propranolol for the treatment of infant haemangiomas · web viewthis document guides the treatment...
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CHHS16/125
Canberra Hospital and Health ServicesClinical Guideline – Propranolol for the Treatment of Infant Haemangiomas Contents
Contents....................................................................................................................................1
Guideline Statement.................................................................................................................2
Scope........................................................................................................................................ 2
Section 1 – Indications for treatment.......................................................................................2
Section 2 – Propanolol..............................................................................................................3
Section 3 – Propanolol Initiation in Hospital (Inpatient Management).....................................4
Section 4 – Medical follow up post discharge...........................................................................5
Implementation........................................................................................................................ 6
Related Policies, Procedures, Guidelines and Legislation.........................................................6
References................................................................................................................................ 6
Definition of Terms...................................................................................................................7
Search Terms............................................................................................................................ 7
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Guideline Statement
This document guides the treatment of infants with infantile haemangiomas with propranolol within the Canberra Hospital and the Centenary Hospital for Women and Children.
BackgroundHaemangiomas are benign skin tumours caused by proliferating vascular endothelial cells. Haemangiomas usually appear shortly after birth and grow rapidly. They usually cease growing by 6 to 9 months of age, but may continue to grow until 18 months of age or more. Thereafter they involute over years and have largely resolved by 5 years of age, although they may leave permanent residua such as telangiectasia, scarring or excess fibro-fatty tissue.
For many haemangiomas, treatment is not required. However, haemangiomas in some locations require treatment to avoid complications such as ulceration, airway compromise, disruption of visual pathways etc.
Generally, the earlier that treatment is commenced, the more effective it will be at preventing long-term complications.
Key ObjectiveTo effect involution of infant haemangioma through use of propranolol.
Alerts The guideline applies to infants up to the age of 18 months.
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Scope
This document applies to the following medical staff working within their scope of practice: Medical Officers Nursing staff Pharmacists.
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Section 1 – Indications for treatment
Haemangiomas are treated to prevent ulceration, cosmetic disfigurement and adverse effects on vital organs.
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Indications for treatment include: subglottic and/or tracheal haemangioma periorbital or retrobulbar haemangioma perioral haemangioma large facial segmental haemangiomas (can be associated with PHACE syndrome) nasal tip, ear, lip, central cheek, large facial haemangioma nappy area and flexural haemangiomas - risk of ulceration lumbosacral haemangioma (can be associated with underlying spinal and urogenital
anomalies) multiple haemangiomas (i.e. visceral) ulcerated haemangiomas.
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Section 2 – Propranolol
Propranolol is a non selective beta adrenergic blocking agent. The mode of action in infantile haemangioma is not clearly defined, although propranolol is thought to reduce the size and stabilise growth by way of vasoconstriction and decreased renin production.Risks and benefits of propranolol should be discussed with the family.
Benefits: most effective treatment modality relatively low risk medication (compared with other treatment modalities) non-surgical approach.
Risks: Bradycardia Bronchoconstriction Hypotension Hypoglycaemia (especially if reduced feeding secondary to illness).
Cautions: Remind parents to feed the child with each dose of the medication. co-existing chronic lung disease or bronchospasm Cardiac disease intercurrent illness causing reduced calorie intake liver involvement suspected PHACES syndrome (risk of stroke).
Standard propranolol dosing (oral):Week 1 – propranolol 1mg/kg/day in two divided doses (for example, a 3.4kg infant would receive 3.4 mg/day = 1.7mg per dose)
Week 2 – propranolol 2mg/kg/day in two divided doses
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Consideration - In very young infants, infants with haemangiomas at risk of ulceration and for head and neck haemangiomas >5cm where PHACES has not been definitively excluded, consider a starting dose of propranolol 0.5mg/kg/day in 3 divided doses. In selected patients higher doses are used at the discretion of physician based on clinical indication.
Optimal treatment period has not yet been established and is dependent on clinical response and consideration of the risk of rebound growth. Treatment periods can vary from 3 to 24 months.
InvestigationsInitial Investigations: Cardiovascular examination (including femoral pulses) ECG if abnormal cardiovascular examination, or if requested Bloods: FBC, renal function, liver function, TFTs as directed by the treating physician.
Other investigations at the discretion of the managing team: For segmental head and neck haemangiomas at risk of PHACES syndrome:
echocardiogram, MRI/MRA head under GA, ophthalmology assessment and consider laryngoscopy & bronchoscopy.
For segmental lumbar region haemangiomas at risk of PELVIS/SACRAL syndrome: consider x-ray &/or USS spine, renal USS.
For multiple haemangiomas: consider USS abdomen, USS/MR head, echocardiogram, TSH.
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Section 3 – Propranolol Initiation in Hospital (Inpatient Management)
Consider propranolol initiation in hospital for infants aged <6 weeks, those with airway haemangioma or other complications.
