• Incidence: 0.5–1% in term babies and 5–10% in premature babies
• Right-sided in 50% of cases, left-sided in 10% and both sides in 40%
• Most cases can be managed with elective surgery before or shortly after discharge from NNU
• Manage incarcerated hernia as a surgical emergency

• Visible swelling or bulge in inguino-scrotal region in boys, inguino-labial region in girls. May be constant or intermittent, becoming more prominent with crying or straining

Simple inguinal hernia

• Often painless, but many babies happier after repair
• Oxygen requirements may fall after repair 

Incarcerated inguinal hernia

• Generally presents with a tender firm mass in the inguinal canal or scrotum
• Swelling can be surprisingly small
• Baby may be fussy, unwilling to feed and crying inconsolably
• Overlying skin may be oedematous, erythematous and discoloured
• May be associated abdominal distension, with/without bilious vomiting
• Arrange emergency surgical referral

Reducible inguinal hernia

• If asymptomatic, refer by letter to surgeon. Include likely date of discharge and parents’ contact details 
• Inform parents of the risk of hernia becoming incarcerated
  
  • if baby develops a tense, painful swelling and is in obvious pain, parents should seek immediate medical advice
  • if swelling not reduced ≤2 hr, complications may arise (bowel compromise – later testicular atrophy) 

Incarcerated inguinal hernia

• Stabilise baby 
• Administer analgesia (morphine IV), then gently try to reduce hernia 
• If fully reduced, arrange elective inguinal hernia repair before discharge. Refer to paediatric surgical team for elective review
• If not reducible, request urgent help from on-call paediatrician/neonatologist
• Keep child nil-by-mouth
• Insert large bore nasogastric tube (NGT), empty stomach and leave on free drainage (see Nasogastric tube insertion guideline)
• Obtain IV access and send blood for FBC and U&E
• Start maintenance IV fluids 
• Aspirate NGT 4-hrly in addition to free drainage and replace aspirate volume, mL-for-mL with sodium chloride 0.9% with 10 mmol potassium chloride in 500 mL IV. Leave NGT on free drainage
• If hernia remains irreducible, refer urgently for surgical assessment 
• Complete detailed transfer letter using BadgerNet system. Ensure parental details and telephone contact numbers included
• If possible, ask parents to travel to planned place of surgery to meet with surgical team

• Reassess baby regularly
• Monitor fluid balance, blood gases, glucose and consider need for fluid resuscitation

• https://bwc.nhs.uk/download.cfm?doc=docm93jijm4n1200
• http://www.e-lfh.org.uk/programmes/paediatric-surgery/