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Background and Objective: There is no published information on the prevalence of malnutrition in Saudi Arabia. The objective of this study was to establish the prevalence data. Methods: The prevalence of nutritional indicators in the form of underweight, stunting, and wasting in a national sample of children younger than 5 years of age was calculated using the new WHO standards as reference. Calculations were performed using the corresponding WHO software. The prevalence of moderate and severe underweight, wasting and stunting, was defined as the proportion of children whose weight for age, weight for height, and height for age were below -2 and -3 standard deviation scores, respectively. Results: The number of children younger than 5 years of age was 15 516 and 50.5% were boys. The prevalence of moderate and severe underweight was 6.9% and 1.3%, respectively. The prevalence of moderate and severe wasting was 9.8% and 2.9%, respectively. Finally, the prevalence of moderate and severe stunting was 10.9% and 2.8%, respectively. The prevalence was lower in girls for all indicators. Comparison of the prevalence of nutritional indicators in selected countries demonstrates large disparity with an intermediate position for Saudi Arabia. Conclusion: This report establishes the national prevalence of malnutrition among Saudi children. Compared to data from other countries, these prevalence rates are still higher than other countries with less economic resources, indicating that more efforts are needed to improve the nutritional status of children.

Background and Objective : There is limited information on overweight and obesity in Saudi children and adolescents. The objective of this study was to establish the national prevalence of overweight and obesity in Saudi children and adolescents. Methods : The 2005 Saudi reference data set was used to calculate the body mass index (BMI) for children aged 5 to 18 years. Using the 2007 WHO reference, the prevalence of overweight, obesity and severe obesity were defined as the proportion of children with a BMI standard deviation score more than +1, +2 and +3, respectively. The 2000 CDC reference was also used for comparison. Results : There were 19 317 healthy children and adolescents from 5 to 18 years of age, 50.8% of whom were boys. The overall prevalence of overweight, obesity and severe obesity in all age groups was 23.1%, 9.3% and 2%, respectively. A significantly lower prevalence of overweight (23.8 vs 20.4; P < .001) and obesity (9.5 vs 5.7; P < .001) was found when the CDC reference was used. Conclusions : This report establishes baseline national prevalence rates for overweight, obesity and severe obesity in Saudi children and adolescents, indicating intermediate levels between developing and industrialized countries. Measures should be implemented to prevent further increases in the numbers of overweight school-age children and adolescents and the associated health hazards.

Background and Objective: The WHO recommends exclusive breastfeeding in the first 6 months of life. Our objective was to evaluate trends in infant nutrition in Saudi Arabia and the degree of compliance with WHO recommendations. Subjects and Methods: A nationwide nutritional survey of a sample of Saudi households was selected by the multistage probability sampling procedure. A validated questionnaire was administered to mothers of chil--dren less than 3 years of age. Results: Of 5339 children in the sample, 4889 received breast milk at birth indicating a prevalence of initia--tion of 91.6%. Initiation of breastfeeding was delayed beyond 6 hours after birth in 28.1% of the infants. Bottle feeding was introduced by 1 month of age to 2174/4260 (51.4%) and to 3831/4260 (90%) by 6 months of age. The majority of infants 3870/4787 (80.8%) were introduced to "solid foods" between 4 to 6 months of age and whole milk feedings were given to 40% of children younger than 12 months of age. Conclusions: The current practice of feeding of Saudi infants is very far from compliance with even the most conservative WHO recommendations of exclusive breastfeeding for 4 to 6 months. The high prevalence of breastfeeding initiation at birth indicates the willingness of Saudi mothers to breastfeed. However, early intro--duction of complementary feedings reduced the period of exclusive breastfeeding. Research in infant nutrition should be a public health priority to improve the rate of breastfeeding and to minimize other inappropriate practices.

Background/Aim: To examine the liver size in Saudi children and adolescents. Methods: A large sample of children was selected from the general population by multistage random probability sampling for the assessment of physical growth. A random subsample of children-newborns to 18 years old-was taken from this larger sample for this study. Liver size below the costal margin and liver span along the midclavicular line were determined by physicians. Data were analyzed using SPSS software and medians and standard deviations were calculated. Results: Between 2004 and 2005, 18 112 healthy children up to 18 years of age were examined. All were term and appropriate for gestational age. There were 9 130 boys and 8 982 girls, yielding a nearly 1:1 male to female ratio. The maximum palpable liver size below the costal margin was 2.4 cm. The median and + 2 SD liver span at birth were 4 and 6.9 cm, respectively. There was no difference in the liver span between boys and girls of up to 60 months of age. Thereafter, a difference could be seen increasing with age, with girls having smaller liver spans than boys. Conclusion: This manuscript reports the liver size in Saudi children and adolescents. The data should help physicians in the interpretation of liver size determined by physical examination of children and adolescents.

