Well-Child Visit: 4 Years

What to Expect During This Visit

Your doctor and/or nurse will probably:

1. Check your child's weight and height, calculate body mass index (BMI), and plot the measurements on a growth chart.

2. Check your child's blood pressure, vision, and hearing using standard testing equipment.

3. Ask questions, address concerns, and offer advice about how your child is:

Eating. Schedule 3 meals and 2 healthy snacks a day. If you have a picky eater, keep offering a variety of healthy foods for your child to choose from. Kids should be encouraged to give new foods a try, but don't force them to eat them.

Peeing and pooping. By 4 years old, most kids are using the toilet. But many preschoolers who are potty trained during the day are not able to stay dry all night. It's also common for busy preschoolers to have an occasional daytime accident. Look for signs of "holding it" and encourage regular potty breaks. Talk to your doctor if your child is not yet potty trained or was previously trained and is now having problems.

Sleeping. Preschoolers sleep about 10–13 hours a day. Many 4-year-olds stop taking an afternoon nap, but be sure to schedule some quiet time during the day.

Developing. By 4 years, most kids:

• say sentences with 4 or more words
• can tell you at least one thing that happened that day
• answer simple questions, like “What is a crayon for?”
• ask to go play with other children if none are around
• comfort others who are hurt or sad
• change their behavior based on where they are, like at a library or a playground
• draw a person with 3 or more body parts
• can name some colors
• can catch a large ball most of the time
• unbutton some buttons

Talk to your doctor if your child is not meeting one or more milestones, or you notice that your child had skills but has lost them.

4. Do an exam with your child undressed while you are present. This will include listening to the heart and lungs, observing motor skills, and talking to your child to assess speech and language development.

5. Update immunizations. Immunizations can protect kids from serious childhood illnesses, so it's important that your child get them on time. Immunization schedules can vary from office to office, so talk to your doctor about what to expect.

6. Order tests. Your doctor may check for anemia, lead, high cholesterol, and tuberculosis and order tests, if needed.

Looking Ahead

Here are some things to keep in mind until your child's next checkup at 5 years:

Eating

1. Make time to eat together as a family most nights of the week.
2. Serve a variety of healthy foods, including lean meats, fish, fruits, vegetables, and whole grains.
3. Preschoolers should get 2½ cups (600 ml) of low-fat milk (or other low-fat dairy products, like yogurt) daily. You can also give an unsweetened, fortified soy beverage.
4. Limit 100% juice to no more than 4–6 ounces (120–180 ml) a day.

Routine Care

1. Let your child be active every day while under adult supervision. Be active as a family.
2. Limit screen time (time spent with TV, smartphones, tablets, and computers) to no more than 1 hour a day of quality children's programming. Watch with your child to boost learning. Keep TVs and devices out of your child's bedroom.
3. If your child doesn't go to preschool, look for ways they can play and be with other kids.
4. To help prepare your child for kindergarten:
   • Keep consistent daily routines and times for meals, snacks, playing, reading, cleaning up, waking up, and going to bed.
   • Practice counting numbers and singing the ABCs, along with other songs and rhymes.
   • Read to your child every day.
   • Encourage drawing, coloring, and recognizing and writing letters.
   • Allow your child to take some responsibility for going to the bathroom, washing hands, brushing teeth, and getting dressed. Offer reminders and help when needed.
   • Teach your child your home address and phone number.
5. Have your child brush teeth twice a day with a pea-sized amount of fluoride toothpaste. Schedule regular dental checkups as recommended by the dentist. To help prevent cavities, the doctor or dentist may brush fluoride varnish on your child’s teeth 2–4 times a year.

Safety

1. Supervise your child outdoors, especially when playing around water and near streets. Consider enrolling your child in a swimming class.
2. Make sure playground equipment is well maintained and age-appropriate. Surfaces should be soft to absorb falls (sand, rubber mats, or a deep layer of wood or rubber chips).
3. Apply sunscreen of SPF 30 or higher at least 15 minutes before your child goes outside to play and reapply about every 2 hours.
4. Protect your child from secondhand smoke, which increases the risk of heart and lung disease. Secondhand vapor from e-cigarettes is also harmful.
5. Make sure your child always wears a helmet when riding a tricycle or bicycle.
6. Kids should stay harnessed in a forward-facing car seat in the back seat until they reach the highest weight or height limit. When your child has outgrown this seat, switch to a belt-positioning booster seat until your child is 4 feet 9 inches (150 cm) tall, usually when they're 8–12 years old.
7. Protect your child from gun injuries by not keeping a gun in the home. If you do have a gun, keep it unloaded and locked away. Ammunition should be locked up separately. Make sure kids can't get to the keys.
8. Discuss appropriate touch. Teach your child that some body parts are private and no one should see or touch them. Tell your child to come to you if anyone ever asks to look at or touch his or her private parts, if he or she is ever asked to look at or touch someone else's private parts, or is asked to keep a secret.
9. Talk to your doctor if you're concerned about your living situation. Do you have the things that you need to take care of your child? Do you have enough food, a safe place to live, and health insurance? Your doctor can tell you about community resources or refer you to a social worker.

These checkup sheets are consistent with the American Academy of Pediatrics (AAP)/Bright Futures guidelines.