Socioeconomic Impacts of Gluten-Free Diet among Saudi Children with Celiac Disease / 대한소아소화기영양학회지

PURPOSE: To determine the socio-economic impact of gluten free diet (GFD) on Saudi children and their families. METHODS: A cross-sectional study was conducted in which an online questionnaire was sent to all families registered in the Saudi celiac patients support group. We included only children (age 18 years of age and younger) with biopsy-confirmed celiac disease (CD). RESULTS: A total of 113 children were included in the final analysis, the median age was 9.9 years; 62.8% were females. One hundred (88.5%) of the participating families reported that GFD food was not easily available in their areas, 17% of them reported that it was not available at all in their area. One hundred and six (93.8%) reported that the price of GFD food was very expensive and 70 (61.9%) families that the diet was heavily affecting their family budget. Significant social difficulties were reported among the participating families and their children including interference with the child's interaction with other children (49.6%), the families' ability to attend social gatherings (60.2%), the families' ability to eat in restaurants (73.5%), and the families' ability to travel (58.4%). CONCLUSION: There is significant negative socio-economic impact of GFD on children with CD & their families. Health care providers should be aware of these psycho-social difficulties and be well trained to provide a proper education and psychological support for these patients and their families.

Clinical Characteristics of Celiac Disease and Dietary Adherence to Gluten-Free Diet among Saudi Children / 대한소아소화기영양학회지

PURPOSE: To describe the clinical characteristics of celiac disease (CD) among Saudi children and to determine the adherence rate to gluten free diet (GFD) and its determinant factors among them. METHODS: A cross-sectional study was conducted, in which all the families registered in the Saudi Celiac Patients Support Group were sent an online survey. Only families with children 18 years of age and younger with biopsy-confirmed CD were included. RESULTS: The median age of the 113 included children was 9.9 years, the median age at symptom onset was 5.5 years and the median age at diagnosis was 7 years, the median time between the presentation and the final diagnosis was 1 year. Sixty two of the involved children were females. Ninety two percent of the patients were symptomatic at the diagnosis while eight percent were asymptomatic. The commonest presenting symptoms included: chronic abdominal pain (59.3%), poor weight gain (54%), abdominal distention, gases, bloating (46.1%) and chronic diarrhea (41.6%). Sixty percent of the involved children were reported to be strictly adherent to GFD. Younger age at diagnosis and shorter duration since the diagnosis were associated with a better adherence rate. CONCLUSION: CD has similar clinical presentations among Saudi children compared to other parts of the ward; however, the adherence to GFD is relatively poor. Younger age at diagnosis and shorter duration since the diagnosis were associated with a better adherence rate.

Menetrier's disease in a Saudi child

Menetrier's disease is a rare form of acquired gastropathy that presents mostly during adulthood, but is extremely rare in children. It is a clinicopathological diagnosis that typically presents with abdominal pain, vomiting, and edema secondary to hypoalbuminemia. Endoscopy usually shows giant gastric mucosal folds, and gastric biopsy shows foveolar hyperplasia and decreased oxyntic glands. Here, we describe a 5-year-old boy from Saudi Arabia with typical presentation of Menetrier's disease and serological evidence of acute cytomegalovirus infection

Gastroesophageal reflux disease in children: a 2013 update

Gastroesophageal reflux [GER] refers to the passage of gastric contents [acid, pepsin, etc] in the esophagus. It is a worldwide physiologic condition most common in infants. This physiologic condition [GER] should be differentiated from the pathologic reflux called gastroesophageal reflux disease [GERD]. The distinction between GER and GERD is based on severity of the reflux episodes.[1,2] The most common mechanism of reflux is transient lower esophageal sphincter relaxation [TLESR] and less commonly low resting LES pressure. [3] GER presents with regurgitation and occasional vomiting only without effects on growth and development whereas GERD usually has additional presentations. The objective of this review is to provide update on recent developments in the diagnosis and management of this condition

Regional variation in prevalence of overweight and obesity in Saudi children and adolescents