Background and Objectives: Blood pressure levels may vary in children because of genetic, ethnic and socioeconomic factors. To date, there have been no large national studies in Saudi Arabia on blood pressure in children.Therefore, we sought to establish representative blood pressure reference centiles for Saudi Arabian children and adolescents. Subjects and Methods: We selected a sample of children and adolescents aged from birth to 18 years by multi-stage probability sampling of the Saudi population. The selected sample represented Saudi children from the whole country. Data were collected through a house-to-house survey of all selected households in all 13 regions in the country. Data were analyzed to study the distribution pattern of systolic (SBP) and diastolic blood pressure (DBP) and to develop reference values. The 90th percentile of SBP and DBP values for each age were compared with values from a Turkish and an American study. Results: A total of 16 226 Saudi children and adolescents from birth to 18 years were studied. Blood pressure rose steadily with age in both boys and girls. The average annual increase in SBP was 1.66 mm Hg for boys and 1.44 mm Hg for girls. The average annual increase in DBP was 0.83 mm Hg for boys and 0.77 mm Hg for girls. DBP rose sharply in boys at the age of 18 years. Values for the 90th percentile of both SBP and DBP varied in Saudi children from their Turkish and American counterparts for all age groups. Conclusion: Blood pressure values in this study differed from those from other studies in developing coun--tries and in the United States, indicating that comparison across studies is difficult and from that every popula--tion should use their own normal standards to define measured blood pressure levels in children.

Background and Objectives: Because there are no reference standards for body mass index (BMI) in Saudi children, we established BMI reference percentiles for normal Saudi Arabian children and adolescents and compared them with international standards. Subjects and Methods : Data from a stratified multistage probability sample were collected from the 13 health regions in Saudi Arabia, as part of a nationwide health profile survey of Saudi Arabian children and adolescents conducted to establish normal physical growth references. Selected households were visited by a trained team. Weight and length/height were measured and recorded following the WHO recommended procedures using the same equipment, which were subjected to both calibration and intra/interobserver variations. Results: Survey of 11 874 eligible households yielded 35 275 full-term and healthy children and adolescents who were subjected to anthropometric measurements. Four BMI curves were produced, from birth to 36 months and 2 to 19 years for girls and boys. The 3 rd , 5 th , 10 th , 25 th , 50 th , 75 th , 85 th , 90 th , 95 th , and 97 th percentiles were produced and compared with the WHO and CDC BMI charts. In the higher percentiles, the Saudi children differed from Western counterparts, indicating that Saudi children have equal or higher BMIs. Conclusion: The BMI curves reflect statistically representative BMI values for Saudi Arabian children and adolescents.

Background and Objectives: No previous study has provided a detailed description of regional variations of growth within the various regions of Saudi Arabia. Thus, we sought to demonstrate differences in growth of children and adolescents in different regions. Subjects and Methods: The 2005 Saudi reference was based on a cross-sectional representative sample of the Saudi population of healthy children and adolescents from birth to 18 years of age. Body measurements of the length, stature, weight, head circumference and calculation of the BMI were performed according to standard recommendations. Percentile construction and smoothing were performed using the LMS (lambda, mu and sigma) methodology, followed by transformation of all individual measurements into standard deviation scores. Factors such as weight for age, height for age, weight for height, and head circumference for children from birth to 3 years, stature for age, head circumference and body mass index for children between 2-18 years of age were assessed. Subsequently, variations in growth between the three main regions in the north, southwest, and center of Saudi Arabia were calculated, with the Bonferroni: method used to assess the significance of differences between regions. Results: There were significant differences in growth between regions that varied according to age, gender, growth parameter and region. The highest variation was found between children and adolescents of the southwestern region and those of the other two regions The regression lines for all growth parameters in children < 3 years of age were significantly different from one region to another reaching - 0.65 standard deviation scores for the southwestern regions ( P =.001). However, the difference between the northern and central regions were not significant for the head circumference and for weight for length. For older children and adolescents a significant difference was found in all parameters except between the northern and central regions in BMI in girls and head circumference in boys. Finally, the difference in head circumference of girls between southwestern and northern regions was not significant. Such variation affected all growth parameters for both boys and girls. Conclusion: Regional variations in growth need to be taken into consideration when assessing the growth of Saudi children and adolescents.

Background and Objectives: There is a high rate of consanguinity in Saudi Arabia; however, information on its relationship with genetic disorders is limited. The objective of this cross-sectional study was to explore the role of consanguinity in genetic disorders. Subjects and Methods: The study sample was determined by a multistage probability random sampling procedure. Consanguinity status was obtained during household visits. Primary care physicians performed a history and physical examination of all children and adolescents younger than 19 years, and all cases of genetic diseases were recorded. The chi-square test was used to compare proportions. Results: During the two-year study period (2004-2005), 11 554 of 11 874 (97%) mothers answered the question on consanguinity, and 6470 of 11 554 (56%) were consanguineous. There was no significant association between first-cousin consanguinity and Down syndrome (P=.55). Similarly, there was no significant association with either sickle cell disease (P=.97) or glucose-6-phosphate dehydrogenase deficiency (P=.67) for first-cous--in consanguinity. A borderline statistical significance was found for major congenital malformations (P=.05). However, the most significant association with first-cousin consanguinity was congenital heart disease (CHD) (P=.01). Finally, no significant association was found for type 1 diabetes mellitus (P=.92). For all types of con--sanguinity, similar trends of association were found, with a definite statistically significant association only with CHD (P=.003). Conclusion: The data suggest a significant role of parental consanguinity in CHD. However, a relationship between consanguinity and other genetic diseases could not be established. The effect of consanguinity on genetic diseases is not uniform and this should be taken into consideration in genetic counseling.

