What is it? Umbilical hernias form when the umbilical ring is delayed in closing/fails to close completely. More common in: premature infants, low weight infants, children of African descent, hypothyroidism, children with certain syndromes e.g. T21 (Down syndrome)

How does it present? Most commonly presents as a reducible painless bulge at umbilicus. Can be more prominent when the baby or child strains or cries.

How to assess:

Thorough history: Exclude red flag symptoms of vomiting/constipation.

Systematic examination: particularly looking to exclude red flag signs of pain on examination, irreducibility of hernia & colour change of overlying skin.

Red flags: The following complications are extremely rare in umbilical hernias.

  • Incarceration: when abdominal viscera/omentum become stuck within the hernia. Usually presents with: painful irreducible hernia, which can have overlying skin colour changes.
  • Strangulation: when viscera become stuck in the hernia with compromise to their blood supply causing ischaemia. Usually present with: painful irreducible hernia, associated vomiting/constipation.

When/who to refer to?

  • If symptoms of incarceration/strangulation – emergency referral is required for assessment by paediatric team in A&E/PAU. The paediatric team will assess and liaise with the paediatric surgical team (usually at St George’s Hospital) as necessary.
  • Asymptomatic umbilical hernia in children <4 yrs old – reassure parents that complications are rare and most hernias will close by 4 years old.
  • Asymptomatic umbilical hernia in children  >4 yrs old – routine referral to paediatric surgeon required as spontaneous closure less likely as child grows older. This can be to the Paediatric Surgical clinic at Kingston Hospital, or to Paediatric Surgery at St George’s Hospital.

What is it? An umbilical granuloma is an overgrowth of tissue during the healing process of the stump. It usually looks like a soft pink/red lump and can be wet or leak small amounts of clear/yellow fluid. It is most common in the first few weeks of a baby’s life. Granulomas can take months to resolve.

Red flags: Signs of infection such as fever, spreading erythema, offensive smell/discharge. See umbilical infection section.

Treatment:

  • Advise hygiene measures: Keeping umbilicus clean and dry, cleaning with water when soiled, exposing umbilicus to air by rolling back the nappy.
  • Salt treatment (first line): twice daily application of a pinch of table salt treatment for 2 days (clean umbilicus, apply a small pinch of salt, cover area with clean gauze and leave for 30 minutes before rinsing off). The granuloma should start to heal after 2 days.
  • We do not recommend the use of silver nitrate anymore as there have been reported incidences of surrounding skin being chemically burnt.

When/who to refer to? If signs of umbilical infection (see below), refer the child for urgent assessment at PAU.

What is it? Umbilical stumps can often appear moist & generally take 5-15 days to detach. Importantly, this must be discriminated from infection. Omphalitis is when the cord and/or surrounding skin becomes infected, and can cause the child to become systemically unwell. The most common sign of infection is purulent/offensive discharge from the umbilicus.

Red flags:

  • Spreading erythema around cord (periumbilical flare – which is usually a flame shaped erythema usually above the stump)
  • Signs suggesting the child is systemically unwell
    • Temperature instability
    • Poor feeding
    • Signs of dehydration, including poor perfusion and tachycardia
    • Abnormal drowsiness or irritability

When/who to refer to?

  • If there are signs of local infection e.g. discharge, but no spreading erythema & child is well: take an umbilical swab for MC&S, treat with oral antibiotics (Flucloxacillin, 5-7 days). Clinical review after 48 hours to ensure improvement & give clear safety net advice.
  • If there is spreading redness or child is systemically unwell/has ‘red flags’, please arrange urgent referral for paediatric assessment as this may require IV antibiotics.  This should be done via the hospital switchboard 0208 546 7711 and ask to speak to paediatrics urgently (this will be a phone during daytime hours and on call registrar out of hours via bleep).

What is it? The urachus is an embryological remnant connecting the bladder to the umbilicus. This usually closes at birth, but in some cases persists as a fistula between the two. These often present as persistent drainage of fluid (urine) from the umbilicus. An ultrasound can confirm the presence of a patent urachus.

Red flags: Urinary tract infection or umbilical infection, particularly if signs of being systemically unwell (as above).

When/who to refer to? If evidence that child is systemically unwell, please arrange an urgent referral for paediatric review via switchboard (0208 5467711)  – this will be to a phone during daytime and registrar bleep out of hours.

If confirmed patent urachus but no red flags: routine referral to paediatric urology (usually requires excision to avoid malignancy in later life) – usually at St George’s Hospital.

Supporting Information

The following are useful resources for parents:

Umbilical hernia & repair information

Umbilical granuloma

  • https://www.hct.nhs.uk/media/1932/umbilical-granuloma.pdf