SciELO - Scientific Electronic Library Online

vol.10 issue1Audiological findings in a group of neurologically compromised children: A retrospective studyHaemophilia: A disease of women as well author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand



Related links

  • On index processCited by Google
  • On index processSimilars in Google


South African Journal of Child Health

On-line version ISSN 1999-7671
Print version ISSN 1994-3032

S. Afr. j. child health vol.10 n.1 Pretoria Jan./Mar. 2016 



Risks for communication delays and disorders in infants in an urban primary healthcare clinic



D ClaassenI; J PieterseI; J van der LindeII; E KrugerII; B VinckIII

IBComm Path; Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
IIMComm Path; Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
IIIPhD; Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa





BACKGROUND: Many risk factors may result in a communication delay. Reliable identification methods are essential to identify infants at risk of communication difficulties in the primary healthcare context. Literature on identifying both at-risk and established risk factors associated with communication disorders in South Africa is limited.
OBJECTIVE: To identify and describe risk factors for communication delays in infants 0 - 12 months of age at Daspoort Polyclinic in Gauteng.
METHODS: A structured interview schedule was utilised to conduct an interview with the caregiver participants. Convenience sampling was used to select 96 caregiver participants.
RESULTS: The results obtained indicated that all infant participants presented with exposure to one or more risk factors that may possibly impact communication development. High frequencies of risk factors included colds and/or flu during pregnancy, previous miscarriages, maternal smoking, low educational levels and unemployment.
CONCLUSION: The high frequency of at-risk conditions within the Daspoort population justifies the importance of implementation of early communication intervention services in primary healthcare



Developmental disorders in infants and toddlers burden the family and society by causing illiteracy, unemployment and low in-come.[1] Communication delays and disorders can be prevented if risks are identified early.[2,3] Established risk factors include genetic, neurological and sensory disorders and severe toxic exposure that may result in conditions such as fetal alcohol spectrum disorder (FASD).[4,5] South Africa (SA) has a higher prevalence of FASD and HIV/AIDS than other countries in the world.[6,7]

The identification of established risk factors for communication delays at birth can ensure that at-risk infants are monitored and integrated into effective early communication intervention programmes.[8] However, infants with established risks within the primary healthcare (PHC) context of SA are not identified and referred for timeous assessment and early intervention.[3] In SA 85% of the population relies on public healthcare services, in which early communication intervention has not been effectively implemented nationally.[9] Identifying at-risk infants early is of importance within the PHC context, as the ultimate goal of early communication intervention is prevention of communication delays and disorders.[3]

Environmental risk factors may lead to developmental difficulties, such as communication delays or disorders, later in life.[1] Environmental factors include alcohol and drug abuse,[10] parental neglect and abuse and lack of parent-child interaction.[11] Parents with low education levels, poor mental or physical health and poor coping strategies contribute to the number of at-risk infants.[2] Therefore a lack of parental knowledge and stimulation due to poor knowledge may lead to communication delays and disorders in young children.[2]

Other factors that place young children at risk include adolescent mothers, single parents and low-income households.[12] In SA 29.8% of the population is unemployed, resulting in many children being raised in low-income households.[13] Poor living conditions hamper the quality and quantity of prenatal care, placing unborn infants at risk of both preterm birth and low birthweight, which are themselves risk factors for communication delay.[10]

The presence of multiple risk factors for communication delays in an infant population warrants the implementation of early identification services in underserved communities in SA. To reduce long-term financial burdens as a result of communication delays, which snowball into social and academic difficulties, at-risk infants must be identified quickly and receive early intervention services.[8] The use of a risk assessment is proposed, in addition to the use of a developmental screening tool, to facilitate early identification of at-risk infants in the PHC context. This will enable professionals from various specialties to identify risk factors associated with communication disorders.