Background and Objectives: The 2000 CDC growth charts for the United States, a revision of the National Center for Health Statistics/World Health Organization (NCHS/WHO) growth charts, were released in 2002 to replace the NCHS/WHO charts. We evaluated the differences between the CDC growth charts and the Saudi 2005 reference to determine the implications of using the 2000 CDC growth charts in Saudi children and ado--lescents. Subjects and Methods: The Saudi reference was based on a cross-sectional representative sample of the Saudi population of healthy children and adolescents from birth to 19 years of age. Measurements of the length/ stature, weight and head circumference were performed according to expert recommendations. The CDC charts from birth to 20 years were based on a cross-sectional representative national sample from five sources collected between 1963 and 1994. The data from the CDC study including the 3rd, 5th, 50th, 95th, and 97th percentiles were plotted against the corresponding percentiles on the Saudi charts for the weight for age, height for age, weight for height for children from 0 to 36 months and weight for age, stature for age and body mass index for children 2 to 19 years of age. Results: There were major differences between the two growth charts. The main findings were the upward shift of the lower percentiles of the CDC curves and the overlap or downward shift of the upper percentiles, especially for weight, weight for height, and BMI. Conclusions : The use of the 2000 CDC growth charts for Saudi children and adolescents increases the preva--lence of undernutrition, stunting, and wasting, potentially leading to unnecessary referrals, investigations and pa--rental anxiety. The increased prevalence of overweight and obesity is alarming and needs further investigation.

Background: Pediatric colonoscopy is routinely performed in most hospitals in Saudi Arabia and yet published data are scarce. The objective of this report is to describe our experience in the practice of pediatric colonoscopy in Saudi Arabia. Patients and Methods: Retrospective analysis of data of all patients below 18 years of age who underwent colonoscopy over a 10-year period. Results: From 1414 H (1993 G) to 1423 H (2002 G), two hundred and seventeen colonoscopies, of which 183 diagnostic procedures, were performed on 183 children. The majority (94%) were Saudi nationals, the age range was between 5 months and 18 years, and the female to male ratio was 1: 0.8. Colonoscopy was total in 58 (32%) and limited in 125 patients (68%). The commonest reason for not completing the procedure was securing the diagnosis in 45/125 patients (36%). The commonest indication was rectal bleeding (35%). The highest yield was in children with bloody diarrhea (91%) and the lowest in those with abdominal pain (27%) with an overall yield of 44%. Colitis was the most common diagnosis occurring in 66% of the children. Conclusion: this report highlights the role of colonoscopy in the recognition of diseases of the colon in our community and identifies some of the problems areas associated with the performance of this procedure in our institution.

There is a high prevalence of consanguinity and bronchial asthma in Saudi Arabia. The objective of this study is to explore the effect of parental consanguinity on the occurrence of bronchial asthma in children. The study sample was determined by multistage random probability sampling of Saudi households. The families with at least one child with asthma were matched with an equal number of families randomly selected from a list of families with healthy children, the latter families being designated as controls. There were 103 families with children having physician-diagnosed bronchial asthma, matched with an equal number of families with no children with asthma. This resulted in 140 children with bronchial asthma and 295 children from controls. The age and gender distribution of the children with bronchial asthma and children from controls were similar. There were 54/103 (52.4%) and 61/103 (59.2%) cases of positive parental consanguinity in asthmatic children and children from controls respectively ( P = 0.40). Analysis of consanguinity status of the parents of children with asthma and parents among controls indicates that 71/140 (51%) of the children with asthma and 163/295 (55.3%) of the children from controls had positive parental overall consanguinity ( P = 0.43). The results of this study suggest that parental consanguinity does not increase the risk of bronchial asthma in children.

Background: Biopsy of the small bowel is frequently obtained by endoscopic forceps instead of the classical suction capsule, yet reports from developing countries are scarce. Aim of the study: to report our experience on the diagnostic value of this procedure in our community. Patients and methods: A retrospective analysis of all endoscopic duodenal biopsies (EDB), performed on all patients below 18 years of age. Data retrieved from the records included age, gender, nationality, indication for biopsy, the endoscopic findings, and the results of histopathology. Results: From 1993 to 2002, 241 endoscopic biopsies were performed on 241 consecutive children. Most of the children (96%) were Saudi nationals, the age range between six weeks to 18 years, and male to female ratio was 0.7: 1. All of the biopsy material was adequate for routine histopathology. The commonest indications for biopsy were short stature and chronic diarrhea in 116/241 (48%) and 102/241 (43%) of the children respectively. Refractory rickets accounted for 11/241 (5%) of the indications. The prevalence of villous atrophy was highest in children presenting with chronic diarrhea (40%), compared to short stature (22%). Other less common, but important findings were villous atrophy in three unusual conditions (one refractory rickets, one unexplained anemia, and one polyendocrinopathy), two cases of intestinal Giardia lamblia infestation, three cases of intestinal lymphangiectasis and one case of Mycobacterium avium intracellulare. Unexpected endoscopic findings were documented in 34/241 (14%) of the children. Conclusions: Endoscopic duodenal biopsy is adequate not only for the diagnosis of villous atrophy, but also for the detection of other gastroenteropathies. Accordingly, when expertise and equipments are available, EDB should be the procedure of choice not only in industrialized but also in developing countries.

