Hernias

Many people are surprised to learn that hernias are fairly common in kids. Babies (especially preemies) can even be born with them.

Hernias in kids can be treated (hernia repair is the one of the most common surgeries performed on children), but it's important to recognize their symptoms so that you can get your child the appropriate medical care.

About Hernias

When part of an organ or tissue in the body (such as a loop of intestine) pushes through an opening or weak spot in a muscle wall, it can protrude into a space where it does not belong. This protrusion is a hernia, which may look like a bulge or lump.

Some babies are born with various small openings inside the body that will close at some point. Nearby tissues can squeeze into such openings and become hernias. Unlike hernias seen in adults, these areas are not always considered a weakness in the muscle wall, but a normal area that has not yet closed.

Sometimes tissues can squeeze through muscle wall openings that are only meant for arteries or other tissues. In other cases, strains or injuries create a weak spot in the muscle wall, and part of a nearby organ can be pushed into the weak spot so that it bulges and becomes a hernia.

Types of Hernias

There are different types of hernias, and each requires different levels of medical care.

In many infant and childhood hernias, the herniated tissues may protrude only during moments of physical pressure or strain. A prominent bulge might only be noticeable when a child is crying, coughing, or straining, and it may seem to retract or go away at other times. Hernias in this state are called reducible and are not immediately harmful.

Sometimes tissue can become trapped in an opening or pouch and do not retract. These are incarcerated hernias, and are a serious problem requiring immediate medical attention. For example, a loop of intestine that is caught and squeezed in the groin area may block the passage of food though the digestive tract.

Symptoms of an incarcerated hernia can include pain, vomiting, and irritability. If you touch the bulge it has created, it may feel hard.

A doctor can usually free the trapped tissues by gently squeezing the lump and trying to force it back into the body opening. Because incarcerated hernias can be painful, the doctor usually provides pain medication during this procedure. Surgery is usually required within a few days to prevent development of another incarcerated hernia.

The most serious type of hernia is a strangulated hernia, in which the normal blood supply is cut off from the trapped tissue. Without that blood supply, the strangulated tissue cannot get oxygen and will die. Surgery is required immediately to dislodge the tissue so that oxygen can get to it again.

The two most common hernias in kids are inguinal hernias in the groin area and umbilical hernias in the belly-button area.

Inguinal Hernias

In infants, an inguinal hernia is most often caused by a protrusion of a loop or portion of intestine or a fold of membrane from the abdomen — or in girls, from an ovary or fallopian tube — through an opening into the groin (the area where the abdomen meets the top of the thigh). The opening is caused by the presence of a fold of the peritoneal membrane, which produces a sac. Within this sac, the loop of bowel can protrude.

The hernia is apparent as a bulge in the groin area, especially when the child cries, coughs, or stands.

Sometimes, in boys, the inguinal hernia extends beyond the groin into the scrotum (the sac that holds the testicles). In girls, it can extend to one of the outer labia (the larger lips of tissue around the vaginal opening). In these cases, an enlargement or swelling can be seen that extends from the groin into the scrotum or labium.

More common on the right side, inguinal hernias occur far more often in boys than girls and are most common in preemies, baby boys with undescended testicles, and kids with cystic fibrosis. Kids with a family history of hernias are also at risk.

Other conditions that may look like inguinal hernias, but are not:

• A communicating hydrocele is similar to a hernia, except that fluid causes the bulge rather than protruding tissue. Depending on its location, the hydrocele may be left to disappear in a year or two or it may be treated with surgery. In infants, the hydrocele may not require surgery, as many go away by the second birthday. Some can change size depending on how much fluid goes in and out, and some may appear bluish because the membrane that causes the hydrocele is blue.
• Occasionally, a retractile testicle (a testicle that retracts from the scrotum from time to time) causes a bulge in the groin area. It may not need treatment but should be evaluated by a pediatric specialist.
• A femoral hernia is rare in kids and can be confused with an inguinal hernia. It consists of tissues that have pushed in alongside an artery into the top of the thigh. It appears as a bulge at the top of the thigh, just below the groin.

Umbilical Hernias

Some babies are born with a weakness or opening in the abdominal muscles around the belly button (under the skin) through which some abdominal membrane or small intestine protrudes.

The soft bulge this creates is an umbilical hernia. It is most obvious when the baby cries, coughs, or strains. Umbilical hernias are more common in females, those of African heritage, and low birth weight babies. These hernias range in size from less than ½ inch (2 centimeters) to more than 2 inches (6 centimeters).

In most instances an umbilical hernia causes no discomfort. Usually, a doctor can easily push it back in. An infant's umbilical hernia (unlike an adult's) rarely obstructs or strangulates. In fact, most umbilical hernias, even the larger ones, tend to close up on their own by age 2. That's why the doctor usually advises waiting and watching this kind of hernia in an infant rather than operating.

Surgery is necessary only if the hernia is very large; grows in size after age 1 or 2; fails to heal by age 4 or 5; or the child develops symptoms of obstruction or strangulation, like swelling, bulging, vomiting, fever, and pain. If such symptoms develop, call the doctor immediately.

Signs and Symptoms

If you think that your child may have a hernia, call your doctor immediately. And ask yourself:

• Is the bulge present when your child is straining, crying, coughing, or standing, but absent when your child is sleeping or resting? This could indicate a reducible hernia.
• Is the bulge present all the time, but with no other symptoms? This could be a hydrocele or something else.
  
• Has the groin area suddenly begun to swell? Do you notice any discoloration of the bulging area or a "swollen" abdomen? Is your child irritable, complaining of pain, constipated, or vomiting? These are signs of an incarcerated hernia, which calls for immediate attention. See a doctor immediately or take your child to the emergency department.
• Is the area swollen, red, inflamed, and extremely painful? Has your child developed a fever? These might be symptoms of a strangulated hernia. Call your doctor and then go directly to the hospital emergency department.

Treatment

Once an inguinal hernia is diagnosed, surgery will be done to prevent it from becoming incarcerated. During surgery, the herniated tissue is put back into its proper space, and the opening or weakness that permitted it to form is closed or repaired.

Surgery to correct inguinal hernias is performed on kids of all ages, sometimes even on premature babies.

Inguinal hernia surgery in kids is usually performed on an outpatient basis with no overnight stay in the hospital, but some kids, particularly young infants, may be kept in the hospital overnight for observation.

The period of recuperation for kids is fairly short. Most can resume normal activities about 7 days after surgery, with the doctor's approval. Until that time, kids should avoid strenuous activity such as bicycle riding and tree climbing. Of course, if you notice any signs of problems after the surgery, such as bleeding, swelling, or fever, call your doctor.