Propranolol for Infantile Hemangioma: Clinical Protocol
Direct Recommendation
Start oral propranolol at 1 mg/kg/day divided into 2-3 doses for 24 hours, then increase to 2 mg/kg/day maintenance (up to 3 mg/kg/day for non-responders), continuing until at least 12 months of age to prevent rebound growth. 1, 2
Indications for Treatment
Propranolol is indicated for:
- Life-threatening hemangiomas (airway obstruction, high-output cardiac failure) 3
- Vision-threatening periocular lesions (risk of amblyopia, refractive errors, strabismus in up to 80% if untreated) 2
- Functional impairment (feeding difficulties, auditory canal involvement) 3
- Ulcerated hemangiomas where topical treatment has failed 3
- Risk of permanent disfigurement 3
Absolute Contraindications
Do not use propranolol in:
- Heart block (second or third degree) 3
- Cardiogenic shock or decompensated heart failure 2
- Sinus bradycardia or hypotension 2
- Bronchial asthma or obstructive airway disease 2
- Active or recent hypoglycemic episodes 3
- Known hypersensitivity to propranolol 3
Pre-Treatment Assessment
Required Baseline Evaluation
- Cardiovascular examination: auscultation for murmurs, peripheral pulses, abdominal exam for hepatomegaly 3, 1
- Heart rate and blood pressure measurement 1, 2
- Clinical photographs for baseline documentation 3
Selective Testing (Not Routine)
- ECG and echocardiogram: only for suspected cardiac disease or PHACE syndrome 3
- Baseline glucose: only for preterm infants, low birthweight, faltering growth, neonates, or history of hypoglycemia 3
- Brain MRI/MRA: mandatory for segmental head/neck hemangiomas before full-dose propranolol (PHACE syndrome screening) 3, 2
- Laboratory tests (CBC, renal, liver, thyroid): NOT routinely required 3
Dosing Protocol
Standard Dosing (Uncomplicated Cases)
- Starting dose: 1 mg/kg/day divided into 2-3 doses 3, 1
- Timing: minimum 24 hours before dose increase 3
- Maintenance dose: 2 mg/kg/day divided into 2-3 doses 3, 1
- Maximum dose: 3 mg/kg/day for non-responders 3, 1
- Preparation: use 5 mg/5 mL solution 3
The landmark RCT demonstrated 60% complete/nearly complete resolution at 3 mg/kg/day for 6 months versus only 4% with placebo 4, establishing this as the evidence-based target dose.
Modified Dosing (High-Risk Patients)
For preterm infants, low birthweight, faltering growth, or conditions predisposing to hypoglycemia:
- Starting dose: 0.5 mg/kg/day 1, 2
- Escalation: more cautious incremental increases determined by supervising physician 3
PHACE Syndrome Protocol
For segmental head/neck hemangiomas with suspected PHACE:
- Starting dose: 0.5 mg/kg/day before imaging 3, 2
- Required workup: brain MRI/MRA, ECG, and echocardiogram interpreted by pediatric cardiologist 3
- Consultation: discuss with pediatric neurologist if arterial stenosis or agenesis found before advancing dose 3
Administration Guidelines
Critical Safety Measures
- Always give with or immediately after feeding to prevent hypoglycemia 1, 2
- Hold doses during reduced oral intake or vomiting 1, 2
- Use a drug dosing card to prevent dosing errors 3
Dose Adjustments
- Weight-based adjustments: can be made at clinic visits, by GP, or by parents with written instructions 3, 1
- Frequency: 2 or 3 daily doses at clinician's discretion 3, 1
Monitoring Protocol
First-Dose Monitoring
- Post-dose observation: NOT routinely needed for uncomplicated cases 3
- When observation required: measure HR and BP with 30 minutes between observations 3
- Total observation time: 2-4 hours 3
- Glucose monitoring: only for at-risk patients (preterm, low weight, faltering growth, neonates, hypoglycemia history) 3
Ongoing Monitoring
- Follow-up interval: every 2-3 months for stable patients without complications 3, 1
- Between appointments: HR and BP monitoring NOT required if infant is well 3
- Clinical photographs: document treatment response at visits 3
Treatment Duration and Discontinuation
Duration
- Minimum treatment: until 12 months of age to minimize rebound growth 1, 2
- Typical duration: most patients do not need treatment beyond 17 months 3, 2
- Evidence-based duration: 6 months superior to 3 months (60% vs lower response rates) 1, 4
Starting treatment before 3 months of age yields significantly better outcomes: 57% total resolution versus 40% when started after 3 months 5.
Discontinuation
- Tapering: NOT required—safe to stop abruptly 3
- Rebound growth: occurs in 9.3% (moderate-to-severe) and 22.5% (mild) after discontinuation 6
- Retreatment: 10% of successful cases require systemic retreatment during follow-up 4
- Post-treatment follow-up: NOT routinely required 3
Expected Response and Efficacy
- Improvement rate: 92.6-99% show clinical improvement 6, 7
- Complete resolution: 48-60% achieve total resolution 4, 5
- Time to response: 88% show improvement by week 5 4
- Clinical changes: color lightening, palpable softening, size/volume reduction 6
Alternative and Adjunctive Therapies
When Propranolol Insufficient
- Laser therapy: used in 75% of partial/non-responders 7
- Steroid injections: used in 31% of partial/non-responders 7
- Topical treatments: for ulcerated lesions where appropriate 3
Special Situations
- Airway hemangiomas: require otolaryngology co-management (suspect in any infant with hoarseness/stridor, especially with mandibular, cervicofacial, or "beard" distribution) 2
- Periocular hemangiomas: require ophthalmology co-management for early treatment 2
Common Pitfalls and Safety Considerations
Adverse Events
Minor side effects occur but are easily managed:
- Somnolence: 27.2% 7
- Gastroesophageal reflux: 9.1% 7
- Respiratory syncytial virus exacerbation: 4.5% 7
- Rash: 4.5% 7
Serious adverse events (hypoglycemia, hypotension, bradycardia, bronchospasm) occur infrequently with no significant difference from placebo 4.