Treatment of complicated infantile hemangiomas* with oral propranolol

ECG: electrocardiogram; MRI: magnetic resonance imaging; PHACE: posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities; bpm: beats per minute.
* Complicated hemangiomas include:

• Large hemangiomas at increased risk of scarring or disfigurement
• Life-threatening hemangiomas
• Hemangiomas carrying functional risks
• Ulcerated hemangiomas

¶ Postnatal age in weeks minus number of weeks preterm.
Δ Falsely low or high blood pressure measurements may occur if an inappropriate cuff size is used. In addition, the infant's behavioral state (crying/agitated versus calm/sleeping) can greatly impact blood pressure measurements. Refer to UpToDate topics on measurement of blood pressure in infants and children.
◊ Baseline head/neck MRI with angiography is also preferred in infants with large facial hemangiomas at risk for PHACE prior to initiating propranolol; however, in infants needing urgent treatment, propranolol may be given in the wait for neuroimaging results. Propranolol can be initiated at a lower dose and slowly titrated up to a maximum dose of 1 mg/kg/day.
§ This is a suggested initial dose; however, the initial dose and titration may vary according to local protocols.
¥ Serious adverse reactions:

• Bradycardia (<90 bpm in newborns and infants ≤3 months)
• Hypotension
• Bronchospasm
• Hypoglycemia

Refer to UpToDate topics on beta-blocker toxicity.
‡ Early signs of hypoglycemia:

• Sweating (most important, not masked by beta blockers)
• Jitteriness
• Irritability
• Cyanosis
• Poor feeding
• Hypothermia
• Lethargy

Refer to UpToDate topics on hypoglycemia in infancy.