The neonatal intensive care unit (NICU) is a tough place to navigate. Everyone is there to make sure their babies are okay and getting stronger, but everyone is watching their little ones facing different challenges every single day.
When our babies were three days old, they needed feeding tubes to keep their feeds down, phototherapy to prevent jaundice from the bilirubin build-up in their blood, monitors to continuously track their heart rate and blood oxygen levels, and incubators to help regulate their temperatures.
On day four, we found out that one of our twins had an inguinal hernia.
On day four, we found out that one of our twins had an inguinal hernia. He wasn't born with the hernia; it had just shown up. It was something they were going to monitor while he was in the NICU, and then after he was older and had put on more weight, they'd schedule a procedure to fix it.
At that point, our other twin didn't have a hernia. When that twin graduated from the NICU four weeks later, he still didn't have a hernia. Then, when he was two months old, while doling out a fresh diaper, we saw the sign we'd been watching for, and we knew he also had an inguinal hernia. We just happened to have an appointment with their pediatrician that week, and he was able to examine the area and confirm our suspicions.
The surgeon had been waiting for this call; she'd told us at the consultation for our first twin a month prior that if our other twin got a hernia, to let her know right away and she would plan to fix both at the same time. She said it wasn't definite that he would get a hernia, too, but that it was certainly possible, so she reminded us of what to watch for over the coming months.
What is an inguinal hernia?
An inguinal hernia appears as a soft and abnormal bulge in the groin or scrotum, and it usually requires surgery to fix. While inguinal hernias are more common in boys (about 85 percent of cases), girls can also have them.
So, what causes an inguinal hernia? As a baby grows, it develops an opening called the inguinal canal between their belly and their groin. The testicles move from the abdomen to the scrotum by way of the inguinal canal.
The canal normally closes before or soon after a baby is born, but when your baby is born prematurely...this process can take longer.
The canal normally closes before or soon after a baby is born, but when your baby is born prematurely, as is often the case with twins, this process can take longer.
When this happens, there's a higher risk that a portion of the intestines or fatty tissue can pass through the canal into the groin, causing the visible bulge—the inguinal hernia—you see.
The hernia can get bigger when your baby is crying, coughing, or straining to poop, and it can get smaller when they're resting or lying down.
As parents and caregivers, you need to watch that the hernia always goes back in, that it retracts after it bulges.
As parents and caregivers, you need to watch that the hernia always goes back in, that it retracts after it bulges.
This type of hernia often occurs on the right-hand side (interestingly, both of our twins had their hernia on the left-hand side), and this type isn't often present at birth, but it can develop in the early days, weeks, or months after a baby is born.
One of our twins' hernias developed when he was just four days old; his twin's hernia didn't develop until he was two months old.
If your babies spend time in the neonatal intensive care unit (NICU), their neonatologist may suspect or diagnose an inguinal hernia after routine examinations.
Speaking of routine examinations while in the NICU, if your babies need to have their blood drawn often during their hospital stay, you may want to read up on a lesser-known condition, Heel Stick Calcinosis.
Back to inguinal hernias, if your twins don't need to spend time in the NICU, your babies' pediatrician might discover the hernia during a routine wellness check.
Inguinal hernias can resolve themselves in adults, but in infants, they do not close on their own and almost always require surgical intervention to fix the issue and prevent complications. While they require medical attention, most cases aren't urgent and can be monitored while babies grow and put on weight.
Most infant inguinal hernia surgeries are scheduled after they graduate from the NICU, but your NICU team (if it's diagnosed during their time at the hospital) or pediatrician (if it's diagnosed during a regular check-up) will refer your child(ren) to a surgeon for a consultation and plan to fix the hernias down the road.
What's the difference between inguinal and umbilical hernias?
In children, there are two common types of hernia: umbilical and inguinal.
According to Johns Hopkins Medicine, inguinal hernias occur in the groin area and umbilical hernias occur around the belly button.
Umbilical hernias are often harmless and rarely need medical intervention. They occur when fat or intestines go through a weak spot in the abdominal muscles.