Fulminant hepatic failure is a devastating disease occurring as a complication of various forms of liver diseases in both children and adults. The objectives of this article is to update the knowledge of physicians, on the most important and recent advances related to this condition with the ultimate goal of improving patient care.

Background: Difficulty in swallowing is not uncommon among children and yet little information is available in the literature. We report our experience on the pattern of this condition. Methods: We extracted data from the medical records of 42 children with dysphagia on age at presentation, nationality, gender, and final diagnosis. Results: From 1993 to 2002, 96% of 42 children presenting with dysphagia were Saudi nationals, ranging in age from 3 months to 18 years, with a male to female ratio of 1:0.6. An etiologic diagnosis was found in 30 children (72%). Esophagitis, esophageal strictures and motility disorders were the most common causes of dysphagia, occurring in 16 (38%), 7 (17%), and 4 (10%) children, respectively. Two children had esophageal webs and one had an esophageal ring. Age-related analysis indicated that most of the cases of esophagitis (11/16, 69%) and strictures (5/7, 71%) occurred in young children whereas most nondemonstrable causes occurred in older children (9/12, 75%). Conclusion: This report documents a pattern of dysphagia in Saudi Arab children that is similar to descriptions from other countries.

Chronic diarrhea is a complex symptom. The clinical approach and management should be based on pathophvsiologic considerations and stepwise laboratory investigations. In infants with severe malnutrition, nutritional support is a priority in the management of this condi-tion.

Chronic diarrhea is an important cause of morbidity and mortality in children. Although the pattern of the problem is well established in Western countries. limited data are available from Saudi Arabia. The purpose of this review is to provide an updated overview of the physiology of digestion, pathophysiology and etiology of diarrhea with particular emphasis on patterns prevalent in Saudi Arabia

Background: The role of microbiota in the pathogenesis of ulcerative colitis (UC) has been increasingly recognized. However, most of the reports are from Western populations. In Middle Eastern countries, including Saudi Arabia, little is known about the role of microbiota. Therefore, our aim was to describe the bacterial microbiota profile and signature in pediatric UC in Saudi Arabia., Methods: Twenty children with UC and 20 healthy controls enrolled in the study gave stool samples. Twenty rectal mucosal samples were taken from UC and 20 from non-UC controls. Inclusion criteria included newly diagnosed and untreated children and lack of antibiotic exposure for at least 6 months before stool collection was required for children with UC and controls. Bacterial deoxyribonucleic acid was extracted and sequenced using shotgun metagenomic analysis. Statistical analysis included Shannon alpha diversity metrics, Bray-Curtis dissimilarity, DESeq2, and biomarker discovery., Results: The demographic characteristics were similar in children with UC and controls. There was a significant reduction in alpha diversity (P = 0.037) and beta diversity in samples from children with UC (P = 0.001). Many taxa were identified with log2 abundance analysis, revealing 110 and 102 species significantly depleted and enriched in UC, respectively. Eleven bacterial species' signatures were identified., Conclusions: In Saudi Arabian children with UC, we demonstrate a dysbiosis similar to reports from Western populations, possibly related to changes of lifestyle. Microbial signature discovery in this report is an important contribution to research, leading to the development of adjunctive non-invasive diagnostic options in unusual cases of UC., (Copyright © 2024 Copyright: © 2024 Saudi Journal of Gastroenterology.)

