Key Points

• Infantile hemangioma is a common, benign vascular neoplasm of infancy composed of proliferating endothelial cells. Lesions follow a characteristic life cycle of proliferation and regression; duration and rate are variable
• Diagnosis of cutaneous hemangioma is typically confirmed by history, physical examination, and observation of clinical course
  • Superficial lesions become apparent weeks after birth; often begin with bright red papule or plaque
  • Deep lesions often become apparent by age 2 to 3 months; can present with subcutaneous swelling with an associated blue hue
  • Lesions involved in specific distributions (eg, periorbital lesions, some segmental facial and perineal lesions, midline lumbar lesions, presence of 5 or more focal cutaneous lesions) require specialized work-up
• Active observation is required for most lesions; treatment is indicated for ulceration, impairment of vital structures, and potential for disfigurement
• When indicated, treatment modalities include pharmacologic, laser, and surgical options; often multimodal
  • Propranolol is typically the first choice for pharmacotherapy^r1; initiation of outpatient treatment requires special monitoring and may require inpatient hospitalization in young infants
• Complications of cutaneous hemangiomas are largely dependent on size of lesion, location, and morphology; they include ulceration, cosmetic disfigurement, and functional problems (eg, ocular complications; airway obstruction; feeding difficulties; impaired mobility; and, rarely, heart failure)
• Overall, prognosis is good for most lesions; approximately 12% to 33% of infantile hemangiomas require some form of intervention ^r2r3
  • Minor residual skin changes often remain after involution of lesions; laser treatment and surgery may be required

Urgent Action

• Emergent treatment is indicated for potentially life-threatening lesions (eg, airway lesions with significant obstruction, abdominal compartment syndrome, hypothyroidism, heart failure associated with hepatic lesions) in consultation with appropriate subspecialist
• Urgent referral to ophthalmologist is indicated for periorbital lesions (high risk for serious visual complications)
• Urgent treatment is indicated for existing or imminent functional impairment, pain, or bleeding in consultation with appropriate subspecialist

Pitfalls

• Failure to consult ophthalmologist for periorbital lesions can lead to increased morbidity; formal ophthalmic examination is indicated for all patients with periorbital hemangioma
• Obtain liver ultrasonogram in infants presenting with 5 or more cutaneous hemangiomas; patients with 5 or more lesions are at high risk for liver hemangiomas
• Prompt thyroid function evaluation required for hepatic lesions owing to risk for consumptive hypothyroidism
• Obtain screening bronchoscopy for patients with segmental hemangiomas in a lower face (beardlike) distribution and multiple hemangiomas in cervical cutaneous distribution; hemangiomas in these cutaneous distribution patterns signal high risk for airway hemangioma
• Obtain evaluation to assess for PHACE syndrome in children with large segmental hemangiomas involving head-neck-face region and LUMBAR syndrome in children with lumbosacral segmental lesions; facilitates proper treatment of hemangioma and other associated underlying abnormalities
  • Assess for underlying abnormalities in children with lower midline lumbar lesions; occult underling spinal and urogenital lesions are associated with significant low-lying midline lumbar lesions
• Remind caregivers at each visit that discontinuation of propranolol is indicated during any intercurrent illness or prolonged period of fasting to prevent hypoglycemia

Clinical Clarification

• Infantile hemangioma is a benign vascular neoplasm of infancy composed of proliferating endothelial cells; lesions commonly manifest as superficial and/or deep subcutaneous masses ^r4
  • Most common tumor of infancy ^r2
• Lesions follow characteristic life cycle of growth and regression; duration and rate are variable
  • Proliferative phase: occurs during early infancy
  • Latent or plateau phase: dramatic slowing of overall growth of lesion by mid-to-late infancy ^r2
    • Likely represents a period of temporarily balanced cell proliferation and apoptosis within the same lesion ^r2
  • Involution phase: spontaneous shrinking of lesion often begins by age 1 year;^r2usually complete by age 4 years^r2, but may not be complete in some children before the age of 10 years^r5
  • Involuted phase: involution is complete and no further changes occur ^r5

