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249 Pre-, pro- and synbiotics 12 INTRODUCTION As a result of the development of culture-independent techniques, we are starting to understand the human microbiome and its role in health and disease. We now know that the vast majority of our resident microbes are contained in the gut and that gut microbiota changes are associated with a wide variety of diseases and disorders. 1 Unfortunately, in most cases it remains unclear whether these microbiota changes are cause, effect or innocent bystander effect of these illnesses. One of the disorders in which the gut microbiota may be involved is functional constipation (FC). 2 FC is a common and bothersome problem in pediatric healthcare. The prevalence ranges between 0.7% and 29.6%. 3 This functional gastrointestinal disorder is defined according to the Rome III criteria (Table 1). Symptoms include infrequent defecation, hard, painful stools that are difficult to pass, fecal incontinence and abdominal pain. These symptoms are known to have a significant impact on the quality of life of children and on healthcare costs. 4 The conventional approach towards FC encompasses education including dietary advice, a toilet program and laxatives. 5 However, conventional treatment turns out to be insufficient in a substantial amount of children. 5 Also, most laxatives have adverse effects such as abdominal pain or flatulence. 4 More importantly, although laxatives are generally considered to be safe, little is known about the long-term adverse effects of chronic laxative usage, such as efficacy, potential electrolyte disturbances or mucosal damage. Therefore, it remains important to develop and evaluate new treatment strategies for FC in children. Pre- and probiotics have been suggested as potential treatment modalities for FC in children. In this systematic review we provide an update on current literature describing the potential role of pre-, pro- and synbiotics in the treatment of FC in children. TABLE 1. Rome III criteria functional constipation Age <4 years Developmental age of ≥4 years Rome III criteria 1. <3 defecations per week 2. ≥1 episode of fecal incontinence per week after the acquisition of toileting skills 3. History of excessive stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet - Must fulfill ≥2 criteria for ≥1 month prior to diagnosis. 1. <3 defecations in the toilet per week 2. ≥1 episode of fecal incontinence per week 3. History of retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet - Must fulfill ≥2 criteria at least once per week for ≥2 months prior to diagnosis - Insufficient criteria for diagnosis of IBS