Background: Ulcerative colitis (UC) is an immune-mediated chronic inflammatory condition with a worldwide distribution. Although the etiology of this disease is still unknown, the understanding of the role of the microbiota is becoming increasingly strong., Aim: To investigate the predictive power of the gut microbiota for the diagnosis of UC in a cohort of newly diagnosed treatment-naïve Saudi children with UC., Methods: The study population included 20 children with a confirmed diagnosis of UC and 20 healthy controls. Microbial DNA was extracted and sequenced, and shotgun metagenomic analysis was performed for bacteria and bacteriophages. Biostatistics and bioinformatics demonstrated significant dysbiosis in the form of reduced alpha diversity, beta diversity, and significant difference of abundance of taxa between children with UC and control groups. The receiver operating characteristic curve, a probability curve, was used to determine the difference between the UC and control groups. The area under the curve (AUC) represents the degree of separability between the UC group and the control group. The AUC was calculated for all identified bacterial species and for bacterial species identified by the random forest classification algorithm as important potential biomarkers of UC. A similar method of AUC calculation for all bacteriophages and important species was used., Results: The median age and range were 14 (0.5-21) and 12.9 (6.8-16.3) years for children with UC and controls, respectively, and 40% and 35% were male for children with UC and controls, respectively. The AUC for all identified bacterial species was 89.5%. However, when using the bacterial species identified as important by random forest classification algorithm analysis, the accuracy increased to 97.6%. Similarly, the AUC for all the identified bacteriophages was 87.4%, but this value increased to 94.5% when the important bacteriophage biomarkers were used., Conclusion: The very high to excellent AUCs of fecal bacterial and viral species suggest the potential use of noninvasive microbiota-based tests for the diagnosis of unusual cases of UC in children. In addition, the identification of important bacteria and bacteriophages whose abundance is reduced in children with UC suggests the potential of preventive and adjuvant microbial therapy for UC., Competing Interests: Conflict-of-interest statement: All authors have no conflicts of interest to disclose., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Functional constipation (FC) is a common condition in children, and information on the clinical characteristics of FC in Saudi children is scarce., Objective: Describe the clinical profile of FC in Saudi children., Design: Retrospective., Setting: Hospital that provides primary, intermediate and tertiary care., Patients and Methods: All children diagnosed with FC according to the Rome IV criteria were included and had at least one follow-up clinic visit. Demographic and clinical data collected from medical records included the age at onset, duration of constipation, clinical features, treatment modalities, and factors associated with clinical response. Descriptive statistics and Pearson's chi-squared test were used in the statistical analysis to see how categorical study variables were linked to clinical response. A P value of ≤.05 was used to report statistical significance., Main Outcome Measure: Compliance and clinical response to polyethylene glycol (PEG) compared with lactulose., Sample Size: 370 children from 0.1 to 13 years of age., Results: The median (IQR) age of onset was 4 (5) years and less than one year in 14%. The median (IQR) duration of constipation was 4 months (11) and less than two months in 93/370 (25%). Abdominal pain was the most commonly associated feature (44%). Screening for celiac disease and hypothyroidism was negative. A Fleet enema was the most common disimpaction method (54%) and PEG was the most common maintenance medication (63.4%). PEG was significantly better tolerated ( P =.0008) and more effective than lactulose ( P <.0001). Compliance was the only variable significantly associated with clinical response., Conclusions: PEG was better tolerated and more effective than lactulose in our study, a finding in agreement with the literature. Therefore, PEG should be the drug of choice in the initial management of FC in Saudi children. Prospective studies on the causes of noncompliance are needed to improve the response to treatment., Limitations: The limitations of retrospective design are missing data, recall bias, and hospital-based limitation, such as missing milder cases treated at the outpatient level. However, the sample size of 370 may have minimized these limitations., Competing Interests: CONFLICT OF INTEREST: None.

Background: Celiac serology can be transiently elevated in patients with type 1 diabetes mellitus (T1DM) and normalized despite gluten consumption. This study aimed to identify the frequency and predictive factors of spontaneous normalization of anti-tissue transglutaminase (anti-TTG-IgA) antibodies in these patients., Methods: The charts of all patients (≤18 years) with T1DM were retrospectively reviewed from 2012 to 2021 at a tertiary care center in Riyadh, Saudi Arabia. The following data were collected: clinical characteristics of the participants, anti-TTG-IgA-immunoglobulin (Ig) A antibody, and histological findings. The outcome of positive anti-TTG-IgA-IgA in patients with T1DM and the predictive factors for spontaneous normalization were investigated., Results: Of the 1,006 patients with T1DM, 138 (13.7%) had elevated anti-TTG-IgA antibodies, celiac disease was diagnosed in 58/138 (42%) patients, spontaneous normalization of anti-TTG-IgA was observed in 65 (47.1%) patients, and fluctuating anti-TTG-IgA antibodies were seen in 15 (10.9%) patients. The patients with anti-TTG-IgA levels at 3-10 times the upper normal limits (UNL), and those with levels ≥10 times UNL were less likely to have spontaneous normalization of anti-TTG-IgA compared to patients with levels at 1-3 times UNL (hazard ratio [HR] = 0.28, 95% confidence interval [Cl] = 0.13-0.61, P = 0.001, and HR = 0.03, 95% Cl = 0.00-0.19, P < 0.001, respectively)., Conclusion: Asymptomatic patients with T1DM with mild elevation of anti-TTG-IgA need not be rushed for invasive endoscopy or exposed to an un-needed gluten-free diet but should rather have a regular follow-up of their celiac serology., Competing Interests: None

