What is the recommended dosing of propranolol (beta blocker) for infantile hemangioma?

Propranolol Dosing for Infantile Hemangioma

Start propranolol at 1 mg/kg/day divided into 2-3 doses, then increase after 24 hours to a maintenance dose of 2 mg/kg/day for uncomplicated cases, with a maximum of 3 mg/kg/day for non-responders. 1

Standard Dosing Protocol

Initial Dosing

• Starting dose: 1 mg/kg/day divided into 2-3 doses for term infants >4 weeks old with no comorbidities 1
• Escalate to maintenance dose after 24 hours: 2 mg/kg/day divided into 2-3 doses 1
• Target maintenance range: 2-3 mg/kg/day based on high-quality RCT data showing 60% complete/nearly complete resolution at 3 mg/kg/day for 6 months versus 4% with placebo 1, 2
• Maximum dose: 3 mg/kg/day for non-responders 1

Administration Guidelines

• Give with or after feeding to reduce hypoglycemia risk 1
• Hold doses during reduced oral intake or vomiting to prevent hypoglycemia 1
• Can divide into 2 or 3 daily doses at clinician discretion 1

Modified Dosing for High-Risk Patients

PHACE Syndrome (Segmental Facial Hemangiomas)

• Starting dose: 0.5 mg/kg/day before brain MRI/MRA completion 1
• Obtain brain MRI/MRA, echocardiogram, and ECG before full-dose propranolol 1
• If arterial stenosis/agenesis present, consult pediatric neurology before escalating dose 1
• Use lowest effective dose, titrate slowly, and give 3 times daily to minimize blood pressure fluctuations 1

Preterm/Low Weight/Comorbidities

• Starting dose: 0.5 mg/kg/day for preterm infants, low birthweight, faltering growth, or conditions predisposing to hypoglycemia (e.g., hyperinsulinism) 1
• Require hospital admission for 2-4 hours on initiation and dose increases >0.5 mg/kg/day 1
• Monitor heart rate and blood pressure every 30 minutes for 2-4 hours after first dose 1
• Check blood glucose only in at-risk patients 1

Treatment Duration

Continue treatment until at least 12 months of age to minimize rebound growth risk 1

• 6 months duration superior to 3 months (60% vs lower response rates) 1, 2
• Majority of patients don't need treatment beyond 17 months 1
• Rebound growth occurs in 10-25% of patients, highest risk when stopping <12 months (especially <9 months) 1
• Risk factors for rebound: mixed/deep morphology, female sex, early discontinuation 1
• Safe to stop abruptly rather than tapering 1

Pre-Treatment Assessment

Required for All Patients

• Thorough history and physical examination including auscultation, peripheral pulses, abdominal exam for hepatomegaly 1
• Heart rate and blood pressure measurement 1
• Baseline photographs 1

Selective Testing

ECG indicated if: 1

• Heart rate outside normal range for age
• Strong family history of sudden death/arrhythmia
• Episodes of loss of consciousness
• Maternal connective tissue disease

Echocardiogram indicated if: 1

• Heart rate outside normal range for age
• Heart murmur on auscultation
• Segmental hemangioma (PHACE risk)

Baseline glucose indicated if: 1

• Preterm infant
• Small for gestational age
• Feeding poorly
• History of hypoglycemic episodes

No Routine Testing Required

• Screening blood tests (CBC, renal, liver, thyroid function) not needed in otherwise healthy infants 1

Monitoring During Treatment

• Routine follow-up every 2-3 months for stable patients 1
• No routine vital sign monitoring between appointments if infant is well 1
• Adjust dose for weight at clinic visits 1
• Use drug dosing card to prevent errors 1

Critical Safety Considerations

When to Hold Propranolol

• Reduced oral intake or vomiting (hypoglycemia risk) 1
• Intercurrent illness affecting feeding 1
• Progressive ulceration while on therapy (rare—propranolol can worsen ulceration via peripheral ischemia; consider dose reduction) 1

Contraindications

• Heart block
• Decompensated heart failure
• Asthma/obstructive airway disease
• Cardiogenic shock
• Sinus node dysfunction without pacemaker 1

Common Adverse Effects

• Sleep disturbances (most common—10/71 patients in one series) 3
• Hypoglycemia, bradycardia, hypotension, bronchospasm (infrequent but serious) 1, 2
• Cool extremities 4

Special Populations

Vision-Threatening Periocular Hemangiomas

• Warrant early treatment to prevent amblyopia, refractive errors, strabismus (complications in up to 80% if untreated) 1
• Require ophthalmology co-management 1

Airway Hemangiomas

• Higher risk with segmental mandibular, cervicofacial, or "beard" distribution 1
• Suspect if hoarseness/stridor present 1
• Require otolaryngology co-management 1