?

Model words for your child, even if he/she doesn’t repeat them. For example, if he/she vocalizes and points to juice, you can say, “juice” or “you want juice.” That way the child is hearing the words even though he/she cannot say them yet.

It’s also good to use comments (i.e. “You want juice.”), rather than questions (i.e. “What do you want?”). Doing so can be less stressful for kids, especially those having some challenges learning to talk.

We also recommend talking to your pediatrician about a referral to see a SLP for an evaluation. The SLP can help you identify your child’s strengths and challenges and may recommend therapy to help give your child a boost!

Is it OK to speak more than one language to my child throughout the day?

Yes, yes and yes! Every child is different and the amount of time they spend using each language can vary, depending on exposure in school, at home or during extracurricular activities.

Sometimes a child may understand multiple languages but will only use one. Keep practicing each language!

Some children may “code switch,” or use both languages when they speak. This is not a disorder. The child is learning how to use the rules of both languages.

How do I know when to be concerned about my child’s communication or when to see a speech therapist?

By the time your child is 12 months old, he/she should be able to speak two to three words. By the time he/she is 2 years old, he/she should be able to speak at least 200 words. By age 3, he/she should be able to speak 900 words.

Trust your gut. If you feel there is a concern, you can ask your pediatrician for a speech therapy referral and have your child evaluated.

Once the evaluation is complete, an SLP can provide information to help with your child’s communication.

Here are links to two helpful speech and language milestone charts:

• Speech and Language Milestone Chart, LD Online
• Speech and Language Developmental Milestones, National Institute on Deafness and Other Communication Disorders

Is there something I could have done as a parent to prevent my child’s speech delay?

No. We often hear parents say, “We never had to worry about my older children talking.” But there is nothing you could have done to prevent your child’s speech delay. In most cases, there are steps you can take now to help your child’s language skills grow.

Since your child has a language delay, we need to be intentional in the language we are using with them.

How long will my child need to be in speech therapy to gain the skills they need to communicate?

Progress can vary from child to child. Our goal is to improve the child’s language while also teaching the parent or caregiver some interaction and language strategies to elicit communication.

What can a speech therapist do with a toddler who cannot sit still?

We can teach language in a variety of ways! Activities involving movement are great for keeping children interested. Sometimes, children are having so much fun that they do not realize they are actually doing a language activity!

Instead of sitting at a table for activities, you could:

• Stand up and sing songs using motions and actions
• Play hide-and-seek
• Play chase while running, jumping or skipping
• Read a book while acting each part out

To learn more about the Cook Children’s speech therapy program, please visit our website. 

Communication is the foundation for building relationships and the process of going back and forth between people. If you can’t play with others nicely, make and keep a friend, or understand directions from adults, it will be difficult to interact with others. Those skills begin forming very early with that beautiful smile, adorable laugh and silly babble as infants.

Every child develops communication skills at their own pace. How do you know if they are on target or if they need to see a specialist? We want to make sure your child has developed some of these skills by certain ages. Here are some guidelines on what your child should be doing by 12, 24 and 36 months of age…

If your child isn’t doing some of these things by these ages, don’t despair! Here are a few things you can be sure to try with your growing toddler…

• Imitate your baby’s communication, even if it is just a smile or coo. Adult conversation is all about turn-taking so teach this skill as early as possible!
• Play with sounds. Blow raspberries, cluck like a chicken, make fishy faces, and have fun doing it! This will help increase their awareness and their ability to make sounds.
• Talk about everything and give things a name! When bathing, feeding, and changing their diapers, talk about what you are doing. You might feel silly, but they are definitely listening!
• When your child makes an attempt at communicating, give them big praise, repeat what they said, and then expand it to a bigger phrase. (Example: “A car? Yes! That IS a car! Good job! Hi, car! Go, car, go!”)

You may feel as though your child just isn’t getting it. You may be right. It may take a higher level of intervention to get your child’s communication skills rolling. Speak with your pediatrician about a speech and language evaluation with your friendly speech-language pathologist. We’re happy to help!

