Hernias 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 requiring bowel resection
- Very rare and noted to be “reportable.” [Zens, 2017]
- Spontaneous evisceration
- Proboscoid hernia
- 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.