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Hi everyone, I'm Em Gootee from Cincinnati Children's.

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Today we will hear from Dr. Rebecca Brown, a pediatric surgeon at Cincinnati Children's

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Hospital Medical Center.

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In today's episode, we are reviewing an important topic, umbilical disorders.

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From understanding the risk of infections like umphalitis to discussing the management

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of common conditions such as umbilical hernias and granulomas, we'll cover everything you

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need to know to ensure the best outcomes.

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What is in the umbilical cord?

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Two umbilical arteries and one umbilical vein surrounding by a gelatin-like extracellular

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matrix known as Wharton's jelly.

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So you've got that umbilical cord there.

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When should it separate?

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And what happens if it doesn't separate?

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Is there anything that you worry about?

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They usually fall off two to three weeks and the delay can be a manifestation of an immune

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deficiency.

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Let's talk about our first case.

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Umbilical cord is separated.

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We're looking at the umbilical stump and patient has severe erythema and edema around the umbilical

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region and it might be accompanied by some drainage.

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And it's a bacterial colonization of that umbilical stump.

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And most commonly due to staph and strep from the skin flora.

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Mild cases, inflammation of the belly button, you may just want to treat with just alcohol,

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drying, ampicillin or amoxicillin and follow up every 24 hours.

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In a similar case like this, our diagnosis should be omphalitis.

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16% of the patients admitted with omphalitis develop necrotizing fasciitis.

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So obviously that's serious, rapidly progressive umbilical edema, erythema, drainage and a

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high mortality rate.

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So it's important to examine the cord whenever you have a newborn.

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Next we'll review umbilical hernias.

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Basically we see these all the time.

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You have the umbilical cord going through before they're born.

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When they cut that cord and everything closes up, that muscle is supposed to re-approximate.

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And sometimes it doesn't, so you get an area that can be a hernia.

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It's more common typically in African Americans in low birth weight premature infants and

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can be associated with some other types of medical problems.

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Umbilical hernias can also be associated with trisomy 13, 18 and 21.

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I don't think their connective tissues are very good and they have hypotonia.

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Although umbilical hernias are common, they usually close on their own in infants with

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most cases healing by the time the child is 3 to 5 years old.

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However, Dr. Brown mentioned that if the opening in the fascia is larger than 1.5 cm, it may

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not close by itself.

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There was a lot of studies done way back by Walker, 96% of them that were very small.

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Less than 0.5 cm closed by 6 years.

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But there is no hernia that was greater than 1.5 cm that closed by 6 years of age.

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There was this thought that if the larger it is, more unlikely to close.

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When we talk about hernias, one thing we worry about is incarceration.

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Does this also apply to umbilical hernias?

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Incarceration with umbilical hernias is actually pretty rare, less than 0.2%.

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And it's more common if you have a smaller defect.

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If incarceration in umbilical hernias isn't a major concern and most small hernias close

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on their own by the time a child is 3 to 5 years old, when is the right time to repair

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them?

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Should we wait?

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So more recently, Tiffany Zins, which was one of our fellows, she had written this article

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on 308 umbilical hernia repairs and they had a higher incidence of complications if they

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were less than 4 years of age versus if they were greater than 4 years of age.

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So maybe we should wait till they're a little bit older to fix them.

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Because there's not a high incidence of incarceration or anything.

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And then they looked at over about 787 manuscripts in the literature, 28 met criteria of being

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good papers.

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The results showed that if a hernia is incarcerated and usually causes symptoms, it's important

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to fix it.

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For asymptomatic umbilical hernias in children around 4 years old, that's when we should

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start considering surgery.

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Early surgical repair before age 4 was not indicated regardless of the size of the defect.

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And Dr. Brown brought another study.

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As always, you can find all studies we mentioned in this podcast linked in the description

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below.

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Don't forget to check them out.

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In 2020, they looked at 9,809 patients.

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The 3-year recurrence rate when you fix umbilical hernia was twice as high in children less

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than 4 years of age versus if they were greater than 4 years of age.

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There was a higher rate of unplanned returns to the emergency department within 30 days

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at 2.5%.

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This rate was twice as high for patients younger than 4 years old.

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Rates of recurrence and unplanned AD visits were higher in children that were less than

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4.

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An asymptomatic umbilical hernia repair should be delayed until greater than 4 years of age.

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Here's the most recent study from Rangel.

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They looked at a big cohort of children that were less than 6 years of age over a 5-year

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period.

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And they've reviewed the electronic medical record at 68 pediatrician's offices around

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the Boston area and off about 167,000 patients, 4,486 of them had umbilical hernia repair

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diagnosis at a median age of about 1.6 months.

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They divided these into small hernias.

