Age Of Toilet Training Research Articles

Token Ekonomi Untuk Mengatasi Enuresis Non Organik Pada Anak

Enuresis is bed wetting behavior experienced by individuals who have gone through the developmental age of toilet training. This condition makes individuals and those around them experience problems in dealing with enuresis. The behavioral approach is an approach used to change maladaptive behavior into adaptive behavior. This approach is an effective therapy for children to carry out agreed behaviors to obtain the expected behavior. The token economy is a behavioral approach to giving tokens (signs) that focuses on modifying behavior to increase expected behavior and reduce unexpected behavior. Obtained tokens are collected in an agreed upon amount to be exchanged for prizes. Children with enuretic behavior can modify behavior using token economy techniques to anticipate enuretic behavior. The results of this study explain that the token economy can help overcome non-organic enuresis in children. Children are able to make changes in behavior according to the contract that has been planned together to avoid enuresis (wetting the bed).

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

Commentary to model for predicting high -grade vesicoureteral reflux in young children presenting with febrile urinary tract infection

The authors employ three well known imaging and clinical risk factors associated with vesicoureteral reflux (recurrent UTI, non-E. coli pathogen, abnormal renal and bladder ultrasound) to create a scoring system for limiting the use of a VCUG in all children who present with a febrile UTI. It is no surprise that the presence of any one of these factors alone identifies an appreciable number of children with high grade (III–V) reflux. The authors, along with the American Academy of Pediatrics and the British National Institute for Clinical Excellence, have striven to reduce the use of the VCUG and are content with missing some with reflux and renal scarring. These efforts are not without controversy. The cohort in this study has particular characteristics that affect the generalizability of the conclusions. The majority was uncircumcised males and this may explain why only 92 of 324 children with febrile UTI's had reflux. Since most were infants under the age of toilet training, bowel and bladder dysfunction could not be evaluated. A small number of children underwent DMSA scanning, so the authors are incapable of legitimately assessing the severity or clinical significance of the reflux in the remainder, independent of grade. Notably, of the small number of low grade reflux children who did undergo DMSA evaluation, 30% had scars. This is the group the authors are suggesting should not undergo a VCUG at presentation, as they argue that the consequences of reflux were “minimal.” Finally, it may be unrealistic to assume that a child with reflux who was not fully evaluated initially would reliably return for evaluation after a second or third UTI. A number of children in this cohort do not live near a center and in any case, follow up in many circumstances is often not perfect. As demonstrated by the data in this report, the use of this scoring system to withhold VCUG imaging will result in missing children with reflux and renal damage. Model for predicting high-grade vesicoureteral reflux in young children presenting with febrile urinary tract infectionJournal of Pediatric UrologyPreviewHigh-grade vesicoureteral reflux (VUR) is associated with long-term renal outcome, and can be missed if voiding cystourethrogram (VCUG) is not performed. The current febrile urinary tract infection (UTI) guidelines have narrowed down the indications for VCUG. This study aimed to determine the predictors and develop a model to predict high-grade VUR (grade III-V) in young children presenting with febrile UTI. Full-Text PDF Response to commentary re model for predicting high -grade vesicoureteral reflux in young children presenting with febrile urinary tract infectionJournal of Pediatric UrologyPreviewThank you so much for your comment. We do agree that voiding cystourethrography (VCUG) examination in young children with first febrile urinary tract infection (UTI) is still a controversial topic. Recently, a reduction in the use of the VCUG has occurred [1,2]. Concern regarding missing those with reflux and renal scarring is important and needs more long-term data analysis. Full-Text PDF

Application of Machine Learning Techniques for Enuresis Prediction in Children.

