What are the recommended assessments and interventions for a 4-year well-child checkup?

4-Year Well-Child Checkup: Recommended Assessments and Interventions

At the 4-year well-child visit, visual acuity testing using LEA SYMBOLS® or HOTV letters becomes the preferred screening method, and this is the critical age to establish baseline hearing and developmental assessments before school entry. 1

Vision Screening

Visual acuity testing is now the gold standard at age 4 years, as most children can reliably participate in monocular testing at this age. 1

• Use LEA SYMBOLS® or HOTV letters as the preferred optotypes for visual acuity screening—these are validated and meet recommended standards for eye chart design. 1
• Avoid Allen figures, Lighthouse chart, or Kindergarten (Sailboat) Eye Chart, as these have not been validated. 1
• Test each eye separately (monocularly) with the fellow eye covered by an adhesive patch or tape to prevent peeking. 1
• Test with any habitual refractive correction in place. 1
• Refer immediately for comprehensive ophthalmologic examination if the child fails visual acuity screening on first attempt—do not wait for a second screening. 1
• Children who cannot complete the test ("untestable") should be rescreened within 6 months or referred, as untestable preschoolers are at least twice as likely to have vision disorders. 1

Additional ophthalmologic assessments recommended by the American Academy of Pediatrics include: 1

• Red reflex examination
• External inspection of eyes and lids
• Ocular motility assessment
• Pupil examination
• Ophthalmoscopy 1

Hearing Screening

Perform age-appropriate audiologic testing annually or every two years starting at this age. 2

• For 4-year-olds, conventional audiometry is appropriate, where the child raises their hand when a stimulus is heard. 1
• Use a fail criterion of >20 dB HL at 1 or more frequencies (500,1000,2000,4000 Hz) in either ear. 1
• If the child fails primary care screening, refer for comprehensive audiologic evaluation by an audiologist, which should include air-conduction and bone-conduction thresholds, speech detection thresholds, and ear-specific testing. 1

Developmental and Behavioral Assessment

Perform developmental surveillance at this visit, focusing on school readiness and language development. 3

• Screen for speech and language delays—by age 4, children should have clear speech and age-appropriate expressive/receptive language. 4
• If speech delay is identified, refer immediately for audiological assessment to rule out hearing loss as a cause. 4
• Consider autism spectrum disorder screening if there are concerns about social communication or repetitive behaviors. 4
• Assess school performance and readiness, as this serves as developmental surveillance. 2

Growth and Nutrition Assessment

Screen for obesity, defined as BMI at or above the 95th percentile for age and sex. 2

• Measure height, weight, and calculate BMI percentile. 2
• Provide resources for comprehensive, intensive behavioral interventions if obesity is identified. 2
• Assess dietary habits, including juice and sugar-sweetened beverage consumption (should be limited). 3
• Ensure the child receives at least 400 IU of vitamin D daily. 2

Blood Pressure Screening

Check blood pressure annually beginning at age 3 years, though evidence for screening before age 18 is mixed. 2

• Many experts recommend this despite insufficient evidence from USPSTF, as early hypertension detection may prevent future complications. 2

Dental Health

Assess dental care habits and fluoride supplementation needs. 2, 3

• Children living in areas with inadequate water fluoride (<0.6 ppm) should receive daily fluoride supplements. 2
• Counsel on limiting juice consumption and maintaining good oral hygiene. 3

Safety and Lifestyle Counseling

Screen for lifestyle habits including: 2

• Physical activity levels
• Daily screen time (television, computer, video games)—the American Academy of Pediatrics recommends limiting to 1 hour per day for children 2-5 years. 3
• Hours of sleep per night
• Safety habits (car seat use, helmet use, water safety)

Car seat guidance: Children should remain in a rear-facing car seat until age 2 years or until height/weight limit is reached, then transition to forward-facing. 3

Immunizations

Review and update immunizations as appropriate for age. 2, 3

• Administer any missed immunizations according to the current CDC schedule. 2

Common Pitfalls to Avoid

• Do not use Snellen letters for vision screening at this age—they are less desirable because individual letters are not of equal legibility and spacing doesn't meet WHO standards. 1
• Do not delay referral for failed vision screening—refer after the first failure, not after multiple attempts. 1
• Do not rely solely on clinical judgment for developmental assessment—studies show physician impression alone misses 45% of children eligible for early intervention. 4
• Do not substitute tympanometry or acoustic reflectometry for formal hearing testing if hearing loss is suspected. 1
• Avoid routine scoliosis screening and testicular examination, as USPSTF recommends against these. 2