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One centimeter was considered small so you don't get the really giant ones versus the

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really small ones.

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And spontaneous closure was identified in 89% by age 5.

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The closure rates for smaller hernias were nearly 90%, while for larger hernias they

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were around 80%.

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And if that umbilical hernia was persistent at age 3, spontaneous closure was 20% by 4

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years and 35% by 5 years.

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So they concluded that you can watch these.

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There's a pretty high incidence of spontaneous closure and you should delay umbilical hernia

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repair until the age of 5 years.

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One thing that I've always looked at is that you may have a big huge hernia but the defect

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may be very small.

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And I think those, if you see them early on, those are the ones that are more likely to

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close.

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If it has a huge defect and it's proboscis it's probably not going to close.

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Now we have a better understanding of the timing of the repair.

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So let's talk more about the indications.

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So basically persistence after 5 years of age, signs or symptoms of incarceration, and

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then the question with the really big large defect when a patient is about to go to school

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and they've got a big proboscoid umbilical hernia.

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The proboscoid hernia is a not so common problem that can happen with an umbilical hernia.

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It occurs when the skin above the hernia grows and pushes through the opening in the abdominal

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wall.

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It's recommended to correct the proboscoid hernia before school age to avoid psychological

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issues for the child.

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I think in general, 5 years, regardless of size, if it hasn't closed, fix it.

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If until then, leave it alone unless they're having symptoms.

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What is the surgical technique to repair an umbilical hernia?

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You need to get around the hernia, around the umbilical spot there, the hernia sac.

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And then once you're clearly around it, you can divide that hernia sac.

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Take the excess sac until you have good edges and then you can close it.

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There's a lot of ways to close it, but the idea is that usually you'll do an interrupted

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type of closure.

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And you can use either Virol or some type of a absorbable suture.

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And then you want to recreate a belly button.

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And that's a really, really important step, I think.

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Because most people want to have a nice looking belly button.

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I would say the majority of belly buttons, even if they're fairly large, you can tack

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it down and you can make it look pretty good.

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This is a practice that varies between providers.

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But Dr. Brown told us that she prefers to do an umbilical plasty in these cases.

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So next, she excises some skin.

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So what I'll do is if it's very, very long, I'll lift up on it and I'll just cut it

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straight across with some big mayo scissors.

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Then I take a 4-0 monocle suture and I keep it really close to the skin surface up here

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and do a very, very nice purse string.

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A little short tiny bite.

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Sometimes you can even tie it up from the inside and then use that stitch to tack it

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down.

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According to Dr. Brown, this technique makes it really, really nice looking umbilicus.

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And then you just tuck that newly created umbilicus down and it looks just normal.

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To finish today's podcast, let's talk briefly about umbilical granulomas.

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So these are the most common umbilical masses of newborns.

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They're usually moist, but very commonly dry up and follow spontaneously over time.

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Often they'll respond to some silver nitrate.

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Give it some time and sometimes it may just go away.

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And if it goes away, I wouldn't worry about it.

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But sometimes patients come to you with burned skin around their belly button due to halved

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silver nitrates applied, which can create a bit of mess to take care of.

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And one thing I always do when you do it is to neutralize the burn and also probably to

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keep it from whatever.

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Get some water, put it on there after you put the silver nitrate on it.

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And this tip isn't just only for babies.

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It works for any type of silver nitrate application.

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If you apply some cold, damp water and clean it up, it might help prevent a lot of problems.

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Now sometimes these can be a little different.

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The ones that are really, really bright red, they're oftentimes very pedinculated and

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they bleed very easily.

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Those are the ones I think that are more commonly associated with ditalin or urethral air remnants.

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We are adding a decision tree in the description below.

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So according to this tree, if you find a granuloma or a pull lip, check for drainage.

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If drainage is present, refer the patient for surgery.

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Review the pathology report and look for granulation tissue.

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If it involves a vitilin duct, proceed with an ultrasound and consider resection and repair,

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among other options.

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We recommend you checking that decision tree if you have a similar patient.

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In summary, normal separation of the umbilical cord happens within 2 to 3 weeks after birth.

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And delays in this process can indicate potential immune deficiencies.

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Problems such as omphalitis can occur at the umbilical stump, requiring careful monitoring

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and treatment to prevent severe complications.

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Umbilical hernias are common in infants and typically resolve on their own.

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Surgical intervention is advised for persistent hernias beyond age 5 or if symptomatic, with

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guidelines suggesting that asymptomatic repairs should be delayed until after age of 4 to

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reduce complications.

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Global granulomas are frequent in newborns and generally resolve without intervention.

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Treatment may involve topical applications of silver nitrate, but care is needed to prevent

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skin irritation or burns.

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Thank you for listening this podcast.

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