====== Hemangioma Treatment ======
===== Propranolol =====
==== Dosing ====
=== Preferred Dosing ===
  * 1 mg/kg/d divided BID for 1 week
  * 1.5 mg/kg/d divided BID for 1 week
  * 2 mg/kg/d divided BID keep at this dose
== Common Alternate dosing ==
  * 1 mg/kg/d divided TID for 1 week
  * 1.5 mg/kg/d divided TID for 1 week
  * 2 mg/kg/d divided TID keep at this dose
== French RCT Dosing ==
  * 1 mg/kg/d divided BID for 1 week
  * 2 mg/kg/d divided BID for 1 week
  * 3 mg/kg/d divided BID
=== Other Considerations ===
  * 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
==== Pre-Treatment issues ====

  * Blood Pressure & Pulse screening:  [[infant_vital_signs|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 ===
  - 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

=== 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|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 2015 {{:oral_propranolol_in_infantile_hemangioma_randomized_controlled_trial_nejm.pdf|PDF}}
  * Initiation and Use of Propranolol for Infantile Hemangioma: Report of a Consensus Conference 2013{{http://pediatrics.aappublications.org/content/131/1/128?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token|Journal of Pediatrics}}


{{tag>drugs}}