Background <p>Few reports have focused on the complications of pediatric kidney biopsy, and no comparative studies between open kidney biopsy (OB) and percutaneous needle kidney biopsy (NB) in pediatric populations are recognized. We aimed to evaluate the safety and diagnostic utility of OB in pediatric patients and to determine whether OB can be a reliable alternative to NB, especially in younger children and those at high risk.</p> Methods <p>This retrospective study included 264 pediatric patients (0–18&#xa0;years) who underwent kidney biopsy at a single center between April 2013 and December 2023. Patients were divided into OB and NB groups. Clinical parameters, biopsy yield (glomeruli number), complications, and time to free ambulation were compared between the groups.</p> Results <p>Of the 264 biopsies, 136 were OB and 128 were NB. Patients in the OB group were significantly younger than those in the NB group. The OB group exhibited significantly more glomeruli than did those in the NB group. There was a biopsy-associated complication (re-admission due to enlargement of subcapsular kidney hematoma) in one NB case (0.8%) and none in the OB group. The OB group demonstrated a shorter duration of postoperative bed rest, with no patients requiring extended rest or re-admission.</p> Conclusions <p>OB in children yields a greater glomeruli number and demonstrates a favorable safety profile, even in young patients unable to remain immobile and patients with a high risk of bleeding. OB is a valuable option for accurate diagnosis and should be considered, particularly in cases where NB is contraindicated.</p> Graphical abstract <p></p>