Patient Presentation
An 8-year-old male came to clinic for his well child visit. He was being treated for strabismus and amblyopia with glasses and patching. His mother said he was mainly compliant with the glasses but wasn’t very much with the patching as he didn’t like looking different than his friends. She had tried multiple methods to try to increase compliance, and reported about 2 hours of patch use/day. “He likely is going to need surgery and I just don’t want to do that,” she said. “I read about some of these vision therapies but he won’t use the patch so I don’t think he’ll do the therapy either. Is there something else?” she asked.

The pertinent physical exam revealed a healthy male with normal vital signs who was growing at the 50%. His physical examination was normal. The diagnosis of a healthy male with vision problems was made. “I’m not the right person to give you all the options; that needs to be his ophthalmologist. But I think there are eye drops that are sometimes used instead of the patching that you can ask them about next week at his appointment. The vision therapies are newer, and again I don’t know much about them. They are certainly not so revolutionary that the studies are being highlighted by the professional organizations and media outlets. I suspect any benefit is probably modest, but again ask the eye doctor next week,” she counseled. “I’ll also give you some ideas how to get him to use the patch.”

Discussion
Amblyopia is a neurodevelopmental visual disorder that is usually monocular but sometimes binocular that has a decrease in visual acuity where there are problems with visual processing but where no organic cause can be identified. Functionally, amblyopia is widely defined based on visual acuity (VA) where there is a “…difference of two or more Snellen’s or logarithm of the minimum angle of resolution (log MAR) lines in BCVA [best-corrected visual acuity] between the normal and amblyopic eye in cases of unilateral amblyopia. For bilateral amblyopia, BCVA should be less than 6/12.” Amblyopia is extremely common with a prevalence between 1-6% in the pediatric age range and 1.43-5.64% in adults. It is classified as mild, moderate or severe based on BCVA, and also classified into refractive, strabismic or stimulus deprivation. Theoretically, the normal and amblyopic eyes have visual images that are mismatched, and the brain suppreses the weaker eye’s image leading to poor acuity in the amblyopic eye. Problems that arise because of amblyopia include “…reduced contrast sensitivity, poor spatial localization, poor stereovision, and foveal crowding.”

Learning Point
The treatment goal is to reduce the acuity differences between the eyes and maintain the improved vision. Most treatments focus on monocular therapy. Treatment at an earlier age has better outcomes than older ages. Patients who are successfully treated still need monitoring.

Potential treatment options include:

• Refractive correction
  • Considered first line treatment
  • 27-32% overall improvement
  • Initially often done alone for several weeks before using other treatments. Also used as combined treatment
• Patching
  • Considered second line treatment
  • Can be used alone or often in combined treatment
  • Up to 70% respond to occlusion (including using cycloplegic penalization – see below)
  • Some studies cite continued amblyopia after refractive correction and patching at 50% of patients
  • Number of patching hours depends on the patient. Studies have shown that shorter time periods may be as effective as longer time periods, but compliance was not objectively measured in at least one major study
  • Preferred patch is a direct skin patch
  • Often needs weaning off the patch after clinically improved VA
• Cycloplegic penalization
  • A cycloplegic drug is instilled in the normal eye to blur its vision and make patient use the amblyopic eye
  • Also considered second line treatment
  • Can be used alone or often in combined treatment
  • Up to 70% respond to occlusion (including using cycloplegic penalization – see below)
  • Can be good in patients with allergies to the patches, non-compliant patients or those with patching failures
• Bangerter filters
  • A filter is attached to glasses and degrades the visual acuity
  • Used as treatment or maintenance therapy after patching or penalization
• Surgery
  • Not a direct treatment, but a treatment for strabismus which can cause amblyopia
  • Corrects visual axis obstruction or misalignment
  • Botulinum toxin can also be used for muscle alignment successfully in some populations
• Other novel therapies
  • These have fewer outcome studies available, potentially high rates of non-compliance with treatment, or limited outcome measures, but do have some data that could be helpful for some patients
  • Liquid crystal glasses
    • Provide intermittent occlusion where crystals in the glasses rapidly alternate between clear and occluded
  • Perception therapy
    • Binocular therapy
    • Idea to improve perception of the visual images
  • Visual display therapy which may include videogame play
    • Binocular therapy
    • Main idea is for visual stimuli to be presented to both eyes and then the eyes have to work together to complete a task
  • Drug treatments
    • Examples include Levo-dopa, Citicoline, Donepezil, and Selective serotonin reuptake inhibitors
    • Main idea is to improve brain plasticity so other treatments may have improved outcomes
    • “…[M]ore randomized trials with larger sample sizes and longer periods of follow-up are required to substantially prove or disprove the benefits of these drugs”

Questions for Further Discussion
1. How good is photoscreening for vision problems in young children? A review can be found here
2. How can you increase compliance for use of glasses? A review can be found here
3. What are potential complications of contact lens use?

