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Hemangioma Treatment

Propranolol

Dosing

  • 1 mg/kg/d divided TID or BID for 1 week
  • 1.5 mg/kg/d divided TID or BID for 1 week
  • 2 mg/kg/d divided TID or BID- keep at this dose (can increase with change in weight)
  • Can go up to 3 mg/kg/d if needed
  • Minimum 6 hours between doses
  • Hold if child can't take PO
  • Child should not skip meals
  • Typically use for minimum 6 months
  • When lesion treated, tapering is common to ensure no recurrence of the lesion
  • Monitor Blood pressure and pulse 1 and 2 hours after any dose increase of >0.5 mg/kg/day

Pre-Treatment issues

  • Blood Pressure & Pulse screening: Normal Infant Vital Signs
  • Inappropriate Bradycardia
    • Newborns (<1 month old) <70 BPM
    • Infants (1-12 months old) <80 BPM
    • Children (>12 months old) <70 PBM
  • Inappropriate Systolic Blood Pressure (< 5th percentile for oscillometric or <2 SD below mean for auscultation)
    • Newborn: <57 mm Hg (oscillometric) or 64 mm Hg (auscultation)
    • 6 months: < 85 mm Hg (oscillometric) or 65 mm Hg (auscultation)
    • 1 year: <88 mm Hg (oscillometric) or 66 mm Hg (auscultation)
  • Rule out PHACES Syndrome: MRI/MRA Head and Neck, Echocardiogram
  • Cardiology consult if considering Propranolol in PHACES

Screening for risks:

  • Cardiovascular and pulmonary history red flags
    • History of: Poor feeding, dyspnea, tachypnea, diaphoresis, wheezing, heart murmur, family history of heart block or arrhythmia would preclude outpatient treatment
  • Exam needed: Heart Rate, Blood Pressure, Cardiac and Pulmonary assessment
    • ECG if determined needed by above especially if:
      • Newborns < 1 month old and pulse is < 70 BPM
      • Infants 1-12 months old and pulse is < 80 BPM
      • Children > 12 months and pulse is < 70 BPM
      • Family history of congenital heart conditions or arrhythmias or maternal history of connective tissue disease
    • Echocardiogram- not needed routinely
  • PHACE syndrome (large segmental hemangioma of head neck, arterial anomalies of head and neck, congenital anomalies of brain, eyes and/or chest wall)- risk of ischemic stroke, needs to be managed by cardiology with neurology input
    • if PHACE is suspected: MRI/ MRA of head and neck and Echocardiogram
    • Slow titration up, lowest effective dosing, inpatient observation and TID dosing

Outpatient Treatment Initiation Protocol

  1. Baseline BP and HR
  2. Propranolol 0.33 mg/kg (1 mg/kg/day) PO TID (minium 6 hours between doses)
  3. Check BP and HR 1 and 2 hours after first dose
  4. IF not tolerated: gradually increase to 0.33 mg/kg PO
  5. IF tolerated: Ensure minimum of 6 hours between doses, warning signs, feed regularly and hold dose if PO intake compromised, Discharge to home
  6. In 3-7 days: Increase dose to 0.5 mg/kg PO TID (minimum 6 hours between doses) (1.5 mg/kg/day)
  7. Check BP and HR 1 and 2 hours after new dose
  8. If not tolerated: Keep at 1 mg/kg/day and assess efficacy
  9. If tolerated: discharge home
  10. In 3-7 days Increase dose to 0.66 mg/kg PO TID (q 6h minimum) (2 mg/kg/day)
  11. Check BP and HR at 1 and 2 hours after new dose

Treatment Location

  • Inpatient for <8 weeks old or any age with inadequate social support or co-morbid conditions affecting the cardiovascular or respiratory system
  • Outpatient for > 8 weeks old with good social support and no co-morbid conditions

Adverse Effects

  • Hypoglycemia- child should eat every 4 hours
  • Hypotension- check blood pressure after dose change
  • Bradycardia- check pulse after dose change
  • Infant Vital Signs

Parents to call if...

  • Lethargy
  • Cool Clammy skin
  • Breathing Difficulties

Intralesional Steroids

  • Triamcinolone 40mg/ml
  • Betamethasone 6mg/ml

Other Treatments

  • Surgical Excision

References

  • A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma PDF
  • Initiation and Use of Propranolol for Infantile Hemangioma: Report of a Consensus Conference 2013Journal of Pediatrics