Well Child Care, 4-Year-Old

PHYSICAL DEVELOPMENT

Your 4-year-old should be able to hop on 1 foot, skip, alternate feet while walking down stairs, ride a tricycle, and dress with little assistance using zippers and buttons. Your 4-year-old should also be able to:

  • Brush his or her teeth.

  • Eat with a fork and spoon.

  • Throw a ball overhand and catch a ball.

  • Build a tower of 10 blocks.  

EMOTIONAL DEVELOPMENT

  • Your 4-year-old may: 

  • Have an imaginary friend.

  • Believe that dreams are real.

  • Be aggressive during group play.

Set and enforce behavioral limits and reinforce desired behaviors. Consider structured learning programs for your child, such as preschool. Make sure to also read to your child. 

SOCIAL DEVELOPMENT

  • Your child should be able to play interactive games with others, share, and take turns. Provide play dates and other opportunities for your child to play with other children.

  • Your child will likely engage in pretend play.

  • Your child may ignore rules in a social game setting, unless they provide an advantage to the child.

  • Your child may be curious about, or touch his or her genitalia. Expect questions about the body and use correct terms when discussing the body.

MENTAL DEVELOPMENT

Your 4-year-old should know colors and recite a rhyme or sing a song. Your 4-year-old should also:

  • Have a fairly extensive vocabulary.

  • Speak clearly enough so others can understand.

  • Be able to draw a cross.

  • Be able to draw a picture of a person with at least 3 parts.

  • Be able to state his and her first and last names.

RECOMMENDED IMMUNIZATIONS

  • Hepatitis B vaccine. (Doses only obtained if needed to catch up on missed doses in the past.)

  • Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (The fifth dose of a 5-dose series should be obtained unless the fourth dose was obtained at age 4 years or older. The fifth dose should be obtained no earlier than 6 months after the fourth dose.)

  • Haemophilus influenzae type b (Hib) vaccine. (Children under the age of 5 years who have certain high-risk conditions or have missed doses in the past should obtain the vaccine.)

  • Pneumococcal conjugate (PCV13) vaccine. (Children who have certain conditions, missed doses in the past, or obtained the 7-valent pneumococcal vaccine should obtain the vaccine as recommended.)

  • Pneumococcal polysaccharide (PPSV23) vaccine. (Children who have certain high-risk conditions should obtain the vaccine as recommended.)

  • Inactivated poliovirus vaccine. (The fourth dose of a 4-dose series should be obtained at age 4–6 years. The fourth dose should be obtained no earlier than 6 months after the third dose.)

  • Influenza vaccine. (Starting at age 6 months, all children should obtain influenza vaccine every year. Infants and children between the ages of 6 months and 8 years who are receiving influenza vaccine for the first time should receive a second dose at least 4 weeks after the first dose. Thereafter, only a single annual dose is recommended.)

  • Measles, mumps, and rubella (MMR) vaccine. (The second dose of a 2-dose series should be obtained at age 4–6 years.)

  • Varicella vaccine. (The second dose of a 2-dose series should be obtained at age 4–6 years.)

  • Hepatitis A virus vaccine. (A child who has not obtained the vaccine before 2 years of age should obtain the vaccine if he or she is at risk for infection or if hepatitis A protection is desired.)

  • Meningococcal conjugate vaccine. (Children who have certain high-risk conditions, are present during an outbreak, or are traveling to a country with a high rate of meningitis should obtain the vaccine.)

TESTING

Hearing and vision should be tested. The child may be screened for anemia, lead poisoning, high cholesterol, and tuberculosis, depending upon risk factors. Discuss these tests and screenings with your child's doctor.

NUTRITION

  • Decreased appetite and food jags are common at this age. A food jag is a period of time when the child tends to focus on a limited number of foods and wants to eat the same thing over and over.

  • Avoid food choices that are high in fat, salt, or sugar.

  • Encourage low-fat milk and dairy products.

  • Limit juice to 4–6 ounces (120–180 mL) each day of a vitamin C containing juice.

  • Encourage conversation at mealtime to create a more social experience without focusing on a certain quantity of food to be consumed.

  • Avoid watching television while eating.

  • Give fluoride supplements as directed by your child's health care provider or dentist.

  • Allow fluoride varnish applications to your child's teeth as directed by your child's health care provider or dentist.

ELIMINATION

The majority of 4-year-olds are able to be potty trained, but nighttime bed-wetting may occasionally occur and is still considered normal.

SLEEP

  • Your child should sleep in his or her own bed.

  • Nightmares and night terrors are common. You should discuss these with your health care provider.

  • Reading before bedtime provides both a social bonding experience as well as a way to calm your child before bedtime. Create a regular bedtime routine.

  • Sleep disturbances may be related to family stress and should be discussed with your physician if they become frequent.

  • Your child should brush teeth before bed and in the morning.

PARENTING TIPS

  • Try to balance the child's need for independence and the enforcement of social rules.

  • Your child should be given some chores to do around the house.

  • Allow your child to make choices and try to minimize telling the child "no" to everything.

  • There are many opinions about discipline. Choices should be humane, limited, and fair. You should discuss your options with your health care provider. You should try to correct or discipline your child in private. Provide clear boundaries and limits. Consequences of bad behavior should be discussed beforehand.

  • Positive behaviors should be praised.

  • Minimize television time. Such passive activities take away from a child's opportunity to develop in conversation and social interaction.

SAFETY

  • Provide a tobacco-free and drug-free environment for your child.

  • Always put a helmet on your child when he or she is riding a bicycle or tricycle.

  • Use gates at the top of stairs to help prevent falls.

  • Continue to use a forward-facing car seat until your child reaches the maximum weight or height for the seat.  After that, use a booster seat. Booster seats are needed until your child is 4 feet 9 inches (145 cm) tall and between 8 and 12 years old.

  • Equip your home with smoke detectors.

  • Discuss fire escape plans with your child.

  • Keep medicines and poisons capped and out of reach.

  • If firearms are kept in the home, both guns and ammunition should be locked up separately.

  • Be careful with hot liquids ensuring that handles on the stove are turned inward rather than out over the edge of the stove to prevent your child from pulling on them. Keep knives away and out of reach of children.

  • Street and water safety should be discussed with your child. Use close adult supervision at all times when your child is playing near a street or body of water.

  • Tell your child not to go with a stranger or accept gifts or candy from a stranger. Encourage your child to tell you if someone touches him or her in an inappropriate way or place.

  • Tell your child that no adult should tell him or her to keep a secret from you and no adult should see or handle his or her private parts.

  • Warn your child about walking up on unfamiliar dogs, especially when dogs are eating.

  • Children should be protected from sun exposure. You can protect them by dressing them in clothing, hats, and other coverings. Avoid taking your child outdoors during peak sun hours. Sunburns can lead to more serious skin trouble later in life. Make sure that your child always wears sunscreen which protects against UVA and UVB when out in the sun to minimize early sunburning.

  • Show your child how to call your local emergency services (911 in U.S.) in case of an emergency.

  • Know the number to poison control in your area and keep it by the phone.

  • Consider how you can provide consent for emergency treatment if you are unavailable. You may want to discuss options with your health care provider.

WHAT'S NEXT?

Your next visit should be when your child is 5 years old.