Related Cases

Disease: Amblyopia | Strabismus | Vision Impairment and Blindness

Symptom/Presentation: Blurred Vision

Specialty: Ophthalmology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Amblyopia and Eye Movement Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bui Quoc E, Kulp MT, Burns JG, Thompson B. Amblyopia: A review of unmet needs, current treatment options, and emerging therapies. Survey of Ophthalmology. 2023;68(3):507-525. doi:10.1016/j.survophthal.2023.01.001

Chaturvedi I, Jamil R, Sharma P. Binocular vision therapy for the treatment of Amblyopia – A review. Indian J Ophthalmol. 2023;71(5):1797-1803. doi:10.4103/IJO.IJO_3098_22

Kaur S, Sharda S, Aggarwal H, Dadeya S. Comprehensive review of amblyopia: Types and management. Indian J Ophthalmol. 2023;71(7):2677-2686. doi:10.4103/IJO.IJO_338_23

Chen DML, Han S, Summers A, et. al. Interventions for improving adherence to amblyopia treatments in children. Cochrane Database of Systemic Reviews 2025 (7). Art. No.: CD015820.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A pediatrician stopped her adolescent medicine colleague in the hallway for a quick consultation. “I have a young adult coming to see me who is a trans male. In their notes from the last visit, I saw that they had asked about a breast binder but I don’t know if that was done and if not, where I can send them or get more information for them,” she asked. “We can work with them in the adolescent clinic to get them measured and fitted. A couple of our nurses are trained to do that, and then they usually give them the resources to have them ordered, or sometimes some of the local non-profit agencies have them for low cost or free. I don’t know if any of the agencies do now, but the nurses will know. What time is the patient coming? I can have one of the nurses come over to your clinic if they want us to do the fitting,” the specialist offered. “They are coming late afternoon and I’ll ask them. They are also using oral contraceptives for pregnancy prevention and menstrual suppression and I’m very comfortable with that,” she said. “You know you can always ask me about any gender-related health issues you might not know about or don’t feel comfortable with. All of us working in the adolescent clinic can help, or we can refer the patient to other services, ” the specialist stated. “That’s why I stopped you. I knew I could ask and learn something. Helps me take better care of patients,” she said.

Discussion
Transgender and gender-diverse (TGD) youth in the US are estimated to be 300,000 or 1.4-2% of youth in the US. These numbers are for youth who identify as transgender or a gender identity that is different from their assigned sex at birth (ASAB). “However, the number of gender-diverse youth or youth whose gender expression does not confirm to societal expectations is estimated to be as high as 10% among U.S. high school students.” Among US adults, 1.4 million (0.6%) adults identify as transgender in a nationwide telephone survey.

TGD youth are or can be at increased risk for a variety of health problems including:

• Bone health – low dietary calcium, risk for bone loss
• Lifestyle – obesity, decreased activity
• Mental health – self-harm, suicidal ideation or attempts, depression, anxiety, eating disorders, substance use
• Sexual health – future fertility loss, pregnancy, sexually transmitted infections
• Social – bullying/harassment, discrimination, violence including sexual assault or dating violence, socioeconomic disparity including homelessness

Gender affirming care (GAC) is a broad term that is not synonymous with gender transition care. In GAC, “”…the goal (…) is to partner with TGD people to holistically address their social, mental and medical health needs and well-being while being respectfully affirming their gender identity.” GAC may include transition-related care such as puberty blockers, gender-affirming hormones (…), mental health support, and /or a range of therapies, including surgery.” GAC is not unlike the care pediatricians and other professionals provide to all patients in their practices, which would be compassionate, inclusive, holistic, and effective care. For any professional, there are limits to one’s knowledge and experience, so when this occurs professionals seek answers themselves or consult specialists who can manage and treat the patient, or partner with the professional to manage the patient.

