Childhood hernias carry special risks

It didn't bother the gymnast, but the girl's little bump got her mother thinking. The child had pointed out a bulgy area on her left side where her torso met up with her upper inner thigh.

Her mother wondered if it could be a hernia but since it didn't hurt and seemed to come and go, she decided to keep a close eye on it. When the bulge kept popping up and seemed to grow larger, Mom brought her 8-year-old into the office for a look-over.

Nothing much was apparent when I examined the second grader on the table, but then I had her stand up. “I know this sounds a little strange,” I instructed my young patient, “but just pretend you're pooping.”

She was a good sport and sure enough, after bearing down and straining, a small balloon-like mass inflated in her groin. The area flattened with application of gentle pressure as the girl relaxed.

I complimented mom on her diagnosis and told her that the hernia was not an emergency, since it was easily reducible and was not painful, red or hard. It would, however require a prompt evaluation by a surgeon since childhood hernias do not fix themselves.

In their section on inguinal hernias in Nelson's Textbook of Pediatrics, medical authors John J. Aiken and Keith T. Oldham explain that unlike adult hernias, hernias of childhood are rarely a result of muscle weakness.

Ninety-nine percent of pediatric inguinal hernias occur when the processus vaginalis, an embryonic out-pouching of the abdominal lining, fails to seal off as expected late in pregnancy or soon after birth. When this structure does not fuse shut, fluid and/or organs can extrude from the abdominal cavity and bulge into the groin or scrotum.

The two surgeons caution that is important to recognize inguinal hernias in children. Occasionally structures become stuck or “incarcerated” in these pouches, with a subsequent risk of strangulation of the intestines, testes, or ovaries if blood supply is cut off to these trapped vital structures. Risk of such surgical emergencies is found to be greatest during the first year of life.

Aiken and Oldham note that up to 5 percent of full term newborns, 10 percent of premature infants and as high as 30 percent of babies born at less than 28 weeks gestation have congenital inguinal hernias.

Pediatric inguinal hernia repair is, therefore, considered a common surgical procedure and can be performed through either the traditional open approach or laparoscopically.

The incidence of inguinal hernias is ten times higher in boys than girls, but the occurrence of bilateral or both-sided hernias is more common in girls. Pediatric hernias also have a high genetic component, as nearly 12 percent of affected patients can claim a relative with a history of inguinal hernia. The genetic link is greatest for females, with sisters of girls with inguinal hernias at highest risk of developing hernias of their own.

Ÿ Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.