There are limited data on regional variation of overweight and obesity in the Kingdom of Saudi Arabia. Therefore, the aim of this report is to explore the magnitude of these variation in order to focus preventive programs to regional needs. Community-based multistage random sample of representative cohort from each region. the study sample was cross-sectional, representative of healthy children and adolescents from 2 to 17 years of age. Body mass index [BMI] was calculated according to the formula [weight/height[2]. The 2000 center for disease control reference was used for the calculation of prevalence of overweight and obesity defined as the proportion of children and adolescents whose BMI for age was above 85[th] and 95[th] percentiles respectively, for Northern, Southwestern and Central regions of the Kingdom. Chi-square test was used to assess the difference in prevalence between regions and a P value of <0.05 was considered significant. The sample size was 3525,3413 and 4174 from 2-17 years of age in the Central, Southwestern and Northern regions respectively. The overall prevalence of overweight was 21%, 13.4% and 20.1%, that of obesity was 9.3%, 6% and 9.1% in the Central, Southwestern and Northern regions respectively indicating a significantly-lower prevalence in the Southwestern compared to other regions [P<0.0001]. This report revealed significant regional variations important to consider in planning preventive and therapeutic programs tailored to the needs of each region

Presenting features of childhood-onset inflammatory bowel disease in the central region of Saudi Arabia

To investigate the presenting features of childhood-onset inflammatory bowel disease [IBD] in the central region of Riyadh, Saudi Arabia and to compare with those reported in the literature. This is a retrospective review of medical records of children below 18 years of age at onset of symptoms with confirmed diagnosis of IBD for age, gender, family history, presenting clinical and laboratory findings in the Divisions of Pediatric and Adult Gastroenterology, King Khalid University Hospital [which provides free health care] and the Department of Gastroenterology Al Mofarreh Poly Clinic, Riyadh, Saudi Arabia, between January 1993 and December 2010. Two hundred and eighteen children diagnosed with IBD with predominance of males in Crohn's disease [CD] [56%] and females in ulcerative colitis [UC] [59%]. There was no significant difference between UC and CD regarding age of onset of symptoms [p=0.347]; however, the difference in the age at presentation and age at final diagnosis were significant [p=0.027 and p=0.008]. There was a significant increase of IBD diagnosis from the period 1993-2001 to 2002-2010 [p<0.0001]. The family history was positive in 15.3%. The presenting clinical features and laboratory abnormalities are similar to those reported in other populations. Further studies are needed to establish the incidence and prevalence

Prevalence of short stature in Saudi children and adolescents

Data on stature in Saudi children and adolescents are limited. The objective of this report was to establish the national prevalence of short stature in Saudi children and adolescents. Community-based, cross-sectional study conducted over 2 years [2004, 2005] The national data set of the Saudi reference was used to calculate the stature for age for children and adolescents 5 to 18 years of age. Using the 2007 World Health Organization [WHO] reference, the prevalence of moderate and severe short stature was defined as the proportion of children whose standard deviation score for stature for age was less than -2 and -3, respectively. In addition, the 2000 Center for Disease Control [CDC] and the older 1978 National Center for Health Statistics [NCHS]TWHO references were used for comparison. Using the 2007 WHO reference, sample size in the Saudi reference was 19372 healthy children and adolescents 5 to 1 7 years of age, with 50.8% being boys. The overall prevalence of moderate and severe short stature in boys was 11.3% and 1.8%, respectively; and in girls, 10.5% and 1.2%, respectively. The prevalence of moderate short stature was 12.1%, 11% and 11.3% in boys and 10.9%, 11.3% and 10.5% in girls when the 1978 WHO, the 2000 CDC and the 2007 WHO references were used, respectively. The national prevalence of short stature in Saudi children and adolescents is intermediate compared with the international level. Improvement in the socioeconomic and health status of children and adolescents should lead to a reduction in the prevalence of short stature

Prevalence of malnutrition in Saudi children: a community-based study

There is no published information on the prevalence of malnutrition in Saudi Arabia. The objective of this study was to establish the prevalence data. 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. 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. 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