As a subset of artificial intelligence, machine learning techniques (MLTs) may evaluate very large and raw datasets. In this study, the aim is to establish a model by MLT for the prediction of enuresis in children. The study included 8,071 elementary school students. A total of 704 children had enuresis. For analysis of data with MLT, another group including 704 nonenuretic children was structured with stratified sampling. Out of 34 independent variables, 14 with high feature values significantly affecting enuresis were selected. A model of estimation was created by training the data. Fourteen independent variables in order of feature importance value were starting age of toilet training, having urinary urgency, holding maneuvers to prevent voiding, frequency of defecation, history of enuresis in mother and father, having child's own room, parent's education level, history of enuresis in siblings, consanguineous marriage, incomplete bladder emptying, frequent voiding, gender, history of urinary tract infection, and surgery in the past. The best MLT algorithm for the prediction of enuresis was determined as logistic regression algorithm. The total accuracy rate of the model in prediction was 81.3%. MLT might provide a faster and easier evaluation process for studies on enuresis with a large dataset. The model in this study may suggest that selected variables with high feature values could be preferred with priority in any screening studies for enuresis. MLT may prevent clinical errors due to human cognitive biases and may help the physicians to be proactive in diagnosis and treatment of enuresis.

Antibiotic prophylaxis for prevention of urinary tract infections in the first year of life in children with vesicoureteral reflux diagnosed in the workup of antenatal hydronephrosis: a systematic review.

Children with antenatal hydronephrosis (ANH) diagnosed with postnatal asymptomatic vesicoureteral reflux (VUR) are thought to be at higher risk of urinary tract infection (UTI). As such, continuous antibiotic prophylaxis (CAP) is empirically recommended until age of toilet training; however, there are limited data to support this. The objective of this systematic review was to summarize the existing data and compare UTI rates in infants with asymptomatic VUR on CAP during the first year of life, to those not on CAP. Secondary objectives were to determine associated risk factors with UTI development. A systematic search of all relevant studies and abstracts was conducted using 4 electronic databases by utilizing appropriate key words by an expert hospital librarian. Eligible studies included children with prenatal hydronephrosis, asymptomatic VUR with or without CAP, and reported on development of UTI in the first year. Of 6903 citations screened, 18 were selected, giving a total population of 829 (69.4% male, median age 57days) who met the inclusion criteria. Most studies were retrospective and of low-quality evidence. Overall, 15.4% of patients developed at least one breakthrough UTI and females had a higher risk of UTI (odds ratio (OR) 2.3, 95% CI 1.1-4.7). Comparison with children not taking CAP was not readily reported, and meta-analysis could not be completed. Randomized controlled trials and standardized reporting of clinical variables are required to understand the protective effect of antibiotic prophylaxis in this cohort.

Patients with Constipation and Related Factors

Objectives: Constipation is a widespread public health problem throughout the world and is commonly seen in the childhood period. The aim of this study is to assess the etiologic causes, clinical features and factors related to constipation among cases attending with constipation complaints.Methods: The files and automation records of 162 cases aged from one month to 18 years attending the pediatric health and diseases clinic with the complaint of constipation from January 2018 to January 2019 were retrospectively investigated.Home accidents were self-reported and questioned for the previous year. We developed a composite index to assess the overall housing conditions. Housing conditions were accepted “inadequate” if the score was below the median. We developed a logistic regression model to predict the housing-related factors in accidents.Results: The mean age of cases included in the study was 51.1±40.8 months (2-192 months), with 53.1% of patients (n=86) in the 1 month-3 years age interval. Of cases, 62.3% were female and 37.7% were male. Toilet training had been given to 56.8% of cases, with mean age of toilet training 2±0.5 years. Fiber intake was insufficient in 72.2%, while fluid intake was insufficient for 84.5%. Of patients, 56.2% (n=91) had begun supplementary nutrition early (before 6 months). Of cases, 22.8% had developmental retardation, while 13% (n=21) had urinary tract infection as an additional accompanying problem. The most common accompanying complaints were abdominal pain and bleeding while defecating. In 39% of patients, there was family history of constipation. The functional constipation rate was 90.1%, while 1.9% had hypothyroidism, 1.9% had anal stenosis, 1.9% had medication use, 1.2% had Hirschprung disease, 1.2% had hypopotassemia, 1.2% had hypercalcemia and 1 case had vitamin D intoxication identified. Conclusion: Constipation is associated with factors like toilet training age, beginning supplementary food early and insufficient fiber and fluid amounts in diet. It may cause growth development delay, urinary system infections and behavior problems.

