Umbilical hernias in babies
An umbilical hernia is a common benign condition in infants, resulting from a failure of the umbilical ring to fully close after birth. The defect allows intra-abdominal contents, typically omentum or a loop of bowel, to protrude through the linea alba. Clinically, it presents as a soft, painless, reducible bulge at the umbilicus, which becomes more prominent with crying, coughing, or straining.
Incidence: It is very common, affecting 10-30% of white children and up to 85% of African and Afro-Caribbean children. It is also more frequent in premature infants and those with certain conditions like Trisomy 21 (Down’s Syndrome) or connective tissue disorders.
Spontaneous Resolution: The majority of umbilical hernias spontaneously close by the age of 4-5 years as the abdominal wall musculature strengthens. The size of the hernia in infancy does not reliably predict the likelihood of spontaneous closure.
Management Guidelines
The standard of care in the UK remains conservative management for asymptomatic umbilical hernias in children under four years old.
Reassurance: The primary role of the paediatric doctor is to reassure parents that the condition is common and benign, and that complications like incarceration or strangulation are extremely rare in this age group (less than 1%).
Referral Criteria: Referral to a paediatric surgeon is typically considered for:
Children with a hernia that persists beyond 4-5 years of age.
Symptomatic hernias (pain or frequent discomfort).
Incarcerated or strangulated hernias (this is a surgical emergency).
Herias with a very thin overlying skin that appears at risk of rupture (a rare but important red flag).
Cosmetic concerns, particularly if the child or family is distressed by the appearance.
What NOT to do:
Do not use binders, strapping, or coins to “treat” the hernia, as these are ineffective and can cause skin irritation or infection.
Avoid routine referral for asymptomatic hernias in young children.
Red Flags: Urgent Referral
While complications are rare, it is crucial to recognise the signs of an incarcerated or strangulated hernia. This requires immediate referral to a paediatric surgeon.
Incarcerated hernia: A hernia that is painful and irreducible, but the child is otherwise well.
Strangulated hernia: A hernia that is painful, irreducible, and associated with systemic signs of bowel obstruction or ischaemia. The child may be unwell with persistent vomiting (especially bile-stained), severe abdominal pain, and a tender, discoloured lump at the umbilicus.
Recent Developments
Recent literature, while affirming the conservative management approach, has focused on surgical techniques and outcomes when an operation is indicated.
Surgical Repair (Hernioplasty): Surgery is a straightforward, day-case procedure performed under general anaesthetic. A small incision is made near the umbilicus to access the defect, which is then closed with sutures.
Focus on Cosmetic Outcomes: A refined surgical technique, described in a 2021 publication in The Annals of The Royal College of Surgeons of England, has been highlighted. This approach involves excising excess umbilical skin and anchoring the neo-umbilicus to the linea alba to create a better cosmetic result and avoid a visible scar. The goal is to provide a more natural “in-ee” appearance.
Incidental Findings: Recent case reports, such as a 2024 publication in PMC, have documented the rare occurrence of unexpected contents within an umbilical hernia sac, such as a Meckel’s diverticulum (known as a Littre’s hernia). This is usually an incidental finding during elective repair. While rare, it is a reminder to the surgeon of the potential for unusual pathology within the sac.
Ongoing Research: The literature continues to reinforce that the risk of complications from an uncomplicated umbilical hernia in a child is far lower than the risks associated with general anaesthesia and surgery, underscoring the “wait and see” approach as the correct management strategy in the majority of cases.