What is the recommended management and referral process for an infant with a hemangioma?

Management and Referral Process for Infantile Hemangiomas

Prompt referral to a specialist is necessary for high-risk infantile hemangiomas during the critical growth phase (1-3 months), as delaying referral is a common mistake that can lead to complications and permanent skin changes. 1

Risk Assessment and Triage

Low-Risk Hemangiomas (Observation)

• Small, localized lesions in non-critical areas
• No functional impairment
• No ulceration or bleeding
• Not rapidly growing
• Not in cosmetically sensitive areas

High-Risk Hemangiomas (Prompt Referral)

• Location-based risks:

  • Periocular (can cause astigmatism, strabismus, amblyopia)
  • Airway (may present with biphasic stridor, barky cough)
  • Large facial hemangiomas
  • Lip and perineal areas (high risk of ulceration)
  • Hepatic hemangiomas 2, 1

• Complication-based risks:

  • Life-threatening conditions
  • Functional impairment
  • Pain or bleeding
  • Ulceration
  • Risk of permanent disfigurement 2, 1

Monitoring and Follow-Up Schedule

• Frequent evaluations during growth phase (1-5 months)
• Most rapid growth occurs between 1-3 months of age
• Growth typically stops by 5 months of age
• 80% of hemangiomas reach final size by 3 months 1, 3

Treatment Algorithm

First-Line Treatment: Oral Propranolol

• Dosage: 2-3 mg/kg/day divided into 2-3 doses
• Monitoring: Initial cardiovascular monitoring every hour for first two hours
• Administration: Give with or after feeding
• Duration: Minimum 6 months of therapy 2, 1, 3

Special Considerations for Propranolol

• For PHACE syndrome: Brain MRI/MRA before starting full dose
• For preterm/low weight infants: More cautious dosing
• Use caution in infants <5 weeks of age or postconceptional age <48 weeks 1

Second-Line Treatment: Corticosteroids

• If propranolol is contraindicated or ineffective
• Dosage: 2-3 mg/kg/day as single morning dose
• Most effective when initiated during proliferative phase 2, 1

Alternative Treatments

• Topical timolol: For thin/superficial hemangiomas
• Intralesional steroid injections: For focal, bulky hemangiomas
• Laser treatment: For early non-proliferating superficial lesions, ulceration, residual telangiectasia 1, 4

Surgical Management

• Generally delayed until after infancy to allow for involution
• Consider for:
  • Residual deformities after involution
  • Specific anatomic locations with functional concerns
  • Cases where resulting scar would be similar to that after involution 2, 1

Location-Specific Management

Periocular Hemangiomas

• Require early ophthalmology evaluation
• Can cause astigmatism, strabismus, or amblyopia 1

Airway Hemangiomas

• Require endoscopy for diagnosis
• Present with biphasic stridor and barky cough 1

Hepatic Hemangiomas

• Screening ultrasound recommended for infants with multiple cutaneous lesions
• Monitor thyroid function as these can deactivate thyroid hormone 2, 1

Lip and Perineal Hemangiomas

• Higher risk of ulceration
• Early intervention may prevent complications
• For perineal lesions: Use topical lubrication with barrier dressing to prevent ulceration 2, 1

Common Pitfalls to Avoid

• Delayed referral: Not referring high-risk hemangiomas during critical growth phase (1-3 months)
• Underestimation: Assuming all lesions will resolve without sequelae (up to 70% leave permanent skin changes)
• Incorrect diagnosis: Confusing "cavernous hemangiomas" with deep IHs or venous malformations
• Inappropriate treatment: Using laser therapy for proliferating lesions rather than for residual telangiectasia 2, 1

Remember that while most infantile hemangiomas do not require treatment and will involute spontaneously, early identification of high-risk lesions and prompt referral to specialists are crucial for preventing complications and optimizing outcomes.