Similar to inguinal hernias, umbilical hernias appear as soft, visible bulges, and they can also get bigger when babies cry, cough, or strain to poop.
Umbilical hernias often resolve themselves by the time kids turn five years old. Inguinal hernias, on the other hand, often will not resolve on their own and require surgery to fix the weak spot and prevent serious complications.
How twin pregnancies and prematurity impact inguinal hernia incidence
Inguinal hernias are more common in twins than they are in a single baby. Even though our twins are identical, it's just pure chance that they both had hernias and needed a procedure to repair the weak spot.
While genetics can play a minor role in the occurrence of inguinal hernias, the main reason they're more common in a multiple birth pregnancy is because of the higher rates of prematurity and low birth weight.
According to the Canadian Premature Babies Foundation, about three percent of babies will develop an inguinal hernia, but as many as 30 percent of premature babies will develop one because the inguinal canal doesn't have a chance to close before they're born. The earlier a baby is born (i.e., the lower their gestational age is at birth), the higher their risk of developing an inguinal hernia.
Symptoms of an inguinal hernia
Inguinal hernias develop as a baby grows and becomes more active. The hernia pushes through the unclosed inguinal canal when a baby cries, coughs, or strains their abdominal muscles, and that's when the hernia bulges and becomes detectable.
According to the Mayo Clinic, symptoms of an inguinal hernia include:
- A bulge on either side of the pubic bone that becomes more obvious when upright, especially when crying, coughing, or straining to poop.
- A burning or aching sensation at the bulge (though your baby won't be able to communicate this to you beyond crying).
- Pain, discomfort, or pressure in the groin, especially when bending, coughing, or lifting.
- If you press very softly on the bulging area when it's protruding, you might hear or feel gas bubbles; if you do, let your pediatrician or neonatologist know.
- Possible pain and swelling around the testicles when the protruding intestine descends into the scrotum.
- Newborns might be irritable and have a smaller than usual appetite.
When to go to the ER
Every parent hopes this never happens, but the chance of a medical emergency happening is always there. If one emerges, do not call your doctor, do not wait for a call back, do not wait for an appointment; go immediately to the nearest emergency room if you see any of the following symptoms in your children.
When babies have inguinal hernias, it's possible for the hernia to become strangulated or incarcerated. What does that mean? It means a loop of intestine or tissue can get trapped in the hernia. If this happens, the blood supply can be cut off, and it's a medical emergency that needs to be treated immediately.
Take your baby to the nearest emergency room if they have any of these symptoms:
- Your baby is vomiting green. Green vomit means there's a blockage in their intestine (also called a bowel obstruction) and that there's likely no blood supply to the trapped tissue.
- The hernia is painful. Not the general discomfort you'll come to witness as your babies grow and their hernias continue to bulge on an almost daily basis; a more pronounced and intense pain that you know is not the norm for each of your babies.
- The hernia is red, purple, or discoloured. Discoloration of the area means the blood supply to the trapped tissue is cut off and that the tissue is dying or has already died due to lack of oxygen.
- The hernia is swollen and / or hard. If you notice the bulge becomes hard and won't retract—meaning, it can't be pushed back into the abdomen when your child is lying down—intestinal tissue could be trapped in the abdominal wall. It gets squeezed so tightly that the blood supply gets cut off, causing the tissue to swell and die.
For nearly seven months, we watched each of our twins closely to make sure the hernias didn't get strangulated, cut off the blood flow to the tissue, and turn into life-threatening medical emergencies.
That worry always lingered with every diaper change, every bulge, every bout of discomfort. And, then, it faded—at least for a while—every time their hernias retracted and their pain subsided.
It was a relief when their surgeries were finally behind them.
What to expect with surgery / recovery
Bathing
You'll want to plan the evening before surgery to be a bath night, as your babies won't be able to be sitting in water for two weeks after their procedure in order to allow their incision to heal.
In our particular case, we were allowed to do a sponge bath after five days, and if everything was looking good, we were allowed to do a shallow bath after 10 days, as long as we were very careful not to get the incision site wet.