Gender identity begins as early as 2 years and continues throughout childhood, adolescence and into young adulthood. The trajectory of gender identity is impossible to predict, and children and youth commonly explore their gender identity. Some people experience gender dysphoria but others may not. Some research “…suggests that the majority of prepubertal youth with gender dysphoria will ultimately identify as cisgender adolescents and adults, whereas postpubertal youth with gender dysphoria are more likely to continue experiencing gender dysphoria through adolescent and adulthood.” Late adolescence and adulthood can also be times where TGD identities also emerge.

Some terminology

• Gender identity – a person’s own felt sense of their gender (female, male, both, neither)
• Transgender/cisgender/nonbinary
  • Transgender – a person whose gender does not align with their ASAB
  • Cisgender – a person whose gender does align with their ASAB
  • Nonbinary – a person whose gender is neither strictly female or male, and exists along or outside of the spectrum of gender identity
• Gender expression – the way a person presents their gender to others
• Sexual orientation – the gender(s) to whom a person is sexually attracted such as gay, straight, bisexual, lesbian. This is distinct from gender identity
• Gender dysphoria – the distress a person experiences when their gender identity is not in alignment with their experience of their body or other’s perception of them
• Transition – “the process whereby an individual makes changes to their gender expression, physical body, name or pronouns for their lived gender role to align more closely with their gender identity”

Learning Point
Most care provided to TGD is the same care providers give to all of their patients. There may be some legal restrictions on specific types of care for TGD. Some specific care that TGD patients may need includes:

• Welcoming environment for all children, youth and young adults
  • Use of preferred name and pronouns has been shown to decrease depression, suicidal ideation and suicidal behaviors. Include this information in electronic medical record if the youth agrees, ASAB also needs to be recorded as some health risks are based on this
  • Inclusive physical space including signage and gender neutral bathrooms if possible
• History and physical examination
  • History taking using non gendered language
  • Appropriate confidentiality
  • Standard history for all youth including social, mental and sexual health histories
  • History includes youths’ experience with their gender identity such as social transitioning, gender dysphoria, family and community support
  • Trauma informed care sensitivity
  • Standard physical examination including monitoring for pubertal changes
• Body contours
  • Breast binding
    • To flatten the chest using breast binders, tight sports bras, or ace wraps
  • Male genital contouring
    • Tucking
      • To move the testicles and penis posteriorly or into the inguinal canals
    • Packing
      • To use devices to create the appearance of a penis such as socks, clothing, pouches, packers, etc.
    • Reversible, recommended to be used only for intervals of time
• Body hair
  • Referrals for body hair removal through lasers/electrolysis, depilatory, threading, waxing, etc.
  • Reversible or permanent
• Speech therapy/Voice training
  • Assistance in utilizing their voice that is more consistent with their gender identity
  • Reversible
• Hormonal therapy
  • Pregnancy prevention and menstrual suppression
    • Usually provided as part of general adolescent care
    • Reversible
  • Pubertal suppression – gonadotropin-releasing hormone analogues
    • May need referral to specialist or multidisciplinary clinic
    • Reversible
  • Exogenous gender affirming hormones – testosterone or estrogen
    • May need referral to specialist or multidisciplinary clinic
    • Most effects are considered irreversible, but some may be reversible
  • Fertility preservation
    • May need referral to specialist or multidisciplinary clinic
• Surgical intervention
  • These procedures may be performed at the age of majority, and need referral to a surgeon
  • Creation of desired anatomy
  • Removal or undesired organs
  • Modification of anatomy
• Sexual health
  • Routine sexual health screening and treatment
  • Pregnancy prevention and menstrual suppression
• Mental health
  • Therapy referrals for mental health or other social problems, including facilitating discussions of gender identity and exploration
• Social support
  • Health care providers are good supports for youth
  • Help assist identity disclosure to family or others
  • Provide support, education and mental health referrals for family members who may face challenges in accepting their child’s gender identity. As with all people, parental support has significant positive effects on TGD
  • Referral for legal services

Questions for Further Discussion
1. What resources do you have in your community for TGD?
2. What if any legal restrictions on treatment exist for TGD in your location?
3. How do you screen for substance abuse and what resources are available in your location?

Related Cases

Disease: Teen Health | Teen Development | Teen Mental Health | Teen Sexual Health

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Adolescent Medicine | Obstetrics / Gynecology | Nephrology / Urology | Social Services

Age:Young Adult

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Teen Health, Teen Development and Teen Sexual Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Voss, RV, Simons S. Supporting the Health of Transgender and Gender-Diverse Youth in Primary Care Settings. Prim Care Clin Office Pract. 2021:48;259-270.

