Umbilical Disorders with Dr. Rebeccah Brown

Hi everyone, I'm Em Gootee from Cincinnati Children's. Today we will hear from Dr. Rebecca Brown, a pediatric surgeon at Cincinnati Children's Hospital Medical Center. In today's episode, we are reviewing an important topic, umbilical disorders. From understanding the risk of infections like umphalitis to discussing the management of common conditions such as umbilical hernias and granulomas, we'll cover everything you need to know to ensure the best outcomes. What is in the umbilical cord?

Two umbilical arteries and one umbilical vein surrounding by a gelatin-like extracellular matrix known as Wharton's jelly. So you've got that umbilical cord there. When should it separate? And what happens if it doesn't separate? Is there anything that you worry about? They usually fall off two to three weeks and the delay can be a manifestation of an immune deficiency.

Let's talk about our first case. Umbilical cord is separated. We're looking at the umbilical stump and patient has severe erythema and edema around the umbilical region and it might be accompanied by some drainage. And it's a bacterial colonization of that umbilical stump. And most commonly due to staph and strep from the skin flora. Mild cases, inflammation of the belly button, you may just want to treat with just alcohol, drying, ampicillin or amoxicillin and follow up every 24 hours.

In a similar case like this, our diagnosis should be omphalitis. 16% of the patients admitted with omphalitis develop necrotizing fasciitis. So obviously that's serious, rapidly progressive umbilical edema, erythema, drainage and a high mortality rate. So it's important to examine the cord whenever you have a newborn.

Next we'll review umbilical hernias. Basically we see these all the time. You have the umbilical cord going through before they're born. When they cut that cord and everything closes up, that muscle is supposed to re-approximate. And sometimes it doesn't, so you get an area that can be a hernia. It's more common typically in African Americans in low birth weight premature infants and can be associated with some other types of medical problems.

Umbilical hernias can also be associated with trisomy 13, 18 and 21. I don't think their connective tissues are very good and they have hypotonia. Although umbilical hernias are common, they usually close on their own in infants with most cases healing by the time the child is 3 to 5 years old. However, Dr. Brown mentioned that if the opening in the fascia is larger than 1.5 cm, it may not close by itself. There was a lot of studies done way back by Walker, 96% of them that were very small.

Less than 0.5 cm closed by 6 years. But there is no hernia that was greater than 1.5 cm that closed by 6 years of age. There was this thought that if the larger it is, more unlikely to close. When we talk about hernias, one thing we worry about is incarceration. Does this also apply to umbilical hernias? Incarceration with umbilical hernias is actually pretty rare, less than 0.2%. And it's more common if you have a smaller defect.

If incarceration in umbilical hernias isn't a major concern and most small hernias close on their own by the time a child is 3 to 5 years old, when is the right time to repair them? Should we wait? So more recently, Tiffany Zins, which was one of our fellows, she had written this article on 308 umbilical hernia repairs and they had a higher incidence of complications if they were less than 4 years of age versus if they were greater than 4 years of age.

So maybe we should wait till they're a little bit older to fix them. Because there's not a high incidence of incarceration or anything. And then they looked at over about 787 manuscripts in the literature, 28 met criteria of being good papers. The results showed that if a hernia is incarcerated and usually causes symptoms, it's important to fix it. For asymptomatic umbilical hernias in children around 4 years old, that's when we should start considering surgery.

Early surgical repair before age 4 was not indicated regardless of the size of the defect. And Dr. Brown brought another study. As always, you can find all studies we mentioned in this podcast linked in the description below. Don't forget to check them out. In 2020, they looked at 9,809 patients. The 3-year recurrence rate when you fix umbilical hernia was twice as high in children less than 4 years of age versus if they were greater than 4 years of age.

There was a higher rate of unplanned returns to the emergency department within 30 days at 2.5%. This rate was twice as high for patients younger than 4 years old. Rates of recurrence and unplanned AD visits were higher in children that were less than 4. An asymptomatic umbilical hernia repair should be delayed until greater than 4 years of age. Here's the most recent study from Rangel. They looked at a big cohort of children that were less than 6 years of age over a 5-year period.

And they've reviewed the electronic medical record at 68 pediatrician's offices around the Boston area and off about 167,000 patients, 4,486 of them had umbilical hernia repair diagnosis at a median age of about 1.6 months. They divided these into small hernias. One centimeter was considered small so you don't get the really giant ones versus the really small ones. And spontaneous closure was identified in 89% by age 5.