Once the two weeks were up, we were allowed to remove the dressings (Steri-Strips) if they hadn't already come off on their own (they hadn't, so they to be soaked in the tub to gently remove them).
Fasting
Unless directed otherwise by your children's surgeon or medical team, your babies can eat as they normally would the evening before their procedure, and then they'll be given specific cut-off times for each baby and when they can no longer have breastmilk or formula and water or other clear liquids.
The cut-off times are based on their actual procedure times, so one baby may be able to have liquids longer than the other. In our case, both were sleeping during the cut-off times, so we set alarms to wake up a half-hour before the cut-off time for each baby, so we could do a dream feed and make sure they were as full as possible before they had to stop having formula.
Then, we brought bottles with water to the hospital, just in case anyone got antsy while waiting to go in for their procedures, but we kept them hidden in the diaper bag, as they were better out-of-sight and out-of-mind unless they specifically wanted them.
If you're at the hospital and it's close to your baby's cut-off time for clear liquid intake, and your baby suddenly wants water, check with the medical team first.
If you're at the hospital and it's close to your baby's cut-off time for clear liquid intake, and your baby suddenly wants water, check with the medical team first. This happened with one of our twins about 10 minutes before his cut-off time. I wanted to give it to him, but a nurse happened to be walking by, so I asked, and she was able to check right away.
They'd bumped his procedure time up sooner than initially planned, so we held off on the bottle, he went in just a few minutes later, and we all got out of there sooner because we'd checked with the team first.
If we'd given the bottle without checking, we'd have had to wait another half-hour before they could get everything set in motion, which would have been fine since we'd blocked off the whole day, but after such a big operation for our little guys, it was nice to be able to get everybody home sooner.
Scheduling
Expect an early wake-up time. Normally, our twins normally sleep in until 8:00, but surgery day called for a 5:00 a.m. wake-up call for their crack-of-dawn morning meeting with Dr. Goodbear at Children's Hospital.
We were worried how this would go, especially since they wouldn't be allowed to have their usual bottle once they were awake—and especially because we still had 2.5 to three hours before their procedures where we hoped they wouldn't realize there were no bottles, but they did great. They were just happy to be going in the car together for an outing.
If both of your twins have inguinal hernias that need to be repaired, you'll need to have one adult there for each baby (your surgeon should offer to do both repairs on the same day, one immediately after they other; if they don't, ask for this), as they'll go into the recovery area separately, once their procedure is complete, and they need to be accompanied by a parent once they're out of surgery.
The actual procedure
The procedure to fix an inguinal hernia is done under general anesthesia (with the tiniest, little pediatric masks) and takes about 25 to 30 minutes per baby. The surgical incision is small and heals fairly quickly.
It's usually done as an outpatient, same-day surgery, so they go in, have their procedures, are monitored afterward, and then cleared to go home after a while, assuming all goes well.
During your pre-op consultation with the pediatric surgeon a few weeks in advance, the doctor will go over what the surgery entails and can answer any questions you have. You should also get another chance to speak with the surgeon on the day of surgery, right before they go into the operating room.
In the recovery room
After the operations were complete, we spent about three-and-a-half hours in the recovery room before we were cleared to take our twins home.
During the time in the recovery area, our hospital provided formula and diapers, but we brought supplies in our diaper bag, just in case something unexpected happened.
Protecting the incision site
After you're back home, you'll need to watch (read: actually, smell) your babies carefully and really be extra "on it" with diapering. As soon as you hear them grunting or smell a poop, change them as soon as they're done to prevent the chance of infection at the incision site.
This also means waking up more often overnight (even if you have to set a few alarms overnight) to double-check no one's done a sneaky sleep-poop because you don't want them sitting in that until morningtime when they've got a fresh incision so close to the action.
Recovery timeline
The recovery for this procedure in babies is phenomenal.
Most babies can go home that same day; they're monitored for a few hours to make sure they come out of general anesthesia as expected and that they can drink normally (hydration is always important with any procedure) and are able to pee.