About the author

Melanie Van Noy is a speech pathologist at Cook Children's.Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.

She is obviously looking for some sort of action on my part other than my smiling and nodding affirmatively. Since she’s my number one girl, I’ve learned the idiosyncrasies of her developing speech and know exactly how to handle this request. But to the layperson (or even Daddy or Grammy), I’m fairly certain I would need to come to the rescue with my toddler translator skills.

Mamas, I know you’ve been there. Your 3 year old launches into a monologue you find equal parts incomprehensible and adorable. Adorable, that is, until the tantrums and frantic attempts to understand and obey her demands kick in. In my practice, I have observed some masterful decoding mamas and some skillfully adaptive little ones navigating the waters of communication breakdown. Let’s talk a little bit about speech sound development and when to fret.

Articulation is the movement of the tongue, lips, soft palate and jaw to make speech sounds. It’s also the driving force behind your toddler’s incomprehensible speech. As parents, we are so excited when our little bundles of joy begin talking, but oftentimes, that excitement is quickly replaced with frustration when we realize we can’t understand a lick of what they’re saying.

An articulation disorder occurs when a child has difficulty forming speech sounds, most likely due to a structural or motor-based deficit. Most children tend to have some difficulty with certain speech sounds. Because creating sounds is challenging, he may substitute easy sounds for tough ones (think dumb for thumb), delete sounds (ha for hat), or distort problematic sounds (this is most often noted when children have a “slushy” quality). An articulation disorder occurs if these substitutions continue past the expected age.

Are all sounds created equal? In short, no. Children master sounds gradually. Most children can pronounce all of the speech sounds of English correctly by age 8. While each child’s speech sound acquisition is different, the following are age ranges in which most children master certain sounds:

• Introducing the “early birds”: Most wee ones will use m, n, y, b, w, d, p and h correctly between 18-30 months. That may explain why mama, dada and ball are frequently reported as first words.
• Not to be outdone, the middle of the road sounds includes: t, ng, k, g, f, v, ch and j. You may hear your little one utter these sound appropriately as early as 2 or as late as 6 years of age.
• Finally, the late bloomers include: sh, zh, r, s, z and th. This final pack of sounds contains the frequent offenders when it comes to articulation disorders. They are challenging for children to master and can wreak serious havoc on the clarity of their speech. We expect children to master these sounds between the ages of 3-8. (Based on Shriberg, 1993)

As children get older and learn new speech sounds, they gradually become easier to understand by a wider variety of listeners. Developing clear speech is a journey for our littles, albeit a frustrating one at times. And like all journeys, no two are equal. Some children are clear as a bell by their second birthday while others need a bit more time. As parents, we typically understand our babes before the rest of the world and therefore, are awarded the esteemed role of toddler translator. In many situations, one parent has a better handle on their child’s speech sound system than the other. But, as a general rule of thumb (or rule of “fum” if you happen to be a toddler):

• By 2 years of age children can be understood by familiar adults most of the time.

• By 3 years of age children can be understood by unfamiliar adults most of the time.

• By 4 years of age children can be understood by unfamiliar adults almost all of the time.

• By 5 years of age children can be understood by unfamiliar adults all of the time.

(Based on Flipsen Jr, 2006)

Although a continuum exists when it comes to speech sound development, there are a few red flags to be mindful of when chatting with your child.

It may be time to check in with your pediatrician regarding an evaluation with a speech language pathologist if your child:

• Uses only vowel sounds and a few consonants or shows limited babbling at 18 months.
• Seems to have a “slushy” (think mouth full of marbles) quality to his speech.
• Is difficult to understand and has a history of frequent ear infections.
• Leaves off the beginning or ending sounds of words (hatàha).
• Leaves off entire syllables of words (pa for purple).
• Is not understood by people outside his immediate family by age 3.
• Seems to be frustrated by his difficulty with speech or appears hesitant to interact or respond to peers or adults.

So what can you do to help him along?

