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

• The neonatal umbilical region can generate concerns:
  • Umbilical Granuloma
  • Omphalitis

• 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