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222 Chapter 10 In 2015, Ciullo et al . published an abstract on adherence to the 2014 ESPGHAN/NASPGHAN guideline. 13 In their study among 147 Italian pediatricians, 63%of responders were unfamiliar or slightly familiar with the guideline. The awareness of the guideline was poor compared to our study, but it should be taken into account that this study was performed when the guideline was only recently published. In our current study, guideline awareness was much higher among pediatric gastroenterologists than among general pediatricians. Although this result was to be expected, it does raise questions on how to improve guideline awareness among general pediatricians, who treat the majority of children with constipation. Interestingly, physicians with less experience reported better familiarity with the guideline, suggesting that junior physicians are more aware of recent guidelines potentially because they are confronted with these guidelines during their training. In an attempt to achieve better awareness and implementation of the 2014 ESPGHAN/NASPGHAN guideline, in 2015 ESPGHAN developed an online course on childhood FC. 14 This course is accessible via United European Gastroenterology (UEG) after obtaining a log in that is available for free through https://www. ueg.eu/myueg/myueg. In a recently published short communication, Mallon et al. described promising results to improve FC guideline awareness and implementation using a “spaced- education”game. 15 The concept of spaced-learning involves repetition of highly condensed information. In the study by Mallon et al. , questions were sent to pediatric primary care providers on a weekly basis. Through an adaptive process, incorrectly answered questions were re-sent after one week and correctly answered questions after two weeks. Participants earned points based on their performance and could eliminate questions by answering them correctly twice. A competition element was added by assigning participants to teams. This intervention significantly improved the performance of participants, comparing final scores with baseline. 15 Hopefully, such attempts to improve guideline awareness and implementation will lead to better guideline awareness and implementation in the future. Previous studies have reported that DRE is often avoided in clinical practice. A study from Saudi Arabia showed that DRE was routinely performed in the evaluation of children with constipation by only 39% of pediatric providers versus 79% of pediatric gastroenterologists. 16 Similarly, a study from Brazil demonstrated that only 43% of non- gastroenterology pediatricians performed a DRE. 17 In the study by Focht et al. , 43% of U.S. pediatricians reported to either never or only occasionally performing a DRE on new patients presenting with constipation. 10 In the more recent study by Yang et al., DRE was never or rarely performed by 61%. 11 In the current study, patient and parental discomfort were commonly reported as reasons not to perform a DRE and this was more frequently reported by U.S. physicians as compared to the Dutch physicians. Patient discomfort has been previously reported as a reason to avoid a DRE as part of the physical examination