Systemic Therapies: Beta-blockers

Oral propranolol is approved for the treatment of infantile hemangiomas that are potentially disfiguring, ulcerated, or threatening vital function.  It is typically started at 1mg/kg/day divided into 2 or 3 doses.  It can be increased to 2-3mg/kg/day divided over the first few weeks of therapy as tolerated.  It is important to thoroughly discuss the side effects of propranolol with parents and review instructions for use. Common side effects include cool extremities and sleep disturbance. Less common but serious side effects include hypoglycemia, hypotension, bradycardia and bronchospasm. Propranolol should be given with feeds and the dose held if there is decreased oral intake or diarrhea to decrease the risk of hypoglycemia.  In very young neonates, those with any cardiac history, and those with risk of PHACES, special care should be taken when beginning propanolol and consulation with cardiology prior to initiation should be considered. In treating ulcerated hemangiomas, initiation of propranolol at usual protocol can worsen the ulcer. The dose should begin at 0.5mg/kg/day or less and increased very slowly.