Note for international readers: In Japan, municipalities conduct a mandatory pre-primary health screening — called the shūgakuji kenshin (就学時健診) — for all children entering primary school the following year. Carried out under Article 11 of the School Health and Safety Act, it must by law be held no later than four months before the school year starts in April (three months if enrollment procedures allow), so most municipalities hold it in the autumn or early winter. The examination covers nutritional status, the spine and thorax, vision and hearing, eye conditions, ear/nose/throat and skin conditions, teeth and mouth, and other conditions — including intellectual development. Every child due to start school the following year is eligible. This article explains how to interpret the results.
Lead
When a follow-up notice arrives after the pre-school health screening, the words re-examination can bring a parent to a brief stop. "Is something wrong?" "Does this affect starting school?" The anxiety is natural — but understanding what a follow-up notice actually means changes how the same notice lands.
The pre-school health screening is a screening. Its purpose is not to confirm a diagnosis; it is to minimize missed findings. To do that, its detection threshold is set generously — which means healthy children are flagged at a predictable rate. Knowing that structure, and knowing what each flagged item is actually looking for, makes the notice much easier to navigate.
Legal Basis and Scope
The screening is conducted by municipal boards of education under Article 11 of the School Health and Safety Act and targets children entering primary school the following year. A cabinet order requires it to be held no later than four months before the school year begins (three months if enrollment procedures allow), so most municipalities hold it in the autumn or early winter [6].
The same cabinet order lists seven items: nutritional status; spine and thorax; vision and hearing; eye conditions; ear/nose/throat and skin conditions; teeth and mouth; and other conditions [6]. "Other conditions" includes intellectual development: the accompanying ministerial ordinance asks examiners to use appropriate tests to identify intellectual disability, and to look for speech and language disorders, among other things [6]. The practical procedures are set out in the Japan Society of School Health's Manual for the School Entry Health Examination [2]. School physicians (internal medicine, ophthalmology, ENT) and school dentists typically share the examination workload, and every child due to start school the following year is eligible.
Vision: What "Below 0.7" Means
The vision component shows single Landolt rings (C-shaped symbols; the child indicates which way the gap faces), testing each eye separately with the other covered, at three levels: 0.3, 0.7, and 1.0 (decimal acuity; 0.7 is roughly 20/30). A child who cannot read the 0.7 symbol is usually advised to see an ophthalmologist [2]. In Japan's School Health Statistics, about 27% of five-year-olds in kindergarten had uncorrected acuity below 1.0 in fiscal 2024 [1]. Not all of those children have an eye condition, but it shows how widely vision still varies at this age.
Two main reasons bring a child below the threshold at this age: refractive error: a defect in the eye's ability to focus light, including near-sightedness, far-sightedness, and astigmatism, correctable with lenses and amblyopia: reduced vision in one eye due to abnormal visual development in early childhood, often called "lazy eye," which responds best to treatment in younger children.
Refractive error (near-sightedness, far-sightedness, or astigmatism) is correctable with lenses. Amblyopia, however, is different. Visual acuity development depends on visual experience in early childhood, and response to treatment is better the younger the child. On average, treatment beyond age 7 tends to be less effective than in younger children [5]. There is no single age at which the window slams shut, though: some older children still improve, and age is only one of several factors that shape the response [5]. Earlier is still better, and one of the main reasons vision is checked at this screening is to avoid missing amblyopia. If acuity could not be measured or was strikingly low, an early ophthalmology appointment — before school entry — is the appropriate next step [3].
Hearing: Catching Otitis Media with Effusion
The hearing component uses pure-tone audiometry: a standardized hearing test presenting tones at specific frequencies and volumes to measure the quietest sounds a person can detect at 1,000 Hz and 4,000 Hz. The most commonly identified finding is OME: otitis media with effusion: fluid accumulating in the middle ear without signs of acute infection, often silent but capable of causing mild hearing loss (otitis media with effusion) — fluid accumulating in the middle ear without active infection, often without noticeable symptoms.
