be attempted The child should be given opioid pain medications, such as intranasal fentanyl or IV fentanyl, with standard cardiopulmonary monitoring The mother should then cuddle the baby until it relaxes and falls asleep An older child may be placed in the Trendelenburg position to allow gravity to facilitate the reduction Once the child is asleep, gentle manipulation of the incarcerated mass should be attempted Mild pressure should be exerted at the internal ring with one hand, while the other attempts to squeeze gas or fluid out of the incarcerated bowel back into the abdominal cavity If the reduction is unsuccessful, a surgeon should be consulted immediately Disposition After the hernia has been reduced manually, the child may be admitted for observation but not immediate repair The hernia sac and spermatic cord are edematous after a reduction, making the repair difficult Usually, it is done 24 hours after admission If a child has persistent emesis after a manual reduction of a hernia, consider the possibility that the bowel was incompletely reduced Children that develop peritoneal signs after manual reduction should be evaluated for possible perforation associated with gangrenous bowel Rarely should a child be sent home after a manual reduction unless the parents are properly informed concerning signs of recurrence or intestinal obstruction Incarcerated Umbilical Hernia Incarceration of an umbilical hernia is rare If present, there is a persistent and tender bulge in the umbilical hernia sac If the incarceration is of short duration, a gentle effort might be made to reduce it manually, but it is often necessary to prepare the child for urgent surgery At the time of surgery, the loop of incarcerated bowel should be inspected, rather than letting it drop back into the abdominal cavity, to be certain there has been no vascular impairment Malrotation of the Bowel With Volvulus Goals of Treatment The goals of treatment are simple: early recognition, emergency surgical consultation, treatment of shock, and immediate operative care to preserve viability of the bowel CLINICAL PEARLS AND PITFALLS