Ideally all children at risk of experiencing possible communication difficulties should receive an intensive, high-quality early communication assessment and, if deemed necessary, early intervention within the first 3 years of life.[1] Being able to identify risk factors in a reliable and effective manner is one step closer to realising the ideal of implementing early communication intervention in the PHC system.



The objective of this study was to describe risk factors for communication delays or disorders in infants aged 0 - 12 months in an urban PHC clinic.



Setting and participants

Daspoort is a suburb situated in Pretoria-West, Gauteng Province, SA. The community consists of 6 355 individuals and 1 582 households. The three official SA languages predominantly spoken in the area are Afrikaans (83.19%), English (6.44%) and Sepedi (1.66%).[13]

All the caregivers of infants aged from birth to 12 months who visited Daspoort Polyclinic on Fridays during March and April 2014 were asked to participate in the study. A total of 96 participants with an equal sex distribution among the infants (54 males and 42 females) were included in the study. The mean age of the infant participants was 4.75 months (standard deviation 3.70) (Table 1).



Data collection

A risk assessment tool compiled as part of a master's study[14] and revised using literature was used to collect data. The tool consisted of five sections including general information, prenatal history, environmental risk factors, perinatal history and established risk conditions. Only risk factors for communication delays/disorders with supporting evidence were included in the tool.[1,8,10,11,15]

Data were collected through a structured face-to-face interview with each caregiver. The interview schedule was administered by two final-year Speech-Language Pathology and Audiology students registered with the Health Professions Council of South Africa. Referrals were made to allied healthcare professionals when infants presented with established risk conditions, or when three or more conditions putting them at risk were identified. Preventive strategies such as developmental screening and parent education on child development and appropriate stimulation of infants were provided upon return after referral. Comprehensive assessment was provided when deemed necessary by the allied healthcare professionals. Infants with one or two at-risk conditions were followed up during health-related or immunisation visits by means of informal general developmental surveillance in addition to the Road to Health booklet screening.

Data analysis

SPSS version 22 (IBM, USA) was used to analyse the data. Descriptive statistics were used to describe the results. Relationships between variables were determined with Pearson product moment correlations. Correlations between risk factors of 0.3 and <0.5 were classified as moderate, and correlations of >0.5 were deemed strong.

Ethics approval

Prior to data collection ethical clearance was obtained from the Research Committee of the Faculty of Humanities at the University of Pretoria. The researchers visited Daspoort Polyclinic one morning per week for 8 weeks. Caregivers were informed about what the study entailed and voluntary participation was requested. Verbal and written informed consent was obtained from the caregivers.



Of the total population (n=96), 13 infants were exposed to >10 risk factors, while a further 35 infants had 6 - 9 risks. More than a third (37 infants) presented with 3 - 5 risk factors, whereas 11 infants only had 1 or 2 risks.

Prenatal risk factors

Eleven mothers were older than 35 years of age at the birth of their infants (Table 2).



Many participants (n=42) reported previous miscarriages. A moderate inverse relationship was found between the mother's age and previous miscarriages (r=-0.306; p=0.002). The younger the mother, the more miscarriages were experienced.

Of the 32 mothers who indicated that they smoked during pregnancy, an average of 6.6 cigarettes was smoked daily. Also, 14 mothers consumed alcohol during their pregnancies. A moderate correlation between alcohol and drug usage and premature rupture of membranes during pregnancy was found (r=0.338; p=0.001). A family history of hearing loss was reported by 14 of the caregiver participants.

Half of the mothers presented with colds, flu or both during pregnancy. A total of 14 mothers were hospitalised during pregnancy as a result of vaginal bleeding, complications associated with a multiple pregnancy, pneumonia and asthma, round ligament disorder and thrombosis as well as placental, umbilical cord and uterine complications. Preterm birth was reported in 16 pregnancies.

Perinatal and established risk factors

The majority (77%) of the participants reported one or more perinatal risk factor (Table 3). Only two of the infants presented with craniofacial abnormalities: a cleft palate in one and deformational plagiocephaly in another.



