====== Propranolol for Hemangioma: Outpatient Protocol ======

==== Dosing ====
  * 1 mg/kg/d divided BID for 1 week (0.5mg/kg/dose)
  * 1.5 mg/kg/d divided BID for 1 week (0.75 mg/kg/dose)
  * 2 mg/kg/d divided BID keep at this dose (1 mg/kg/dose)

=== 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

==== Protocol Details ===
  - 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

=== Vital Sign Information ===
  * 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)


=== Treatment Location Considerations ===
  * 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

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