Umbilical Hernia in Children

Umbilical hernia in children is protrusion of intra-abdominal contents through a defect in the linea alba at the umbilical ring, due to delayed closure of the umbilical ring after cord separation.

• It occurs in about 15 to 20 percent of infants, and is commoner in African children (up to 50 percent), premature infants and low birth weight babies.
• Associations include hypothyroidism, Down syndrome, mucopolysaccharidoses, Beckwith-Wiedemann syndrome and conditions raising intra-abdominal pressure.
• Most close spontaneously by age 3 to 5 years, with defects under 1 cm closing most reliably.
• Complications such as incarceration and strangulation are rare in children.

A soft, painless swelling at the umbilicus.

• Soft, reducible swelling that bulges with crying, coughing or straining and disappears when the child is calm or supine.
• The skin is intact. Fascial defect is palpable.
• Painless in most cases.
• Irreducibility, tenderness, discolouration, vomiting or abdominal distension suggest incarceration.
• Differential diagnosis: paraumbilical hernia, epigastric hernia, umbilical granuloma, omphalocele, urachal anomalies, omphalomesenteric duct remnant and divarication of recti.
• Complications: incarceration, strangulation, skin ulceration or rupture (rare), and persistence to school age.

Diagnosis is clinical.

• Inspect and palpate the umbilicus with the child calm and supine; measure the fascial defect.
• Ultrasound only if diagnosis is uncertain.
• Check thyroid function and look for syndromic features if the hernia is large or persistent, or if growth or development is abnormal.

Observation until at least age 4 to 5 years.

• Supportive: reassure parents. Strapping, coins or tight bandages do not help and may cause skin damage; they are not advised.
• Pharmacological: none.
• Procedures: elective repair (primary suture of the fascial defect) at age 4 to 5 years if the hernia persists, or earlier if the defect is large (over 1.5 to 2 cm) and not narrowing by 2 to 3 years, symptomatic, or has a narrow neck. Emergency surgery for incarceration or strangulation.
• Special groups: children with recurrent incarceration, very large defects, or conditions that raise intra-abdominal pressure may need earlier repair.
• Red flags: painful, tense, irreducible swelling, discolouration, bilious vomiting, abdominal distension and fever.
• Follow-up: review every 6 to 12 months for spontaneous closure. Refer to surgery at age 4 to 5 years if persisting.