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The Informed Parent

Reflux and Hernias

by Louis P. Theriot, M.D., F.A.A.P.
Published on Aug. 11, 2003

Mrs. Wanda H. wrote The Informed Parent to share a story about her daughter that she hoped would be helpful to other families. Her daughter is a healthy and happy two-year-old little girl who was born with an umbilical hernia. The doctors assured Wanda that this type of hernia was not a problem, and it would close on it’s own in a couple of years.

Everything was fine until she started giving her baby solid foods at around six months. The baby would “suddenly and unexpectedly vomit” after which time she could be happy and playful, or be miserable and distressed for hours. There were times when she would experience distress without even vomiting. What the parents noticed was that whenever their daughter was “in pain”, her belly button would be hard...and when the distress seemed to pass, the belly button would again be soft.

This progressively worsened. It was not uncommon for the baby to cry up to seven hours a night, regardless of what she ate, and the vomiting persisted (it actually did not worsen). Needless to say, Wanda took her baby to the doctor on many occasions just to be told that she “had a sensitive stomach” and that the hernia was NOT an issue. Finally, at 13 months of age, the baby’s umbilical hernia was repaired and Wanda says that ever since the surgery was performed, her daughter has had NO problems at all.

I am at a great disadvantage in trying to reply to Wanda’s letter for the obvious reasons. And, as her story was written to share her experience with other families who might be going through the same problems as her daughter, she was not expecting a response. I would not, nor could I ever make any specific comments about what her daughter might or might not have had. But I would like to propose a model of what could tie her symptoms together.

A review of the pediatric and surgical literature states that umbilical hernias are common, especially in low birth weight infants and black infants, and rarely cause problems other than cosmetic. This type of hernia is due to an imperfect closure, or weakness, of the umbilical ring. This is the opening in the abdominal wall that allows the blood vessels of the umbilical cord to pass. When a baby has such a hernia, whenever there is an increase in the intra-abdominal pressure such as straining, crying, coughing or sneezing, some of the intestines can protrude, or “herniate”. This, then, appears as a bulge in the belly button. Although portions of the intestines do in fact herniate, it is almost unheard of for the intestines to become strangulated. This is a condition whereby the loop of intestine that is trapped in the hernia has its blood supply cut off. This can cause a portion of the bowel to become gangrenous and die. And while this is a surgical emergency and must be repaired immediately, it doesn’t happen with umbilical hernias. It is a very real concern in inguinal hernias, which is a hernia of a portion of the intestine into the scrotum.

The surgical and pediatric literature states emphatically that umbilical hernias usually resolve spontaneously before kindergarten. They rarely cause any problems. If, for any reason, the child becomes embarrassed or self-conscious about it, the hernia can be repaired for cosmetic reasons.

As Wanda’s story unfolded, what came to mind was the fact that her daughter may very well have had gastro-esophageal reflux disease, GERD. GERD is a common condition in infants whereby there is a looseness or laxity between the esophagus and the stomach, when normally there is a high-pressure area where the two structures come together. This insures that the stomach contents will not backflow, or reflux, into the esophagus. When GERD occurs, it can cause the infant to spit up considerably, or even vomit. It can cause an inflammation of the esophagus because the acid of the stomach literally burns the lining, which is not usually exposed to an acid environment. This “esophagitis” can be exquisitely painful, and certainly could cause a baby to cry inconsolably for hours on end.

It sounds like Wanda’s baby could very well have had GERD because of the symptoms of vomiting and being in severe pain. Then, being in pain without vomiting...with no relationship to certain foods. GERD is a complex topic, far beyond the scope of this article. But, suffice to say that most babies outgrow GERD by the time they are 12 - 14 month of age.

In piecing together what Wanda’s daughter might have been experiencing, it is possible that she did, in fact, have an umbilical hernia. AND, she had severe GERD with esophagitis. When the GERD was acting up she would spit up or vomit. In time this lead to esophagitis, which caused her to cry inconsolably for hours on end. At times the reflux was not severe enough to cause vomiting, but there was reflux of acid on the already inflamed esophagus for which her daughter would just cry. Each time she would reflux, it would cause her to increase her intra-abdominal pressure. This, in turn, would cause the hernia to protrude.

I propose then that the sequence of events was the reflux caused the increase in pressure, which caused the hernia to “pop out”, rather than the other way around. She had her hernia repaired at 13 months of age. But, remember that most babies outgrow GERD by 12 - 14 months of age. No one will ever know what role the surgery played in resolving her symptoms or if it was just coincidental. The bottom line is that it really does not matter since her daughter is doing great and is symptom free.

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