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223 Guideline adherence 10 in both children and adults. 10,18,19 Moreover, examination of the anorectum seems to be a sensitive issue for parents and physicians. Perhaps the difference between Dutch and U.S. responders indicates that cultural differences exist regarding the opinions on this topic, even between two Western countries. The recommendations regarding DRE have also changed in guidelines over time. While the 1999 NASPGHAN guideline recommended to perform a DRE in all children with FC 20 , the 2014 ESPGHAN/NASPGHAN guideline recommends that this is only necessary in children who fulfill only one of the Rome criteria and where a DRE may therefore help to establish a diagnosis of FC. 7 Although a fecal mass in the rectum remains one of the diagnostic Rome IV criteria 2,3 , the perceived value of a DRE seems to have decreased over the past two decades. However, a DRE can provide valuable information on the presence of a rectal fecal mass, anorectal sensation, and sphincter tone. 7,21–24 Moreover, in a child with functional fecal incontinence it can be difficult to differentiate between FC and functional nonretentive fecal incontinence and in these children, detection of a fecal mass during DRE will help to establish a diagnosis of FC and thereby guide management. 7,25 In accordance with the guideline, the majority of responders in the current study reported to use PEG as treatment of first choice for disimpaction in children. The guideline also recommends PEG as the first-line maintenance treatment of FC in children of all ages. 7 For the treatment of children ≥1 year of age, this recommendation was well adhered to in our study sample. For the treatment of children <1 year of age, most responders indeed reported to use PEG as treatment of first choice, but lactulose was also commonly used as treatment of first choice. The guideline recommends lactulose if PEG is not available. 7 In the present study, a remarkably high rate of physicians reported to prescribe pre- or probiotics to children with FC, this rate was significantly higher among U.S. physicians compared to Dutch physicians. These findings confirm results from a previous survey study among 74 pediatric surgeons and pediatric gastroenterologists, where 18% of responders reported to prescribe pre- or probiotics to children with FC. 26 Currently, there is no sufficient evidence to support the use of pre-, pro- or synbiotics in the treatment of childhood FC. 7,27 It is therefore unclear why physicians prescribe pre- or probiotics and which pre- or probiotics they actually prescribe. This should be sought out in future studies and it may be necessary to educate physicians about the benefits, risks and costs of prescribing pre- and probiotics. Some limitations need to be taken into account when interpreting the results of this study. Because we primarily invited participants of selected meetings focused on pediatric gastroenterology, our results are at risk of selection bias. In order to include more general pediatricians who did not attend a pediatric gastroenterology focused meeting, the questionnaire was also distributed in two regional hospitals (one secondary care center, one tertiary care center). Furthermore, the questionnaire was distributed among all pediatric