Pediatric Umbilical Hernia


Article Author:
Alexandre Troullioud Lucas


Article Editor:
Magda Mendez


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/4/2019 3:03:32 PM

Introduction

An umbilical hernia presents as a bulge at the site of the umbilicus,  and in the pediatrician’s office, it is a common finding during routine well-baby visits for the first few months of life. New parents who are not very familiar with this anomaly might verbalize great concerns during these visits because they tend to become very worried when they see the bulge in their infant’s belly button. On the one hand, parents might be concerned with the idea that their child will suffer serious complications from an umbilical hernia, and they wonder if there are be any measures that they should take to avoid complications. On the other hand, they often are concerned about the cosmetic aspect of a hernia, and would like to know if their child will have this defect for the rest of his or her life. As a pediatrician, it is important to understand how to answer these questions and when it is time to refer the patient for surgical evaluation. Here we will discuss the background and general management of pediatric umbilical hernias.[1][2][3]

Etiology

There are three causes of an umbilical hernia:

  1. A congenital umbilical hernia is a congenital malformation of the navel (umbilicus).
  2. An acquired umbilical hernia results from increased intra-abdominal pressure caused by obesity, lifting, coughing, or multiple pregnancies.
  3. A paraumbilical hernia occurs in adults and involves a defect in the midline near the umbilicus, and from omphalocele.

Epidemiology

Pediatric umbilical hernias are very common in children, with 15% to 23% of newborns affected in the United States. The defect is seen more often in certain ethnic groups. They are very common in African-American infants as well as in Hispanic infants, compared to whites, for reasons not precisely understood. This abdominal wall defect is also more commonly seen in low-birth-weight babies, but there has been no description of increased frequency in either of the genders.

Pathophysiology

It is important to know the embryologic processes involved in the formation of the umbilicus to understand more about umbilical hernias. In utero, the midgut initially develops extra-abdominally, until during the second trimester, when it will return to the fetal abdominal cavity. Once the midgut is back in the abdominal cavity, fascia forms to ensure the midgut remains in place. In case of weak fascia or failure to fully form the fascia, abdominal weakness may occur, which may predispose the newborn to an umbilical hernia. When the midgut fails to return intra-abdominally during the second trimester, and the newborn is born with the gut bulging out of the umbilicus, surrounded by a sac, this is not considered an umbilical hernia, but an omphalocele (one of the differential diagnoses for umbilical hernias). An omphalocele requires medical attention immediately after birth and surgical correction as soon as possible to prevent further damage to the protruding organs.[4]

Additionally, for the umbilical vessels to pass to the umbilical cord, there is an opening in the umbilicus, a reason for which all newborns are born with a small umbilical defect. Since there is no function for the umbilical cord after birth, the umbilical ring usually closes in a matter of days to weeks. When the closure of the umbilical ring does not occur, it is considered an umbilical hernia, shown as a bulging through the umbilicus.

Of the hernias that appear before 6 months of age, the majority resolve by 1 year of age. Larger umbilical hernias may take longer, but most will be closed by 5 to 6 years of age. It is important to know what the risk of complications is when waiting for the defect to close spontaneously, to determine if and when the surgical repair would be needed.

Most studies looking into the complications of umbilical hernias have a significant selection bias because they only take into account patients that have undergone a surgical correction, leaving out a large proportion of patients with umbilical hernias who have never had any complication. The consensus remains that the risk of complications of a unrepaired umbilical hernia is very low.[5][6]

History and Physical

During a well-child care visit, the history given by parents might include a swelling of the belly button, which increases when the baby is crying, coughing, or straining. During a physical examination, it is important to distinguish an umbilical hernia from an omphalocele. The pediatrician should determine the size of the abdominal wall defect and determine if a hernia is reducible, without having signs of incarceration or strangulation. An “elephant’s trunk” appearance (a crescent-shaped defect above an umbilical hernia) may indicate a component above the umbilicus and warrants surgical evaluation since these usually do not close spontaneously.

Evaluation

In the majority of cases, there are no medical sequelae to umbilical hernias. No tests are recommended, a thorough physical exam is sufficient to make the diagnosis and to discuss the common course of the condition with concerned parents. Although pediatric umbilical hernias are a common entity in healthy infants, they are also associated with some specific conditions, which the pediatrician should keep in mind when evaluating a patient. Pediatric umbilical hernias are seen more often in common autosomal trisomies (e.g., Trisomy 21 and 18), metabolic disorders (e.g., hypothyroidism, mucopolysaccharidoses) and some dysmorphic syndromes (e.g., Beckwith-Wiedemann syndrome, Marfan syndrome). For this reason, it is important to distinguish healthy patients with an innocent finding of an isolated umbilical hernia, from patients with an umbilical hernia and other syndromic features, for example, macroglossia or hypotonia, the latter group warranting further evaluation.