A lot of the time, babies are back to themselves the next day and totally heal up within about five days. An adult who has the same procedure can take several weeks to fully recover.
You can expect your children to be a little slower than usual for a few days, but you'll be surprised how quickly they'll bounce back to their happy, wiggly selves...
You can expect your children to be a little slower than usual for a few days, but you'll be surprised how quickly they'll bounce back to their happy, wiggly selves and back into their regular activities.
In general, babies and young kids recover in about a week. Some are good to go in as little as two days, but it can take up to seven days before they get back to their usual energy levels. Once they're feeling better, most kids can get back to their normal (read: fully-mobile-chaotic-baby-speed) activities within a week or two.
But beware, even though they'll have their energy back pretty soon after their surgery, you need to be careful of their incision site. It can be tricky trying to prevent two very mobile babies from trying to crawl and stand-up while they're recovering (I say this from personal experience).
As hard as it may be, do your best to prevent jumping, rolling, or wrestling, so they, hopefully, don't tear any incisions while they're trying to have fun.
When to call the surgeon during post-op recovery
After your babies' surgery, you'll want to keep a close eye on them as they recover. Your surgeon or hospital should provide after-care instructions, pain management prescriptions (if needed), and a list of complications to watch for.
Mild pain, bruising, and swelling in the groin or genitals are all a normal part of the healing process, but you should contact your surgeon immediately if you notice any of the following with either of your babies after their procedure:
- A fever over 101° F or 38.3° C.
- Redness, swelling, or pus / drainage from the incision.
- Pain that gets worse.
- The incision opens.
- No bowel movement for 48 hours or more.
- After your babies have recovered from their procedure, you'll still want to keep an eye on your little ones as they grow because, while it's not common, there's a chance their inguinal hernia could come back.
Prepare yourself for a possible re-do
Most repairs are successful, but recurrence rates are higher in infants who are under one year old, babies who were born prematurely, and for those whose hernia was very large.
Our twins were born early and they had their surgery before they were one year old. While one of our twins had a "regular-sized" hernia, our other twin had a pretty big hernia, so he ended up checking all three boxes.
His hernia returned eight months after their surgery, so he fell into the 0.5 to 1.5 percent recurrence rate for pediatric inguinal hernia repairs. It was imperceptible at first, and I thought my eyes were playing tricks on me, causing me to see a bulge that wasn't there after seeing one every day for the first nearly seven months of his life.
But then, at the next diaper change, it happened again, and I was sure it was back, and it was.
The surgeon thought it best to wait until he was a little older to do the second repair, in the hopes it would "stick" this time around. Our twin was booked in for the re-do surgery seven months later, and this time, the procedure took.
As of two days ago, it's been two years since the second repair, and neither of them has had any recurrence since then.
Two babies, two surgeries
Because of the higher rates of prematurity and low birth weight, inguinal hernias are more common in twins than they are in singletons, with as many as 30 percent of premature babies developing one because the inguinal canal can't close before they're born.
The lower a baby's gestational age is at birth, the higher their risk of developing an inguinal hernia. If, like us, both of your twins end up with inguinal hernias, you need to monitor each of them every single day for potential complications.
It's a lot to watch for, but if you pay close attention, you'll know right away if anything serious requires a trip to the emergency room before your twins' scheduled surgery date.
While it can be stressful planning for a dual surgery day for your twins, it's much easier to go through the steps once and know that both of your twins will have their hernias repaired at the same time.
While the recurrence rate is quite low, there's always the chance your baby's hernia could come back. If it does, let your pediatric surgeon know right away, so you can plan the best course of action for a secondary repair.
Once the hernias are fixed, you'll be surprised at how quickly they recover and get back to their usual high-action activities, so you can get back to being amazed at how resilient your small but mighty warriors are.
Did one or both of your twins have hernias? Were they umbilical or inguinal? Were they fixed after one procedure or did they require multiple surgeries? Let us know in the Comments section below or connect with us on Instagram to share your thoughts!
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