Change of hospitals was reported by 14 participants; reasons included depleted medical aid, cleft palate, maternal high blood pressure, extreme vaginal bleeding and meconium aspiration. A change in hospitals was also associated with infants receiving phototherapy for hyperbilirubinaemia (r=0.452; p<0.001) or for those who had facial abnormalities (r=0.335; p=0.001). Phototherapy was provided to 7 of the infants, for an average of 39 hours, while 3 received exchange blood transfusions for treatment of hyperbilirubinaemia.

Low birthweight was described in 28 of the infants. After birth, 12 of the infants received oxygen for an average of 9 hours. Meningitis had been diagnosed in 3 infants. Other infections reported included laryngitis, respiratory syncytial virus and otitis media. The majority of mothers (n=51) preferred breastfeeding, whereas a third (n=32) formula-fed their infants.

A strong association was found between instruments (e.g. forceps and vacuums) used during birth and meconium aspiration (r=0.520; p<0.001). Moderate correlations were found between meconium aspiration and change of hospitals (r=0.302; p=0.003), and meconium aspiration and Apgar score at 1 minute (r=0.308; p=0.002).

Environmental risk factors

Most ofthe mothers (n=75) were unemployed and were the primary caregivers responsible for the daily care of the infant. Half (n=50) of the caregivers reported their highest level of education being Grade 10, while six had tertiary qualifications (Table 4).



The majority of participants (n=58) used public transport or reached the clinic as pedestrians. A third of the participants (n=31) lived in informal housing or with others and had three or more children.



All participants presented with one or more risk factors, while 50% had six or more risks for communication delays or disorders. The higher the number of risk factors, the greater the impact on infant development.[16] The high prevalence of risks confirms the necessity of a reliable screening tool to identify possible communication problems timeously.

Half the participants reported that they had had colds and/or flu during their pregnancies. Pregnant women are at high risk of experiencing infections like influenza (flu).[17] This is of concern as infections can reach the fetus through the feto-placental barrier, which can affect the developing fetus' health later in life.[18] A mother's behaviour and general health during a pregnancy has a long-term impact on the health of a child.[19] Mothers should be encouraged to modify their own behaviour during pregnancy in order to ameliorate possible risks.

A disturbing finding was that one-third of the participants had smoked during pregnancy. Smoking during pregnancy is associated with attention-deficit hyper-activity disorder,[5] preterm birth, low birthweight and infant morbidity and mortality.[20] Also, 15% indicated alcohol consumption during pregnancy, which could have resulted in FASD. Alcohol exposure during pregnancy may have devastating effects on neurological development and can lead to difficulties in a many areas including language, memory, learning, attention, motor coordination, problem-solving skills and abstract thinking.[4,5] A moderate correlation was also found between alcohol and drug usage during pregnancy and premature rupture of membranes.

Creating awareness in mothers on the impact of their health, alcohol use and smoking on their unborn children may help to eliminate these risks. Preterm birth (16%) and low birthweight (29%) were prevalent amongst participants in this study. Infants who present with perinatal risk conditions have a tendency to present with a general developmental delay as well as delayed language and learning development.[21] Previous research revealed that preterm and low birthweight infants present with language delays by the age of 3 years.[21]

A disturbingly high percentage of young mothers who had had miscarriages (44%) was noted. Prior miscarriages are associated with preterm delivery and low birthweight.[22] Studies found that women who experienced a previous spontaneous abortion were 2.8 times more likely to have low birthweight babies and 1.7 times more likely to give birth preterm.[22] Thus the higher the number of previous miscarriages, the greater the risk of having a preterm, low-birthweight infant.[22]

Assisted vaginal delivery (AVD) is often associated with fetal distress or incorrect fetal head position, requiring the use of forceps or vacuum extraction.[23] Distressed fetuses may aspirate meconium, but possibly also vernix, blood and pus. Distressed fetuses are prone to aspiration, and AVD is often implemented when fetal distress occurs. This may explain the correlation between instrumentation use during birth and meconium aspiration.

