🔍💡 Health assessment in nursery: a clear national protocol to early identify sensory, language and neurodevelopmental disorders, and organise appropriate referrals. #BSEM #PMI🧠🏃 Early identification at 4 years: the HAS equips PMI teams to articulate screening, prevention and child protection directly in nursery school. #EarlyYears #SchoolHealth
📌 This guide provides a very concrete national framework for the health assessment of 3–4 year olds, detailing who does what, at what age, with which tests and what referral criteria. PMI teams and school doctors find a step-by-step protocol to standardise practices, avoid 'gaps in the net' and secure referral decisions. Service managers (departments, National Education, early years structures) can use it to size resources, organise cooperation between school–PMI–city–hospital and monitor results. It is also a support for dialogue with families, particularly around prevention, vaccinations and child protection.
📜🔗LINK to the source
1. Analytical summary
1.1. Context, legal framework and issues
The guide is part of the framework of the Public Health Code and the Education Code, which make a health assessment at school mandatory for all children between 3 and 4 years old, integrated into the 20 medical examinations of childhood. It recalls the structuring texts (articles L.541‑1 of the Education Code, L.2112‑2 and R.2132‑1 of the Public Health Code, decrees of 2015, 2019 and 2024) and positions the BSEM as a screening assessment, and not a diagnostic assessment, within a national mass screening programme. The document responds to a request from the DGS to harmonise very heterogeneous practices across departments, in a context of strong tensions on medical resources of PMI and territorial inequalities in access to paediatric follow-up. It targets all enrolled children, including those monitored for chronic conditions, disabilities, neurodevelopmental disorders or benefiting from a PAI, with an emphasis on continuity with the health insurance screenings in the nursery section. The BSEM thus becomes a pivotal moment for global identification (growth, sensory, language, neurodevelopmental and psycho-affective development) and child protection, with clearly reiterated reporting obligations.
1.2. Operational contributions for field teams
The guide provides an extremely detailed outline of the BSEM: preparation with the school, summoning of parents, content of the interview, standardised tests for vision (Lea, HOTV, photoscreening), hearing (audiometry at 35 dB or Audio 4), growth, language (ERTL4), neurodevelopment and psycho-affective aspects, as well as the referral criteria for each identified anomaly. It formalises the role of the doctor-nurse duo in PMI, recommends an average duration of 45 minutes per child, and emphasises continuous training, the quality of material conditions, and the structuring of interpretation and consultation times. The synthesis section (chapter 5) offers a genuine decision-making tree to refer to the general practitioner, ophthalmologist, ENT specialist, speech therapist, orthoptist, dentist, PCO or other specialised resources. The guide also frames the return of results (health record, general practitioner, school doctor, My health space), the follow-up of referrals, and compliance with GDPR, by providing templates for summons, questionnaires, interview frameworks, and letters. Finally, it sets the epidemiological expectations of the BSEM to make it a public health management tool, through indicators of coverage, detection, and access to specialised evaluations.