Background: Celiac disease (CeD) is a multisystem immune-mediated multifactorial condition strongly associated with the intestinal microbiota., Aim: To evaluate the predictive power of the gut microbiota in the diagnosis of CeD and to search for important taxa that may help to distinguish CeD patients from controls., Methods: Microbial DNA from bacteria, viruses, and fungi, was isolated from mucosal and fecal samples of 40 children with CeD and 39 controls. All samples were sequenced using the HiSeq platform, the data were analyzed, and abundance and diversities were assessed. For this analysis, the predictive power of the microbiota was evaluated by calculating the area under the curve (AUC) using data for the entire microbiome. The Kruskal-Wallis test was used to evaluate the significance of the difference between AUCs. The Boruta logarithm, a wrapper built around the random forest classification algorithm, was used to identify important bacterial biomarkers for CeD., Results: In fecal samples, AUCs for bacterial, viral, and fungal microbiota were 52%, 58%, and 67.7% respectively, suggesting weak performance in predicting CeD. However, the combination of fecal bacteria and viruses showed a higher AUC of 81.8 %, indicating stronger predictive power in the diagnosis of CeD. In mucosal samples, AUCs for bacterial, viral, and fungal microbiota were 81.2%, 58.6%, and 35%, respectively, indicating that mucosal bacteria alone had the highest predictive power. Two bacteria, Bacteroides intestinalis and Burkholderiales bacterium 1-1-47 , in fecal samples and one virus, Human&#95;endogenous &#95;retrovirus&#95;K , in mucosal samples are predicted to be "important" biomarkers, differentiating celiac from nonceliac disease groups. Bacteroides intestinalis is known to degrade complex arabinoxylans and xylan which have a protective role in the intestinal mucosa. Similarly, several Burkholderiales species have been reported to produce peptidases that hydrolyze gluten peptides, with the potential to reduce the gluten content of food. Finally, a role for Human&#95;endogenous &#95;retrovirus&#95;K in immune-mediated disease such as CeD has been reported., Conclusion: The excellent predictive power of the combination of the fecal bacterial and viral microbiota with mucosal bacteria alone indicates a potential role in the diagnosis of difficult cases of CeD. Bacteroides intestinalis and Burkholderiales bacterium 1-1-47 , which were found to be deficient in CeD, have a potential protective role in the development of prophylactic modalities. Further studies on the role of the microbiota in general and Human&#95;endogenous &#95;retrovirus&#95;K in particular are needed., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Intestinal dysbiosis has been reported to be associated with celiac disease (CeD) in Western populations but little is known in other populations who have different dietary lifestyle and genetic background. The purpose of this study was to determine whether a different microbiota profile is associated with CeD in children in Saudi Arabia., Results: Forty children with CeD, 20 healthy controls, and 19 non-CeD controls were enrolled. The median age at diagnosis was 10.3, 11.3 and 10.6 years in children with CeD, fecal, and mucosal control groups, respectively. Significant differences in microbial composition between children with CeD and controls both at fecal and mucosal level were identified. Fecal samples were more diverse and richer in bacteria as compared with mucosal samples. Proteobacteria were more abundant in duodenal mucosal samples and Firmicutes and Bacteroides were more abundant in stools. The abundance of many taxa was significantly different between children with CeD and non-CeD controls. In mucosal samples, Bifidobacterium angulatum (unadjusted p = 0.006) and Roseburia intestinalis (unadjusted p = 0.031) were examples of most significantly increased species in children with CeD and non-CeD controls, respectively. In fecal samples, there were 169 bacterial species with significantly different abundance between children with CeD and non- CeD controls., Conclusions: To our knowledge, this is the first report on the microbial profile in a non-Western population of children with new onset CeD. The fact that mucosal and fecal samples were collected from newly diagnosed children with CeD on normal gluten-containing diet suggests strong association between the identified bacteria and CeD. The identification of many unreported bacterial species significantly associated with CeD, indicates the need for further studies from different populations to expand our understanding of the role of bacteria in the pathogenesis of CeD, hopefully leading to the discovery of new adjuvant treatment options., (© 2022. The Author(s).)

Background: Knowledge of microbiota in health is essential for clinical research on the role of microbiota in disease. We aimed to characterize the intestinal microbiota in healthy Saudi children., Methods: In this community-based study, stool samples were collected from a randomly selected sample of 20 healthy school children of Saudi origin. The samples were frozen at -80°C till analysis. Bacterial DNA was isolated and libraries were prepared using the Illumina Nextera XT library preparation kit. Unassembled sequencing reads were directly analyzed and quantified for each organism's relative abundance. The abundance for each organism was calculated and expressed as the average relative percentage from phyla to species., Results: The median age was 11.3 (range 6.8-15.4) years, and 35% of them were males. The three most abundant phyla were Firmicutes, Bacteroidetes, and Actinobacteria accounting for 49%, 26%, and 24%, respectively. The most abundant genera included Bifidobacterium, Bacteroides, and Blautia accounting for 18.9%, 12.8%, and 8.2%, respectively. Finally, the most abundant species included 14 species belonging to the genus Bacteroides and nine species belonging to Bifidobacterium., Conclusions: The abundance of intestinal microbiome in healthy Saudi children is different from that of other populations. Further studies are needed to understand the causes of variation between populations, which might lead to new preventive methods and treatment strategies of diseases caused by microbial dysbiosis., Competing Interests: None

Viruses are common components of the intestinal microbiome, modulating host bacterial metabolism and interacting with the immune system, with a possible role in the pathogenesis of immune-mediated diseases such as celiac disease (CeD). The objective of this study was to characterize the virome profile in children with new-onset CeD. We used metagenomic analysis of viral DNA in mucosal and fecal samples from children with CeD and controls and performed sequencing using the Nextera XT library preparation kit. Abundance log2 fold changes were calculated using differential expression and linear discriminant effect size. Shannon alpha and Bray-Curtis beta diversity were determined. A total of 40 children with CeD and 39 controls were included. We found viral dysbiosis in both fecal and mucosal samples. Examples of significantly more abundant species in fecal samples of children with CeD included Human polyomavirus 2, Enterobacteria phage mEpX1, and Enterobacteria phage mEpX2; whereas less abundant species included Lactococcus phages ul36 and Streptococcus phage Abc2. In mucosal samples however, no species were significantly associated with CeD. Shannon alpha diversity was not significantly different between CeD and non-CeD groups and Bray-Curtis beta diversity showed no significant separation between CeD and non-CeD samples in either mucosal or stool samples, whereas separation was clear in all samples. We identified significant viral dysbiosis in children with CeD, suggesting a potential role in the pathogenesis of CeD indicating the need for further studies., Competing Interests: The authors have declared that no competing interests exist.