The closure rates for smaller hernias were nearly 90%, while for larger hernias they were around 80%. And if that umbilical hernia was persistent at age 3, spontaneous closure was 20% by 4 years and 35% by 5 years. So they concluded that you can watch these. There's a pretty high incidence of spontaneous closure and you should delay umbilical hernia repair until the age of 5 years. One thing that I've always looked at is that you may have a big huge hernia but the defect may be very small.

And I think those, if you see them early on, those are the ones that are more likely to close. If it has a huge defect and it's proboscis it's probably not going to close. Now we have a better understanding of the timing of the repair. So let's talk more about the indications.

So basically persistence after 5 years of age, signs or symptoms of incarceration, and then the question with the really big large defect when a patient is about to go to school and they've got a big proboscoid umbilical hernia.

The proboscoid hernia is a not so common problem that can happen with an umbilical hernia. It occurs when the skin above the hernia grows and pushes through the opening in the abdominal wall. It's recommended to correct the proboscoid hernia before school age to avoid psychological issues for the child. I think in general, 5 years, regardless of size, if it hasn't closed, fix it. If until then, leave it alone unless they're having symptoms.

What is the surgical technique to repair an umbilical hernia? You need to get around the hernia, around the umbilical spot there, the hernia sac. And then once you're clearly around it, you can divide that hernia sac. Take the excess sac until you have good edges and then you can close it. There's a lot of ways to close it, but the idea is that usually you'll do an interrupted type of closure. And you can use either Virol or some type of a absorbable suture.

And then you want to recreate a belly button. And that's a really, really important step, I think. Because most people want to have a nice looking belly button. I would say the majority of belly buttons, even if they're fairly large, you can tack it down and you can make it look pretty good. This is a practice that varies between providers. But Dr. Brown told us that she prefers to do an umbilical plasty in these cases. So next, she excises some skin.

So what I'll do is if it's very, very long, I'll lift up on it and I'll just cut it straight across with some big mayo scissors. Then I take a 4-0 monocle suture and I keep it really close to the skin surface up here and do a very, very nice purse string. A little short tiny bite. Sometimes you can even tie it up from the inside and then use that stitch to tack it down. According to Dr. Brown, this technique makes it really, really nice looking umbilicus.

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

To finish today's podcast, let's talk briefly about umbilical granulomas. So these are the most common umbilical masses of newborns. They're usually moist, but very commonly dry up and follow spontaneously over time. Often they'll respond to some silver nitrate. Give it some time and sometimes it may just go away. And if it goes away, I wouldn't worry about it.

But sometimes patients come to you with burned skin around their belly button due to halved silver nitrates applied, which can create a bit of mess to take care of. And one thing I always do when you do it is to neutralize the burn and also probably to keep it from whatever. Get some water, put it on there after you put the silver nitrate on it. And this tip isn't just only for babies. It works for any type of silver nitrate application.

If you apply some cold, damp water and clean it up, it might help prevent a lot of problems. Now sometimes these can be a little different. The ones that are really, really bright red, they're oftentimes very pedinculated and they bleed very easily. Those are the ones I think that are more commonly associated with ditalin or urethral air remnants. We are adding a decision tree in the description below. So according to this tree, if you find a granuloma or a pull lip, check for drainage.

If drainage is present, refer the patient for surgery. Review the pathology report and look for granulation tissue. If it involves a vitilin duct, proceed with an ultrasound and consider resection and repair, among other options. We recommend you checking that decision tree if you have a similar patient.

In summary, normal separation of the umbilical cord happens within 2 to 3 weeks after birth. And delays in this process can indicate potential immune deficiencies. Problems such as omphalitis can occur at the umbilical stump, requiring careful monitoring and treatment to prevent severe complications. Umbilical hernias are common in infants and typically resolve on their own.

Surgical intervention is advised for persistent hernias beyond age 5 or if symptomatic, with guidelines suggesting that asymptomatic repairs should be delayed until after age of 4 to reduce complications. Global granulomas are frequent in newborns and generally resolve without intervention. Treatment may involve topical applications of silver nitrate, but care is needed to prevent skin irritation or burns. Thank you for listening this podcast.

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