Treatment / Management

There are no strict guidelines as to the management of pediatric umbilical hernias, especially as to when to repair an asymptomatic umbilical hernia. [6][7]Some textbooks recommend that surgery might be indicated in the following cases: 

  • An umbilical hernia is larger than 2 cm
  • There is an “elephant’s trunk” appearance
  • It did not spontaneously close by 5 to 6 years of age if the patient becomes symptomatic
  • There is strangulation 
  • The hernia increases in size after the age of 1 to 2 years.

Cultural sensitivity and knowledge of how certain groups traditionally manage umbilical hernias allow practitioners to discuss the issue in a non-argumentative manner while respecting the family’s traditions and facilitating the education of parents about any misconceptions they might have. Some parents, for example, believe that placing a coin on the hernia will help to reduce it, but physicians should educate the parents about the ineffectiveness of that practice and the risk of dermatologic irritation and infection. It would be a good practice to ask parents what their thoughts are about an umbilical hernia and what they are concerned about, to be able to address those concerns individually.

While umbilical strapping has been suggested in the past as the treatment for umbilical hernias and this is a common practice in certain ethnic groups, this is not part of the routine treatment. The management for umbilical hernias is watchful waiting, together with educating the parents of the natural course of the condition: most hernias resolve in the first few years of life. Strapping might lead to some skin irritation when adhesives are used. Above all, do no harm.

Enhancing Healthcare Team Outcomes

The management of an umbilical hernia is with a multidisciplinary team that includes a pediatrician, pediatric nurse, primary care provider, pediatric surgeon and the emergency department physician. The key is to understand that the majority of pediatric umbilical hernias will spontaneously close by ages 5-7. Unless the infant has signs of bowel obstruction or incarceration, the child can be followed. If in doubt, a referral to a pediatric surgeon is recommended.[8]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Pediatric Umbilical Hernia - Questions

Take a quiz of the questions on this article.

Take Quiz
You are seeing an infant for the first time at his 1 month well child visit. On physical exam, you notice a reducible umbilical hernia. Although an umbilical hernia is a common finding in infants, you want to look for any other findings on physical exam that could indicate a syndrome or condition associated with this finding. Which of the following conditions is generally not associated with a pediatric umbilical hernia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The mother of an infant in your pediatric outpatient clinic is worried about her child's umbilical hernia and asks you when you would expect the hernia to close. By what age have most pediatric umbilical hernias closed spontaneously?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You are supervising a medical student who is seeing a 2-month-old infant for his 2 months well child visit. The student notices a reducible umbilical hernia of approximately 1 cm and asks you when you would refer the patient for a surgical evaluation. Which of the following is not an indication for surgical repair?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
During a well-child visit, you notice that a 4-month-old baby girl has a reducible umbilical hernia with a crescent-shaped component above it. What will be your management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Pediatric Umbilical Hernia - References

References

Zens TJ,Rogers A,Cartmill R,Ostlie D,Muldowney BL,Nichol P,Kohler JE, Age-dependent outcomes in asymptomatic umbilical hernia repair. Pediatric surgery international. 2019 Apr;     [PubMed]
Pallister ZS,Angotti LM,Patel VK,Pimpalwar AP, Transumbilical repair of umbilical hernia in children: The covert scar approach. Journal of pediatric surgery. 2018 Sep 9;     [PubMed]
Zens T,Nichol PF,Cartmill R,Kohler JE, Management of asymptomatic pediatric umbilical hernias: a systematic review. Journal of pediatric surgery. 2017 Nov;     [PubMed]
Lauriti G,Miscia ME,Cascini V,Chiesa PL,Pierro A,Zani A, Intestinal malrotation in infants with omphalocele: A systematic review and meta-analysis. Journal of pediatric surgery. 2019 Mar;     [PubMed]
Zenitani M,Sasaki T,Tanaka N,Oue T, Umbilical appearance and patient/parent satisfaction over 5years of follow-up after umbilical hernia repair in children. Journal of pediatric surgery. 2018 Jul;     [PubMed]
Abdulhai SA,Glenn IC,Ponsky TA, Incarcerated Pediatric Hernias. The Surgical clinics of North America. 2017 Feb;     [PubMed]
Appleby PW,Martin TA,Hope WW, Umbilical Hernia Repair: Overview of Approaches and Review of Literature. The Surgical clinics of North America. 2018 Jun;     [PubMed]
Coste AH,Parmely JD, Umbilical Hernia 2019 Jan;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.