Umbilical Hernia

Pediatric Umbilical HerniaHernias can lead to significant pain and even emergent complications. We have previously discussed inguinal hernias and the need to always consider them as a cause of inconsolability or acute abdominal pain and/or vomiting in a child.  It is really suboptimal to work a child up for intussusception only to discover the problem was discreetly covered by the diaper.  There is, however, a hernia that is easily apparent when examining the abdomen… and fortunately, rarely causes problems. The Umbilical Hernia can raise many questions though.  Let us take a moment to digest a Morsel on the Umbilical Hernia:

 

Pediatric Umbilical Hernia: Basics

  • Umbilical hernias occur due to a failure of the umbilical ring to completely close after birth.
    • All newborns, by definition, have a small umbilical hernia that the umbilical vessels pass through.
    • Typically, the umbilical ring closes during the first few days to weeks of life.
  • Umbilical hernias are very common!
    • ~15-23% of newborns in the USA will have one
    • More common with some syndromes (ex, Down  Syndrome) [Kelly, 2013; Brandt, 2008]
    • More common in infants born weighing less than 1200 grams [Kelly, 2013]

 

Pediatric Umbilical Hernia: Problems

  • Rates of complications of pediatric umbilical hernias are low, but vary between studies. [Zens, 2017]
    • Complication rates range from 0% – 7.2%.
  • Specific complications noted to occur: [Zens, 2017]
    • Proboscoid hernia
      • Umbilical wall defect is similar in size as others, but there is large amount of redundant skin overlying it.
    • Symptomatic, intermittent incarceration
    • Strangulation
    • Strangulation requiring bowel resection
      • Very rare and noted to be “reportable.” [Zens, 2017]
    • Spontaneous evisceration
  • Based on the current evidence, it is unclear whether larger defects are truly associated with greater risk for complication. [Zens, 2017]

 

Pediatric Umbilical Hernia: When to Fix

  • There is consensus that pediatric umbilical hernias can close spontaneously. [Zens, 2017]
    • 93% have been shown to close in 1st year of life.
    • Even large defects tend to close within the first 3-4 years of life.
      • “Large” is a variable term in the literature, but tends to pertain to defects >1 cm (although, some report it as >2 cm).
      • Those >1.5 cm have greater chance of remaining open past infancy. [Zens, 2017]
  • Risk of watchful waiting needs to be weighed with risk of repair. [Zens, 2017]
    • Surgery can lead to post-operative complications (ex, infection).
    • Anesthesia in young children (<4 years) is more problematic:
      • Potential for respiratory complications
      • Potential for neurologic consequences
  • Watchful waiting is advised for: [Zens, 2017; Brandt, 2008]
    • Asymptomatic pediatric umbilical hernias in children <4 years of age;
    • Initially advised for “large” hernias as well
    • Some evidence that umbilical hernias can spontaneously close even up to age 14 years.
  • Repair is recommended for: [Zens, 2017]
    • Symptomatic or complicated umbilical hernias (obviously)
    • “Large” or enlarging can be considered;
      • Often cosmetic consideration
      • Risk/benefit needs to be weighed
      • Should wait until >4 years of age
    • Asymptomatic umbilical hernia in child after age 4 years, but before adulthood.

 

Moral of the Morsel

  • Umbilical hernias are common. Fortunately, they are not often complicated.
  • Their presence may inspire parental questions. Knowing what the pediatric surgeons will recommend is helpful to avoid confusion.
  • Just because it is rare, doesn’t mean it cannot happen. Complications do occur, so don’t be dismissive.

 

References

Zens T1, Nichol PF1, Cartmill R2, Kohler JE3. Management of asymptomatic pediatric umbilical hernias: a systematic review. J Pediatr Surg. 2017 Jul 24. PMID: 28778691. [PubMed] [Read by QxMD]

Kelly KB1, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North Am. 2013 Oct;93(5):1255-67. PMID: 24035087. [PubMed] [Read by QxMD]

Zendejas B1, Kuchena A, Onkendi EO, Lohse CM, Moir CR, Ishitani MB, Potter DD, Farley DR, Zarroug AE. Fifty-three-year experience with pediatric umbilical hernia repairs. J Pediatr Surg. 2011 Nov;46(11):2151-6. PMID: 22075348. [PubMed] [Read by QxMD]

Brandt ML1. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. PMID: 18267160. [PubMed] [Read by QxMD]

Gill FT1. Umbilical hernia, inguinal hernias, and hydroceles in children: diagnostic clues for optimal patient management. J Pediatr Health Care. 1998 Sep-Oct;12(5):231-5. PMID: 9987252. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. waseem says:

    so helpful! thanks so much for the basic and informative post

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