Classification

• Based on depth of tissue involvement ^r4r6
  • Superficial
    • Involves superficial dermis ^r5
  • Deep
    • Involves deep dermis and subcutaneous tissue ^r5
  • Mixed or compound or combined
    • Lesion composed of both superficial and deep components
  • Reticular/abortive /minimal growth ^r6
• Based on pattern of distribution ^r4r6
  • Focal (localized)
    • Solitary discrete lesion that appears to arise from a single focal point
    • Accounts for approximately 80% of lesions ^r7
  • Multifocal
    • Lesions that occur at more than 1 anatomic site ^r2
    • 5 or more discrete lesions are associated with increased incidence of liver hemangioma ^r2
  • Segmental
    • Large lesions that cover a territory that loosely corresponds to a neuroectodermal placode ^r2
    • Segmental lesions on the face are subclassified into 4 distinct zones: ^r2r8
      • Zone 1: frontotemporal
      • Zone 2: maxillary
      • Zone 3: mandibular
      • Zone 4: frontonasal
    • Associated with increased risk for complications ^r9
    • Often the most difficult type of lesion to treat; associated with worse outcome
    • May be associated with other vascular and nonvascular anomalies, including: ^r6r9
      • PHACE syndrome: posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, eye abnormalities, sternal clefting, and/or supraumbilical raphe
      • LUMBAR syndrome: lower body hemangioma and other cutaneous defects, urogenital anomalies, ulceration, myelopathy, bony deformities, anorectal malformations, arterial anomalies, and renal anomalies
      • Airway lesions when distribution involves lower face (ie, beard area), which includes some or all of the following cutaneous areas: preauricular, mandibular, lower lip, chin, and anterior neck
  • Indeterminate ^r6

Clinical Presentation

Causes and Risk Factors

Diagnostic Procedures

Differential Diagnosis

Goals

• Early consultation with a specialist to assist with treatment plan for lesions likely to result in functional impairment or permanent disfigurement ^r2
• Minimize associated morbidity and complications ^r4
• Maximize functional and cosmetic result ^r4

Disposition

Treatment Options

Decide whether treatment intervention is indicated or if initial observation is reasonable ^r2

• Most infantile hemangiomas follow benign course without need for therapeutic intervention; approximately 12% of lesions are complex, requiring referral for specialist evaluation ^r8
  • Indications for intervention ^r2
    • Emergency treatment of potentially life-threatening complications (eg, obstructing airway lesions, liver lesions associated with high-output heart failure and severe hypothyroidism)
    • Urgent treatment of existing or imminent functional impairment, pain, or bleeding (eg, due to ulceration, ocular complications, impaired feeding from perioral lesions, or reduced mobility)
    • Elective treatment to reduce likelihood of long-term or permanent disfigurement (eg, scarring from severe ulceration; certain anatomic areas including eyelid, nasal tip, lip, breast, and genitalia)
    • Evaluation to identify associated structural anomalies (eg, spinal malformations associated with lumbosacral lesions, anomalies related to PHACE syndrome)

Therapeutic interventions are individualized; appropriate therapy and timing of intervention depends on various factors: ^r2

• Age of patient
• Location, size, and growth phase of lesion(s)
• Degree of skin involvement
• Intervention urgency and complication severity
• Potential for adverse psychosocial consequences
• Physician experience
  • Initiate systemic therapy in consultation with a clinician with expertise in managing infants with hemangioma (eg, pediatric dermatologist) ^r3
  • Multidisciplinary team composed of experts in treating significantly complicated hemangiomas may be key to obtaining optimal results in complex cases ^r5
• Parental preference (especially in elective cases)