Approximately one-third of the mothers were found to be using formula feeding after birth. The introduction of formula milk before the age of 6 months increases the risk of otitis media,[24] which may result in conductive hearing loss if left untreated. Conductive hearing loss causes infants to miss out on early language learning opportunities and may therefore negatively impact an infant's communication development.[14] In contrast, breastmilk provides the infant with antibodies to protect against infections, enhances the function of the intestinal barrier and also protects the infant from inflammation.

Low maternal education and higher birth order have been identified as risk factors predictive of potential communication dis-orders.[14] Half of the mothers received schooling only up to Grade 10, this possibly contributing to the high unemployment rate (78%). Unemployment is associated with a lack of sufficient financial resources, requiring supplementary support such as income from grandparents (20%), government grants or other family members. Poverty as such is an indirect cause of communication difficulties, as poverty-associated conditions rather than poverty itself cause communication delays or disorders.[14] Living in poor socioeconomic circumstances with increased environmental stressors has an adverse impact on a child's development and specifically on language abilities.[14]

There was a moderate correlation between change of hospitals after birth and phototherapy for hyperbilirubinaemia. This raises concerns with regard to secondary healthcare/regional hospitals' ability to render these basic services, as a change in hospital is regarded as a risk in itself. In a developing SA the majority of patients rely on public healthcare services, which are often conservative.[9] Early intervention services in PHC are lacking as a result of limited human and financial resources as well as a lack of equipment, materials and an effective referral framework.[3]

These results confirmed a need for early communication intervention in an underserved community. The services required include a risk assessment, communication screening and developmental surveillance and, if deemed necessary, comprehensive assessment and early intervention. It is recommended that future research should compare the outcome of a risk assessment against the outcome of a diagnostic tool.

Study limitations

A possible limitation of the current study involved the use of a structured interview schedule, implying that the researchers had to rely on the caregivers' report. However, it is widely accepted that parents hold a key position in the early identification and diagnosis of communication disorders within their children.[8,14]



Within this population, where all infants are at risk, regular communication screening and developmental surveillance should occur in order to monitor development. However, all children experiencing a possibility of a communication delay or disorder should receive early communication intervention within the first 3 years of life.'11 The high frequency of at-risk conditions within the Daspoort population justifies the need to implement early communication intervention services in PHC.

Finally, preventive strategies such as parental training, communication screening, general developmental surveillance and a risk assessment should be implemented in underserved communities in SA, to support families burdened by communication delays or disorders.



1. Guralnick MJ. Developmental science and preventative intervention for children at environmental risk. Infants Young Child 2013;26(4):270-285. []        [ Links ]

2. Harrison LJ, McLeod S. Risk and protective factors associated with speech and language impairment in a nationally representative sample of 4- to 5-year-old children. J Speech Lang Hear Res 2010;53(2):508-529. []        [ Links ]

3. Van der Linde J, Kritzinger A, Redelinghuys A. The identification process in early communication intervention (ECI) by primary healthcare personnel in Ditsobotla sub-district. South Afr J Commun Disord 2009;56:48-59.         [ Links ]

4. Premji S, Benzies K, Serrett K, Hayden KA. Research-based interventions for children and youth with a Fetal Alcohol Spectrum Disorder: Revealing the gap. Child Care Health Dev 2007;33(4):389-400. []        [ Links ]

5. Gillberg C, Soderstrom H. Learning disability. Lancet 2003;362(9386):811-821. []        [ Links ]

6. Rehle TM, Hallett TB, Shisana O, et al. A decline in new HIV infections in South Africa: Estimating HIV incidence from three national HIV surveys in 2002, 2005 and 2008. PLoS One 2010;5(6):e11094. [        [ Links ]

