Choosing Wisely:

Avoid referring most children with umbilical hernias to a pediatric surgeon until around age four to five years.

Rationale and Comments: Patients with umbilical hernias may safely be observed until at least age four 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 five 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% to 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. Nonoperative 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% to 2.44%). Recurrence rates appear to be higher in children repaired at an early age (less than four years).
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Surgery
  • Sources:
  • Systematic review
  • Disciplines:
  • Pediatric
  • Surgical
  • References: • 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.

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