Treatment modalities include pharmacologic, laser, and surgical options ^r2

• Pharmacologic treatment
  • Systemic therapy is usually indicated for patients with lesions that are: ^r2
    • Large or medically complex
    • At high risk for functional impairment or disfigurement
    • Refractory to other initial therapies
  • β-adrenergic blockers are typically first line medical therapy ^r1r2
    • Systemic propranolol is the most effective and is associated with the fewest treatment-related complications ^r1r10r23r24
      • Effective in reducing size and color intensity of lesions; treats both deep and superficial components
        • Reported overall response rates range from 86% to 98%;^r1r4r2early response often occurs within 1 to 3 days of treatment^r9
      • Atenolol and nadolol appear to have similar efficacy and fewer adverse events as propanolol but use of these is limited ^r25r26
      • Contraindications to propranolol therapy ^r2
        • Cardiogenic shock
        • Heart failure
        • Heart block greater than first degree
        • Hypotension
        • Sinus bradycardia
        • Asthma or reactive airway disease
        • Known hypersensitivity to the drug
        • Caution suggested for patients with PHACE syndrome and significant intracranial vascular anomalies ^r2
      • Pretreatment risk assessment ^r2
        • Document complete history and physical examination, with special attention to cardiac and pulmonary systems ^r2
        • Recommendations for extent of pretreatment assessment are evolving and vary between clinicians ^r2
          • Some clinicians obtain ECG and/or cardiologist consult before starting propranolol
            • Of uncertain value in patients with unremarkable history or examination
          • Relative risks that require further evaluation (eg, ECG, cardiologist consultation) before propranolol initiation include: ^r3
            • Heart rate below reference range for age
            • Family history of congenital heart conditions or arrhythmias (eg, heart block, long QT syndrome, sudden death)
            • Maternal history of connective tissue disease
            • History of or auscultation of an arrhythmia
            • PHACE syndrome diagnosis ^r4
      • Initiation of treatment
        • Recommendations for optimal setting may vary between clinicians
        • Inpatient initiation of treatment is suggested for patients who: ^r2
          • Are aged 8 weeks or younger
          • Are preterm infants younger than 48 weeks of postconceptional age
          • Have inadequate social support
          • Have significant comorbidity (eg, cardiac or pulmonary risk factors)
        • Outpatient clinic treatment recommendations (for infants older than 8 weeks)
          • Assess heart rate and blood pressure at 1 and 2 hours after first dose and with any new dose increase of more than 0.5 mg/kg/day ^r2
      • Adverse effects ^r2
        • Serious adverse effects are rare
          • Bradycardia and hypotension (typically asymptomatic)
          • Bronchospasm
          • Hypoglycemia/seizures
            • Reduce risk of hypoglycemia by giving medication after feeding, avoiding prolonged intervals between feedings, and holding doses when oral intake is decreased (eg, illness, vomiting, fasting) ^r2r10
        • Common adverse effects include sleep disturbances^r27r28, acrocyanosis, diarrhea, and bronchial hyperreactivity
      • Duration of treatment ^r2
        • Varies with age of initiation and clinical response
          • Typically continues for at least 6 months, often up to age 12 months (some experts recommend extending treatment until patient is aged 15 months) ^r10r29
        • Discontinue medication by gradual tapering over 1 to 3 weeks to prevent rebound sinus tachycardia
        • Rebound growth of hemangioma
          • Observed in 6% to 25% of cases (notably in those with long proliferative phase and large subcutaneous component)
          • Consider tapering propranolol over weeks to months
          • May require reinitiation of therapy for variable periods
    • Topical β-adrenergic blockers
      • Consider topical timolol for treatment of small, thin, uncomplicated, superficial lesions ^r2r10
        • Topical propranolol and topical timolol were as effective as oral propranolol in treating superficial infantile hemangiomas, and topical timolol was associated with fewer adverse effects ^r30
        • Useful when treatment is desired but risks are considered too high to justify systemic β-blocker therapy
        • Use of topical timolol after oral propanolol may allow reduced duration of systemic beta blocker therapy and minimize the potential adverse effects ^r31
        • Available in extended-release gel-forming solution with less systemic absorption than regular solution
          • Concerns remain regarding bioavailability in neonates and infants, especially with large or ulcerated lesions and those involving mucous membranes
    • Intralesional propranolol administration is reported but efficacy data are limited ^r4
  • Corticosteroids
    • Alternative therapy if propranolol cannot be used or is ineffective ^r2
    • Systemic (oral) corticosteroids ^r10
      • Overall response rate (43%-84%) is inferior to propranolol and rate of relapse is higher with corticosteroids ^r2r4r32
      • More adverse effects are associated with oral administration of corticosteroids (23%) than with propranolol (9.6%) ^r4
      • Potential adverse effects include hypothalamic-pituitary-adrenal axis suppression, growth deceleration, hypertension, gastric irritation, mild behavioral changes, cushingoid facies, and immunosuppression ^r2
        • Periodic monitoring of infants with attention to growth and blood pressure is suggested ^r2
      • Duration of therapy ^r2
        • Varies with clinical response, patient age, and growth phase of lesion
          • Generally ranges 4 to 12 weeks at full dose and tapers over weeks to months ^r2
            • Typically completed by age 9 to 12 months;^r2 some experts aim to discontinue by age 11 months in effort to avoid interference with 12-month immunization schedule
    • Intralesional corticosteroids ^r2
      • Consider intralesional injection of triamcinolone and/or betamethasone to treat focal, bulky lesions during proliferation phase or in certain critical anatomic locations (eg, lip) ^r10
      • Often requires multiple injections, typically at 4- to 6-week intervals
      • Complications include local hypopigmentation, fat and/or dermal atrophy, and systemic effects at large doses
        • Use in lesions of upper eyelid may cause retinal embolization
    • Topical corticosteroids
      • Consider use of high-potency topical formulations for small (less than 5 cm), thin, superficial lesions
  • Other medical therapies ^r2
    • Typically reserved for recalcitrant lesions owing to limited safety profiles
    • Sirolimus has potent antiangiogenic activity but is not well studied for infantile hemangiomas ^r22
    • Vincristine and interferon-alfa are rarely used owing to adverse effects ^r22
• Laser treatment
  • Pulsed dye laser therapy provides selective photothermolysis of vascular tumor while sparing normal surrounding tissue ^r4
  • Primary use is to treat residual skin changes (eg. telangiectasia and refractory ulceration) after involution ^r22
  • Other uses may include: ^r2
    • As a component in multimodal therapy
    • To treat early, nonproliferating superficial lesions and areas of critical skin (eg, nasal tip, facial lesion)
      • Controversial; use of laser on early proliferating and superficial lesions may lead to ulceration ^r2
• Surgical treatment
  • Surgical resection may be necessary for up to 40% of patients requiring treatment overall ^r4
  • Suggested criteria for intervention are somewhat vague owing to difficulty in predicting some final tumor manifestations ^r4
    • Base timing of surgery on patient age, location and degree of deformity, and stage of tumor growth ^r2
      • Elective resection during proliferative phase is not usually indicated ^r2
        • Vascularity of tumor can place infant at greater risk of anesthetic morbidity, blood loss, and iatrogenic injury; cosmetic result is usually superior with fewer interventions after growth of lesion has stopped ^r2
        • Early surgical intervention may be indicated for certain patients with significant, recalcitrant complications or functional impairment
      • Preferred timing for repair for most lesions requiring surgical intervention is during the involution stage between the ages of 3 and 4 years ^r5

