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215 Guideline adherence 10 INTRODUCTION Functional constipation (FC) is a common problem in childhood, with a worldwide reported prevalence up to 29.6%. 1 The diagnosis is based on the pediatric Rome IV criteria. 2,3 Symptoms of FC include infrequent, painful defecation, hard stools, fecal incontinence and abdominal pain. 4 These bothersome symptoms negatively affect quality of life in patients and their families and contribute to increased health care utilization and associated costs. 5,6 In 2014, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published the ESPGHAN/NASPGHAN guideline for FC in children. 7 This guideline provides evidence-based recommendations for the evaluation, treatment and follow-up of children with FC. Key recommendations include that the diagnosis is based on history and physical examination and that the Rome criteria should be used to define FC. 7 If only one of the Rome criteria is present and the diagnosis of FC is uncertain, a digital rectal examination (DRE) is recommended. 7 A normal fiber intake, fluid intake and physical activity level are recommended and the routine use of pre- or probiotics is not recommended in the treatment of childhood constipation. 7 Non-pharmacological interventions consist of demystification, explanation, and guidance for toilet training (in children with a developmental age of at least 4 years). For disimpaction, the guideline recommends polyethylene glycol (PEG) orally 1-1.5g/kg/day for 3 to 6 days or an enema once per day for 3 to 6 days if PEG is not available. 7 PEG with or without electrolytes is also recommended as the first-line maintenance treatment. 7 In order to improve medical care, it is important that physicians are aware of guidelines and that these guidelines are adhered to in clinical practice. Previous studies on guideline adherence in the Netherlands and the U.S. have suggested that approximately 30-40% of patients do not receive care according to current evidence. 8,9 Focht et al. andYang et al. have shown poor familiarity with and low adherence to the NASPGHAN guidelines for childhood FC from 1999 and 2006 respectively. 10,11 These studies addressed the need for educational strategies to improve guideline adherence in order to achieve effective management of FC in children. Unfortunately, educational interventions have shown low levels of improvement regarding guideline implementation. 12 Numerous potential barriers may impede guideline awareness, these barriers can occur at the level of the individual professional, the healthcare team, the healthcare organization or the wider environment. 12 Therefore, it is important to understand the specific barriers to change certain practices and to tailor strategies to improve guideline adherence to these specific barriers. 12