Effect of urinary training on urination control of infants using nappies after birth

Objective To investigate the effect of urinary training on urination control in infants using nappies after birth. Methods Stratified sampling method was used to investigate the daytime urination control and the using of diapers by children in kindergartens of 6 prefecture-level cities in Henan Province, China.The survey was conducted among parents of healthy children. Results In a total of 12 250 questionnaires, 11 697 had response, and 10 562 valid questionnaires were collected, and the effective recovery rate was 86.22%.After the birth of infants, the age of toilet training was divided into 6 groups(0- 0.05). After 12 months, the urination control rate decreased with the start time delayed till 2 years of age, and the urinary control rate at the age of 2 years old n different groups was 59.97%(1 314/2 191 cases) and 54.10%(231/427 cases) respectively.The results of other ages(0.5, 1.0, 1.5 years old) were similar to those of 2 years old.There was no difference between the groups of different genders(all P>0.05). Conclusions The use of diapers in infants before the age of 1 year to start urinary training is conducive to the development of urinary control in infants. Key words: Infant and young child; Early toilet training; Urination control; Use of diaper

Age of Initiation and the Factors Associated with Toilet Training in Healthy Saudi Children

With the appropriate knowledge of the age to initiate toilet training and acknowledging the factors that influence it, parents can prevent many health issues related to voiding. Our study aimed to determine the average age of the initiation of toilet training among Saudi children and the factors that may affect this training. This study was carried out by distributing questionnaires to mothers who attended various clinics in our institute. A sample included 1000 healthy Saudi children. The mean age of the initiation of toilet training in healthy children was 25.6 ± 9.4 months while the median was 24 months, the mean duration of training was 6.3 ± 9.1 months. Most children (92%) were trained in the summer months. Mother’s educational level, number of siblings, and socioeconomic status were significant factors that affected the age of initiation. However, mother’s occupation, caregiver, and the order and gender of the child did not have a significant effect on the initiation of toilet training. The median age of toilet training among our children matched other studies. Summer seems to be the preferred season to initiate training.

Anatomic findings associated with epispadias in boys: Implications for surgical management and urinary continence

Pre-operative physical examination of male epispadias allows for classification of epispadias level as glanular (GE), penile (PE) or penopubic (PPE), and for delineation of anatomic anomalies. The incidence of associated extragenital abnormalities, such as vesicoureteral reflux (VUR), bladder neck (BN) abnormality and abnormal pubic diastasis (PD), and their impact on urinary continence has not yet been systematically studied. The goal of this study was to evaluate whether the more proximal level of epispadias correlated with associated extragenital anatomic anomalies seen on initial imaging or endoscopic evaluation, and whether these pre-operative findings contributed to subsequent surgical management and impacted on achieving urinary continence. It was hypothesized that the more severe forms of epispadias may be associated with a higher frequency of associated anomalies. The study was an IRB-approved, retrospective case study of all male patients treated initially for isolated epispadias at the current institution between 1994 and 2011. Data collection was achieved by chart and radiology review evaluating PD, BN appearance, presence of VUR, surgical treatment, and urinary continence. A total of 26 patients were identified and divided into three groups based on appearance at physical examination: four glanular (GE), eight penile (PE), and 14 penopubic (PPE); 17 patients had an abnormal BN. Reflux was noted in nine of 20 patients who had a voiding cystourethrogram (VCUG), two of which had an episode of pyelonephritis. Of the 22 patients past the age of toilet training, 17 were continent (64% (9/14) penopubic, 63% (5/8) penile, and 75% (3/4) glanular). Anatomic classification for male epispadias did not provide sufficient information regarding extragenital findings. This study provided new information regarding PD, BN appearance, presence of reflux, and ultimate urinary continence. Pubic diastasis and BN abnormalities were more frequently seen in more severe forms of epispadias, whereas VUR seemed more prevalent in less severe forms. A template for pre-operative evaluation was outlined. Limitations of the study were its retrospective design and relatively small cohort of patients, which reflected the rarity of the condition. Based on the information generated, additional anatomic information was generated regarding boys with epispadias. This information will help guide the evaluation and the management of these patients in the future.

