Well-Child Checkup: 4 Years

Development and milestones

The healthcare provider will ask questions and observe your child’s behavior to get an idea of their development. By this visit, most children are doing these:

• Comforts others who are hurt or sad, like hugging a crying friend

• Likes to be a "helper"

• Talks about at least one thing that happened during their day

• Tells what comes next in a well-known story

• Names a few colors of items

• Says sentences of 4 or more words

• Holds crayon or pencil between fingers and thumb (not a fist)

• Draws a person with 3 or more body parts

• Catches a large ball most of the time

• Unbuttons some buttons

School and social issues

The healthcare provider will ask how your child is getting along with other kids. Talk about your child’s experience in group settings, such as preschool. If your child isn’t in preschool, you could talk instead about behavior at daycare or during play dates. You may also want to discuss preschool choices and how to help your child get ready for kindergarten. The healthcare provider may ask about:

• Behavior and taking part in group settings. How does your child act at school or other group settings? Do they follow the routine and take part in group activities? What do teachers or caregivers say about your child’s behavior?

• Behavior at home. How does your child act at home? Is behavior at home better or worse than at school? Be aware that it’s common for kids to be better behaved at school than at home.

• Friendships. Has your child made friends with other children? What are the kids like? How does your child get along with these friends?

• Play. How does your child like to play? For example, do they play “make believe”? Does your child interact with others during playtime?

• Independence. How is your child adjusting to school? How do they react when you leave? Some anxiety is normal. This should get better over time, as your child becomes more independent.

Nutrition and exercise tips

Healthy eating and activity are 2 important keys to a healthy future. It’s not too early to start teaching your child healthy habits that will last a lifetime. Here are some things you can do:

• Limit juice and sports drinks. These drinks—even pure fruit juice—have too much sugar. This leads to unhealthy weight gain and tooth decay. Water and low-fat or nonfat milk are best to drink. Limit juice to a small glass of 100% juice each day, such as during a meal.

• Don’t serve soda. It’s healthiest not to let your child have soda. If you do allow soda, save it for very special occasions.

• Offer healthy foods. Keep a variety of healthy foods on hand for snacks. These can include fresh fruits and vegetables, lean meats, and whole grains. Foods such as french fries, candy, and junk foods should only be served rarely.

• Serve child-sized portions. Children don’t need as much food as adults. Serve your child portions that make sense for their age. Let your child stop eating when they are full. If your child is still hungry after a meal, offer more vegetables or fruit. It's OK to put limits on how much your child eats.

• Encourage at least 3 hours of physical activity through active play each day. Moving around helps keep your child healthy. Bring your child to the park, ride bikes, or play active games like tag or ball.

• Limit screen time to no more than 1 hour each day. This includes TVs, phones, tablets, video games, computers, and other devices. When your child is using a screen, content should be of a children’s program with an adult present. Don’t put any screens in your child’s bedroom. Children learn by talking, playing, and interacting with others.

• Ask the healthcare provider about your child’s weight. At this age, your child should gain about 4 to 5 pounds each year. If they are gaining more than that, talk with the provider about healthy eating habits and activity guidelines.

• Have regular dental visits. Take your child to the dentist at least twice a year for teeth cleaning and a checkup.

• Encourage good sleep habits. For preschool-age children, ages 3 to 5, 13 hours of sleep are recommended in a 24-hour period. Create a quiet, calm bedtime routine.

Safety tips

Bicycle safety equipment, such as a helmet, helps keep your child safe.

Advice to keep your child safe includes: 

• When riding a bike, have your child wear a helmet with the strap fastened. While roller-skating or using a scooter or skateboard, it’s safest to wear wrist guards, elbow pads, knee pads, and a helmet.

• Keep using a car seat until your child outgrows it. This is when your child's height or weight is more than the forward-facing limit for their car seat. Check your car seat owner’s manual for the specific height or weight. Ask the healthcare provider if there are state laws regarding car seat use that you need to know about.

• Once your child outgrows the car seat, switch to a high-back booster seat. This allows the seat belt to fit correctly. A booster seat should be used until your child is 4 feet 9 inches tall and between 8 and 12 years of age. All children younger than 13 years old should sit in the back seat.

• Teach your child not to talk to or go anywhere with a stranger.

• Start to teach your child their phone number, address, and parents’ first names. These are important to know in an emergency.

• Teach your child to swim. Many communities offer low-cost swimming lessons. Never leave your child unattended near any body of water.

• If you have a swimming pool, check that it's entirely fenced on all sides. Close and lock gates or doors leading to the pool. Don't let your child play in or around the pool without adult supervision, even if they know how to swim.

• Teach your child to stay away from strange dogs, cats, and other animals. Never leave your child alone around animals.

• Remember sun safety. Wear protective clothing. Try to stay out of the sun between 10 a.m. and 4 p.m. That's when the sun's rays are strongest. Apply sunscreen 30 minutes before going outdoors. Apply sunscreen with an SPF of at least 15 or up to 50 to your child's skin that isn't covered by clothing.

• If it's necessary to keep a gun in your home, store it unloaded and locked. Keep ammunition stored and locked in a separate location.

• Use correct names for all body parts and teach your child the correct names of all body parts. Teach your child that no one should ask them to keep secrets from their parents or caregivers, to see or touch their private parts, or for help with an adult's or other child's private parts. If a healthcare professional has to examine these parts of the body, be present.

• Teach your child it is OK to say "No" to touches that make them uncomfortable. For example, if your child does not want to hug a family member or friend, respect their decision to say “No” to this contact.

Vaccines

Based on recommendations from the CDC, at this visit your child may get the following vaccines:

• Diphtheria, tetanus, and pertussis

• Flu (influenza) every year

• Measles, mumps, and rubella

• Polio

• Chickenpox (varicella)

• COVID-19

Give your child positive reinforcement

It’s easy to tell a child what they’re doing wrong. It’s often harder to remember to praise a child for what they do right. Rewarding good behavior (positive reinforcement) helps your child gain confidence and a healthy self-esteem. Here are some tips:

• Give your child praise and attention for behaving well. When appropriate, let the whole family know that the child has done well.

• Reward good behavior with hugs, kisses, and small gifts, such as stickers. When being good has rewards, kids will keep doing those behaviors to get the rewards. Don't use sweets or candy as rewards. Using these treats as positive reinforcement can lead to unhealthy eating habits and an emotional attachment to food.

• When your child doesn’t act the way you want, don’t label them as bad or naughty. Instead, describe why the action is not acceptable. For example, say “It’s not nice to hit” instead of “You’re a bad girl.” When your child chooses the right behavior over the wrong one, such as walking away instead of hitting, remember to praise the good choice!

• Pledge to say 5 nice things to your child every day. Then do it!