Hernias in Children

Umbilical Hernias in Children

An umbilical hernia is caused by a weakness in the layer of muscle of the abdominal wall, just behind the umbilicus.

All babies have umbilical hernias when they develop in the womb. The hernia will usually close before birth; however, approximately 1 in 5 babies born at term still have an umbilical hernia.

In many cases, the umbilical hernia goes back in and the muscles reseal before the child’s first birthday.

The risk of developing complications is low and therefore surgery isn’t usually recommended unless there are complications, the hernia is large or the hernia hasn't disappeared by the time the child is 3 or 4 years old.

Clinical Presentation

• Usually asymptomatic
• Becomes more apparent with activities causing increased intra-abdominal pressure, such as crying, straining, defecation
• May get protrusion of hernia sac due to its contents
• Obstruction and strangulation is uncommon in children

Management

• Most children younger than age 4 years may be managed conservatively in primary care as there is the potential for spontaneous closure
• Provide information about the nature of an umbilical hernia, indications for operation, and the low risk if surgery is not carried out
• Provide reassurance that the majority of umbilical hernias will close spontaneously shortly after birth
• A diameter more than 1.5cm is less likely to spontaneously close
• If after age 4 years the hernia has not spontaneously closed, consider referral to a paediatric surgeon.
• The child may want to undergo surgery because of the appearance or because the defect is large

Who to Refer

• Consider referral for children with umbilical hernia aged 4 years or over (and under 16) if there are concerns. Not all children with umbilical hernias need surgery as the risk of complications is very low and surgery is largely cosmetic.
• Please note that the adult hernia funding policy does not apply to children aged under 16.

Inguinal Hernias in Children

An inguinal hernia is a common condition. It is caused by the contents of the abdomen pushing down towards the scrotum or labia. If left untreated, an inguinal hernia can cause serious complications.

Congenital inguinal hernias are usually detected at birth and all need urgent outpatient referral for surgical repair.

Clinical Presentation

• Most commonly occurs in the first 6 months
• Swelling (or bulge) in the groin that may appear with lifting and be accompanied by sudden pain
• Will present by activities increasing intra-abdominal pressure, e.g. straining or crying
• The infant or child may appear to be in discomfort
• The child may present with incarceration (irreducible) or strangulation (loss of blood supply)
• Indirect hernias are more prone to cause pain in the scrotum and cause a 'dragging sensation'
• It may not be possible to see the hernia if it is reduced
• If bowel obstruction is present the child may be vomiting, have abdominal distention and absence of flatus/stool
• The incidence of incarceration is much higher in infants than children

Management

The incidence of incarcerated or strangulated hernias in paediatric patients is 12-16%. 50% of these occur in infants aged younger than 6 months.- see Patient.co.uk. The criteria based access policy for hernia in adults does therefore not apply in children and all patients under 16 should be referred even if the hernia is asymptomatic.

• Paediatric surgeons will repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible inguinal hernias. There is no significant difference in operative time for unilateral hernias but laparoscopy is faster than open surgery for bilateral hernias. There is no difference in recurrence rate but wound infection is higher with open surgery than with laparoscopy.
• Inguinal hernias in premature infants are usually repaired prior to discharge from the neonatal intensive care unit (NICU). Since infants are now being discharged home at much lower weights there has been a trend towards postponing surgery for 1-2 months to allow further growth. However one study advocated early surgery in order to avoid perioperative morbidity and to reduce the risk of incarceration, subsequent testicular ischemia and hernia recurrence.
• Herniotomy is all that is required with ligation and excision of the patent processus vaginalis.

Who to Refer

• Refer all children with inguinal hernia at any age under 16 as risk of complications is high. 
• Please note that the adult hernia funding policy does not apply to children aged under 16.

Red Flags

Emergency referral to a paediatric surgeon is indicated if:

• the hernia is incarcerated
• strangulation or obstruction is suspected

Referral

Refer to the clinical guidance for Management & Referral of Common Surgical Conditions provided by Bristol Royal Hospital for Children which includes advice on umbilical hernia in children.

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