A Two-Year-Old Who Is Not Talking
A 24-month-old boy is brought to the anganwadi worker by his mother. He says about three words clearly and does not point to show things. When his name is called, he sometimes looks up and sometimes does not. He has had no hearing test. He spends about four hours a day in front of a television while his grandmother cooks and cleans; the television is kept loud. His parents both work as daily-wage labourers and return after dark. The grandmother feeds him while the television is on, and he eats only soft rice and dal. He was breastfed until 18 months but has not had a growth check in a year. The mother says, 'His father also spoke late, so we are waiting.' The family has no idea that a hearing assessment can be done free of cost at the district hospital.
1. Identify the developmental red flags in this history and explain why 'waiting' is not the safest plan.
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At 24 months, a child should use far more than three words, should point to show interest, should respond to his name consistently, and should be starting to join words. Three words, infrequent response to name, and no pointing are red flags for hearing loss, language delay, or a broader developmental concern. The loud television and long screen time reduce the chances for back-and-forth talk, but they do not explain away the red flags. A family history of late talking is not a reason to wait, because hearing problems and developmental delays can also run in families, and early help is more effective than late help. Waiting risks missing the period when language and social skills develop fastest. The child needs a hearing test and a developmental assessment, not a diagnosis from the anganwadi worker. The message to the mother should be calm and practical: 'We are not saying something is definitely wrong; we are saying it must be checked now.'
2. What practical home stimulation and feeding changes would you suggest while the referral is being arranged?
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Reduce television to no more than a short, supervised programme, and turn it off during meals and play. The grandmother should talk to the boy while cooking, name vegetables and utensils, and respond to his sounds and gestures. Reading a picture book and singing action songs for 10–15 minutes several times a day are more useful than long videos. Give him chances to ask: place a favourite food slightly out of reach and wait for him to point or vocalise. At meals, offer mashed but textured foods, not only soft rice and dal, and add a source of iron such as well-mashed dal, egg, or green leafy vegetables. Continue breastfeeding only if the mother wishes; at this age food must be the main source of energy and iron. Get a growth check and ask about deworming and iron supplementation according to the local programme. These steps support development but do not replace the hearing test and assessment.
3. How should the worker explain the referral without alarming the family, and what should be checked at the district hospital?
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The worker should first acknowledge the mother's care and the family's hard work, then say clearly that all children should have their hearing checked if they are not talking much by two years. Use a simple comparison: just as the family checks the child's eyes or weight, the ears and development also need a check. Explain that a free hearing test is available and that finding a problem early makes a big difference. Give a written slip with the date, place, and person to meet, and help with transport or a referral card if possible. At the hospital, the child should have a hearing assessment, an ear examination, a developmental assessment, a growth check including weight and height, and a nutrition review. The family should be told that the test does not mean the child is 'mad' or 'abnormal'; it is a routine check that many children need. A follow-up date should be fixed before they leave.