Treatment is often multimodal ^r4

• Combining various treatment methods to optimize different components of individual lesions is common
  • For example, a common treatment approach for compound lesions includes systemic propranolol to address deep component and laser therapy to treat superficial component; surgery and/or additional laser therapy may be used for any unacceptable, residual cosmetic issues ^r4
• Aggressive early multimodal therapy is often used for lesions in sensitive anatomic areas prone to significant complications, such as: ^r5
  • Periorbital, tip of nose, and lip lesions
  • Airway lesions
  • Large segmental or nodular lesions in trauma-prone areas at high risk for ulceration

Management for lesions in specific anatomic locations

• Periorbital
  • Early consultation with ophthalmologist is essential; extent and depth of periorbital lesions intruding into the orbit is often unappreciated on routine physical examination ^r2
    • Manage aggressively with multimodal therapy; early systemic pharmacotherapy is imperative for most lesions, even when surgical therapy is unavoidable ^r5
• Tip of nose
  • Tissue in this area is difficult to excise without considerable cosmetic consequence; lesions are prone to injure underlying cartilage and may obstruct nasal airway
  • Aggressive multimodal therapy with early initiation of systemic pharmacotherapy is recommended to avoid poor outcome ^r2
• Lip
  • Distortion of lip contour is common and difficult to reconstruct; lesions are highly prone to complications such as ulceration, scarring, and disfigurement
  • Aggressive multimodal therapy with early initiation of systemic pharmacotherapy is recommended to avoid poor outcome ^r2
• Perineal
  • Early pharmacotherapy may be appropriate given high risk for ulceration and complications associated with ulceration in this region (eg, infection) ^r2
• Those obstructing auditory canal
  • Manage aggressively with trial of systemic pharmacotherapy ^r5
  • Early multimodal approach may be necessary with laser therapy and surgical resection ^r5
• Those prone to ulceration
  • Lesions over pressure points (eg, back), near mucosa (eg, lip, perineum), and intertriginous areas are prone to ulceration and require meticulous local care ^r14
  • Consider early pharmacotherapy and/or multimodal approach to lesions at high risk for ulceration
• Hepatic
  • Management is based on type of lesion (ie, focal, multifocal, or diffuse), presence and degree of vascular shunting, and presence of complications (eg, high-output heart failure, abdominal compartment syndrome, consumptive hypothyroidism) ^r19
  • Suggested algorithm for management of infantile hepatic hemangioma is available; multimodal therapy is often used, beginning with pharmacotherapy ^r19
  • Additional specific surgical management may include embolization, hepatic artery ligation, resection, and even transplant for patients with failure of medical therapy or recalcitrant heart failure ^r5
  • Associated consumptive hypothyroidism requires thyroid hormone replacement, sometimes intravenously, until hepatic hemangioma has involuted
• Airway
  • Manage life-threatening lesions with immediate surgical resection; temporary tracheostomy may be required ^r5
  • Manage lesions causing significant airway obstruction with carbon dioxide laser treatment ^r5
  • For lesions that are not immediately life-threatening, initial management is systemic pharmacotherapy ^r5

