Growth Milestones – FOUR YEARS

“Growing self-reliance”

Can you believe that four years ago your child was born? Boy, “does time fly when you are having fun.” Now you know why your parents used to say that you were growing up too fast. Ties to your apron strings will begin to loosen as the 4-year-old develops more independence and self-confidence. Before you know it, it will be time to start kindergarten. In previous generations, moms and dads learned what to expect of their child from their mother, grandmother or another family member. Today, most families are so scattered that parents do not have this help available. Therefore, do not hesitate to ask any questions you might have about your child’s growth and development during the four year checkup. This is the reason for regular well-child exams.

Parenting and Behavioral
  • The 4-year-old really enjoys playmates. At this stage the toddler will begin to play cooperatively with others.
  • It is normal for children this age to have imaginary friends. Parents can sometimes use the youngster’s imaginary “playmate” to their advantage (like getting your 4-year-old to do something you want him or her to do.)
  • Limit television viewing to one hour per day. Do not use the TV as a baby sitter or it as a substitute for interaction with your child. Watch children’s programs with your child when possible.
  • Do not worry if your child becomes curious about body parts. This is normal at this age. Always use the correct terms for genitals. Modesty and a desire for privacy begin to emerge at this age. When your child starts to want privacy of his or her own, let your child know that you think this is good.
  • Your child may continue to use a security object (such as a blanket, favorite stuffed toy, night light, etc.). This is normal and your youngster will give up the item when he or she is ready.
  • If you are expecting another baby, discuss with your child’s physician how to prepare your 4-year-old.
  • Allow your child to participate in setting and cleaning up the table. Always praise him or her for a job well done.
  • Provide some type of structured learning environment in preparation for kindergarten next year. Examples include preschool, Head Start or Sunday School. Show an interest in your child’s preschool activities.
  • Discipline should be firm and consistent, but loving and understanding. Praise your child for his or her good behavior and accomplishments.
  • Continue to allow your 4-year-old to make choices whenever possible but the
  • choices should be limited to those you can live with (“red shirt or green shirt”). Never ask a 4-year-old an open question (“Do you want to take a bath”) unless you are willing to accept the answer.
  • Use the two “I’s” of discipline (ignore or isolate) rather than the two “S’s” (shouting or spanking). When disciplining, try to separate your child and his or her behavior (“I love you, but I do not like it when you touch the VCR.”)
  • Provide your 4-year-old with clearly stated limits along with an explanation of the consequences if rules are broken. Making children stand in the corner (“time out” by themselves for four minutes is usually an effective punishment. If you have any questions about your child’s behavior, discuss them with the doctor.
  • Meaningless threats are ineffective. Follow through with the previously stated consequences when rules are broken.
  • Whenever possible, give reprimands privately.
  • Always bear in mind the positive effects of praise.
  • Speech is almost always understandable.
  • Can usually count from 1 to 10.
  • Can walk on tiptoes, climb a ladder and ride a tricycle.
  • May name and match three or four primary colors.
  • Knows his or her own name.
  • Correctly uses the pronoun “I.”
  • Children this age recognize gender differences and will correctly say “I am a girl” or “I am a boy.”
  • Can dress and undress with supervision but still has trouble with laces and buttons. Children this age also begin to be selective about what they wear.
  • Holds and uses a pencil with good control. Can copy a cross, circle and possibly a square.
  • Can to draw a person with a face, arms and legs.
  • Engages in conversational “give-and-take.”
  • Can sing a song.
  • Talks about his or her day’s activities and experiences.
  • Can identify emotions such as sadness, anger, anxiety and fear.
  • Enjoys the companionship of other children; plays cooperatively and shows interest in other children’s bodies.
Oral Health
  • Supervise brushing twice a day with a small amount of fluoridated toothpaste.
  • Take your 4-year-old to the dentist again this year and schedule re-checks as recommended by the dentist.
  • If the child sucks his or her fingers or thumb, ask the dentist how to discourage these habits. Stop pacifier use.
  • Continue giving a fluoride supplement if your drinking water is not fluoridated. Some dentists recommend fluoride be continued through age 8; others recommend continuing through age 12 or 16. Check with your pediatrician and dentist.
  • Learn how to prevent dental injuries and what to do in case of a dental emergency, especially the loss or fracture of a tooth.
  • The 4-year-old continues in a period of relatively slow growth. Average weight gain per year is only three to four pounds. Therefore, the appetite still is not what most parents (or grandparents) think it should be. Remember, feeding problems may arise if parents make their child eat more than he or she needs to, or show too much concern in what their child eats.
  • Provide snacks rich in carbohydrates and limit high-fat, low nutrient foods.
  • The 4-year-old can and usually insists on feeding himself or herself.
  • Mealtime should be pleasant and food should never be forced. Provide nutritious foods and let your child decide what and how much to eat. Offer small portions with the availability of a second helping.
