The parent/guardian is concerned that the child cries when the hernia is "bulging" or "out".

• Crying increases intra-abdominal pressure, which can cause the hernia to become more apparent as contents are pushed through the defect.  Often, the crying is causing the hernia to bulge, rather than the other way around. 
• However, if the mass becomes tender to touch, firm, or red, this is cause for concern and should prompt immediate referral to an acute care setting.

Is there any sort of management to keep the hernia inside until the child is old enough for surgery?

• Currently, there are no effective non-operative interventions for umbilical hernia.  Umbilical strapping can lead to skin breakdown and has not been shown to be effective.

My patient has a very large hernia.  Should they be referred earlier?

• Hernia defect size has not consistently been shown to correlate with likelihood of spontaneous closure, and very large hernias often still close spontaneously.  There are no definitive data to support earlier closure at certain sizes. 
• The size of the "bulge" does not necessarily correlate with the size of the underlying defect, and has also not been shown to correlate with likelihood of spontaneous closure or complications.

What about proboscis/"elephant-trunk" type hernias?  Are these hernias less likely to close, and will there be a less favorable cosmetic outcome with the extra skin?

• The proboscis or "elephant trunk" appearance reflects the herniation of intraabdominal contents, not necessarily the size of the abdominal wall defect.
• The cosmetic outcomes are similar for more protuberant hernias and can be addressed at the time of surgery.
• There is no evidence of increased complications with this type of umbilical hernia.

I have a patient with drainage from the umbilicus.  Is this related to a hernia?

• Umbilical hernias should not be associated with drainage.  This may represent an infection or umbilical granuloma, but could also be caused by an omphalomesenteric duct cyst or patent urachus.  Patients with persistent umbilical drainage should be evaluated by a pediatric surgeon.

Why should we repair umbilical hernias at all?

• As a child gets older and the abdominal wall musculature becomes more well-defined, the risk of incarceration or strangulation may be higher.  Early repair is considered preventive.
• Additionally, as children get older, they may feel self-conscious or may withstand teasing from their peers for these physical differences.  Repair is recommended prior to starting school so it is less disruptive to their social development.

Does this also apply to other types of hernias, like inguinal hernias?

• These recommendations are specific to umbilical hernias.  Inguinal hernias are not expected to close spontaneously and have a higher risk of incarceration, and should be referred to a pediatric surgeon upon discovery.

What about patients with other congenital or medical conditions?

• We are always happy to see any patients in consultation in our clinic!  Children with multiple medical conditions may benefit from further specialty evaluation.