Monitoring

• Monitoring for lesions that do not require immediate treatment
  • Monitor clinical examination in office weekly to monthly^r7 during proliferative phase if lesion has potential for causing obstruction, destruction, or ulceration requiring intervention ^r2c208
  • Observe annually after lesion stabilizes during involution phase to assess need for repair of excess skin, intervention for residual fibrofatty tissue, or reconstruction of damaged structures ^r7c209
• Monitoring for infants requiring systemic propranolol
  • Adjust dose for growth based on weight gain at each visit and continue to monitor lesion for clinical response and development of complications ^c210
  • Monitor clinically for serious adverse effects of therapy (eg, bradycardia, hypotension, bronchospasm, hyperkalemia, hypoglycemia) ^{c211c212c213c214c215}
• Monitoring for patients requiring systemic corticosteroids ^c216c217
  • Observe clinically for adverse effects of medication with specific focus on growth parameters and blood pressure ^r2
    • Adjust dose for growth based on weight gain at each visit and continue to monitor lesion for clinical response and development of complications
  • Consider checking vaccine titers after completion of treatment to assess adequacy of response ^r2c218
  • Consider assessing adrenal function at the end of therapy to determine need for stress dose steroid requirement on cessation of therapy ^r2c219
• Monitoring for hepatic hemangiomas
  • Varies depending on type of lesion (ie, focal, multifocal, diffuse), presence of shunts, risk for complications, clinical course, and response to treatment ^r19
  • Management algorithm is available; in general, monitoring ultrasonography is suggested every 2 to 8 weeks after initial diagnosis ^r19c220
• Monitoring for infants with segmental hemangiomas
  • Observe for symptomatic visceral involvement (eg, central nervous system, eye, pancreas, gastrointestinal tract, lungs) if early evaluation is otherwise not indicated for assessment of other associations (eg, PHACE syndrome, LUMBAR syndrome, airway lesions)
  • Regional imaging is indicated if infant becomes symptomatic ^c221

