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20 Pre-, pro- and synbiotics Prebioticsarenondigestiblecompoundsthatinducethegrowthoractivityofmicroorganisms and probiotics are live bacteria or fungi that confer a health benefit for the host. Synbiotics are defined as products that contain both pre- and probiotics. 70 Pre-, pro- and synbiotics have been suggested as potential treatment modalities for FC in children. In chapter 12 , we systematically review the literature to investigate the efficacy and safety of pre-, pro- and synbiotics in the treatment of childhood FC. Pharmacological treatment of functional constipation The pharmacological treatment of FC consists of treatment with laxatives and involves three steps; disimpaction, maintenance treatment and weaning. Disimpaction, maintenance treatment and weaning Fecal impaction occurs in approximately 50% of children with FC. 16,71 The fecal mass needs to be evacuated prior to initiating maintenance treatment in order to increase treatment success. 10 Disimpaction can be achieved with enemas or oral intake of high-dose oral polyethylene glycol (PEG) (1-1.5g/kg/day) during 3-6 days. 72–74 High-dose PEG and sodium docusate enemas have been found to be equally effective for disimpaction and although high-dose PEG is associated with a higher risk of fecal incontinence, PEG is recommended as first choice for disimpaction because it is administered orally. 33,72 After successful disimpaction, maintenance therapy with osmotic laxatives should be initiated to prevent the re-accumulation of feces. 10 Osmotic laxatives are poorly absorbed by the intestinal wall, causing osmotic water retention in the intestinal lumen. This softens the stools and increases peristalsis through intestinal distension, facilitating easy and frequent bowel movements. PEG is the first choice osmotic laxative in children with FC based on its effectiveness and safety profile. 43,75 Chapter 11 describes a cross-sectional survey study on therapy adherence in children with FC treated with PEG. Maintenance treatment should be gradually weaned rather than abruptly discontinued in order to prevent a relapse. 76 Weaning can be considered when symptoms are stable for at least 1 month under maintenance treatment, which means that children have a defecation frequency of ≥3 times per week and do not fulfill any other Rome criteria. It is recommended to evaluate symptoms again two months after cessation of treatment, to prevent or detect relapses.