Diapering habits: a global perspective.

There are tremendous variations in diapering practices, reflecting varying cultural practices and regional difference. Around the world, more than 134 million babies are born each year, a rate of 255 births per minute or 4.3 births each second. While global population growth has been steadily declining from its peak in 1963, several regions, including the Middle East and Sub-Saharan Africa, continue to maintain high birth rates. Though the essential needs of infants are largely similar, family habits and practices during early years of life vary dramatically. This article surveys data documenting variations in diaper frequency, types, and duration of use internationally, including age of toilet training. These factors may influence diaper rash and skin health of infants and young children. Much of this data was collected as part of analysis of the international commercial diaper market, evaluated and organized as part of an international initiative on Global Infant Skin Care, and presented to a panel of experts for critique and commentary in a symposium held in December, 2013.

The association of age of toilet training and dysfunctional voiding.

ObjectiveTo determine whether age of toilet training is associated with dysfunctional voiding in children.Materials and methodsWe compared patients referred to the urologic clinics for voiding dysfunction with age-matched controls without urinary complaints. Characteristics including age and reason for toilet training, method of training, and encopresis or constipation were compared between both groups.ResultsInitiation of toilet training prior to 24 months and later than 36 months of age were associated with dysfunctional voiding. However, dysfunctional voiding due to late toilet training was also associated with constipation.ConclusionDysfunctional voiding may be due to delayed emptying of the bowel and bladder by children. The symptoms of dysfunctional voiding are more common when toilet training early, as immature children may be less likely to empty in a timely manner, or when training late due to (or in association with) constipation.

State's pull-through for total colonic aganglionosis and GI dismotility.

Total colonic aganglionosis (TCA) is present in 4% - 5% of the patients with Hirschsprung's disease and has a high surgical mortality rate between 13% - 23%. Diagnosis and treatment of TCA is still a major challenge for pediatric surgeons. Many techniques with several advantages and disadvantages were established for its treatment. We have performed State's pull-through as total colectomy and ileo-proctostomy with long posterior rectal myotomy in TCA and severe dysmotility disorders. In this retrospective study, 13 patients with TCA were evaluated from 1992 through 2012 in two pediatric surgery centers, which consisted of 10 TCA, one intestinal neuronal dysplasia (IND), and two chronic intestinal pseudo- obstruction syndrome (CIP). All patients underwent total colectomy, resection of part of the involved small intestine, and rectal anastomosis in one layer with 4/0 vicryl with long posterior rectal myotomy. All patients had preoperative barium enema and rectal biopsy for diagnosis. Leveling ileostomy was performed in 12 patients and mid-jejunostomy in one patient. In two of 13 children, proximal diverting loop ileostomy was established after definitive operation. In three patients, trans-rectal myotomy was needed two weeks after the initial operation. All patients were females with the age ranging from six months to six years. State's pull-through was carried out for all (the mean age of definitive procedure was 5.1 months). Rectal biopsy of 10 patients reported no ganglion cells of which one had extended aganglionosis to mid- jejunum, one had IND, and two had ganglionicbowel bowel with clinical presentation of CIP. The follow- up period was from six months to 10 years (the mean follow- up period was 10 months). There were no significant complications in 12 patients except episodes of diarrhea and severe dehydration which needed hospitalization. One patient with mid- jejunum aganglionosis had severe failure to thrive and needed repeated hospitalization for parenteral nutrition. All patients had acceptable bowel function following operation (two to six times a day). Now, five of the 13 patients are above the age of toilet training, having voluntary bowel movement with little or no medication (Leopromid). State's pull-through is recommended in all cases of TCA and severe dysmotility problems of the colon. This technique is less difficult to perform, and avoids the complications and disadvantages of removal of the rectum and has satisfactory results.

