Umbilical Disorders with Dr. Rebeccah Brown

Published: 2025-01-08

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

I Goddy — host
Dr. Rebecca Brown — guest

Chapters

0:03Introduction and Omphalitis — Introduction to umbilical disorders, umbilical cord anatomy, normal separation timing, and omphalitis presentation and management.
2:01Umbilical Hernias: Natural History and Timing of Repair — Epidemiology of umbilical hernias, spontaneous closure rates, incarceration risk, and evidence supporting delayed repair until 4-5 years of age.
6:22Surgical Repair Technique — Indications for umbilical hernia repair, surgical technique including fascial closure and umbilicoplasty.
8:48Umbilical Granulomas and Summary — Management of umbilical granulomas with silver nitrate, prevention of skin burns, and episode summary.

Key claims

0:34The umbilical cord contains two umbilical arteries and one umbilical vein surrounded by Wharton's jelly — I Goddy
0:50Umbilical cords usually fall off at 2 to 3 weeks — I Goddy
0:50Delayed umbilical cord separation can be a manifestation of immune deficiency — I Goddy
1:12Omphalitis is bacterial colonization of the umbilical stump — Dr. Rebecca Brown
1:16Omphalitis is most commonly due to staph and strep from skin flora — I Goddy
1:20Mild omphalitis cases may be treated with alcohol, drying, ampicillin, or amoxicillin with follow-up every 24 hours — I Goddy
1:30Advanced omphalitis cases require hospital admission and pediatric surgery consultation — Dr. Rebecca Brown
1:4016% of patients admitted with omphalitis develop necrotizing fasciitis — I Goddy
2:17Umbilical hernias are more common in African Americans, low birth weight infants, and premature infants — Dr. Rebecca Brown
2:27Umbilical hernias can be associated with trisomy 13, 18, and 21 — I Goddy
2:38Most umbilical hernias heal by the time the child is 3 to 5 years old — I Goddy
2:47If the fascial opening is larger than 1.5 centimeters, the hernia may not close by itself — I Goddy
2:55In Walker's study, 96% of umbilical hernias less than 0.5 centimeters closed by six years, but no hernia greater than 1.5 centimeters closed by six years — I Goddy
3:21Incarceration with umbilical hernias is rare, less than 0.2%, and more common with smaller defects — Dr. Rebecca Brown
3:42In a study of 308 umbilical hernia repairs by Tiffany Zinz, there was higher incidence of complications if patients were less than 4 years of age versus greater than 4 years — Dr. Rebecca Brown
4:20For asymptomatic umbilical hernias in children around 4 years old, that is when surgery should be considered — I Goddy
4:26Early surgical repair before age 4 was not indicated regardless of the size of the defect — Dr. Rebecca Brown
4:40In a 2020 study of 9,809 patients, the 3-year recurrence rate for umbilical hernia repair was twice as high in children less than 4 years versus greater than 4 years — Dr. Rebecca Brown
4:54Unplanned emergency department returns within 30 days occurred at 2.5% and were twice as high for patients younger than 4 years old — I Goddy
5:10Asymptomatic umbilical hernia repair should be delayed until greater than 4 years of age — I Goddy
5:18In Rangel's study of 167,000 patients, 4,486 had umbilical hernia diagnosis at median age of 1.6 months — I Goddy
5:53Spontaneous closure of umbilical hernias occurred in 89% by age 5 — I Goddy
5:53Closure rates for smaller hernias (less than 1 cm) were nearly 90%, while for larger hernias they were around 80% — I Goddy
6:03If umbilical hernia was persistent at age 3, spontaneous closure was 20% by 4 years and 35% by 5 years — Dr. Rebecca Brown
6:12Umbilical hernia repair should be delayed until age 5 years based on high spontaneous closure rates — I Goddy
6:22A large hernia may have a very small defect, and those seen early are more likely to close — Dr. Rebecca Brown
6:34If a hernia has a huge defect and is proboscoid, it is probably not going to close — Dr. Rebecca Brown
6:43Indications for umbilical hernia repair include persistence after 5 years of age, signs or symptoms of incarceration, and large proboscoid hernias in children about to start school — Dr. Rebecca Brown
7:00Proboscoid hernia should be corrected before school age to avoid psychological issues — I Goddy
7:11General guideline is 5 years regardless of size; if it hasn't closed, fix it; until then leave it alone unless symptomatic — Dr. Rebecca Brown
7:22Umbilical hernia repair involves interrupted closure using vicryl or absorbable suture — I Goddy
8:52Umbilical granulomas are the most common umbilical masses of a newborn — Dr. Rebecca Brown
8:55Umbilical granulomas are usually moist but commonly dry up and fall off spontaneously over time — I Goddy
9:00Umbilical granulomas often respond to silver nitrate treatment — I Goddy
9:07Silver nitrate application can cause burnt skin around the belly button if not properly applied — I Goddy
9:17Applying water after silver nitrate application helps neutralize the burn and prevent it from spreading — Dr. Rebecca Brown
9:37Bright red, pedunculated umbilical granulomas that bleed easily are more difficult to manage — I Goddy

