Propranolol therapy for cutaneous infantile haemangiomas initiated safely as a day-case procedure

Abstract

Propranolol is emerging as the treatment of choice for high-risk infantile haemangiomas. Current protocols recommend overnight admission for initiation of propranolol as well as baseline investigations including electrocardiography (ECG) and echocardiography (ECHO). Our study examined the safety profile of propranolol for the treatment of infantile haemangiomas using a simplified day-case initiation protocol. We evaluated 20 consecutive patients commencing propranolol as a day case for the treatment of an infantile haemangioma over an 18-month period. Investigations were carried out according to our local protocol. Cardiac investigations were not routinely performed. Patients were observed for 2 h following administration of the first dose of propranolol (0.5 mg/kg orally). If no adverse effects were observed, patients were discharged on a daily dose of propranolol of 1 mg/kg, increased to 2 mg/kg on day 4. Patients were reviewed on the day ward on day 8. All haemangiomas requiring treatment were small to moderate in size (median maximum diameter 2.35 cm). Except for capillary blood glucose measurement, no patient required venepuncture for additional blood investigations. As all patients had a normal clinical examination, none required ECHO. An ECG was performed on just one patient. No adverse reactions were observed following administration of propranolol. All patients were discharged home on the same day. No serious adverse events were reported at follow-up. We demonstrate that with targeted cardiac screening, propranolol can be safely initiated on a day-case basis for the treatment of small- to moderate-sized infantile haemangiomas.

Predicting complications with pretreatment testing in infantile haemangioma treated with oral propranolol

“…In this same consensus report, the authors have not advocated the use of echocardiography as a routine screening tool in the absence of abnormal clinical findings. Several papers have also reported adopting a more indication-driven approach in using ECG10 and echocardiography3 10 for screening in children with signs of a syndromal IH associated with cardiac pathology, such as PHACES (posterior fossa malformations–haemangiomas–arterial anomalies–cardiac defects–eye abnormalities–sternal cleft and supraumbilical raphe syndrome), cardiac murmur, ECG abnormalities, or signs of cardiac failure and in children with a large bulky IH 3…”

Diagnosis and Management of Infantile Hemangioma

“…However, pretreatment cardiac screening appears to be of limited value in patients with an unremarkable cardiac history and examination. [176][177][178][179] Relative contraindications to the use of propranolol for IH include cardiogenic shock, sinus bradycardia, hypotension, heart block greater than the first degree, heart failure, bronchial asthma, and known hypersensitivity to the drug (Table 5). 161 Special precautions have been suggested for children diagnosed with PHACE syndrome and significant intracranial vascular anomalies because of the theoretically increased risk of acute ischemic stroke.…”

Safety profile during initiation of propranolol for treatment of infantile haemangiomas in an ambulatory day‐care hospitalization setting

“…Using a study design similar to ours, McSwiney et al . treated 20 infants with propranolol on a day‐hospitalization basis for three consecutive days.…”

“…We also started with a low dose of 0.5 mg/kg/day with gradual escalation to 2 mg/kg/day on day 3 in order to monitor the initial cardiac response to the beta blockage. According to the literature, most physicians start at a lower dose and escalate to the full dose within 2–5 days . Others start at the full dose (2 mg/kg/day) or start at a low dose and escalate to the full dose the following day or start at a low dose and escalate to the full dose after 1–2 weeks …”

“…Using a study design similar to ours, McSwiney et al 27 treated 20 infants with propranolol on a day-hospitalization basis for three consecutive days. BP, HR and blood glucose level were measured at baseline and 2 h after drug administration.…”