High Grade Vescicoureteral Reflux in Children Presenting with Urinary Incontinence Without a History of Urinary Tract Infection

Purpose Urinary Tract Infection(UTI)is the most common clinical presentation of vesicoureteral reflux(VUR).However,VUR has also been reported in children with voiding disorders with or without history of UTI.The aim of this study was to determine the prevalence of VUR in children presenting with urinary incontinence without a history of UTI among a large group of patients with intermediate and high grade VUR. Material and Methods The medical records of 1432 children diagnosed with intermediate and high grade VUR(Grade III to V)during 1998 to 2008 were reviewed. VUR was diagnosed in all patients by voiding cystourethrogram(VCUG).Renal parenchymal scarring was evaluated by DMSA scans and classified into three groups:mild with relative uptake between 40%and45%,moderate with relative uptake between 20%and40% and severe with relative uptake Results Of the 36patients with urinary incontinence,11children had day and night incontinence,6 had only daytime wetting and 19 had only bedwetting at night.There were 19boys and 17girls and their ages ranged from 4years to 12.1years(median age 6.5years).24children had unilateral VUR and 12 bilateral with a total of 48 refluxing units.VUR was grade II in 2ureters,grade III in 30ureters,grade IV in 15 and grade V in 1.Both patients with grade II VUR had a higher grade VUR on the contralateral side.11(30.5%) patients demonstrated renal scarring on DMSA scans.Scarring was mild in 5 patients,moderate in 5 and severe in 1patient. Conclusions Our large series of intermediate and high grade VUR has identified a small but definite subgroup of patients whose sole presenting symptom is urinary incontinence.We recommend VCUG in all children beyond the age of toilet training who present with urinary incontinence without UTI but sonographic evidence of pelvicalyceal and ureteral dilatation.

Voiding dysfunction: Outcome in infants with congenital vesicoureteral reflux

Objectives To assess the rate of development of voiding dysfunction as an outcome in patients with congenital vesicoureteral reflux. Methods A computerized database was used to review the medical records of all patients with congenital reflux diagnosed before 6 months of age from 1988 to 2002. Only those infants with reflux who were followed up for at least 6 months past the age of toilet training were included. The parameters tabulated in this group included the presence of frequency, daytime wetting, urge incontinence, and infrequent voiding. The variables were summarized using contingency tables, and associations were evaluated using chi-square analysis and Fisher’s exact test. Results Of 342 patients (145 boys and 197 girls) with reflux, 67 (19.6%) developed voiding dysfunction (17.9% boys and 20.8% girls). No statistically significant difference was found between high grade (IV and V) and low grade (I and II) or grade III reflux, or between unilateral and bilateral reflux for the development of voiding dysfunction. Of the patients with reflux who had renal damage on dimercaptosuccinic acid scan, 24.3% of girls and 30.4% of boys developed voiding dysfunction, which was not significantly different from those without renal damage. Conclusions Approximately 20% of patients with vesicoureteral reflux diagnosed before 6 months of age demonstrated dysfunctional voiding after the age of toilet training. Voiding dysfunction occurred independent of sex, laterality, or severity of vesicoureteral reflux. Infants with renal damage on dimercaptosuccinic acid scan developed dysfunctional voiding only at a slightly greater, but not significantly different, rate than those with normal kidneys.