2. Key points of the document
A consolidated legal framework for a mandatory and universal assessment
The guide clarifies the articulation between the Education Code, the Public Health Code, and the schedule of the 20 mandatory examinations, reminding of the obligation for a visit at 3–4 years and the possibility of data collection for epidemiological follow-up. (p. 6‑9, 52)
A global screening assessment, non-diagnostic, focused on 4 years
The BSEM is defined as a screening assessment covering growth, physical development, sensory, language, neurodevelopment and psycho-affective aspects, ideally to be carried out between 3 years 9 months and 4 years 6 months, in continuity with screenings in the nursery section. (p. 10‑15)
Standardised protocols for sensory, language and neurodevelopmental assessments
Chapters 2.5.7 and 2.5.8 precisely describe visual tests (Léa, HOTV, photoscreening) and auditory tests (pure tone audiometry, Audio 4), the use of the ERTL4 for oral language and the use of national grids for identifying developmental gaps, with thresholds of normality and referral criteria. (p. 21‑35)
A structured integration of child protection into the BSEM
The guide dedicates an entire section to identifying situations of danger or risk of danger, detailing the legal framework (CRIP, reporting to the public prosecutor, shared professional secrecy) and describing the course of action to take in cases of serious and immediate danger or weak signals. (p. 36‑39)
Annexes directly usable by field teams
The annexes provide ready-to-use templates: invitations to parents, family questionnaires, parent/educational team interview grids, referral letter templates and GDPR mentions, facilitating the uniform implementation of the BSEM across departments. (p. 54‑65)
3. Action points for local stakeholders
Organise local PMI–National Education agreements around the BSEM
Formalise at the beginning of the year a shared calendar of assessments, the modalities of convening, the availability of premises (quiet, bright, spacious room) and the exchange of information (Health Insurance results in the small section, feedback of concerns). (p. 12‑15, 49)
Standardise sensory and language screening practices
Equip all PMI teams with the required materials (Léa/HOTV scales, audiometers, Audio 4 test, ERTL4 tools), train in the use of neurodevelopmental grids and set departmental target deadlines for referrals to ophthalmology, ENT and speech therapy. (p. 21‑26, 31‑35)
Structure the child protection circuit based on the BSEM
Update, with the CRIP and the child protection referring doctors, operational procedures for information sharing, additional assessment in PMI, criteria for direct reporting to the public prosecutor and coordination with the UAPED. (p. 36‑39)
Systematically integrate the BSEM into the child's file (paper and digital)
Secure the return of results in the health record (versions 2018 and 2025), in My health space and to the school doctor, by harmonising at the service level the formulations, locations and template letters. (p. 46‑49)
Establish a follow-up of referrals and outcome indicators
Create an internal PMI dashboard to monitor the coverage of the BSEM, the anomalies identified by area, the referrals actually made (diagnostic confirmation, access times to specialists) and mobilise this data to adjust the local healthcare and prevention offer. (p. 50‑52)
4. Additional references
🔍➕ For more information, see the articles referenced by "Health Practices" on the topic of Maternal and Child Protection ➡️🔗 https://www.pratiquesensante.com/3-6-protection-maternelle-infantile.
5. Frequently Asked Questions
Is the BSEM mandatory for all children aged 3–4 years? (p. 6‑8)
Yes, the law requires a school visit for all children aged 3 to 4 years, integrated into the mandatory medical examinations for the child. Parents can choose a professional of their choice provided they produce a certificate confirming that the corresponding examination has been carried out.
At what specific age should the BSEM be scheduled in the school year? (p. 14‑15)
The guide recommends targeting children aged 3 years 9 months to 4 years 6 months, most of whom are in the middle section, in order to respect the validation ages of the tests (notably ERTL4) and the continuity with the Health Insurance screenings in the small section.
Who should carry out the BSEM and how to organise the teams? (p. 15‑16)
The priority goes to health professionals from PMI (doctors, nursery nurses or nurses trained in paediatrics), with substitution by the national education doctor if PMI cannot ensure the assessment. The guide strongly recommends a doctor-nurse duo to increase efficiency and allow for immediate overall interpretation.
What are the mandatory tests for vision, hearing and language? (p. 21‑26, 31‑32)
For vision: acuity measurement with the Lea or HOTV scale, cover test and measurement of refraction by photoscreening. For hearing: tonal audiometry at 35 dB across four frequencies, with recourse to Audio 4 in case of refusal of the headset. For oral language: use of the ERTL4 tool, validated from 3 years 9 months to 4 years 6 months.
How to decide to refer a child to a specialist? (p. 23‑26, 28‑35, 42‑45)
For each area, the guide sets precise thresholds (for example acuity < 5/10 or deviation > 1 line, anomalies in the cover test, inconclusive audiometry, profiles 2 or 3 at the ERTL4, anomalies in growth curves, neurodevelopmental warning signs) and describes the timelines for referral to an ophthalmologist, ENT, speech therapist, PCO, etc. The evaluation must always be comprehensive, taking into account risk factors and the concerns of parents or the school.
What to do if a situation of abuse or danger is suspected? (p. 36‑39)
The guide reminds of the obligation to promptly report concerning information to the CRIP or to make a report to the public prosecutor in cases of serious and immediate danger, detailing the criteria for danger, the place of "weak signals" and support resources (designated child protection doctor, UAPED). Abuse does not need to be "certain" to act.
