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19 General introduction and outline of the thesis Nonpharmacological management Education Education is the first step in the non-pharmacological treatment of FC and FNRFI. 64 This should include an explanation of physiological defecation dynamics, tailored to the developmental age of the child. In children with FC, the negative chain of events that may have been prompted by a painful defecation experience should be explained to parents and, if possible, children. The concept of overflow incontinence and the pivotal role that withholding behavior plays in the pathophysiology need to be explained. Toilet training program In order to prevent the occurrence of fecal impaction and to decrease the risk of fecal incontinence episodes, it is important to evacuate stools regularly. In children with a developmental age of ≥4 years, this can be established by introducing a toilet training program, with scheduled toilet sit moments throughout the day, usually after most meals and after coming home from school. The toilet sit moments are scheduled after a meal to benefit from the gastrocolic reflex which increases colonic peristalsis and tone in response to ingestion of a meal. To motivate children to maintain this toilet training program, a reward system can be introduced. By rewarding the child for completing toilet sit moments, the child is positively reinforced to comply with therapy. A non-accusatory approach of both physicians and parents is of key importance since children may feel guilty or embarrassed, especially about episodes of fecal incontinence. 64 Only rewarding periods without fecal incontinence is therefore not recommended, as this may increase feelings of guilt and can be experienced as punishment for having fecal incontinence. Lifestyle interventions Insufficient fiber intake is associated with FC and a normal fiber intake should therefore always be recommended. 65 However, there is insufficient evidence to support the use of supplementary dietary fiber in excess of the daily recommended intake. 33,66 Epidemiological studies have suggested an association between a low fluid intake and FC, but there is insufficient evidence for a favorable role of fluid intake exceeding normal recommended amounts in the treatment of FC. 67  Therefore, a normal fluid intake based on the age of the child is recommended in children with FC. 33 Although higher levels of physical activity may be associated with a decreased risk of developing FC 68,69 , no studies have been performed to assess the effect of increasing physical activity to treat FC in children. 33