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

Propranolol Dosing for Infantile Hemangioma

Recommended Dosing Regimen

Start propranolol at 1 mg/kg/day divided into 2-3 doses, then escalate after 24 hours to a maintenance dose of 2-3 mg/kg/day, with a maximum target of 3.4 mg/kg/day for 6 months. 1, 2, 3

Standard Initiation Protocol

• Begin at 1 mg/kg/day divided into 2-3 doses for the first 24 hours 1, 2
• Escalate to maintenance dose of 2-3 mg/kg/day after the initial 24-hour period, divided into 2-3 daily doses 1, 2
• Maximum dose is 3.4 mg/kg/day for non-responders, based on FDA-approved dosing that achieved 60% complete or nearly complete resolution versus 4% with placebo 1, 3
• Dosing frequency: Three times daily is recommended by consensus guidelines, though twice daily dosing has also shown safety and efficacy 1

Modified Dosing for High-Risk Infants

For preterm infants, low birthweight, or those with conditions predisposing to hypoglycemia, start at 0.5 mg/kg/day and titrate more cautiously 2

High-risk populations requiring modified initiation include:

• Infants ≤8 weeks of age 1
• Preterm infants <48 weeks postconceptional age 1
• Infants with poor social support 1
• Those with cardiac or pulmonary risk factors 1

These high-risk infants should be considered for inpatient hospitalization during propranolol initiation 1

Administration Guidelines

Timing and Food Intake

• Administer propranolol with or immediately after feeding to reduce hypoglycemia risk 2
• Feed infants at intervals not exceeding 8 hours (or 6 hours in younger infants) when on propranolol 1
• Hold doses during reduced oral intake, vomiting, or acute illness to prevent hypoglycemia 1, 2

Treatment Duration

• Continue treatment until at least 12 months of age to minimize rebound growth risk 2
• Six-month duration is superior to 3 months based on RCT data showing 60% response with 6-month treatment 2, 3
• Most dramatic improvement occurs within 3-4 months of initiation 1
• Rebound growth occurs in 6-25% of children, more likely with long proliferative stage and large subcutaneous component 1

Discontinuation

• Taper propranolol gradually over 1-3 weeks when discontinuing to prevent rebound sinus tachycardia 1
• Reinitiate therapy if rebound growth occurs, which may happen well after the first birthday 1

Pre-Treatment Assessment

Mandatory Cardiovascular Evaluation

Before initiating propranolol, perform:

• Complete cardiac history and physical examination with auscultation, peripheral pulse assessment, and abdominal examination for hepatomegaly 1, 2
• Baseline heart rate and blood pressure measurement 2
• Electrocardiography, particularly in younger infants, those with low heart rate, or abnormal examination findings 1

Pretreatment cardiac screening appears to be of limited value in patients with unremarkable cardiac history and examination 1

Absolute Contraindications

Do not use propranolol in infants with:

• Cardiogenic shock 1, 2
• Sinus bradycardia 1, 2
• Hypotension 1, 2
• Heart block greater than first degree 1, 2
• Heart failure 1, 2
• Bronchial asthma or reactive airways 1, 2
• Known hypersensitivity to propranolol 1

Special Populations Requiring Additional Workup

For infants with PHACE syndrome, obtain brain MRI/MRA, echocardiogram, and ECG before initiating full-dose propranolol 2

Monitoring During Treatment

Routine Follow-Up

• Follow-up every 2-3 months for stable patients 2
• Adjust dose for weight at clinic visits 2
• Monitor for common adverse effects: sleep disturbance, cool extremities, diarrhea, hypoglycemia 1

Critical Safety Monitoring

Watch for serious adverse effects:

• Hypoglycemia (particularly concerning in younger infants) 1, 2
• Bradycardia 1
• Hypotension 1
• Bronchospasm 1

Temporarily discontinue propranolol during any acute illness interfering with oral intake or causing vomiting/diarrhea 1

Clinical Efficacy Evidence

The highest quality evidence comes from a large multicenter RCT of 460 infants:

• 60% achieved complete or nearly complete resolution at 3.4 mg/kg/day for 6 months versus 4% with placebo 3
• 88% showed improvement by week 5 with the selected regimen 3
• 10% required systemic retreatment during follow-up after successful initial treatment 3
• Propranolol stopped hemangioma growth by week 4 in treated patients 4

Common Pitfalls to Avoid

• Do not initiate propranolol without assessing feeding schedule - hypoglycemia risk is highest with prolonged fasting 1
• Do not continue propranolol during acute illness with reduced intake - this significantly increases hypoglycemia risk 1
• Do not abruptly discontinue after chronic use - taper over 1-3 weeks to prevent rebound tachycardia 1
• Do not assume all hemangiomas respond equally - rebound growth is more common with long proliferative stage and large subcutaneous components 1