American Academy of Pediatrics – Section on Surgery

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November 4, 2019

Avoid referring most children with umbilical hernias to a pediatric surgeon until around age 4-5 years.

Patients with umbilical hernias may safely be observed until at least age 4 years; at that point pediatric surgical consultation is recommended to discuss surgical repair option. Special consideration for earlier consultation can be given in cases of parental concern.

Umbilical hernias, resulting from failure of complete closure of the umbilical ring after birth, affect up to 25% of newborns. Unlike inguinal hernias, or umbilical hernias in adults, a majority of newborn umbilical hernias will close spontaneously – about 85% closure rate by age 5 years. Larger umbilical hernias – vaguely defined as those over 1.5 cm in diameter – have a lower likelihood of spontaneous closure. Complications of umbilical hernia, such as incarceration (where omentum or bowel is “stuck” in the hernia sac, estimated at 0.2-4.5%) or strangulation (where omentum or bowel is incarcerated and proceeds to suffer ischemic damage, estimated at less than 0.8%) are very rare; thus the risk/benefit ratio in surgical closure of umbilical hernias strongly favors observation. Even markedly large or protuberant umbilical hernias (such as a proboscis, or elephant-trunk, type hernia) may undergo spontaneous closure and are not clearly associated with an increased risk of complications when not surgically closed. Non-operative closure techniques such as umbilical strapping are generally ineffective, can lead to skin breakdown, and should be avoided.

Complications following umbilical hernia repair in children are rare and may include infection (estimated at less than 1%) and recurrence (estimates ranging from 0.27%-2.44%). Recurrence rates appear to be higher in children repaired at an early age (less than 4 years).


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

Members of the American Academy of Pediatrics Section on Surgery Subcommittee on Education and Delivery of Surgical Care submitted the top 5 topics for Choosing Wisely items based on a review of the literature and expert opinion. The items were refined, ranked and approved by the Section on Surgery leadership. The list was then reviewed and approved by more than a dozen relevant AAP Committees, Councils and Sections. The AAP Executive Committee granted final approval of the list.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

Zens T, Nichol PF, et al. Management of asymptomatic pediatric umbilical hernias: A systematic review. J Pediatr Surg 2017;52:1723-1731.

Chirdan LB, Uba AF, Kidmas AT. Incarcerated umbilical hernia in children. Eur J Pediatr Surg. 2006 Feb;16(1):45-48.

Yanagisawa S, Kato M, et al. Reappraisal of adhesive strapping as treatment for infantile umbilical hernia. Pediatr Int. 2016 May;58(5):363-368

Abdulhai SA, Glenn IC, Ponsky TA. Incarcerated pediatric hernias. Surg Clin North Am. 2017 Feb;97(1):129-145.

Brown RA, Numanoglu A, Rode H. Complicated umbilical hernia in childhood. S Afr J Surg. 2006 Nov;44(4):136-137.

Ireland A, Gollow I, Gera P. Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood. J Paediatr Child Health. 2014 Apr;50(4):291-293