What is the pediatric dose for propranolol (beta blocker)?

Pediatric Propranolol Dosing

For most pediatric patients, propranolol should be initiated at 1 mg/kg/day divided into 2-3 doses, then increased to a maintenance dose of 2-3 mg/kg/day, with the maximum dose being 3 mg/kg/day for non-responders. 1, 2

Standard Dosing Algorithm

Initial Dose

• Start at 1 mg/kg/day divided into 2-3 daily doses for uncomplicated patients 1, 2
• Increase to maintenance dose after a minimum of 24 hours 1, 2

Maintenance Dose

• Target 2-3 mg/kg/day for optimal efficacy 1, 2
• The 2 mg/kg/day dose is standard for uncomplicated cases 1
• Studies demonstrate that 3 mg/kg/day for 6 months provides superior outcomes, with 60% achieving complete or nearly complete resolution 1

Maximum Dose

• 3 mg/kg/day for non-responders 1, 2
• Limited evidence supports doses higher than 3 mg/kg/day 3

Special Populations Requiring Lower Doses

Start at 0.5 mg/kg/day for:

• Suspected PHACES syndrome (segmental hemangiomas of head/neck with potential arterial anomalies) 1, 2
• Preterm infants or those <48 weeks postconceptional age 1, 2
• Low birth weight infants 1, 2
• Infants <8 weeks of age 1, 2
• Comorbidities increasing hypoglycemia risk (e.g., hyperinsulinism) 1, 2
• Progressive ulceration while on therapy 1, 2
• Adverse effects such as sleep disturbances 1, 2

For PHACES syndrome patients, administer 3 times daily to minimize abrupt blood pressure changes, and co-manage with pediatric neurology 1, 2

Administration Guidelines

Timing with Feeds

• Administer with or after feeding to reduce hypoglycemia risk 1, 4
• Hold doses during diminished oral intake or vomiting 1, 4
• Maintain dosing intervals not exceeding 8 hours (or 6 hours in younger infants) 1

Dosing Frequency

• Twice daily (BID) or three times daily (TID) are both acceptable 1, 5
• Pharmacokinetic modeling shows BID and TID regimens produce similar steady-state concentrations 5
• TID dosing may be preferred for high-risk patients to minimize blood pressure fluctuations 1

Duration of Treatment

• Continue until at least 12 months of age to minimize rebound growth 1, 2
• Greatest rebound risk occurs when discontinued before 9 months of age 2
• Most patients do not require treatment beyond 17 months of age 1
• Treatment can be stopped abruptly without gradual weaning 1, 2

Monitoring Requirements

High-Risk Patients (requiring admission for 2-4 hours):

• Measure heart rate and blood pressure before first dose 2
• Monitor every 30 minutes for 2-4 hours after first dose 2
• Repeat monitoring for dose increments >0.5 mg/kg/day 2

Standard Patients:

• Baseline heart rate and blood pressure before initiation 1, 4
• No routine monitoring between appointments if infant is well 1
• Follow-up every 2-3 months for stable patients 1

Blood Glucose:

• Only monitor in patients at risk for hypoglycemia 2
• Not routinely required for healthy term infants 2

Critical Contraindications

Absolute contraindications include: 1, 4

• Cardiogenic shock
• Sinus bradycardia
• Hypotension
• Heart block greater than first degree
• Decompensated heart failure
• Bronchial asthma or reactive airway disease
• Known hypersensitivity to propranolol

Common Pitfalls

Dosing Errors

• Use 5 mg/5 mL preparation (least likely to cause errors) 2
• Manual splitting of 40 mg tablets produces 42% of quarters outside acceptable ±10% range 6
• Pediatric oral solution formulations prevent dosing inaccuracies 6

Illness Management

• Stop propranolol during acute illness with reduced feeding, vomiting, or diarrhea 1, 4
• Resume only when normal feeding resumes 2

Rebound Growth

• Occurs in 10-25% of patients 1
• More likely with mixed/deep morphology, female sex, and early discontinuation 2
• May require reinitiation of therapy 1

Dose Adjustments

• Adjust for weight at clinic visits, by primary care provider, or by parents with written instructions 1
• Minimum 24-hour interval between dose increases 1, 2
• Use drug dosing card to prevent errors 1