Abstract
Background
Obstructed inguinal hernia in children is associated with high morbidity in developing countries due to delay in accessing care. Attempts made to reduce waiting time to herniotomy are not backed by a predictive model of disease occurrence and modeling obstructed inguinal hernia implies knowledge of factors associated with this complication.
Aim & Objectives
To determine the relationship between socio-demographic variables and obstructed inguinal hernia in children.
Design
Case controlled
Setting
Paediatric surgery unit of a tertiary hospital
Materials and Methods
The study was prospective – all children presenting with obstructed inguinal hernia at University College Hospital, Ibadan, Nigeria between May 2009 and April 2014 were studied. For each case, two children with non-obstructed inguinal hernia were recruited consecutively as controls. Their demographics, clinical features, management and outcomes were obtained including the socio-demographic attributes of the parents. The data obtained were computed using SPSS; the p-value for significance was set at < 0.05.
Results
A total of 81 consecutive patients (27 with obstructed inguinal hernia and 54 with non-obstructed inguinal hernia) were studied; they were aged between 2 weeks and 13 years with a mean of 25.9 ± 3.8 months. There were no differences between cases and controls based on gender, parents’ religion, tribe, social status and side affected (p > 0.05). The mean age at presentation was 13.7 ± 5.6 months in the obstructed inguinal hernia vs. 32.0 ± 4.8 months in the non-obstructed inguinal hernia groups (p = 0.016). The duration of groin swelling before presentation was not significantly different (30.0 ± 7.7 vs. 28.3 ± 6.4 months, p = 0.893). Infants were three times more likely than older children to develop obstruction (OR = 3.33, CI: 1.20, 9.09, p = 0.020).
Conclusion
The age at presentation is the significant socio-demographic variable in this study that could predict obstruction in healthy children with inguinal hernia delivered at term.
Keywords: Obstructed inguinal hernia, Children, Predictive factors, Nigeria
Introduction
Obstructed inguinal hernia is a major cause of intestinal obstruction in children, with a higher morbidity reported in developing countries due to delay in accessing care1. Efforts have been made, globally, to establish strict guidelines for waiting times before herniotomy. However, controversies still surround the length of time before surgery while considering the challenges encountered at surgery for former preemies and small infants2,3,4,5,6,7. Indeed some have suggested that stricter waiting times may not reduce incarceration rates while waiting for surgery5.
In resource limited settings with suboptimal health financing and large population of children, such as in developing countries, waiting times may be longer than in industrialized nations. Attempts made to reduce the waiting time to herniotomy need to be supported by a predictive model of disease occurrence and/or comparative controls. Modeling obstruction in inguinal hernia implies knowledge of factors and co-variates associated with this complication. A search for possible variables to input in the modeling equation will involve intrinsic elements such as medical risk factors and extrinsic ones such as socioeconomic and demographic factors4. A good knowledge of the predictive socioeconomic and demographic variables will be a good starting point in prioritization and allocation of health resources as well as in health educational and promotional activities at the different level of health care delivery in developing countries. The aim of the study, therefore, was to determine the relationship between socio-demographic variables and obstruction in childhood inguinal hernia.
Materials & Methods
This prospective study involved patients aged 14 years or younger diagnosed with obstructed inguinal hernia between May 2009 and April 2014 at University College Hospital, Ibadan, Nigeria. For each case, two patients with non-obstructed inguinal hernia and booked for elective herniotomy were recruited consecutively in the surgical outpatients’ clinic of the same hospital as controls. Information was obtained from the parents using a proforma. Details were obtained on age, gender, presenting complaint, duration of symptoms, duration of prior groin swelling for obstructed inguinal hernia, pregnancy and birth history, examination findings and diagnosis. Information was also obtained on the parents’ religious beliefs, tribe and occupation and social status. The occupation of the parents was used to derive the family’s socioeconomic status and categorized using a modification of the Economic and Social Research Council (ESRC) guidelines into: Class I – managerial and professional class, Class II – intermediate class and Class III – working class and dependants8,9. In situations where the parents belonged to different socioeconomic classes, the family was allocated to the higher class. Former preemies were excluded from both the cases and control arms of the study.
Data were collated, inputted into a computer and statistical analysis performed using SPSS version 21 software. Descriptive variables were summarized using percentages and proportions for categorical variables and mean ± standard deviation for continuous variables. Bivariate analysis was done to test for association between variables using Chi square for categorical and student t-test for continuous variables with the p value set at < 0.05. Multinomial logistic regression was performed to identify predictive variables appropriate for the model and determine the odds ratio.
Results
A total of 81 patients - 27 with obstructed inguinal hernia and 54 with non-obstructed inguinal hernia were included in this study. Their ages ranged from 2 weeks to 13 years with a mean of 25.9 ± 3.8 months. There were 70 (86.4%) males and 11 (13.6%) females with a male to female ratio of 6.4:1. The majority, 72 (88.9%), of parents were Yorubas (the major ethnic group in the region) and 50 (61.7%) were Christians. The majority 53 (65.4%) of parents were in the intermediate social class, 8 (9.9%) in the managerial and professional class while 20 (24.7) were in the working class/dependants. The inguinal hernia was on the right side in 42 (51.9%) patients, left in 26 (32.1%) and bilateral in 13 (16.0%).
