Paediatric Infantile Haemangioma (IH)
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define Infantile Haemangioma and understand its natural history.
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Recognize clinical features and complications requiring treatment.
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List appropriate investigations for evaluation of IH.
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Identify indications and contraindications for propranolol therapy.
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Describe the stepwise dosing and monitoring of propranolol.
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Counsel caregivers regarding treatment, follow-up, and side effects.
Description
Infantile Haemangiomas (IH) are the most common vascular tumours in infants, affecting approximately 4% of newborns. IH appear within the first few weeks of life, proliferate rapidly during the first months, and may continue slow growth for 6–12 months. Most spontaneously involute and do not require treatment, but about 15% develop complications including obstruction, ulceration, or disfigurement, necessitating therapeutic intervention.
Investigations
| Investigation | Purpose / Notes |
|---|---|
| FBC | Baseline evaluation |
| Blood glucose | Detect hypoglycemia risk before propranolol |
| Urea & electrolytes | Assess renal function |
| Thyroid function tests (TFTs) | Baseline assessment |
| Liver function tests (LFTs) | Baseline assessment |
| ECG & ECHO | Detect cardiac contraindications |
| Liver ultrasound | For infants with >5 cutaneous IH to detect liver involvement |
| MRI scan | For complex or deep lesions requiring detailed imaging |
Indications for Treatment with Oral Propranolol
| Indication | Reason / Clinical Concern |
|---|---|
| Vision compromise | Protect sight |
| Airway IH | Prevent obstruction |
| Nasal IH | Avoid nasal obstruction |
| Lip IH | Prevent functional impairment and/or disfigurement |
| Auditory canal involvement | Prevent recurrent infection |
| Ulcerated IH | When topical therapy is inadequate |
| Risk of permanent disfigurement | Cosmetic/functional concern |
| Spinal cord compression | Prevent neurological sequelae |
| Liver IH with cutaneous IH | Multidisciplinary management in select cases |
Contraindications
| Type | Details |
|---|---|
| Absolute | Recent/ongoing hypoglycemia, 2nd–3rd degree heart block, hypersensitivity to propranolol |
| Relative | Frequent wheezing, abnormal BP or HR for age; require paediatrician supervision |
Dosing Protocol (Oral Propranolol, 1 mg/ml solution preferred)
| Week | Dose | Notes |
|---|---|---|
| Week 1 | 1 mg/kg/day in 3 divided doses | Start low to monitor tolerance |
| Week 2 | 2 mg/kg/day in 3 divided doses | Monitor for side effects |
| Dose escalation | 3 mg/kg/day in 3 divided doses if inadequate response | Only after 4 weeks and no adverse effects |
Administration: Give with or shortly after food. Hold medication if significant vomiting occurs to reduce hypoglycemia risk.
Potential Side Effects
| Side Effect | Clinical Concern |
|---|---|
| Bradycardia | Monitor HR |
| Hypoglycemia | Especially if reduced oral intake |
| Heart failure | Monitor cardiac status |
| Hypotension | Monitor BP |
| Cardiac conduction disorders | ECG monitoring |
| Bronchospasms | Caution in asthmatic children |
| Peripheral vasoconstriction | Monitor extremities |
| Weakness, fatigue | Supportive care |
| Sleep disturbances | Inform caregivers |
Follow-Up and Stopping Therapy
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Reassess 4 weeks after treatment initiation.
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Duration should extend beyond proliferative phase to prevent rebound growth.
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European studies suggest risk of rebound decreases significantly after 17 months of age.
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Temporarily discontinue propranolol if:
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Significant reduced oral intake
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Wheezing requiring treatment
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Parental Education: Explain administration, side effects, and monitoring. Provide written information leaflet.
Summary
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IH are common vascular tumours of infancy; most involute spontaneously.
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About 15% require treatment due to complications.
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Propranolol is first-line therapy for complicated IH.
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Indications include airway, vision, nasal, lip involvement, ulceration, risk of disfigurement, spinal cord or liver involvement.
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Monitor for cardiac, respiratory, and metabolic side effects.
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Therapy should continue through proliferative phase; rebound risk decreases after 17 months.