Pediatric Emergency Playbook

Hernia

Myth: "If it's not strangulated, it's elective"

Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because:

• The risk of incarceration and strangulation is high
• There is a 30% risk of testicular infarction due to pressure on the gonadal vessels
• It is not worth messing around and "trying to navigate the system"

Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis).

Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well. 15% are bilateral.

Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney. They hate it and will cry. For older children, have them laugh, cough, or blow through a syringe.

The "silk glove sign" is not reliable, but if found is highly suggestive of an inguinal hernia. Roll the cord structures across the pubic tubercle. If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis.

Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved. Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation.

Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention. Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age.

Girls may have an ovary incarcerated in hernial sac.

Open repair or laparoscopic techniques are used. The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens.

A metachronous hernia develops later on the other side. Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored)

My take: regardless of presentation, needs admission

Selected References

Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877

Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006.

Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468.

Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254

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Chances are, you'd be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed.

We're not here for "chances are"; we're here for "why isn't it?"

Ask yourself, could it be:

Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma

Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy

Neuropathic: spinal cord abnormalities, trauma, tethered cord

Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome

Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome

Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics

Ingestions: heavy metals, vitamin D overload, botulism, cow's milk protein intolerance

Failure to thrive

Abdominal distention

Lack of lumbosacral curve

Midline pigmentation abnormalities of the lower spine

Tight, empty rectum in presence of a palpable fecal mass

Gush of fluid or air from rectum on withdrawal of finger

Absent anal wink

You gotta push the boat out of the mud before you pray for rain.

Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days. Maximum daily dose: 100 g/day PO. Follow-up with maintenance dose (below) for at least 2 months (usually 6 months)

Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days

Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days

Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO. Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.

Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily. Maximum daily dose: 60 mL/day in adults.

Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day

Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID)

Senna, Bisocodyl — complicated regimens; use your local reference

1. Are you sure? Have you tried oral disimpaction over days?
2. No phosphate enemas for children less than 2.
3. Saline enemas are generally safe for all ages
4. Be careful with the specific dose — please use your local reference

Selected References

Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13.

Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.

1. Set the stage – exude confidence and be prepared
2. Choose the right cannula size – a smaller working IV is infinitely better than none
3. Feeling is better than looking – trust yourself
4. Mark the site – things get wonky when you take your hands off to disinfect
5. Tourniquets can mess you up – try to use a holder's hand to occlude the vein
6. The holder rules – get as many hands on deck as you need.
7. Tension is good – a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers.
8. Stay in line – your needle is an extension of your arm
9. Gravity is your friend – the kinder, gentler tourniquet
10. The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success

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