Hodax JK, Crouch JM. Sethness JL. et. al. Strategies for Providing Gender-Affirming Care for Adolescents in the Primary Care Setting. Pediatr Ann. 2023;52(12);e442-e449.

Salvetti B, Gallagher M, Schapiro NA, Daley AM. Prioritizing Gender-Affirming Care for Youth: The Role of Pediatric-Focused Clinicians. Journal of Pediatric Health Care. 2024;38(2):253-259. doi:10.1016/j.pedhc.2023.12.006

Ho T, Ricklefs C. Healthcare for Sexual and Gender Minority Adolescents. Primary Care: Clinics in Office Practice. 2024;51(4):675-688. doi:10.1016/j.pop.2024.05.007

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 2.5 year-old female came to clinic for followup of hospitalization from an outside hospital 2 days after discharge for pneumococcal pneumonia. She had presented with fever, severe cough, and increased work of breathing. She was treated with high flow oxygen and ceftriaxone with improvement after 5 days. She was discharged on oral antibiotics to continue a 10 day course. The mother reported that she remained tired, wasn’t sleeping as well because of the cough, and was drinking but not eating solid foods that well. She was taking her medication. The past medical history was significant for 2 otitis media episodes, a documented influenza infection 1 year prior, and she was unimmunized.

The pertinent physical exam showed a tired appearing female with normal vital signs and oxygen saturation at 96% on room air. She appeared hydrated. HEENT was normal. Her lungs had very coarse breath sounds overall that were decreased on the right side with some crackles. The rest of her examination was normal.

The diagnosis of presumed pneumococcal pneumonia was made. The pediatrician reiterated the importance of finishing all of the antibiotics. He also discussed symptomatic treatment and brought up that when she felt better she could be immunized against pneumococcus and other infectious diseases, and provided some resources again to her mother. Her mother said she would think about it.

Figure 151 – A chest radiograph showing pneumococcal pneumonia.

Discussion
Streptococcus pneumoniae causes invasive or non-invasive disease. Invasive disease examples include bacteremia, meningitis and pneumonia, as well as less commonly septic arthritis, endocarditis, or osteomyelitis. Non-invasive (local) examples include otitis media and sinusitis. Pneumococcal disease causes significant morbidity and mortality world-wide, especially in the young children and older adult age groups. There are more than 100 serotypes with a relatively small number of them causing the majority of human disease. Studies over the last 25 years have shown pneumococcal vaccines (PV) to be effective against invasive and non-invasive diseases. Antibody production is good. Etiology/radiological confirmation of pneumonia shows marked decrease in cases. There is also data that supports PV vaccine as effective against viral lower respiratory tract diseases with the strongest evidence for decreased influenza but also seasonal coronavirus, human metapneumovirus and parainfluenza. This is important as co-infections in the respiratory tract are known to be associated with more severe disease. This could be due to one or more of the following such as decreasing the overall number of PV infections, changes to the PV serotypes, changes in the nasopharyngeal carriage and therefore biome of the individual, or other reasons.

Learning Point
Some of the main differences in the 20- and 23-valent vaccines are which serotypes are used, how they are produced and reduction in nasopharyngeal carriage.

Pneumococcal vaccine development started with a few serotypes and grew over time. Additional serotypes were added based on residual serotype prevalence and geographical distribution.

• 7 valent – 4, 6B, 9V, 14, 18C, 19F, 23F
  • FDA approved 2000
• 13 valent – 7 valent + 1, 3, 5, 6A, 7F, 19A
  • FDA approved 2010
• 20 valent – 13 valent + 8, 10A, 11A, 12F, 15B, 22F, 33F
  • Valences given are for Pfizer manufacturer
  • Prevnar® FDA approved in 2023
  • Conjugated vaccine (often abbreviated as PCV) with carrier protein diphtheria CRM197 protein
  • Does significantly reduce nasopharyngeal carriage
• 23 valent – has slightly different valences as it is produced by Merck with 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F
  • Pneumovax® FDA originally approved 1983 and updated in 2021
  • Polysaccharide vaccine (often abbreviated as PPSV) with carrier protein non-type Haemophilus influenza (NTHi)
  • Does not significantly reduce nasopharyngeal carriage

10-, 15- and 21 valent were, or are available as well. However two of the common ones used in the US currently are 20- and 23-valent. 20- and 23- valent have many additional serotypes that are important in the pediatric age range as well as the adults. PVs are given as intramuscular or subcutaneous injection. They induce IgG antibody production as well as opsonophagocystic activity. Side effects are usually mild to moderate with pain or redness or swelling at the injection site, fever, fussiness, decreased appetite or fatigue.

