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214 Chapter 10 ABSTRACT Objective: To assess if physicians approach children with functional constipation according to the 2014 ESPGHAN/NASPGHAN guideline. Methods: We invited pediatricians and pediatric gastroenterologists in the Netherlands and the U.S. to participate in this anonymous survey using a self-developed questionnaire containing 19 multiple-choice questions concerning evaluation and treatment of children with constipation. Results: We included 328 physicians (67% from the U.S., 34% from the Netherlands). The majority of U.S. responders (53%) worked in primary care whereas all Dutch responders worked in a hospital. In total, 31% of responders were not familiar with the guideline, (38% U.S. responders vs. 16% Dutch responders, P < .001). Perianal inspection was frequently (‘often’ or ‘always’ on a 5-point Likert scale) conducted by 78% of responders. Digital rectal examination was frequently done by 42%. Inquiry about sexual abuse was made by 18%. Commonly reported reasons for omitting these items were perceived patient or parental discomfort. Most implemented initial non-pharmacological interventions included: a toilet training program (89%), optimizing fluid and fiber intake (86% and 81%), a defecation diary (62%) and a reward system (60%). Polyethylene glycol was the most prescribed medication for disimpaction (68%) and maintenance treatment (57% for infants, 97% for children ≥1 year). Conclusions: Many responders were not familiar with the ESPGHAN/NASPGHAN guideline for functional constipation. Nonetheless, therapeutic decisions correlated fairly well with recommendations from the guideline, especially for children ≥1 year. Guideline awareness and adherence remain to be improved. Future studies should focus on exploring strategies to improve guideline implementation through the development of digital learning tools.