Starship Childrens Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
HAEMANGIOMA PROPRANOLOL TREATMENT
Introduction
Potential Indications for Treatment
Propranolol
Propranolol Dose
Investigations
Inpatient Management
Daystay Management
Complications
Follow-up
References
Appendix 1
Appendix 2 Parent Information
Introduction
Haemangioma are benign skin lesions caused by proliferating endothelial cells. They appear
shortly after birth, and grow rapidly to reach 80% of maximal size by 3 months. Most stop growing
by 6 months, but some continue to grow until 18 months of age or more. Subsequently they
involute over years, being largely resolved by 5 years of age, although some may leave permanent
residua such as telangectasia, scarring or excess fibro-fatty tissue.
Following case reports of rapid resolution of haemangioma in children on propranolol for
cardiomyopathy, propranolol has been used as a treatment for this condition. Although
corticosteroids remain the gold-standard treatment at this time, many clinicians are opting to use
propranolol off-licence due to its better side effect profile. Propranolol has been used for both
cutaneous and subglottic/tracheal haemangioma. The mechanism of action of propranolol may
include vasoconstriction, decreased expression of VEGF and bFGF genes, down regulation of the
RAF-mitogen-activated protein kinase pathway, or triggering of apoptosis of endothelial cells.
For many haemangioma treatment is not required, however haemangioma in some locations need
treatment to prevent complications such as disruption to visual pathways, risk to the
airway/feeding, ulceration, or poor cosmetic outcome.
There does seem to be response from haemangiomas even after the proliferative phase ie
treatment has been effective in some children aged up to 4 years.
Potential Indications for Treatment
1.
2.
3.
4.
5.
6.
7.
Subglottic and/or tracheal haemangioma
Periorbital or retrobulbar haemangioma
Perioral haemangioma
Large facial segmental haemangiomas (can be associated with PHACES syndrome)
Nasal tip, ear, lip, central cheek, large facial haemangioma
Nappy area and flexural haemangiomas risk of ulceration
Lumbrosacral haemangioma (can be associated with underlying spinal and urogenital
anomalies)
8. Multiple haemangiomas (ie visceral)
9. Ulcerated haemangiomas
Author:
Editor:
Drs Diana Purvis, Tania Kraai & Anne Tait
Dr Raewyn Gavin
Haemangioma Propranolol Treatment
Service:
Date Reviewed:
Paed Dermatology, Paed ORL
September 2013
Page:
1 of 4
Starship Childrens Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
HAEMANGIOMA PROPRANOLOL TREATMENT
Children will be assessed by ENT or Dermatology depending on the location of the haemangioma.
Most children can commence treatment in Daystay, however for very young babies (i.e. <6 weeks)
or those with airway involvement admission overnight admission should be considered. This would
be at the discretion of the managing team. Children will be admitted under ENT or
Dermatology/General Paediatrics.
Propranolol
Risks and benefits of propranolol should be discussed with the family. Whilst it is still a new
therapy, there are a number of case series in literature. Reviews comparing propranolol with
corticosteroids have found propranolol to be more effective. Other beta blockers are also being
studied.
Benefits
Risks
Relatively low risk medication (compared with other treatment modalities)
Non-surgical approach
New treatment option, off-licence use of a medication
Bradycardia
Bronchoconstriction
Hypotension
Hypoglycaemia (esp if reduced feeding secondary to illness)
Propranolol dose
1mg/kg/day in two divided doses as starting dose, then 2mg/kg/day in two divided doses. In
selected patients higher doses are used at the discretion of physician based on clinical indication.
Propranolol 4mg/ml (Roxane) commercial preparation is available on NPPA application. This is
preferable due to better stability data and does not need refrigeration.
Alternatively Propranolol liquid 2mg/ml can be mixed by a pharmacist and has a shelf life of 30
days (see Appendix 1). It needs to be stored in the refrigerator. For those starting treatment as
outpatients, families should be asked to fill the prescription beforehand and bring the medicine with
them to the Daystay unit.
Investigations
Initial Investigations
1.
2.
3.
4.