Background: Although intestinal fungi are known to interact with the immune system, the relationship between intestinal fungi and childhood celiac disease (CeD), an immune-mediated condition, has rarely been reported., Aims: The aim of this study was to describe gut fungal profiles in a cohort of children with new-onset CeD., Methods: Mucosal and fecal samples were collected from children with CeD and controls and subjected to metagenomics analysis of fungal microbiota communities. DNA libraries were sequenced using Illumina HiSeq platform 2 × 150 bp. Bioinformatic analysis was performed to quantify the relative abundance of fungi. Shannon alpha diversity metrics and beta diversity principal coordinate (PCo) analyses were calculated, and DESeq tests were performed between celiac and non-celiac groups., Results: Overall more abundant taxa in samples of children with CeD included Tricholomataceae, Saccharomycetaceae, Saccharomycetes Saccharomyces cerevisiae, and Candida, whereas less abundant taxa included Pichiaceae, Pichia kudriavzevii, Pneumocystis, and Pneumocystis jirovecii. Alpha diversity between CeD and control individuals did not differ significantly, and beta diversity PCo analysis showed overlap of samples from CeD and controls for both fecal or mucosal samples; however, there was a clear separation between mucosal and fecal overall samples CONCLUSIONS: We report fungal dysbiosis in children with CeD, suggesting a possible role in the pathogenesis of CeD. Further larger, controlled, prospective and longitudinal studies are needed to verify the results of this study and clarify the functional role of fungi in CeD., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Study Aim: The prevalence of nutritional disorders in Saudi children with inflammatory bowel diseases (IBDs) has been reported using the World Health Organization (WHO) reference. Our aim was to provide more accurate definition of the prevalence of nutritional impairment in Saudi children with IBDs based on the national growth reference and to demonstrate the effect of using a reference from other populations on the prevalence rates., Patients and Methods: Weight, height, and body mass index data, from the multicenter study of IBDs in Saudi children and adolescents, were plotted on the new Saudi national growth reference. Statistical analyses included frequency calculations and z-test for proportions to investigate the significance of the difference in prevalence. A p-value of < 0.05 was considered significant., Results: Among a total of 374 patients, 119 (32%) had ulcerative colitis (UC) and 255 (68%) had Crohn's disease (CD). Compared with the WHO reference, the Saudi national reference produced a significantly lower prevalence of thinness in patients with UC (24% vs. 8%, p = 0.001), CD (35% vs. 20%, p = 0.002), and of short stature in patients with CD (28% vs. 11%, p < 0.001). The difference in the prevalence of overweight was not significant., Conclusions: We provide more accurate prevalence estimate of nutritional disorders in Saudi children with IBDs based on national reference. The use of the WHO reference overestimated the prevalence of thinness and short stature in Saudi children. Prevalence estimates based on references from other populations should be interpreted with caution., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Although increasing evidence suggests a role for fungi in inflammatory bowel disease [IBD], data are scarce and mostly from adults. Our aim was to define the characteristics of fungal microbiota in newly diagnosed treatment-naïve children with Crohn's disease [CD]., Methods: The children referred for colonoscopy were prospectively enrolled in the study at King Khalid University Hospital, King Saud University, and Al Mofarreh Polyclinics in Riyadh. Tissue and stool samples were collected and frozen till sequencing analysis. The children with confirmed CD diagnosis were designated as cases and the others as non- IBD controls; 78 samples were collected from 35 children [15 CD and 20 controls]. Statistical analysis was performed to investigate CD associations and diversity., Results: CD-associated fungi varied with the level of phylogenetic tree. There was no significant difference in abundance between normal and inflamed mucosa. Significantly abundant CD-associated taxa included Psathyrellaceae [p = 0.01], Cortinariaceae [p = 0.04], Psathyrella [p = 0.003], and Gymnopilus [p = 0.03]. Monilinia was significantly depleted [p = 0.03], whereas other depleted taxa, although not statistically significant, included Leotiomycetes [p = 0.06], Helotiales [p = 0.08], and Sclerotiniaceae [p = 0.07]. There was no significant difference in fungal diversity between CD and controls., Conclusions: We report highly significant fungal dysbiosis in newly diagnosed treatment-naïve CD children. Depleted and more abundant taxa suggest anti-inflammatory and pro-inflamatory potentials, respectively. Further studies with larger sample size and including functional analysis are needed to clarify the significance of the fungal community in the pathogenesis of CD., (Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background: The objectives of this multicenter national study were to compare the clinical phenotype of early-onset inflammatory bowel disease (IBD) (EO-IBD) with IBD in older children and to examine whether there is any variability in consanguinity rate and familial aggregation in EO-IBD compared with later onset IBD., Methods: A retrospective analysis was performed on children aged 0 to 14 years with IBD in 17 centers located in geographically distinct regions in Saudi Arabia, from 2003 to 2012. Data of patients with EO-IBD (0 to <6 yrs) were compared with those with later onset IBD (6-14 yrs). Moreover, we evaluated differences in clinical pattern of infantile or toddler onset IBD subgroup (0-3 yr) as compared with those presenting in older children., Results: Of 352 IBD patients identified during the 10-year study period, 76 children (21.6%) younger than 6 years were diagnosed with IBD. Among the Crohn's disease (CD) group, infantile or toddler onset CD subgroup showed a more frequent isolated colonic involvement (L2) than later-onset group (57% versus 20%; P = 0.002). Positive family history was significantly more common in the infantile or toddler onset ulcerative colitis subgroup (29.4% versus 4.2% in later onset ulcerative colitis; P < 0.0001). The consanguinity rate was significantly higher in the infantile or toddler onset CD subgroup as compared with later onset CD group (57.1% versus 25.3%; P = 0.04)., Conclusions: In conclusion, EO-IBD exhibits a unique clinical phenotype with a strikingly higher familial aggregation in early-onset ulcerative colitis. Our data suggest a significant genetic impact on the onset of CD in the very young children.

