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339 Summary and discussion lack of pediatric reference data. This lack of pediatric healthy control data is inherent to the invasive nature of this investigation. Since data from healthy pediatric controls are simply not available, comparison with healthy adult data is the only option at this point. 34,35 In the future, efforts should be made to obtain reference data from adolescents or young adults. This could be of great value to help understand the complex processes underlying colonic motility and to help put the findings from our recent studies into perspective. In chapter 9 , results from contrast enemas and colonic manometry in children with FC are compared. We performed this study because we had observed that in some patients with FC, high-amplitude propagating contractions would terminate in the sigmoid or descending colon, whereas in others they would propagate all the way to the rectum. At the same time, in some children with FC we observed elongated, tortuous, wide diameter colons on contrast enema investigations. Therefore, we hypothesized that there might be a relationship between colonic sizemeasurements and colonic dysmotility.We retrospectively analyzed colonic manometry data and contrast enema results from 30 children with intractable FC and found that children with high-amplitude propagating contractions terminating >15 cm from the anal verge had a larger diameter of the colon. We therefore concluded that colonic dilation may be a useful indicator of colonic dysmotility. There are several uncertainties that should be taken into account when interpreting these results and it should be noted that unlike colonic manometry, contrast enemas do not provide information on colonic contractility. However, in a child with a wide, tortuous colon and problems related to defecation, a colonic manometry should be considered. Part III provides an overview of studies concerning the medical management of childhood FC. In chapter 10 , we assessed the awareness and implementation of the childhood FC guideline published by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) in 2014. This questionnaire study was conducted among 328 pediatricians and pediatric gastroenterologists from the United States and the Netherlands. Although many responders were not familiar with the ESPGHAN/NASPGHAN guideline for functional constipation, therapeutic decisions correlated fairly well with recommendations from the guideline, especially for the treatment of children over one year of age. Guideline awareness and adherence were lower among general pediatricians, an observation which raises questions on how to improve guideline awareness in this group. We suggested that digital learning methods may be useful for this purpose, but future studies are required to assess the efficacy of such methods.