Management of Umbilical Hernia in a 20-Month-Old
Watchful waiting with observation until age 4 years is the appropriate management for this uncomplicated umbilical hernia, as the vast majority close spontaneously and complications are extremely rare at this age.
Natural History and Spontaneous Closure
The natural history of pediatric umbilical hernias strongly favors conservative management at 20 months of age:
- Most umbilical hernias close spontaneously before age 3-4 years, making observation the standard approach for uncomplicated cases 1
- The incidence of spontaneous closure is highest during the first few years of life, with the majority resolving without any intervention 1, 2
- Complications are exceedingly rare, with incarceration occurring in only 1:1,500 umbilical hernias 2, 3
- Strangulation is even more uncommon than incarceration 2
Risks of Early Surgical Intervention
Operating before age 4 years carries significant risks that outweigh the minimal complication risk of observation:
- 12.3% of patients under 4 years old who undergo herniorrhaphy experience postoperative complications 2
- Early repair (younger than age 2 years) is associated with higher costs, higher rates of postoperative hospitalization, and increased emergency room encounters 2
- Anesthesia-related complications and local wound infections are additional surgical risks 1
Observation Protocol
Continue monitoring with the following approach:
- Schedule periodic follow-up examinations to assess for spontaneous closure or any concerning changes 1
- Educate parents to watch for signs of incarceration: irreducibility, tenderness, overlying skin erythema, vomiting, or abdominal distension 3
- Reassure parents that strapping or taping has no proven benefit in accelerating closure 1
Indications for Earlier Surgical Referral
Refer to pediatric surgery before age 4 years only if:
- The fascial defect is greater than 2 cm in diameter, as these are less likely to close spontaneously 1, 3
- The hernia enlarges during the observation period 1
- Any signs of incarceration or strangulation develop (pain, irreducibility, skin changes, systemic symptoms) 3
- The hernia becomes symptomatic with persistent umbilical or abdominal pain 1
Definitive Management Timeline
If the umbilical hernia persists beyond age 4 years without spontaneous closure, refer to a pediatric surgeon for elective repair 1, 2. This timing balances the high likelihood of spontaneous resolution against the very low complication risk, while avoiding the higher perioperative risks associated with surgery in younger children.