Hemangioma Treatment

Try for 6 hours between doses
Hold if child can't take PO
Child should not skip meals
Typically use for minimum 6 months, 12 months have less recurrences
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

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

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

Baseline BP and HR
Propranolol 0.5 mg/kg (1 mg/kg/day) PO BID
Check BP and HR 1 and 2 hours after first dose
IF not tolerated: gradually increase to 0.5 mg/kg PO
IF tolerated: Ensure minimum of 6 hours between doses, warning signs, feed regularly and hold dose if PO intake compromised, Discharge to home
In 3-7 days: Increase dose to 0.75 mg/kg PO BID (1.5 mg/kg/day)
Check BP and HR 1 and 2 hours after new dose
If not tolerated: Keep at 1 mg/kg/day and assess efficacy
If tolerated: discharge home
In 3-7 days Increase dose to 1 mg/kg PO BID (2 mg/kg/day)
Check BP and HR at 1 and 2 hours after new dose

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

A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma 2015 PDF
Initiation and Use of Propranolol for Infantile Hemangioma: Report of a Consensus Conference 2013Journal of Pediatrics

Propranolol