Regional disparity in prevalence of malnutrition in Saudi children

To evaluate the regional difference in the prevalence of malnutrition in Saudi children. Data for this study were collected over 2 years [2004 and 2005]. A cross-sectional representative sample of the Saudi population of healthy children below 5 years of age was used to calculate the prevalence of malnutrition. The study was carried out in the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia. Body measurements of the weight, length, and height were performed according to standard recommendations. Standard deviation scores were determined using the Lambda, Mu, and Sigma [LMS] statistical methodology. The 1978 NCHS/WHO growth reference was used for the calculation of prevalence of underweight, wasting, and stunting defined as the proportion of children whose weight for age, weight for height, and height for age was below minus standard deviation [-2 SD] for Northern, Southwestern, and Central regions of the Kingdom of Saudi Arabia. Chi-square test was used to assess the difference in prevalence between regions, and a p<0.05 was considered significant. The sample size of children <5 years of age in Central region was 5067, Southwestern 2285, and Northern 2933. The prevalence of underweight was 4%, 19.7% and 5.5%, that of wasting was 6.5%, 16.7% and 6.5% and of stunting was 6.4%, 13.2% and 6.4% in the Central, Southwestern, and Northern regions indicating a significantly-higher prevalence in Southwestern compared to other regions [p<0.001]. This report revealed a high prevalence of significant nutritional indicators in the Southwestern regions than in other regions. This finding indicates that this region should be given priority for further studies to identify causes, and to design health promotion programs

Prevalence of overweight and obesity in Saudi children and adolescents

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. 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. There were 19317 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. 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

Trends in infant nutrition in Saudi Arabia: compliance with WHO recommendations

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. 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 childdren less than 3 years of age. Of 5339 children in the sample, 4889 received breast milk at birth indicating a prevalence of initiattion 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. 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 introdduction 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

Blood pressure standards for Saudi children and adolescents

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. 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. 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. Blood pressure values in this study differed from those from other studies in developing countries and in the United States, indicating that comparison across studies is difficult and from that every population should use their own normal standards to define measured blood pressure levels in children

Age related reference ranges of heart rate for Saudi children and adolescents

To evaluate the resting heart rate to define reference values for healthy Saudi children and adolescents. To establish representative heart rate [HR] reference values for Saudi Arabian children and adolescents, a sample of children, and adolescents was selected by multi-stage probability sampling of the Saudi population from birth to 20 years of age. The selected sample represents Saudi children from the whole country. Data were collected by a house-to-house survey of all selected households in all the 13 regions in the country. A total of 10,458 Saudi children were included in the study. The HR was measured by oscillometric-automated devices. Upper and lower reference values of the HR in boys and girls were calculated as mean +/- 2 SD. The study is cross-sectional, community based, and conducted over 2 years [2004-2005]. Data management and analysis were performed in the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia. Determination of the HR values in a sample representing healthy Saudi children and adolescents from birth to 20 years of age. The present study provides age-specific reference values for heart rate [HR] of Saudi children and adolescents based on a large study sample. The use of these standards should aid the identification of children with abnormal HR

Consanguinity and major genetic disorders in Saudi children: a community-based cross-sectional study

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. 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. 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]. 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

Trends in the nutritional status of Saudi children

To evaluate the trend in the nutritional status of Saudi children over a 10-year period. The growth data collected between 1993-1994 were compared with those collected between 2004-2005 from all regions of the Kingdom. Both nutritional surveys had a similar design leading to representative samples of Saudi children determined by multistage probability sampling. Similar methodology of measurements of the weight and height were used. The data from the 1994 study, including the third, fifth, fiftieth, ninety-fifth, and the ninety-seventh percentiles, were plotted on the 2005 charts for the weight for age, height for age, weight for height. Compared to the 1994 results, the data of the 2005 study indicate an upward shift of the lower percentiles of the weight for age, and the weight for height, more than height for age, indicating improved nutritional status. However, the upward shift of the higher percentiles for the weight for age, and weight for height in the 2005 survey, indicate increased trend for overweight and obesity. There is a demonstrable improvement in the nutritional status of Saudi children, and also tendency toward overweight and obesity over the last decade

Comparison of the 2005 growth charts for Saudi children and adolescents to the 2000 CDC growth charts

