A 4-hour-old boy is evaluated in the nursery for routine newborn care. The patient was born at 38 weeks gestation via spontaneous vaginal delivery to an 18-year-old woman who did not receive prenatal care or take prenatal vitamins. Birth weight is 3.6 kg (8 lb). Vital signs are normal. Examination shows a sleeping infant in no distress. There is molding of the occiput. A soft mass inferior to the umbilical stump is 1.4 cm in diameter and covered by skin. The mass increases in size when the infant cries and reduces into the abdominal cavity with gentle pressure. The mass does not seem to be tender to palpation. The rest of the examination is normal. Which of the following is the best next step in management of this patient's mass?

Question

A 4-hour-old boy is evaluated in the nursery for routine newborn care.  The patient was born at 38 weeks gestation via spontaneous vaginal delivery to an 18-year-old woman who did not receive prenatal care or take prenatal vitamins.  Birth weight is 3.6 kg (8 lb).  Vital signs are normal.  Examination shows a sleeping infant in no distress.  There is molding of the occiput.  A soft mass inferior to the umbilical stump is 1.4 cm in diameter and covered by skin.  The mass increases in size when the infant cries and reduces into the abdominal cavity with gentle pressure.  The mass does not seem to be tender to palpation.  The rest of the examination is normal.  Which of the following is the best next step in management of this patient's mass?

Quizplus · Accepted Answer

11ec25c8_d68c_a0dc_bc81_8d744588741f_MD0003_00 A congenital umbilical hernia is due to incomplete closure of the abdominal muscles around the umbilical ring at birth. It is commonly associated with hypothyroidism and Ehlers-Danlos, Beckwith-Wiedemann, and Down syndromes, but also occurs frequently in normal newborns. Physical examination shows a soft, nontender bulge covered by skin that protrudes with increased abdominal pressure (eg, crying, straining). The hernia may contain omentum or portions of the small intestine. Most umbilical hernias are reduced easily through the umbilical ring with very low risk of incarceration and strangulation. Small umbilical hernias typically close spontaneously as the rectus abdominis muscles grow together and fascial layers fuse. Spontaneous closure is less likely with large (>1.5 cm diameter) hernias or in patients with underlying medical problems. Surgery is recommended around age 5 for persistent hernias, or sooner if complications occur. Small umbilical hernias large (>1.5 cm diameter) hernias (Choice A) Abdominal ultrasound is often performed in an older child or adult when an acquired umbilical hernia is suspected. This patient has a congenital hernia, which is diagnosed clinically. (Choice B) Immediate surgery is performed for gastroschisis, an intestinal protrusion lateral to the umbilicus, and omphalocele, a covered protrusion of abdominal contents. However, it is not indicated for an uncomplicated umbilical hernia. gastroschisis omphalocele (Choice C) Karyotype analysis evaluates for Down syndrome in a patient with characteristic features (eg, single palmar crease, hypotonia, sandal gap deformity, upslanting palpebral fissures, epicanthal folds). Although more common in patients with Down syndrome, an umbilical hernia alone does not warrant further workup. (Choice E) An umbilical granuloma presents in newborns after the umbilical cord has separated with a moist, red, pedunculated, friable umbilical mass. Treatment is with silver nitrate. Educational objective: A congenital umbilical hernia is typically soft and reducible and does not require intervention. These hernias usually close spontaneously by age 5. References: Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood. (http://www.ncbi.nlm.nih.gov/pubmed/24372946) Profile of paediatric umbilical hernias managed at Federal Medical Centre Umuahia. (http://www.ncbi.nlm.nih.gov/pubmed/23304935)

A 4-Hour-Old Boy Is Evaluated in the Nursery for Routine