Cardiovascular examination (incl femoral pulses)
ECG
Bloods: FBC, renal function, liver function, TFTs
Clinical photography to include front and side-on views
Other investigations at the discretion of the managing team:
For segmental head and neck haemangiomas at risk of PHACES syndrome: consider
echocardiogram, laryngoscopy & bronchoscopy, MRI/MRA head under GA, ophthalmology
assessment
Author:
Editor:
Drs Diana Purvis, Tania Kraai & Anne Tait
Dr Raewyn Gavin
Haemangioma Propranolol Treatment
Service:
Date Reviewed:
Paed Dermatology, Paed ORL
September 2013
Page:
2 of 4
Starship Childrens Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
HAEMANGIOMA PROPRANOLOL TREATMENT
For segmental lumbar region haemangiomas at risk of PELVIS/SACRAL syndrome: consider xray &/or USS spine, renal USS
For multiple haemangiomas: consider USS abdomen, USS/MR head, echocardiogram
Inpatient Management
Consider for those <6 weeks, airway haemangioma or other complications.
Baseline cardiovascular examination, observations (HR, BP) and investigations (ECG, bloods etc
as above).
Give Propranolol at starting dose 1mg/kg/day in 2 divided doses
Hourly HR & BP observations
Glucose to be checked after 3 hrs
Increase dose when stable until on 2mg/kg/day in 2 divided doses
Daystay Management
Ensure prescription for propranolol is filled prior to admission and baseline investigations have
been performed.
Admit to Daystay in the morning (0830hrs).
Baseline cardiovascular examination, observations (HR, BP) ECG. Bloods if not done prior.
Give Propranolol at starting dose 1mg/kg/day in 2 divided doses
Hourly HR & BP observations
Glucose to be checked after 3-4hours.
If observations and glucose stable, then discharge home.
Patient to return in 4-7 days for increase in Propranolol dose to 2mg/kg/day in 2 divided doses
Complications
Risk of hypoglycaemia 1-3% If hypoglycaemia (BSL <3.5 mmol/L), then feed and recheck BSL. If
<2.0, consider IV dextrose.
Parents to be aware of symptoms of hypoglycaemia (i.e. jitteriness, lethargy, sweatiness). Parents
need to be aware that the risks of hypoglycaemia and/or hypotension are increased if the child is
unwell, taking reduced feeds, and/or having vomiting/diarrhoea.
If hypotensive, then consider fluid bolus.
Author:
Editor:
Drs Diana Purvis, Tania Kraai & Anne Tait
Dr Raewyn Gavin
Haemangioma Propranolol Treatment
Service:
Date Reviewed:
Paed Dermatology, Paed ORL
September 2013
Page:
3 of 4
Starship Childrens Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
HAEMANGIOMA PROPRANOLOL TREATMENT
Follow-up
Dermatology patients
Outpatient review with dermatology to be arranged within 2-4 weeks to assess response.
ENT patients
Repeat L&B to be scheduled at 1 week, 4 weeks, and then every 6 months until age 18 months.
If no response then consider introduction of corticosteroids or other treatments.
Treatment may be continued for up to 9 24 months. Propranolol should be weaned and stopped
over a minimum two week period to prevent rebound tachycardia, but usually over a longer period
to prevent rebound growth.
Regular weight checks by GP or specialist to increase Propranolol dose accordingly .
References
DermNet NZ. Infantile Haemangioma.
Leaute-Labreze et al. Propranolol for severe hemangiomas of infancy. NEJM 2008; 358 (24):
2650-51.
Denoyelle F. Role of Propranolol in the therapeutic strategy of infantile laryngotracheal
hemangioma. Int J Ped Otorhino 2009; 73: 1168-72.
Hussain T, Greenhalgh K, McLeod K. Hypoglycaemic syncope in children secondary to betablockers. Arch Dis Child 2009; 94: 968-969.
Sans V et al. Propranolol for severe infantile haemangioma: Follow-up report. Pediatrics 2009;
124: e423-431.
Lawley LP, Siegfried E, Todd JL. Propranolol treatment for hemangioma of infancy: risks and
recommendations. Pediatric Dermatology 2009; 26 (5) 610-614.
Author:
Editor:
Drs Diana Purvis, Tania Kraai & Anne Tait
Dr Raewyn Gavin
Haemangioma Propranolol Treatment
Service:
Date Reviewed:
Paed Dermatology, Paed ORL
September 2013
Page:
4 of 4
