Step-by-Step Approach to Infantile Hemangiomas in Newborns
Propranolol is the first-line treatment for high-risk infantile hemangiomas requiring intervention, with early referral (ideally by 1 month of age) recommended for potentially problematic lesions. 1
Initial Assessment and Risk Stratification
Identify the type of hemangioma:
- Infantile hemangiomas (IHs) - appear in first few weeks of life, grow rapidly between 1-3 months
- Congenital hemangiomas - fully formed at birth (different management approach)
Risk assessment factors - evaluate for high-risk features:
- Location: facial (especially periorbital, nasal tip, lip), airway, hepatic, genital, lumbosacral
- Size: large or extensive lesions
- Morphology: segmental pattern (higher risk than localized)
- Number: multiple hemangiomas (≥5 may indicate visceral involvement)
- Complications: ulceration, bleeding, functional impairment
Growth monitoring:
- Most rapid growth occurs between 1-3 months of age
- Growth typically completes by 5 months
- Document with serial photographs
Management Algorithm
Low-Risk Hemangiomas:
- Small, localized, non-facial lesions without complications
- Management: Observation with regular monitoring
- Parent education about natural history (70% resolve by age 7) 1
High-Risk Hemangiomas:
- Urgent referral (ideally by 1 month of age) to a hemangioma specialist for:
- Facial hemangiomas (risk of permanent disfigurement)
- Periorbital hemangiomas (risk of visual impairment)
- Airway hemangiomas (respiratory compromise)
- Large segmental facial hemangiomas (risk of PHACE syndrome)
- Perineal/genital hemangiomas (risk of ulceration)
- Multiple hemangiomas (≥5, risk of hepatic involvement)
Indications for Active Treatment:
- Life-threatening conditions
- Functional impairment (breathing, feeding, vision)
- Pain or bleeding
- Ulceration or impending ulceration
- High risk for permanent disfigurement 1
Treatment Options
First-Line Therapy:
- Oral propranolol (2-3 mg/kg/day divided into 2-3 doses) 1
- Initiate in clinical setting with cardiovascular monitoring
- Monitor heart rate hourly for first 2 hours
- For infants <8 weeks or postconceptual age <48 weeks: consider inpatient initiation
- Continue treatment for at least 6 months, often until 12 months of age
Alternative/Adjunctive Therapies:
- Topical timolol: For small, thin, superficial hemangiomas 1
- Oral corticosteroids: If propranolol contraindicated or ineffective
- Prednisolone/prednisone 2-3 mg/kg/day as single morning dose 1
- Intralesional steroid injections: For small, bulky, well-localized IHs 1
Surgical Interventions:
- Laser therapy: For early hemangiomas, superficial components, or residual telangiectasia
- Surgical resection: Generally delayed until after infancy
- Indications for early surgery: failure of medical therapy for critical IHs
- Most appropriate after age 4 when involution is complete 1
Monitoring and Follow-up
- Early phase (1-5 months): Frequent monitoring (every 1-4 weeks depending on risk)
- Growth plateau (5-12 months): Monitor every 1-3 months
- Involution phase (>12 months): Monitor every 3-6 months
Special Considerations
- Ulcerated hemangiomas: Focus on wound care, pain control, preventing infection
- Multiple hemangiomas: Consider abdominal ultrasound to rule out hepatic involvement
- Segmental facial hemangiomas: Consider evaluation for PHACE syndrome
Common Pitfalls to Avoid
- Delayed referral: Missing the window of opportunity for early intervention (1-3 months)
- Reassurance without monitoring: The myth that "all hemangiomas go away" can lead to missed opportunities for intervention
- Inappropriate surgical intervention: Performing surgery during proliferative phase rather than waiting for involution
- Inadequate parent education: Failing to explain natural history and treatment rationale
Remember that while most infantile hemangiomas are benign and self-resolving, early identification of high-risk features and prompt referral to specialists can prevent significant morbidity and improve long-term outcomes.