How to document and track the BSEM in information systems? (p. 46‑51)
Results must be recorded in the health booklet (sections adapted according to the 2018 or 2025 version), in secure professional applications and, with the parents' consent, in the shared medical record via My health space. The guide also describes GDPR obligations (DPIA, legal basis, information for families, retention period) and recommends that the PMI organise to monitor the effective implementation of referrals.
6. FALC Version
Title
Guide for the health assessment in nursery school
Who is concerned?
This guide talks about the health assessment in school for children aged 3 to 4 years.
The assessment is carried out by the PMI or the school doctor.
All children in nursery must have this assessment.
Parents can come and ask questions.
Why this assessment is important
We check the growth of the child: weight, height, BMI.
We test the sight and the hearing with appropriate tools.
We look at the language and the development (walking, playing, talking, concentrating).
We check the vaccinations required in the health booklet.
We identify situations where a child may be in danger at home or elsewhere.
How the assessment takes place
The PMI contacts the school at the beginning of the school year.
Parents receive a notification with the date and time.
Parents fill out a questionnaire about the child's health and life.
On the day of the assessment, it is necessary to bring the health booklet of the child.
The assessment lasts about 45 minutes per child.
What the health professional does
They measure the weight, the size and sometimes the head circumference.
He listens to the heart and the lungs and looks at the ears, the eyes, the mouth.
He talks with the child and the parents to understand the sleep, the diet, the screens, the games.
He conducts simple tests for vision, hearing and language.
He observes the behaviour of the child in class and at home.
What happens after the assessment?
If all is well, the professional writes it in the health record.
If something is concerning, he suggests seeing a doctor or a specialist (ophthalmologist, ENT, speech therapist, dentist, etc.).
For some children, he recommends a specialised platform for development.
In case of serious danger, he immediately informs the child protection services. les services de protection de l’enfance.
Family rights and data
Health information is confidential.
The PMI explains how the data is used and kept.
Parents can request to see the data about their child.
With agreement, the results can be included in My health space.
7. Cross-sectional analysis – Values of health practices
Literacy : The document proposes structured written tools (invitation, questionnaire, interview supports) but in technical language, requiring local adaptation for parents with low levels of understanding.
Empowerment : Parents are recognised as partners (presence desired, time for exchange, parental guidance), but their co-decision-making power remains underdeveloped beyond the right to refuse accompanied by a certificate.
Participation : The participation of the educational team is formalised through a structured interview and observation grids, reinforcing the co-construction of identification with the school.
Community health : The BSEM is designed as a mass screening programme at the territorial level, with a prevention component and a goal of reducing inequalities in access to child monitoring.
Ethics : The guide clearly addresses possible biases (territorial inequalities, socio-economic vulnerability) and emphasises professional secrecy, sharing of information limited to what is necessary, and compliance with GDPR.
Human rights : It reminds of children's rights to protection, health monitoring, and consideration of their voice, while securing the procedures for reporting abuse.
Intersectorality : The text organises cooperation between PMI, National Education, Health Insurance, child protection services, hospital structures, and coordination platforms.
Partnership : The models of annexes institutionalise the partnership with general practitioners, specialists, CRIP, UAPED and child protection referral doctors, even if the practical arrangements remain to be defined locally.
Fight against discrimination : The guide explicitly mentions socio-economic and psycho-affective vulnerability and includes recommendations on interpreting; it does not address in detail the discriminations related to gender, origin or disability, leaving this work to local adaptation.
8. Assessment of the reliability of the resource
Scientific relevance : The recommendation follows the HAS methodology for good practice recommendations, with a grading of evidence (A, B, C, expert agreement) and a separate scientific argument. The recommended tests (ERTL4, Léa, HOTV, audiometry at 35 dB, TND grids) rely on tools validated in French or on expert consensus when data is limited. The regulatory references are up to date as of 1 January 2025 (mandatory examinations, vaccination schedule, GDPR).
Operational relevance : The guide is highly operational: detailed chronological flow, precise referral criteria, ready-to-use document templates and numerical benchmarks (blood pressures, acuity thresholds, BMI, referral timelines). However, it remains demanding in resources (pairs, specialised equipment, coordination time), which will require trade-offs and prioritisation in the most constrained departments.