Background: Information on LMS parameters and percentiles reference for Saudi children and adolescents is not available., Objective: To report the L, M, and S parameters and percentile reference graphs for growth., Design: Field survey of a population-based sample of Saudi school-age children and adolescents (5-18 years of age)., Setting: A stratified listing of the Saudi population., Subjects and Methods: Data from the national study of healthy children were reanalyzed using the Lamba-Mu-Sigma (LMS) methodology. The LMS parameters of percentiles for weight, height, and body mass index for age were calculated for children and adolescents from 5 to 18 years of age., Main Outcome Measure: The main outcomes were the LMS parameters and percentiles of growth., Results: There were 19299 and 9827 (50.9%) were boys. The data for weight, height, and BMI for age for boys and girls are reported for the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles including LMS parameters for each percentile and age. Figures corresponding to each table are color coded (blue for boys and pink for girls)., Conclusions: This report provides a reference for growth and nutrition of Saudi school-age children and adolescents. The detailed LMS and percentile tables and graphs provide essential information for clinical assessment of nutritional status and growth in various clinical conditions and for research., Limitations: This report does not reflect regional variations in growth.

Background and Aims. Crohn's disease (CD) is an evolving disease in KSA. Little is known about its characteristics in the Saudi population. The aims of this study were to describe the characteristics of Saudi children with CD and to determine whether the characteristics of CD in KSA are different from those seen in Western countries. Methods. In this study, children younger than eighteen years of age diagnosed with CD between January 2003 and December 2012 were included. Results. Of 330 patients identified, 186 (56.4%) were males. The median age at diagnosis was 15.8 years. A positive family history for IBD in first-degree relatives occurred in 13.6% of patients. The most common symptoms were abdominal pain (84.2%), weight loss (75.2%), and diarrhea (71.8%). The main disease location was ileocolonic (42.1%) and the main disease behavior was nonstricturing and nonpenetrating (63.6%). Perianal involvement was seen in 60 (18.2%) patients. Laboratory findings revealed anemia in 57.9% of patients, low albumin in 34.5%, and high CRP in 39.4%. Conclusions. Saudi children with CD have lower frequency of first-degree relatives with IBD, lower prevalence of early onset disease, longer diagnostic delay, higher prevalence of growth failure, and greater frequency of stricturing and penetrating disease behavior compared to Western patients.

Biliary ascites in children due to perforation of bile duct is a rare entity. The exact pathogenesis is not known but there are proposed mechanisms including congenital weakness of ductal wall, pancreaticobiliary malunion, tuberculosis, necrotizing enterocolitis and rupture of choledochal cyst. Presentation may be acute or sub-acute. Progressive insidious course is the common presentation in children with jaundice, clay colored stool, abdominal distension with slightly elevated liver enzymes but well documented cholestasis. Clinical suspicion with ultrasound, CT, MRCP and ascitic tap provides clue to the diagnosis. Both conservative and surgical interventions are in practice for managing these children. We report a 7 months old infant with biliary ascites due to perforation of bile duct.

Objective: The aim of the present study was to investigate the relation between consanguinity and inflammatory bowel diseases (IBD)., Methods: Review of the medical records of children with a final diagnosis of IBD to determine age, sex, and type of IBD, supplemented by information on consanguinity and family history (FH) of IBD in relatives. There were 138 children, ages 1.4 to 19.3 years, and 50% were girls., Results: The prevalence of consanguinity was 50%, 53%, 39% and 60% in IBD, Crohn disease (CD), ulcerative colitis (UC), and controls, respectively. There was a significantly higher prevalence of consanguinity in controls than in patients with IBD and UC (P = 0.02 and 0.026, respectively), whereas the difference between CD patients and controls was not significant (P = 0.20). The prevalence of first cousin consanguinity was 71%, 73.2%, 61.5% and 70.5% in patients with IBD, CD, UC, and controls, respectively, indicating no significant difference between these conditions and controls (P = 0.95, P = 0.78, P = 0.33, respectively). There was no significant difference in the prevalence of consanguinity in the parents of children with or without a FH of either CD (P = 0.89) or UC (P = 0.32)., Conclusions: There is no significant relation between parental consanguinity and IBD in this population, especially when there is no FH of disease, suggesting reduced genetic susceptibility; however, further studies including larger sample size and details of FH of consanguinity and IBD in multiple generations are needed for further definitions of the role of consanguinity.