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 adollescents. 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. 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. The use of the 2000 CDC growth charts for Saudi children and adolescents increases the prevalence of undernutrition, stunting, and wasting, potentially leading to unnecessary referrals, investigations and parrental anxiety. The increased prevalence of overweight and obesity is alarming and needs further investigation

Yield of Colonoscopy in Children with Rectal Bleeding

Rectal bleeding is a common complaint in children and is the most common indication for colonoscopy. The aim of this study is to report the yield of this procedure in children. Analysis of the medical records of all children below 18 years of age, who underwent colonoscopy from 1993 to 2002, in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia for the evaluation of rectal bleeding. Eighty-nine children presented with bleeding per rectum, accounting for 49% of the indications for colonoscopy. The majority [92%] was Saudi nationals, the age range was from 5 months to 18 years, and the male to female ratio was 1.1: 0.9. There were 22 children between 0-12 years and 35 between 13-18 years. The overall yield of colonoscopy was 57/89 [64%]; however, the yield was slightly better 22/32 [69%] for children 0-12 years. In a subset of children [22 patients, 21 of them were in the age group 0-12 years] where rectal bleeding was associated with diarrhea, the yield was 22/23 [97%]. The causes of bleeding per rectum are presented in the table indicating that colitis was the most common cause 30/57 [36%], followed by polyps in 15 [27%]; whereas rectal ulcers, chronic anal fissures and hemorrhoids accounted for 5% each. However, age-related analysis shows that colitis occurred more commonly in older children and polyps were found almost with equal frequency in both age groups. The diagnostic yield of colonoscopy is very high especially in children presenting with bloody diarrhea

Indications and yield of upper gastrointestinal endoscopy in children

Knowledge of the pattern of gastrointestinal tract [GIT] disorders detected by endoscopy is important for clinicians. The objective of this paper is to report on the indications and yield of endoscopy. Retrospective analysis of data of all patients below 18 years of age who underwent upper GIT endoscopy from 1414 H [1993 G] through to 1424 H [2002 G] over a 10-year period at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. One thousand and fifteen upper GIT endoscopies were performed, of which 851 diagnostic procedures were performed on 851 children. The majority [96%] were Saudi nationals, the age range was between 4 days and 18-years, and the male to female ratio was 0.7: 1. The 2 most common indications were duodenal biopsy [29%] and abdominal pain [24%]. The best diagnostic yield was in children presenting with ingestion of caustic substances, followed by hematemesis, and vomiting in 86%, 75% and 67%. The overall yield, however, was 43%. Finally, the most common diagnoses were gastritis and esophagitis occurring in 32% and 30% of the children. Age related variations are reported. The increasing practice of endoscopy in children resulted in the development of new indications such as endoscopic small bowel biopsy. The differences in indications and yield of endoscopy with age reflecting the varying pattern of diseases

Pattern of gastroesophageal reflux in children

Gastroesophageal reflux disease is a common health problem in children worldwide. There are no published data on this disease in children from Saudi Arabia. The objective of this study is, therefore, to report on the pattern of gastroesophageal reflux disease in Saudi children. Retrospective review of all children referred to the Pediatric Gastroenterology Division at King Khaled University Hospital in Riyadh. The diagnosis was confirmed in 85 children, all but 2 were Saudi nationals, and the male to female ratio was 1.6. The median age of onset of symptoms was 10 months, whereas the median age at referral was 20 months. The pattern of clinical presentation indicates that vomiting is the most common presentation occurring in 82% of the children, followed by respiratory disease in 38%. An underlying condition was found in 41% of the children, [35/85] the most common of which was neurological impairment. Peptic esophagitis was present in 51.5% of the children who underwent endoscopy. The median duration of follow up was 6 months. Good response to medical therapy was documented in 72% of normal children and 27% of those with underlying disease. All of the 23 children who had fundoplication in our institution had one or more of the underlying disorders. Gastroesophageal reflux disease is a common problem in Saudi children. The overall pattern in this report is similar to descriptions in the literature. Prospective multicenter studies are needed to confirm this pattern and to provide more focused descriptions of other aspects of the disease