Above all, it is important to always show your child you value WHAT he is saying regardless of HOW he is saying it. Always reinforce his attempts at striking up conversation with you! When you hear one of those adorable substitutions, help him to learn by repeating it correctly (If he says “tar” you can say “yes! A car!”) and moving on with the flow of conversation. Play face to face with him so he can watch the way your mouth moves to make sounds. Emphasize beginning and ending sounds in your own speech so he can hear them and begin to realize they are part of the word, too. If all else fails, ask him to SHOW you what he needs. And take comfort in the knowledge that this process is a gradual one.

Oh, and my daughter? She wanted to watch Frozen on the big T.V. and relax a little bit. Obviously.

1. Shriberg, L.D. (1993). Four new speech and prosody-voice measures for genetics research and other studies in developmental phonological disorders. Journal of Speech and Hearing Research, (36), 105-140.

2. Flipsen, P., Jr (2006). Measuring the speech intelligibility of conversational speech in children. Clinical Linguistics and Phonetics, (20) 4, 303-312.

3. http://www.asha.org/public/speech/disorders/SpeechSoundDisorders/

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

We love to hear the first sweet sounds from newborn babies when we feed them and cuddle with them. Then they quickly progress to happy babbling and, at last, WORDS! All within a fast moving, short 12 months. Somewhere between the ages of 3 and 4 years old, a parent may say, “My child has so many words; I couldn’t possibly count them!” Then, babies progress to speaking sentences, having conversations, and using their words for imaginative play. Of course, there are also the fun word skills they learn when they enter the amazing world of reading.

This describes typical, fantastical language development ... BUT what if things are not typical? What if there are concerns? What can the parent expect? When should a parent seek help and from whom?

Some concerns may include:

1. Little or no babbling. Well-formed babbling should be in place by 10 months of age at the latest. Vowel sounds, e.g., ah, oo, ee, etc., are used first, and then they will start pairing consonants with vowels to make syllables like, “ba-ba-ba-go-da-tee” and more.

2. Slow in saying first words (after 12 months)

3. Vocabulary count is low. (See my previous blog on Is my child's speech 'normal?' )

4. Significant drooling beyond 18 months of age.

5. Difficulty understanding what your child says or you are one of the few people that can understand what he or she says.

6. Not speaking in 2 -3 word combinations by 24 months of age, e.g, “I fishing;” “My toys;” etc.

7. Child acts frustrated by difficulties with his or her own communication skills.

8. Child overuses gestures to communicate his or her wants and needs.

9. Poor eye gaze to the speaker’s face.

10. Lack of variety of play skills.

11. Lack of interest in engaging others in play.

Who can help a parent sort out these concerns?

Talk with your pediatrician and ask for referral to a speech/language pathologist for an evaluation if you have concerns. A speech-language pathologist (SLP) is educated and trained to evaluate and treat communication problems from birth through to adulthood. A speech/language evaluation will identify your child’s communication strengths and challenges, and a plan of care will be recommended, if necessary. You, as the parent, will want to see a SLP who is experienced with children.

Speech/language therapy can be provided in a number of different settings - therapy provided in a clinic setting is primarily on an individual basis: one child – one therapist. Therapy provided in the public schools is typically in a group setting. Different settings and models of care can be selected based on your child’s and family’s needs. Participating with your child in therapy is an important part of care and will help maximize your child’s progress.

We all want our children to develop skills with ease. Remember, when that development is on a continuum and there is a range of typical development. However, if there is a concern, ask your doctor for a referral to see an SLP. By identifying potential challenges early and obtaining intervention such as speech/language therapy, the outlook is definitely brighter. Early identification and intervention are key.

For more information:

• Cook Children's speech therapy
• Is my child's speech 'normal?'
•  http://www.cdc.gov/ncbddd/childdevelopment/screening.html
• http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/developmentalscreening.pdf
• http://www.cdc.gov/ncbddd/childdevelopment/freematerials.html - Positive Parenting tips based on child’s age.
• http://www.asha.org