URINARY CONTINENCE IS WELL PRESERVED AFTER TOTAL UROGENITAL MOBILIZATION

Total urogenital sinus mobilization (TUM) has been advocated as a successful technique in the repair of common urogenital sinus anomalies. To our knowledge the long-term effects on continence, voiding pattern and bowel control have not been published. We present our experience and assessment regarding these issues. We retrospectively reviewed our experience with TUM. Medical records were reviewed for each patient along with long-term followup by telephone questionnaire and clinical visits. Uroflowmetry was performed in recent patients who were old enough to cooperate in the study. A total of 13 females underwent TUM. Medical records were reviewed for all patients. Patients were divided into 2 groups. Group 1 consisted of 7 patients who underwent surgery before the age of achieving continence, and group 2 consisted of 6 patients who were incontinent before surgery. One patient in group 2 was lost to long-term followup. Two children in group 1 have enuresis, a 27-month-old with day and nighttime enuresis and a 3-year-old with only nocturnal enuresis. All patients in group 2 were continent immediately postoperatively. TUM preserves urinary continence immediately postoperatively among patients who are continent before surgery. Furthermore, it does not appear to delay the natural development of continence among patients undergoing surgery before the age of toilet training.

Enuresis and the effective factors--a case-control study.

Enuresis is widespread and affects the child and the family both psychologically and socially. This research was performed between 1 February and 30 June 1998, in Gemlik district to investigate the effective factors on enuresis among 5-9 year-old children. A questionnaire containing 31 questions was answered by the mothers during the house visits. Two hundred and seventy-seven cases were determined in a previous study and randomly selected 277 controls were matched according to their ages, gender and residential districts. Younger mothers, mothers with less education and working mothers have more enuretic children. Enuresis is more prevalent within the first children. Odds ratio is 11.1 if his/her mother and/or father has had enuresis. The age of toilet training was earlier among controls than cases. As enuresis is rather widespread, the parents may consider this as a transient problem and therefore no effort might be given for the solution. Trained health personnel and physicians should enlighten the parents about enuresis in order to eliminate the negative effect on the child.

BLADDER FUNCTION IN HEALTHY NEONATES AND ITS DEVELOPMENT DURING INFANCY

Bladder function in healthy neonates and its development during infancy are described. Results of free voiding studies of healthy neonates and infants using 4-hour voiding observation and urodynamics studies were reviewed. According to these studies, voiding in the healthy neonate is characterized by small, frequent voids of varying volume in the individual case and interrupted voiding in 30% of the cases. Interrupted voiding is clearly an immature phenomenon since it is seen in 60% of preterm neonates and disappears completely before the age of toilet training. These voidings are considered to be due to a dyscoordination between the sphincter and detrusor, which has also been observed on urodynamic studies and which probably also explains incomplete emptying seen in this age group. Emptying remains incomplete to the age of toilet training when residual urine is median 0 ml. during 4 hours of observation. Voiding rarely occurs during quiet sleep even in the neonatal period, when signs of arousal are often noted before voiding. However, voiding during sleep in 60% occurs of preterm infants, indicating that it may be due to maturation of the central nervous system. Bladder instability is rarely seen in healthy neonates and infants according to urodynamic studies but hyperactivity is suggested in the neonatal bladder with premature voiding contractions after only a few milliliters of filling and with leakage of urine. This latter phenomenon probably explains the low cystometric bladder capacity in this age group. High voiding pressure levels also accompany this low bladder capacity. Thus, it can be suggested that the neonatal bladder is regulated by neuronal pathways with connections to the cerebral cortex in the neonatal period, which is contrary to the earlier concept of voiding as an automatic event in response to a constant volume in the bladder. This theory does not mean that voiding is conscious or voluntary in this age group, but only that the voiding reflex disturbs the neonate. New characteristics include the concept of physiological dyscoordination, such as hyperactivity of the detrusor seen as low bladder capacity, and high voiding pressures in the neonatal period.

Toilet training.

Toilet training.