Hemangioma Treatment

• 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

• 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

• 1 mg/kg/d divided BID for 1 week
• 2 mg/kg/d divided BID for 1 week
• 3 mg/kg/d divided BID

• 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

See Outpatient Treatment of hemangioma with Propranolol Protocol

• 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

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

• Lethargy
• Cool Clammy skin
• Breathing Difficulties

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

• Surgical Excision

• See Protocol for Outpatient Propranolol for Infantile and Childhood Hemangioma
• 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