The preschool years (3 to 6 years) are a period of imagination, language growth, and increasing social skill. Physical growth is slow and steady, motor skills become refined, and the child begins to plan, pretend, and play with others. Thinking is still preoperational — vivid, magical, and centered on the child's own viewpoint — which shapes how preschoolers understand illness, rules, and hospital experiences.

Physical growth

Developmental milestones (CDC 2022)

Other typical skills: rides a tricycle at about 3 years; balances on one foot for a few seconds at 3–4 years and longer at 5; copies a cross at about 4 years, a square at about 4–5 years, and a triangle at about 5–6 years; uses scissors to cut a line at about 4–5 years; handwriting with large letters and heavy pressure is normal at 5 years.

Cognitive (Piaget — preoperational, 2–7 years)

Fantasy and reality blur: preschoolers tell "tall tales" that are imagination, not deliberate lying. Imaginary friends are normal.

Psychosocial

• Erikson: initiative vs. guilt — plans, starts, and completes activities; guilt if made to feel their initiative is bad
• Freud: phallic stage — curiosity about the body and gender differences; identification with the same-sex parent (Oedipus/Electra complex)
• Play: associative (playing together in a shared activity without formal rules or roles) and dramatic/pretend play; parallel play still occurs, especially around age 3
• Moral development: preconventional (Kohlberg) — behavior guided by punishment and reward; heteronomous morality (Piaget) — rules are fixed and set by adults, and wrongness is judged by consequences, not intent
• Gender identity is established; preschoolers often hold rigid gender-role stereotypes
• Common fears: the dark, monsters, animals, being left alone, and bodily injury and mutilation
• Speech: normal dysfluency (repeating words or phrases) is common between about 2 and 4 years

• Yearly growth and BMI-for-age percentiles; a single measurement should be compared with the child's previous trend (a short child growing steadily along a percentile is usually healthy)
• Blood pressure screening yearly from age 3
• Vision screening: instrument-based at 3 years; optotype charts (LEA symbols, HOTV) from about 4 years
• Hearing: conditioned play audiometry; pure-tone audiometry from about 4 years
• Developmental surveillance; school-readiness assessment; dental screening

Management is health promotion and anticipatory guidance.

Nutrition

• Portions roughly one-quarter to one-third of an adult portion; offer a variety; parents decide what and when, the child decides how much
• About 2–2.5 cups (480–600 mL) of low-fat milk or equivalent daily; water instead of sugary drinks
• Continue cutting high-risk foods until about 4 years

Dental

• Pea-size fluoride toothpaste from age 3; parents help brush until good dexterity (about 6–8 years); flossing when teeth touch
• Limit sugary and sticky foods and sweet drinks; regular dental visits and fluoride varnish or sealants per dentist

Sleep

• About 10–13 hours per 24 hours (including naps if taken); consistent bedtime routine
• Nightmares (child wakes frightened and can be comforted) vs. night terrors (partial arousal from deep sleep early in the night — child screams, seems awake but is not responsive and does not remember): for night terrors, keep the child safe, do not try to wake them, and keep a regular sleep schedule
• Bruxism (tooth grinding) during sleep is common and often linked to stress or anxiety; assess daytime stressors and refer to a dentist if there is tooth wear or pain
• Bedwetting is common until about age 5

Listed in priority order.

1. Injury prevention
   • Car safety: forward-facing seat with a 5-point harness until the child outgrows it, then a belt-positioning booster until the adult belt fits (usually 145 cm (4 ft 9 in) tall, often at 8–12 years); back seat always
   • Drowning: supervision near water; swimming lessons do not replace supervision
   • Pedestrian and bicycle safety: hold hands when crossing streets; helmet for tricycles, bikes, and scooters
   • Fire and burns: matches and lighters out of reach; teach "stop, drop, and roll"
   • Firearms: stored unloaded and locked, ammunition separately
   • Body safety: teach correct names for body parts, that no one may touch private parts, and to tell a trusted adult
2. Prepare for health care procedures using preoperational thinking
   • Simple, concrete explanations shortly before the procedure, focused on what the child will see, hear, and feel
   • Therapeutic play with dolls and real equipment; let the child handle a stethoscope or syringe without a needle
   • Correct the belief that illness or procedures are punishment: "You did not do anything wrong. The medicine helps your body get better."
   • Avoid frightening words ("cut," "take blood," "shot"); use bandages over puncture sites — preschoolers fear their "insides leaking out"
   • Allow parents to stay; offer choices; praise cooperation
3. Support initiative: allow the child to help (hold the tape, choose a sticker); avoid criticism that produces guilt
4. Developmental surveillance and referral for concerns
5. Promote play and learning: dress-up and role play, drawing, clay, puzzles, simple board games, climbing, swinging, running, and ball play for gross motor skills; reading together daily; screen time no more than 1 hour per day of high-quality content, watched together
6. Guidance for parents: consistent limits, time-out, praise for desired behavior; explain rules simply

• Tall tales, imaginary friends, animism, and magical thinking are normal; respond calmly, separate fantasy from reality gently
• Rigid gender stereotypes and curiosity about bodies are normal; answer questions honestly and simply
• Associative play and occasional difficulty sharing are expected; small group play builds social skills
• Stuttering that is mild and occasional in a 2- to 4-year-old usually resolves; do not finish the child's sentences
• A preschooler who does not understand that the same amount of juice in a taller glass is "the same" is showing normal preoperational thinking, not a learning problem
• Prepare for school: routines, independence in dressing and toileting, reading together
• Growth concerns: keep following the child's growth chart over time before seeking tests

• Loss of previously acquired skills; missed milestones on the CDC checklists
• Speech unintelligible to strangers by about 4 years; stuttering with visible struggle, tension, or avoidance, lasting more than about 6 months, or beginning after age 5
• Persistent aggression, severe tantrums, or inability to separate from caregivers beyond expected levels
• Daytime wetting or new bedwetting after being dry (urinary infection, constipation, diabetes, stress, or abuse)
• Growth velocity falling (crossing percentiles downward) — endocrine or chronic disease
• Injuries or sexualized behavior inconsistent with development — consider abuse and follow reporting laws

• Preschool = 3–6 years; ~2 kg/year and 6–8 cm/year; birth length doubles by 4 years
• CDC: uses fork and draws circle 3 years; catches ball, unbuttons, 4-word sentences, draws person with 3 parts 4 years; hops on one foot, counts to 10 at 5 years
• Initiative vs. guilt; phallic stage
• Preoperational: egocentrism, animism, magical thinking, centration, no conservation, irreversibility
• Illness viewed as punishment; fear of mutilation → bandages and reassurance
• Associative play and pretend play
• Heteronomous morality: rules fixed; judged by consequences
• Therapeutic play and concrete explanations before procedures
• Tall tales = imagination, not lying
• Pea-size fluoride toothpaste from 3 years
• Booster seat until the adult belt fits (about 145 cm)
• Screen time ≤ 1 hour/day