A 4-year-old cannot speak intelligibly to strangers (though parents understand >75% of speech), shows sound substitutions and deletions, but has normal receptive language and hearing. The most appropriate referral is:

• A Audiology for formal hearing assessment
• B Speech-language pathologist for articulation therapy ✓
• C Child neurologist for apraxia evaluation
• D Ear, nose and throat surgeon for adenotonsillectomy

Explanation

By age 4, speech should be intelligible to strangers approximately 80–100% of the time. If strangers cannot understand a 4-year-old despite normal hearing and receptive language, a speech sound disorder (articulation or phonological disorder) is likely. Referral to a speech-language pathologist (SLP) for articulation assessment and therapy is the most appropriate step. Audiology is indicated if hearing loss is suspected; here, hearing is noted as normal. Adenotonsillectomy addresses velopharyngeal insufficiency, not sound substitutions.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.