Highlights
- •33% of all umbilical hernia referrals are potentially avoidable.
- •68% of referrals in children <3 y are potentially avoidable.
- •Rates of avoidable referrals remained unchanged following guideline release.
Abstract
Introduction
The American Association of Pediatrics released guidelines in 2019 recommending delay
of surgical referral in children with asymptomatic umbilical hernias until 4-5 y of
age. The purpose of this study was to assess contemporary rates of potentially avoidable
referrals in this cohort of children, and to assess whether rates have decreased following
guideline release.
Methods
Retrospective analysis of umbilical hernias referrals evaluated at a single pediatric
surgery clinic from October 2014 to August 2021. Potentially avoidable referrals (PAR)
were defined as asymptomatic, non-enlarging umbilical hernia referrals in a child
3 y of age or younger without a history of incarceration. Referral indication, disposition
following clinic visit, and rates of PAR were compared before and after guideline
release.
Results
A total of 803 umbilical hernia referrals were evaluated, of which 48% were in children
3 y of age or younger at time of evaluation (“early” referrals). 33% of all referrals
and 68% of early referrals were categorized as a PAR, and rates were similar before
and after guideline release (all referrals: 32% versus 33%, P = 0.94; early referrals: 68% versus 67%, P = 0.94). Of the 333 early referrals who were managed expectantly per guideline recommendations,
2 (0.6%) developed incarceration which was managed with successful reduction and interval
repair.
Conclusions
One-third of all referrals for umbilical hernia evaluation are potentially avoidable,
and this rate did not change following release of American Academy of Pediatrics guidelines.
Aligning expectations between surgeons and referring providers through improved education
and guideline dissemination may reduce avoidable visits, lost caregiver productivity,
and exposure to potentially avoidable surgery.
Keywords
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References
- FastStats.(Available at:)
- Incidence of umbilical hernia in African children: redefinition of “normal” and reevaluation of indications for repair.World J Surg. 2001; 25: 645-648
- Umbilical and epigastric hernia repair.Surg Clin North Am. 2003; 83: 1207-1221
- The management of umbilicial hernias in infancy and childhood.J Pediatr Surg. 1975; 10: 405-409
- Repair of umbilical hernias in childhood to prevent adult incarceration.Am Surg. 1971; 37: 245-246
- Incarcerated pediatric hernias.Surg Clin North Am. 2017; 97: 129-145
- Umbilical hernia: what happens after age 5 years?.J Pediatr. 1981; 98: 415-417
- Variation in surgical management of asymptomatic umbilical hernia at freestanding children’s hospitals.J Pediatr Surg. 2019; 55: 1324-1329
- AAP SOSu – avoid surgery referral for umbilical hernias until age 4-5. Choosing wisely.(Available at:)https://www.choosingwisely.org/clinician-lists/aap-sosu-avoid-surgery-referral-for-umbilical-hernias-until-age-4-5/Date accessed: October 8, 2020
- Contemporary practice and perceptions surrounding the management of asymptomatic umbilical hernias in children: a survey of the American Pediatric Surgical Association.J Pediatr Surg. 2020; 55: 2052-2057
- When should a patient be referred to the pediatric surgeon?.Cir Pediatr. 2012; 25: 177-181
- Inappropriate referrals in pediatric surgery.J Pediatr Surg. 2020; 55: 2596-2601
- Age-dependent outcomes in asymptomatic umbilical hernia repair.Pediatr Surg Int. 2019; 35: 463-468
- Association between age and umbilical hernia repair outcomes in children: a multistate population-based cohort study.J Pediatr. 2020; 217: 125-130.e4
- Geographic distance to pediatric surgical care within the continental United States.J Pediatr Surg. 2019; 54: 1112-1117
- Campaigns against ionizing radiation and changed practice patterns for imaging use in pediatric appendicitis.JAMA Pediatr. 2015; 169: 720-721
- A 20-year observational cohort of a 5 million patient population—tonsillectomy rates in the context of two national policy changes.Clin Otolaryngol. 2019; 44: 7-13
- Is Scottish Intercollegiate Guidelines Network guidance for GP management of tonsillitis suitable? A qualitative study.Fam Pract. 2018; 35: 633-637
Article info
Publication history
Published online: May 04, 2022
Accepted:
April 8,
2022
Received in revised form:
March 10,
2022
Received:
February 4,
2022
Identification
Copyright
© 2022 Published by Elsevier Inc.