Vaccine schedules vary. Some children who previously received PV with fewer serotypes may be recommended to be re-vaccinated with higher valent vaccines. These include children who are immunocompromised or have chronic health conditions putting them at higher risk for pneumococcal disease.

Questions for Further Discussion
1. What other diseases are caused by Streptococcus?
2. What are common causes of community acquired pneumonia in your location?
3. What are potential complications of pneumonia?

Related Cases

Disease: Childhood Immunization | Streptococcal Infections | Pneumonia

Symptom/Presentation: Cough | Fever and Fever of Unknown Origin

Specialty: Infectious Diseases | Preventive Medicine and Health Maintenance

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Pneumococcal Infections, Pneumonia and Streptococcal Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Gessner BD, Isturiz R, Snow V, Grant LR, Theilacker C, Jodar L. The rationale for use of clinically defined outcomes in assessing the impact of pneumococcal conjugate vaccines against pneumonia. Expert Rev Vaccines. 2021;20(3):269-280. doi:10.1080/14760584.2021.1889376

Shirley M. 20-Valent Pneumococcal Conjugate Vaccine: Pediatric First Approval. Paediatr Drugs. 2023;25(5):613-619. doi:10.1007/s40272-023-00584-9

Sepulveda-Pachon IT, Dunne EM, Hanquet G, et al. Effect of Pneumococcal Conjugate Vaccines on Viral Respiratory Infections: A Systematic Literature Review. J Infect Dis. 2024;230(3):e657-e667. doi:10.1093/infdis/jiae125

Feng S, McLellan J, Pidduck N, et al. Immunogenicity and seroefficacy of pneumococcal conjugate vaccines: a systematic review and network meta-analysis. Health Technol Assess. 2024;28(34):1-109. doi:10.3310/YWHA3079

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Date
April 27, 2026

Patient Presentation
A 5-year-old male came to the emergency room with nausea, vomiting and lower abdominal pain that had been increasing for 5-6 hours. He was well overall when he started to have right lower abdominal pain that increased in intensity. He became nauseous and had 3 separate episodes of emesis of food that was non-bloody and non-bilious. He had no fever, rash, rhinorrhea or cough. He had awoken normally and had eaten breakfast without incident. His last bowel movement was possibly the night before and he had urinated in the morning. He didn’t know if he was passing gas. His parents were worried that he had appendicitis. The past medical history was non-contributory.

The pertinent physical exam showed that he was afebrile, with a heart rate of 115 beats per minute, blood pressure of 95/62, respiratory rate of 24 per minute and an oxygen saturation of 98% on room air. His abdominal examination was normal including no pain at McBurney’s point. His genitourinary examination showed a bulging right inguinal area with a very tender palpable mass in the inguinal canal. The left inguinal canal was normal. His testes were both palpable, non-tender and in the appropriate scrotal location.

The diagnosis of an incarcerated inguinal hernia was made. Ice was applied to the area and pain medication given. Emergency room personnel were able to reduce the hernia with pressure. Surgery was consulted and after discussion with the parents and several hours monitoring in the emergency room he was discharged home with strict instructions for monitoring and return. He underwent laparoscopic repair 11 days later without complications and did not have a contralateral hernia.

Discussion
Inguinal hernia repair is one of the most common surgical procedures. Incarceration rates for pediatric patients are between 2-30%, with 6-18% commonly cited and higher rates of up to 30% in infants especially premature infants. Presentations include irreducible bulging in the inguinal area that is often erythematous and/or painful, emesis and nausea, inguinal or abdominal pain, abdominal distention, and lack of bowel function including lack of flatulence and/or bowel movements.

Incarceration complications include bowel compromise and/or necrosis, sepsis, and potential risk for severe morbidity and/or mortality. Damage to other structures that could be incarcerated includetestes, ovaries, uterus and bladder among others. This could cause organ atrophy and/or necrosis necessitating resection.