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Topic overview

A pediatric surgery discussion covering umbilical disorders in newborns and children. The episode addresses umbilical cord separation timing (normally 2-3 weeks, delays may indicate immune deficiency), omphalitis as a bacterial infection requiring urgent evaluation with 16% developing necrotizing fasciitis, and umbilical hernia management. Multiple studies support delaying asymptomatic umbilical hernia repair until 4-5 years of age due to high spontaneous closure rates (89% by age 5) and increased complication rates in younger children. Umbilical granulomas typically resolve spontaneously or with silver nitrate treatment.

Key takeaways

Delay umbilical hernia repair until age 4-5: 89% close spontaneously by age 5, complications double in children <4 years. (3:42)
Omphalitis requires urgent evaluation: 16% progress to necrotizing fasciitis; advanced cases need hospital admission. (1:30)
Umbilical cord separation delay beyond 2-3 weeks may indicate immune deficiency and warrants investigation. (0:50)
Incarceration in umbilical hernias is rare (<0.2%) and more common with smaller defects, not larger ones. (3:21)
Umbilical granulomas typically resolve spontaneously or with silver nitrate; apply water after to prevent skin burns. (8:55)

Keywords

omphalitis necrotizing fasciitis umbilical hernia trisomy 13 trisomy 18 trisomy 21 immune deficiency hypotonia proboscoid hernia umbilical granuloma incarceration umbilical hernia repair umbilicoplasty silver nitrate application fascial closure

Hashtags

#PediatricSurgery #UmbilicalHernia #Omphalitis #NeonatalCare

Transcript

Click "Show Transcript" to view the full text (11104 characters)

Hi everyone, I'm I Goddy from Cincinnati Children's. Today we will hear from Doctor 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 phalitis 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 Worthin'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 2 to 3 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 the 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. But in those advanced cases, you need to bring them into the hospital. Pediatric surgery needs to be consulted. In a similar case like this, our diagnosis should be onphalitis. 16% of the patients admitted with onalittis develop necrotizing fasciitis. So obviously that's serious, rapidly progressive umlial 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 1318, 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 centimeters, 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 centimeters, closed by six years, but there is no hernia that was greater than 1.5 centimeters that closed by six 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, it's actually pretty rare, less than 0.2%, and it's more common if you have a smaller defect. If incarceration and 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 Zinz, 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 literature, 28 met criteria being, you know, 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 Doctor 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 pediatricians' offices around the Boston area, and of 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. 1 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 proboscoid, it's probably not gonna 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. Effect in a patient that's about to go to school or they've got a big probosciid 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 probosciid 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 Need to repair an umbilical hernia. You need to get it 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 vicro or some type of an 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 Doctor Brown told us that she prefers to do an umblicoplasty. 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, and I'll just cut it straight across with some big nail scissors. Then I take a 40 monochro suture and I keep it really close to the skin skin surface up here. And do a very, very nice purse string, a little short tiny bite. Sometimes you can't even tie it up from the inside and then use that stitch to tack it down. According to Doctor Brown, this technique makes a 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 a newborn. They're usually moist, but very commonly dry up and fall 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 burnt skin around their belly button due to how silver nitrateus is 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 going over. Get some water and 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 difficult. The ones that are really, really bright red, they're oftentimes very pedunculated, and they bleed very easily. Those are the ones I think that alms. We are adding a decision tree in the description below. So according to this tree, if you find a granuloma or a polyp, 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 vital and 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 umbilical cord happens within 2 to 3 weeks after birth, and delays in this process can indicate potential immune deficiencies. Infections such as phalitis 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 the age of 4 to reduce complications. Umbilical 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 to this podcast. Don't forget to subscribe to our YouTube channel, follow us on social media, and download the Stay Current app for hundreds of pieces of content in pediatric surgery. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

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