Initiation and Use of Propranolol for Infantile Hemangioma: Report of a Consensus Conference abstract

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available. Pediatrics 2013;131:128–140 AUTHORS: Beth A. Drolet, MD,a Peter C. Frommelt, MD,b Sarah L. Chamlin, MD,c Anita Haggstrom, MD,d Nancy M. Bauman, MD FACS FAAP,e Yvonne E. Chiu, MD,f Robert H. Chun, MD,g Maria C. Garzon, MD,h Kristen E. Holland, MD,f Leonardo Liberman, MD,i Susan MacLellan-Tobert, MD,j Anthony J. Mancini, MD,c Denise Metry, MD,k Katherine B. Puttgen, MD,l Marcia Seefeldt, RN,m Robert Sidbury, MD,n Kendra M. Ward, MD MS,o Francine Blei, MD,p Eulalia Baselga, MD,q Laura Cassidy, PhD,r David H. Darrow, MD,s Shawna Joachim,f Eun-Kyung M. Kwon, BA,f Kari Martin, MD,f Jonathan Perkins, DO,b Dawn H. Siegel, MD,a Robert J. Boucek, MD,n and Ilona J. Frieden, MDt aDepartments of Pediatrics, and Dermatology, bPediatric Cardiology, fDermatology, gOtolaryngology, and rBiostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin; cDepartments of Pediatrics and Dermatology, Northwestern University, Chicago, Illinois; dDepartments of Dermatology and Pediatrics, Indiana University, Indianapolis, Indiana; eDepartment of Otolaryngology, Children’s National Medical Center, Washington, District of Columbia; hDepartments of Dermatology, and Pediatrics, and iPediatrics, Columbia University, New York, New York; jDepartment of Cardiology, Gunderson Lutheran Hospital, La Crosse, Wisconsin; kDepartment of Dermatology, Baylor College of Medicine, Houston, Texas; lDepartment of Dermatology, Johns Hopkins Hospital, Baltimore, Maryland; mDepartment of Dermatology, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; nDepartments of Pediatrics, and Cardiology, Seattle Children’s Hospital, Seattle, Washington; oDepartment of Pediatrics, Northwestern University, Chicago, Illinois; pDepartments of Hematology & Oncology, Vascular Birthmark Institute of New York, New York, New York; qDepartment of Dermatology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain; sDepartments of Otolaryngology and Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia; and tDepartments of Dermatology & Pediatrics, University of California San Francisco, San Francisco, California