Management in Paediatric Day Stay Unit (PDSU): Ensure baseline investigations have been performed. Admit at 0900. Baseline cardiovascular examination and observations. Week 1 Protocol: Give propranolol at starting dose of 0.5mg/kg/dose with a feed or
within 1 hour of a feed. The dose on discharge will generally be propranolol 1mg/kg/day in two divided doses. A one week supply of medication for discharge is dispensed by Pharmacy.
Monitoring during admission:o hourly HR & BP observations o Blood Glucose Level (BGL) to be checked after 4 hours (heel prick)o If observations and BGL are stable (>2.5 mmol/L), and the infant has fed, then
discharge home.
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Week 2 Protocol: The patient is re-admitted in 7 days for an increase in propranolol dose to 2mg/kg/day in 2 divided doses. The same management process as above is to be followed. Note: the patient must not be given the morning dose of propranolol at home on the day of this admission. A PBS prescription for propranolol is to be given upon discharge.
ComplicationsThe risk of hypoglycaemia is 1-3%. If hypoglycaemia occurs (BSL <3.5 mmol/L), feed infant and recheck BSL. If BSL <2.0, consider glucose IV.Parents are to be educated about the symptoms of hypoglycaemia (i.e. jitteriness, lethargy, sweatiness), and be provided with advice on how to respond.
If hypotension develops (a drop in blood pressure of 15% from baseline), discuss with treating consultant or, if unavailable, with consultant of the day. This should occur regardless of the PEWS. If hypotensive, consider an intravenous fluid bolus.
Parents need to be aware that the risks of hypoglycaemia and/or hypotension are increased if the child is unwell, taking reduced feeds, and/or having vomiting/diarrhoea. Propranolol should be ceased if the infant develops a diarrhoeal or vomiting illness.
If parents are concerned about their child in relation to possible side effects/complications, they should be instructed to contact the Paediatric or Dermatology Registrar via the hospital switchboard (business hours) or present to the Emergency Department (after hours).
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Section 4 – Medical follow up post discharge
It is important to ensure appropriate follow up has been organised prior to discharge home.
Patients under the care of a DermatologistEnsure a follow up appointment has been made in two weeks with the treating Dermatologist prior to discharge from PDSU.
Patients under the care of an Ear, Nose, Throat (ENT) SurgeonEnsure a follow up appointment has been made with the ENT Surgeon involved in treatment prior to discharge from PDSU.
Patients under the care of a Paediatrician Ensure a follow up appointment has been made with the treating Paediatrician prior to
discharge from PDSU. Treatment may be continued for up to 9 - 24 months. Propranolol should be weaned
and stopped over a minimum two week period to prevent rebound tachycardia, but usually over a longer period to prevent rebound haemangioma growth.
Regular (approximately monthly) weight checks by GP or treating specialist to increase propranolol dose accordingly.
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Cessation of therapy Weaning the dose of propranolol does not prevent rebound haemangioma growth,
which will occur in approximately 15% of infants.
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Implementation
This guideline will be: discussed at the Paediatric Clinical Governance and Resource Education Meeting; distributed to paediatric staff via email; distributed to dermatology staff via e-mail.(Paediatric Unit medical and nursing staff are shown how to access documents on the Policy Register during orientation to the unit)
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Related Policies, Procedures, Guidelines and Legislation
Procedures Health Directorate Nursing and Midwifery Continuing Competence Policy
Procedures CHHS Clinical Procedure – Vital Signs and Early Warning Scores
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References
1. Drolet BA et al.. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Paediatrics. 2013; 1: 128-140.
2. Price CJ et al.. Proppranolol vs corticosteroids for infantile hemangiomas. A multicenter retrospective analysis. Archives of Dermatology. 2011; 147 (12): 1371-1376.
3. Starship Children’s Health Clinical Guideline. Haemangioma – propranolol treatment. [Internet, last updated August 2015, date viewed October 2015] Available from https://www.starship.org.nz/for-health-professionals/starship-clinical-guidelines/haemangioma - propranolol treatment
4. South Australia Paediatric Practice Guidelines. Propranolol for infantile haemangioma. [Internet, last updated October 2015, date viewed October 2015] Available from https://www.sahealth.sa.gov.au/wps/wcm/connect/e1c9ef804233d33986aeeeef0dac2aff/propranolol%2Bfor%2Binfantile%2Bhaemangioma.pdf?
5. Nottingham Children’s Hospital. Propranolol for haemangiomas (over 3 months). [Internet, last updated September 2013, date viewed October 2015]
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Availble from https://www.nuh.uk/handlers/downloads.ashx%3Fid%%3D61048&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahU
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Definition of Terms
PHACE syndrome: Is a cutaneous condition characterized by multiple congenital abnormalities - Posterior fossa malformations, Haemangiomas, Arterial anomalies, Cardiac defects, Sternal cleft and supraumbilical raphe syndrome.
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Search Terms
Haemangioma, Propranolol, Blood vessels, Dermatofibroma
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Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair
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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register