About 90% of children have OME at some point by age 5, and it is the leading cause of hearing loss in children in developed countries [4]. Given that even mild hearing reduction can affect language development and learning, finding it at a pre-school screening carries practical value: there is still time before the school year starts.
Most OME clears up on its own, which is why guidelines recommend three months of watchful waiting for children without risk factors [4]. A follow-up notice about hearing is best used as a prompt to have the ears checked by an ENT physician between now and school entry — to confirm the current state and decide whether watchful waiting is appropriate.
Language and Developmental Assessment: What Screening Can and Cannot Tell You
The rules ask examiners to use appropriate tests to identify intellectual disability, and speech and language disorders are also within scope [6]. Methods vary by municipality, combining brief tests, questionnaires, and interviews to form a broad impression of language, communication, and cognitive development. But these are brief screenings, not formal evaluations, and they cannot produce a clinical diagnosis.
Formal developmental assessment — using standardized developmental tests or cognitive measures — is conducted by specialized services: developmental support centers (hattatsu shien sentā), pediatric neurology, or child psychiatry. When a screening flags "developmental concerns — consultation recommended," the usual next step is a referral to one of those services before school entry.
It is natural for parents to feel alarmed when a child is flagged in this category. Another way to frame it: a support pathway was identified before difficulties in the classroom forced the issue. When a school knows in advance what a child may need, it can prepare; what gets identified after school starts can mean the child has already struggled for months before help arrives.
What to Do With a Follow-Up Notice
The first question to answer is: which item triggered the follow-up? The appropriate action and urgency differ by category.
- Vision: Ophthalmology. If amblyopia is a possibility, go before school entry
- Hearing: ENT. OME is likely; timing depends on symptoms, but a pre-entry check is valuable
- Cardiac finding: Pediatrician or your primary care physician
- Language / developmental: Contact a developmental support center, or speak with your child's current pediatrician
When you attend the follow-up appointment, what helps most is: the Maternal and Child Health Handbook (boshi techō, which records development from birth), and any clinical notes from your pediatrician if available.
It is worth noting the child's state on the day of the original screening — whether they seemed anxious, tired, or had been in a noisy environment shortly before the hearing test. A brief note like that can be useful context when the follow-up appointment happens.
The screening record is prepared by the municipal board of education and sent to the child's future primary school before entry [6]; families often do not keep a copy. Taking a photograph of the results to keep at home means you have a reference point when annual school health checkups begin — the start of a longitudinal record.
Summary
The pre-school health screening is not a mechanism for excluding children with problems. It is designed to minimize missed findings and connect children to appropriate support. A follow-up notice is a signal to take the next step — not a verdict.
What each item means differs. What the appropriate response is differs. The most reliable course of action after a follow-up notice is to identify the specific item, and then consult the relevant specialist.
References
- Ministry of Education, Culture, Sports, Science and Technology (Japan). School Health Statistics Survey (final figures for fiscal 2024). 2025. Available from: https://www.mext.go.jp/b_menu/toukei/chousa05/hoken/1268826.htm
- Japan Society of School Health. Manual for the School Entry Health Examination (FY2017 revision) [in Japanese]. 2018. Available from: https://www.gakkohoken.jp/books/archives/205
- Donahue SP, Nixon CN; Section on Ophthalmology, American Academy of Pediatrics; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):e20153596. doi:10.1542/peds.2015-3596. PMID: 29756730.
- Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1–S41. doi:10.1177/0194599815623467. PMID: 26832942.
- Holmes JM, Levi DM. Treatment of amblyopia as a function of age. Vis Neurosci. 2018;35:E015. doi:10.1017/S0952523817000220. PMID: 29905125.
- Enforcement Order of the School Health and Safety Act (Cabinet Order No. 174 of 1958), Articles 1, 2 and 4; Enforcement Regulations of the School Health and Safety Act (Ministry of Education Ordinance No. 18 of 1958), Article 3 [in Japanese]. e-Gov Law Search. Available from: https://laws.e-gov.go.jp/law/333CO0000000174 and https://laws.e-gov.go.jp/law/333M50000080018