The American Academy of Pediatrics Section on Surgery and the American Academy of Family Physicians recommend waiting until age 4-5 years before referring most children with umbilical hernias to a pediatric surgeon.  This is based on the risk/benefit ratio of surgical closure and the high rate of spontaneous closure - about 85% by 5 years of age.

This tool and the accompanying resources can be used to empower clinicians to advise families in their own primary care setting, minimizing time off work and school for patients and families, and ensuring better availability of specialty appointments.

Risks of Surgery

Complications are of umbilical hernia repair are rare.  Postoperative wound infections occur in less than 1% of repairs and most can be managed with antibiotics and basic wound care.  Formation of hematoma or seroma is also rare (0.1-0.5%).  The most common postoperative complaints are pain and constipation.

However, complications are more frequent in younger children, and are up to 3 times higher in children under 2 years of age.  Younger children are significantly more likely to require postoperative admission or visit the ED within 30 days after surgery.

Recurrence after surgery is estimated at 2%, usually within less than a year.  The recurrence rate is higher in children repaired prior to age 4.

Risks of Waiting

Incarceration: bowel or omentum becomes "stuck" inside the hernia sac and cannot be pushed back into the peritoneal cavity. The American Academy of Pediatrics cites a prevalence of incarceration in 0.2-4.5%.

Strangulation: incarcerated bowel or omentum becomes strangulated, losing its blood supply.  While this is a surgical emergency, it is extremely rare, occurring in less than 0.8% of pediatric umbilical hernias. 

The risk-benefit ratio for both of these strongly favors observation and delayed closure.

Other Options?

Umbilical strapping is not recommended, as it has not been shown to improve closure and there is around a 25% risk of skin irritation or excoriation.

"Elephant trunk"/proboscis-type hernias may also close spontaneously. There is no clear association with increased risk of complications when these are not surgically closed.  The excess skin can be addressed at the time of closure, and cosmetic results are typically quite favorable.