There were no differences between cases and controls in terms of their gender, parents’ religion, tribe or social status Table 1. Among patients with obstructed inguinal hernia, the swelling was on the right in 18 (66.7%), left in 7 (25.9%) and bilateral in 2 (7.4%) compared to the controls with 24 (44.4%), 19 (35.2%) and 11 (20.4%) respectively (p = 0.130). The mean age at presentation was 13.7 ± 5.6 months in the obstructed inguinal hernia vs. 32.0 ± 4.8 months in the non-obstructed inguinal hernia groups (t = -2.488, p = 0.016). The duration of groin swelling before presentation was not significantly different (30.0 ± 7.7 vs. 28.3 ± 6.4 months, t = 0.169, p = 0.893).
Table 1 . Socioeconomic status and demographics of the patients versus controls.
| Variable | Patients: No (%) | Controls: No (%) | χ2 | p-value |
| Gender | ||||
| Male | 24 (88.9) | 46 (85.2) | 0.210 | 0.646 |
| Female | 3 (11.1) | 8 (14.8) | ||
| Religion (of parents) | ||||
| Christianity | 17 (63.0) | 33 (61.1) | 0.026 | 0.872 |
| Others | 10 (37.0) | 21 (38.9) | ||
| Tribe (of parents) | ||||
| Yoruba | 24 (88.9) | 48 (88.9) | 0.000 | 1.000 |
| Others | 3 (11.1) | 6 (11.1) | ||
| Social class (of parents) | ||||
| Managerial and professional | 2 (7.4) | 6 (11.1) | 1.711 | 0.425 |
| Intermediate class | 16 (59.3) | 37 (68.5) | ||
| Working class | 9 (33.3) | 11 (20.4) |
The proportion of infants amongst those with obstructed inguinal hernia (70.4%) was higher than that amongst the controls (31.5%), p = 0.004 Table 2. Infants, on logistic regression, were three times more likely than children older than 12 months to develop obstruction in their inguinal hernia (OR = 3.33, CI: 1.20, 9.09, p = 0.020).
Table 2 . Age distribution of patients versus controls .
| Age group | Cases: No (%) | Controls: No (%) | χ2 | p value |
| < 12 months | 19 (70.4) | 17 (31.5) | 11.072 | 0.004* |
| 1 – 5 years | 6 (22.2) | 26 (48.1) | ||
| > 5 years | 2 (7.4) | 11 (20.4) | ||
| * - Statistically significant | ||||
Discussion
The main finding of this study was that age of a child was a significant predictor of obstruction in inguinal hernia. Inguinal hernia is a common reason for pediatric surgical consultations10. It is easily diagnosed clinically and runs an uncomplicated course before surgery in most children. However, in as much as 12% to 16%1,10,11, there could be incarceration, which may progress to frank intestinal obstruction causing intestinal ischemia and gangrene or be complicated by testicular ischemia with subsequent atrophy1,12. In view of the consequences, when complicated, and the fact that treatment for inguinal hernia is a simple herniotomy as a day procedure with minimal post operative complications10,13,14, it would seem ideal to institute measures to prevent incarceration by shortening the time from diagnosis of hernia to surgery. On the other hand, in view of the fairly prevalent nature of inguinal hernia, there are more children with the condition than most health care systems can cater for in terms of immediate operative lists. This problem is further compounded in developing countries with poorer access to health care and relatively inadequate health care professionals resulting in longer waiting times before herniotomy than obtains in advanced economies15.
In this study, a case controlled research design was adopted, which allowed a comparison of prior socio-demographic exposure and environment of cases and equivalent controls. The patients with obstructed inguinal hernia and non-obstructed inguinal hernia in the study were comparable in terms of baseline characteristics of their hernia. The male to female ratio of 6.4:1 is within the range of 3.6:1 to 10.6.1 reported by others3,10,11,16. The preponderance of inguinal hernias on the right side in 52% compared to 32% on the left side is, similarly, compatible with 47% to 61% right sidedness documented in the literature3,10,16.
None of the parents’ socio-demographic variables evaluated in this study was associated with the occurrence of obstruction in inguinal hernia in children. Furthermore, the mean duration of groin swelling before presentation was similar in both groups of patients. From this study, the interval between the time the parents noticed the swelling and the time obstruction occurred or when patients presented for elective care to the hospital was not different between parents within various social classes, tribes or religious beliefs. Similarly, in a retrospective review of 131 infants aged 24 months or less who had inguinal herniotomy at the Hospital for Sick Children in Toronto, Gholoum et al.5 found that the parents’ income or closeness to the hospital did not influence mean waiting time to incarceration or elective repair. Age was the single predictor variable for the occurrence of obstruction in groin hernias in children in this study. Younger children, especially, infants were more likely to develop obstruction compared to older children. This finding has been corroborated by other studies elsewhere3,11,12.
A major limitation of the study was the non-inclusion of the distance from homes to the hospital where the study was conducted. This is a factor to evaluate in subsequent studies on inguinal hernia in children in this environment.
Conclusions
The age at presentation is the significant socio-demographic variable in this study that could predict obstruction in healthy children with inguinal hernia delivered at term. This underscores the need for early repair of inguinal hernia in infants.
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
References
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