7. Viljoen DL, Gossage PJ, Brooke L, et al. Fetal alcohol syndrome epidemiology in a South African community: A second study of a very high prevalence area. J Stud Alcohol 2005;66(5):593-604. []        [ Links ]

8. Rossetti L. Communication Intervention Birth to Three. Vancouver: Singular Thomson Learning, 2001.         [ Links ]

9. Swanepoel D, Störbeck C, Friedland P. Early hearing detection and intervention in South Africa. Int J Pediatr Otorhinolaryngol 2009;73(6):783-786. []        [ Links ]

10. Cone-Wesson B. Prenatal alcohol and cocaine exposure: Influences on cognition, speech, language, and hearing. J Commun Disord 2005;38(4):279-302. []        [ Links ]

11. Barwick MA, Cohen NJ, Horodezky NB. Infant communication and the mother-infant relationship: The importance of level of risk and construct measurement. Infant Ment Health J 2004;25(3):240-266. []        [ Links ]

12. Qi CH, Kaiser AP, Milan S, Hancock T. Language performance of low-income African American and European American preschool children on the PPVT-III. Lang Speech Hear Serv Sch 2006;37(1):5-16. []        [ Links ]

13. Statistics South Africa. Census 2011. (accessed 20 February 2014).         [ Links ]

14. Kritzinger AM. Vroeë kommunikasie-ontwikkeling van biologiese risikobabas. Pretoria: University of Pretoria, 1994.         [ Links ]

15. Beitchman JH, Jiang H, Koyama E, et al. Models and determinants of vocabulary growth from kindergarten to adulthood. J Child Psychol Psychiatry 2008;49(6):626-634. []        [ Links ]

16. Paul R, Roth FP. Characterizing and predicting outcomes of communication delays in infants and toddlers: Implications for clinical practice. Lang Speech Hear Serv Sch 2010;42(3):331-340. []        [ Links ]

17. Zerbo O, Iosif A-M, Walker C, Ozonoff S, Hansen RL, Hertz-Picciotto I. Is maternal influenza or fever during pregnancy associated with autism or developmental delays? Results from the CHARGE (Childhood Autism Risks from Genetics and Environment) Study. J Autism Dev Disord 2013;43(1):25-33. []        [ Links ]

18. Murphy VE, Mattes J, Powell H, Baines KJ, Gibson PG. Respiratory viral infections in pregnant women with asthma are associated with wheezing in the first 12 months of life. Pediatr Allergy Immunol 2014;25(2):151-158. []        [ Links ]

19. Tomlinson M, O'Connor MJ, Le Roux IM, et al. Multiple risk factors during pregnancy in South Africa: The need for a horizontal approach to perinatal care. Prev Sci 2014;15(3):277-282. []        [ Links ]

20. Machaalani R, Ghazavi E, Hinton T, Waters KA, Hennessy A. Cigarette smoking during pregnancy regulates the expression of specific nicotinic acetylcholine receptor (nAChR) subunits in the human placenta. Toxicol Appl Pharmacol 2014;276(3):204-212. []        [ Links ]

21. Schirmer CR, Portuguez MW, Nunes ML. Clinical assessment of language development in children at age 3 years that were born preterm. Arq Neuropsiquiatr 2006;64(4):926-931. []        [ Links ]

22. Brown JS, Adera T, Masho SW. Previous abortion and the risk of low birth weight and preterm births. J Epidemiol Community Health 2008;62(1):16-22. []        [ Links ]

23. Naz H, Sarosh M, Parveen S, Sultana A. Fetomaternal morbidity associated with vacuum versus forceps delivery. Pak J Surg 2012;28(2):126-129.         [ Links ]

24. Abrahams SW, Labbok MH. Breastfeeding and otitis media: A review of recent evidence. Curr Allergy Asthma Rep 2011;11(6):508-512. []        [ Links ]



J van der Linde

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License