  • The 4-year-old will often imitate peers in food likes and dislikes.
  • Avoid nuts, hard candy, uncut grapes, hot dogs or raw vegetables. Control sweets and avoid junk food.
  • Eat dinner together as a family whenever possible.
  • Insist on good table manners and encourage pleasant conversation during meals.
  • Turn the TV off during meals.
  • An afternoon nap may still be necessary.
  • Fears of the dark, thunder, lightning, etc. are quite common at this age.
  • Maintain a consistent bedtime and bedtime routine, using a night light, security blanket or toy are all ways to help lessen nighttime fears.
  • Nightmares can wake a child up from sleep. They can be triggered by changes or stress. Reassure your child and put him or her back to bed.
  • Your child may receive one or more immunization depending on your doctor’s schedule. Other doctors prefer to wait until the child is five for these immunizations.
  • Annual flu vaccines may be recommended for children with chronic illnesses like asthma and heart defects. Check with your doctor.
  • If the child can cooperate or a problem is suspected, vision and hearing will also be checked. The child’s blood pressure will be recorded. A urinalysis will be preformed and many physicians apply a tuberculin test at this checkup as well.
Toilet Training
  • By age 4, 95 percent of children are bowel trained.
  • By age 4, 90 percent of children are dry in the daytime and 75 percent at night.
  • Your child continues to require close supervision. Accidents continue to be the principal cause of death in children in this age group.
  • Know where your child is at all times. A 4-year-old is too young to be roaming the neighborhood alone.
  • If your home uses gas appliances, install and maintain carbon monoxide detectors.
  • The purchase of a trampoline is not recommended because of the risk of serious injury.
  • Insist that your home and car be smoke free.
  • Select toys that are safe.
  • Electrical tools, firearms, matches and poisons should be locked up, out of reach.
  • The child should not have unsupervised access to, or ride a bike in, the street.
  • Some 4-year-olds can be taught their full name, address and phone number.
  • If bicycling, teach safety rules and insist on helmet use.
  • It is too ealy to expect your child to look both ways before crossing the street. Supervise all street crossings.
  • Continue to use a car seat or booster seat secured properly until the child weighs at least 60 pounds or his or her head is higher than the back of the rear seat. The greatest risk to your child’s health continues to be motor vehicle accidents. Remember, it is impossible for you to protect your child during an accident by just holding him or her. Set a good example by always using a seat belt when driving.
  • Always walk behind your car before backing out of the driveway.
  • Many 4-year-olds are fairly good “swimmers,” but knowing how to “swim” does not make the youngster water safe. Never leave a child unattended in a bathtub, even for a few seconds. Ensure that your child wears a life vest if boating.
  • There is no such thing as a “child proof cap.” Ingestion of toxic substances is common at this age. Keep syrup of Ipecac in the home to be used only as directed by your child’s doctor or the poison control center.
  • Never buy toys or other objects that can be cut or ingested. Suffocation by plastic bags and balloons still occurs at this age.
  • Be especially careful when using power lawn mowers and other power tools.
  • Test smoke detectors to ensure they are working properly.
  • Continue to use a water proof sunscreen on your child before he or she goes outside. If possible, avoid the hours between 10 a.m. and 3 p.m. when the sun is the most dangerous.
  • Advise your 4-year-old to be careful around strange dogs, especially ones that are eating.
  • Begin to teach your child not to talk to strangers or accept food from strangers. Teach your child the first and last names of family members.
  • Teach your child pedestrian safety (“look both ways before crossing the street”).
  • The 4-year-old experiences less respiratory infections, such as colds, ear infections and sinus infections than the previous year. Begin to teach good habits: washing his or her hands after using the toilet, putting his or her hands in front of his or her mouth before coughing or sneezing, and washing his or her hands after coughing or sneezing.
  • Remember, most illnesses at this age are viral, which means antibiotics will not shorten the course of the illness.
  • Your child may receive one or more immunization depending on your doctor’s schedule. Other doctors prefer to wait until the child is five for these immunizations.
  • Annual flu vaccines may be recommended for children with chronic illnesses like asthma and heart defects. Check with your doctor.
  • If the child can cooperate or a problem is suspected, vision and hearing will also be checked. The child’s blood pressure will be recorded. A urinalysis will be preformed and many physicians apply a tuberculin test at this checkup as well.
  • The following immunizations may be given at the 4-year old checkup.
  1. 1 dose of DTaP vaccine
  2. 1 dose of the MMR vaccine
  3. 1 dose of the Inactivated Polio Vaccine
  4. 1 dose of the varicella (chickenpox vaccine)
Since immunization schedules vary from doctor to doctor, and new vaccines may have been introduced,it is always best to seek the advice of your child’s health care provider concerning your child’s vaccine schedule.   The information presented in Growth Milestones was obtained with the help of our pediatric experts and with material from The American Academy of Pediatrics’ Guidelines for Health Supervision and Bright Futures’ Guidelines for Health Supervision of Infants, Children, and Adolescents. Bright Futures is supported by the Maternal and Child Health Bureau, U.S. Department of Health and Human Services.. Updated 05-08-07