Complications

• Disease-related complications
  • General risk for complications include: ^r4
    • Lesion in rapid proliferation phase of growth
    • Facial location
      • Risk is increased for obstruction of vital function and cosmetic disfigurement
    • Segmental morphology
      • Associated with up to 8-fold increased risk for complications ^r8
    • Larger size
      • 5% increase in the likelihood of developing a complication occurs for every 10 cm² increase in size ^r4
  • Ulceration ^c222c223
    • Reported to occur at highest frequency during proliferative phase;^r39most ulceration occurs during the first 4 months of life ^r8
    • Lip, periorbital, cheek, scalp, neck, perineal, and anogenital locations are commonly affected ^r2r8r9
    • Segmental lesions ulcerate (50%) more frequently than focal lesions (10%-15%); mixed lesions ulcerate more frequently than superficial lesions ^r9
    • Early, central blanching of proliferating lesion is a marker for impending ulceration (average age, 2.6 months) ^r39
    • Requires aggressive local care similar to burn treatment; significant pain common with ulceration and requires treatment ^r2
      • Occasionally results in secondary infection requiring topical or oral antibiotics ^r2
    • Self-limited bleeding responsive to local pressure is common; hemostatic agents are occasionally necessary ^r5r14
      • Severe bleeding is rare (less than 1% of ulcerations) ^r8
    • Almost all lesions that ulcerate result in residual scarring ^r8
  • Cosmetic disfigurement ^c224
    • High-risk lesions include those involving the lip, eyelid, ear, nasal tip, breast, and genitalia ^r2r7
      • Necrosis to underlying cartilage can occur with lesions in areas supported largely by cartilaginous structures (eg, nose, ear) ^r2
    • Risk of scarring is increased with pedunculated lesions and lesions with a steep marginal slope (ie, sharp, steep drop of at margins)
  • Ocular complications
    • Periocular lesions can cause globe compression, obstruction of the visual axis, and extension into retrobulbar space, leading to many potential complications (eg, strabismus, proptosis, refractive errors, optic nerve compression, amblyopia) ^{r14c225c226c227c228c229}
      • Amblyopia develops in up to 60% of untreated periocular lesions and strabismus develops in up to 33% ^r2
      • Patients with periocular lesions larger than 1 cm in diameter and diffuse periorbital segmental hemangiomas are at highest risk for associated amblyopia ^r14
      • Other lesions at high risk for amblyopia include upper eyelid location, nasal location, associated ptosis, eyelid margin change, and displacement of globe ^r2
    • Lesions in the periorbital region can result in permanent visual loss if left untreated ^c230
  • Airway obstruction
    • Subglottic or laryngeal obstruction ^c231
      • Patients with lower face (beardlike) cutaneous distribution of facial hemangioma(s) are at risk for hemangiomas of the airway ^r14
      • Mean age at diagnosis is 3 to 4 months ^r2
    • Nasal obstruction ^c232
  • Bleeding ^r2c233
    • Common concern among caregivers and providers, but it is rarely a problem
  • Feeding difficulties and failure to thrive ^{r2c234c235c236c237}
    • Can occur with perioral or airway lesions
  • Parotid gland dysfunction ^c238c239
    • Large preauricular segmental lesions often affect parotid gland function and rarely affect facial nerve function ^r5
  • Auditory canal obstruction ^c240c241
    • Large periauricular lesions can lead to obstruction and if untreated can result in conductive hearing loss of the affected canal; speech delay is uncommon without bilateral involvement ^r5
    • Obstruction or partial obstruction leads to increased risk of otitis externa ^r7
  • Impaired mobility ^c242
    • Can occur with large extremity lesions ^r2
  • High-output congestive heart failure (rare) ^c243
    • Can occur with large cutaneous hemangiomas, owing to arteriovenous shunting of large blood volume through the lesion ^r2
  • Residual skin changes after involution
    • Occur in up to 40% ^r9
    • Minor residual skin changes include focal telangiectasias, atrophic wrinkling, hypopigmentation, and refined textural changes ^{r5c244c245c246c247}
    • Major residual skin deformity includes anetoderma (a crepelike laxity scarring), a fibrofatty residuum, and significant swelling of the redundant skin ^{r5c248c249c250}
  • Complications associated with hepatic hemangioma
    • High-output heart failure ^c251
      • Can result from very large, diffuse, or multifocal hepatic lesions associated with a large volume of arteriovenous shunting ^r2
    • Consumptive hypothyroidism ^c252
      • Multifocal hepatic lesions can lead to hypothyroidism as a result of increased type 3 iodothyronine deiodinase activity in the hepatic hemangioma tissue ^r2
    • Abdominal compartment syndrome ^c253
      • Can be caused by diffuse hepatic hemangioma ^r2

Prognosis

• Cutaneous hemangiomas
  • Vast majority of lesions proliferate and involute spontaneously without sequelae and require active observation without further intervention ^r7
    • Most lesions are small and localized, occurring in aesthetically or functionally unimportant areas ^r7
    • 50% to 70% of involuted hemangiomas leave residual skin changes such as telangiectasia, fibrofatty tissue, atrophy, scarring, hypopigmentation, or alopecia ^r22
  • Approximately 12% to 33% of infantile hemangiomas require some form of intervention ^r2r3
  • 10% to 20% of infantile hemangiomas are associated with complications such as ulceration, infection, bleeding, functional impairment, permanent disfigurement, hypothyroidism, and airway obstruction ^r22
  • Treatment efficacy is approximately 96% with oral propranolol, 62% with topical timolol, 58% with intralesional triamcinolone, and 43% with oral steroids (compared to 6% a control group) ^r22r32
  • After successful treatment with propanolol, rebound growth may occur in 10% to 25% of patients; this usually responds to repeat treatment with propranolol ^r22
• Hepatic hemangiomas
  • Mortality is high among infants who develop heart failure from hepatic hemangiomas ^r5
    • Patients are at high risk for persistent heart failure, infection, and bleeding

Screening ^c254

Prevention ^c255