Chronic voice disorders are fairly common in children. About 4-6 children out of every 100 have a voice disorder.

Children can have many types of voice disorders. Most of them are harmless and are caused by excessive shouting and loud talking, excessive use of certain harsh voice 'sound effects' during play, or they can be caused by common childhood infections. 

Your child's voice may sound harsh, hoarse or they may have 'lost' their voice entirely. If you are concerned about your child's voice, please see your local doctor.

What is 'voice'?

Voice is the sound produced by the vocalfolds in the larynx (voice box). The vocal folds are thin muscle bands which open to let the air in and out of the lungs during breathing. They close to produce vibrations (sound) used for speaking. You can feel the sound vibrations if you gently rest your hand at the front of your neck and say the sound 'aaaaaah'. This sound is then modified by the movement of the lips, tongue, jaw and palate to produce speech.

The human voice has a number of features:

• Pitch - which can vary between high and low during speech.
• Volume - which can vary between loud and soft. Loudness duringspeech varies to show emphasis and emotion.
• Quality is what the voice sounds like. The quality of a voice may be described clear, croaky, strained, hoarse, breathy or rough.
• Resonance - some children may sound like they are speaking through a blocked nose (hyponasal) while other children may sound like they have too much air coming down the nose during speech (hypernasal).

Generally, the human voice conveys a lot of information about how a person is feeling. For example, when a child is angry their voice might sound louder and more strained than when he or she is calm.

What is a voice disorder?

A voice disorder is when the quality of a person's voice is noticeably different to that of others their age and sex. People with voice disorders often complain that their voices tire easily or that they have difficulty projecting their voice.

Children with voice disorders may have harsh or hoarse voices or voices which are too high or low, too loud or too nasal. 

A poor voice quality may make it hard for a child to communicate effectively, and may make them lose self confidence or affect the way other people see them. 

Causes

• talking or shouting loudly
• talking or shouting excessively
• common childhood infections
• Some children's voice problems may be related to how they are feeling emotionally or psychologically

There are some rare medical conditions which may cause a child's voice to change in quality. Please see your local doctor if you have concerns about your child's voice or refer to www.voiceproblem.org for further information about medical conditions which affect children's voices (follow the prompts: 'voice disorders', 'paediatric voice disorders').

Hoarse voice

Hoarseness is quite common in children. It is usually related to the way children use their voices rather than a serious or life threatening illness. There are some rare medical conditions however, which need prompt medical attention by an Otolaryngologist (Ear, Nose and Throat specialist), especially if the hoarseness persists or if there is a marked deterioration in voice quality. A joint assessment by an Otolaryngologist and a Speech Pathologist in a specialist voice clinic may be needed for your child.

Common causes of hoarseness in children:

Infections

• A hoarse voice often occurs when a child has a virus infection such as a cold or Laryngitis (inflammation of the larynx / vocal cords). The hoarseness resulting from a viral infection is temporary and usually disappears when the infection clears. Encourage your child to frequently sip fluids and rest their voice until they get better.

Reflux

• (Laryngopharyngeal reflux) is thought to be a cause of some children's voice problems. At this stage there is not enough evidence to suggest this is the case.

Vocal Nodules / Cysts / Polyps

• These are known as benign lesions of the vocal folds which involve a thickening of the lining of the vocal fold. They are caused by tissue 'stress' during excessive voice use such as screaming or prolonged loud talking or crying.
• The most common treatment for a hoarse voice associated with benign vocal fold lesions in childhood is voice therapy. Voice therapy is based on voice care education and training. This involves your child, their family and their social and educational environment, such as a school.
• Some lesions may require surgical removal.

Uncommon causes of hoarseness in children

Recurrent Respiratory Papillomatosis (RRP)

• This is a viral infection caused by the human papilloma virus (HPV) which results in wart like growths on the vocal folds. A child with this condition often has a very hoarse and harsh sounding voice. Breathing problems may occur if the growths obstruct the breathing passage. Treatment for RRP is medical and surgical and usually managed by an Otolaryngologist.

Tumours / Cancers

• These are extremely rare in children but any persistent voice problem or breathing problems should be investigated by an Otolaryngologist, especially if they are getting worse.
• A Hemangioma (an abnormal collection of blood vessels) is an example of benign (not cancerous) tumour which is usually detected in young babies and associated with an abnormal cry.

Weak voice

A weak voice is often the result of poor vocal fold movement or incomplete closure of the vocal folds during speech.Neurological causessuch as vocal fold paralysis or non-neurological causes such as laryngeal stenosis (narrowing of the larynx) are associated with a weak voice. For example, children who are born very premature and have long term intubation (breathing tube) through the larynx (throat) to help them breathe are at risk of long term voice problems. Children with poor vocal fold movement generally have difficulty raising their voices and being heard over background noise. This can be quite frustrating for the child and adolescent.

There are some surgical procedures which are used to correct vocal fold paralysis in adults but these are not commonly done for children. Voice therapy is sometimes used for children with weak voices and may help your child achieve optimum voice volume and quality. It teaches your child different ways to communicate effectively with others without straining their voice. 

Abnormal sounding cry or noisy breathing in infants

When an infant's cry is weak or has a harsh or hoarse quality it needs to be assessed by an Otolaryngologist (ear, nose and throat doctor). Certain medical conditions can be associated with noisy breathing (stridor) in infants.

Laryngomalacia(floppy larynx) is a common cause of noisy breathing in infants. It generally resolves by itself by the second year of life without any long term voice problems. Your child will be closely monitored by doctors to make sure they are breathing well. If the condition is severe an operation may be necessary. 

What should I do if I think my child has a voice disorder?

• Talk to your family doctor about a possible referral either to a speech pathologist or specialist doctor depending on the problem your child has.
• The RCH Voice Service provides a service for children and adolescents with voice disorders.
• You can also contact a speech pathologist directly (www.speechpathologyaustralia.org.au)or ask your doctor for a list of speech pathologists in your area.
• If your child is school-age, their school may have a speech pathology service and your child's teacher may be able to help you with a referral.

Key points to remember

• Most voice disorders are harmless and disappear on their own or with professional help. Encourage your child to 'rest' their voice by not talking loudly or shouting and keeping their throat moist by frequently sipping on fluids (especially after an infection).
• Your child may need an assessment by a specialist doctor (otolaryngologist) and a speech pathologist if they have a hoarse or weak voice that is getting worse or not getting better.
• Some voice disorders need surgery although this is uncommon.

For more information

• Ask your local doctor for a referral to a speech pathologist if you are concerned about your child's voice. You can see a speech pathologist privately. If you do, fees will apply and vary.
• Fact sheet: Voice: caring for your voice
• Fact sheet: Voice: Laryngology clinic 
• www.speechpathologyaustralia.org.au
• http://www.voiceproblem.org/