Rates of complications are low for all types of surgical procedures and potential complications of hernia repair include:

• Iatrogenic injury to the groin and abdominal structures
• Testicular atrophy
• Acquired ascending testis
• Pneumonia
• Wound infection
• Wound disruption with needed additional repair
  

Premature infants commonly have inguinal hernias and the optimal timing for treatment is controversial as the risk of potential incarceration with the operative, post-operative and needs to be balanced again the increased risk of respiratory complications (especially apnea) in this age group. Early treatment appears to have lower risk of incarceration but increased risk of respiratory complications. Both early and delayed treatment had similar surgical complications in one study.

Learning Point
Evaluation and management for possible incarcerated inguinal hernia includes several steps and decision points, along with many factors such as age. It is not a “one-size fit most” situation either and needs to be tailored to the patient and their risk factors.

• Patients need a complete history and physical examination
  • Laboratory testing for other diagnoses as well as pre-surgical testing should be considered
  • Imaging, using ultrasound or computed tomography, may be used if the physical examination is inconsistent or non-diagnostic
  • Patients should be provided with fluid resuscitation if needed, and medications for pain relief. Ice to the site also helps to decrease edema
• Attempted hernia reduction using gentle pressure after diagnosis of inguinal hernia and pain relief provided
  • If hernia reduction is not successful, then immediate surgical treatment is needed
  • If hernia reduction is successful, the patient may be monitored in the hospital or discharged home. Elective repair is then usually scheduled within a short time (usually a few days)
• Operative repair
  • Immediate surgical repair may be done using open surgical procedures or using laparoscopic surgical techniques. Traditionally open procedures are the standard but laparoscopic surgery or combinations of both may be used. Robotic surgery is less common.
  • Both open and laparoscopic procedures evaluate the structures that are incarcerated especially the bowel to make sure it is viable. Bowel resection or treatment of other structures may be necessary.
    • Open procedures do not need specialized equipment and the anatomy is usually relatively straight forward to analyze and repair. Unusual anatomy or organs entrapped and their potential complications can be visualized and managed.
      There are risks for iatrogenic complications which may be higher than laparoscopic techniques.

    • Laparoscopic techniques have the major advantage of being able to evaluate the contralateral side for possible contralateral inguinal hernia and possibly its simultaneous treatment (especially if performed electively). Laparoscopy has lower complication rates for certain risk groups, and may in some circumstances decrease operative time and hospital length. This may be due to easier pain control for laparoscopic procedures.
      Laparoscopic techniques require additional equipment, incisions to use the equipment with inherent but low potential risk for abdominal organ damage, need for pneumoperitoneum which may be contraindicated for some patients or which may increase potential respiratory problems for some patients
  • Elective repair is usually done within a few days and may be done using open, laparoscopic or robotic surgical techniques.
    • Timing depends on risk factors, and type of technique planned. There is always a risk of re-incarceration during this time period with 3% of pediatric patients re-admitted during the waiting period in one study. However, patients who are not treated at the original admission may have lower complication rates. L and robotic techniques usually involve the evaluation of the contralateral side and repair of both if needed
• Post-operative management
  • Decreasing increased intra-abdominal pressure is important to maintain the repair and allow for healing
    • Pain control including medication and/ice for a week or longer may be needed
    • Stool softener to decrease valsalva maneuvers
    • Activity limitation such as not lifting weights or daily items (i.e. backpacks, groceries etc.)
  • Routine followup care and surgical planning for contralateral inguinal hernia repair if appropriate
    • Most patients can be released to regular activities around 6 weeks post-operatively

Questions for Further Discussion
1. How common is incarcerated umbilical hernia? A review can be found here
2. What causes testicular pain? A review can be found here
3. What are spermatic cord hydrocoeles? A review can be found here

Related Cases

Disease: Inguinal Hernia | Hernia

Symptom/Presentation: Mass or Swelling | Abdominal Pain

Specialty: Emergency Medicine | Surgery

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Hernia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Choo CS, Chen Y, McHoney M. Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis. Journal of Pediatric Surgery. 2022;57(11):527-533. doi:10.1016/j.jpedsurg.2022.07.001

Zubaidi SA, Ezrien DE, Chen Y, Nah SA. Laparoscopic versus Open Incarcerated Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg. 2023;33(05):414-421. doi:10.1055/a-1958-7830

Ramsey WA, Huerta CT, O’Neil CF, et al. Timing of Pediatric Incarcerated Inguinal Hernia Repair: A Review of Nationwide Readmissions Data. Journal of Surgical Research. 2024;295:641-646. doi:10.1016/j.jss.2023.11.059

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa