IH

Question 1

What is the most likely diagnosis for a 7-week-old baby with a rapidly growing, ulcerated 5 x 7 cm lesion on the neck?

Answer 1

A complicated infantile hemangioma (IH).

Question 2

What key history questions should be asked regarding the onset and progression of the lesion?

Answer 2

• When was the lesion first noticed?
• How rapidly has it increased in size and changed in appearance (color, elevation)?

Question 3

Which symptoms related to the lesion are important to assess during history-taking?

Answer 3

• Presence of pain, bleeding, or ulceration
• Signs of infection (discharge, redness, fever)
• Impact on feeding, breathing, or neck mobility (e.g., stridor, difficulty swallowing)

Question 4

What birth and family history aspects are relevant in this case?

Answer 4

• Term vs. preterm birth and any perinatal complications (e.g., placental abnormalities)
• Family history of hemangiomas, vascular anomalies, or syndromic conditions

Question 5

What are the potential complications associated with a high-risk infantile hemangioma?

Answer 5

• Local complications: Ulceration, bleeding, infection, and scarring
• Functional complications: Airway compromise, feeding difficulties, and impaired neck mobility
• Cosmetic/disfigurement issues

Question 6

Which syndromic association should be considered with large or segmental hemangiomas in the head and neck region?

Answer 6

PHACE syndrome (Posterior fossa malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye abnormalities).

Question 7

What is the first-line treatment for problematic infantile hemangiomas?

Answer 7

Oral propranolol.

Question 8

What are alternative therapeutic options for treating IH if beta-blockers are contraindicated or not effective?

Answer 8

• Topical timolol for superficial lesions
• Oral corticosteroids
• Wound care (for ulceration)
• Laser therapy or surgical intervention for refractory cases

Question 9

Before initiating propranolol, what key assessments must be performed?

Answer 9

• A thorough cardiovascular examination (auscultation, check peripheral pulses)
• A respiratory exam and abdominal exam (to assess for hepatomegaly)
• In selected cases, an ECG/Echocardiogram
• Baseline blood glucose in infants at risk for hypoglycemia

Question 10

What is the recommended starting dose of propranolol in term infants with IH?

Answer 10

Approximately 1 mg/kg/day divided into 2–3 doses, with escalation to a target of 2 mg/kg/day once tolerated.

Question 11

How should the dosing regimen be modified for preterm or low-birthweight infants?

Answer 11

Start at a lower dose of 0.5 mg/kg/day (divided into 2–3 doses) and gradually increase to 2 mg/kg/day with careful monitoring.

Question 12

What advice should be given to parents regarding the administration of propranolol?

Answer 12

• Give propranolol during or immediately after feeding to reduce hypoglycemia risk.
• Space doses at least 9 hours apart.
• Monitor for signs of side effects such as bradycardia, hypotension, hypoglycemia, sleep disturbances, and bronchospasm.
• Temporarily withhold the dose if the infant has decreased oral intake or intercurrent illness.

Question 13

What monitoring protocol should be followed during the initiation of propranolol?

Answer 13

• For infants at higher risk (e.g., <5 weeks corrected age, preterm, or with comorbidities), consider inpatient observation for 2–4 hours with heart rate and blood pressure checked immediately before the first dose and then every 30 minutes.
• For stable infants, routine follow-up every 2–3 months is generally sufficient.

Question 14

How long is propranolol typically continued for infantile hemangiomas, and what is the approach to discontinuation?

Answer 14

• Treatment usually continues for 6–12 months (often stopping around 1 year of age) with dose adjustments for weight gain.
• Propranolol can generally be stopped abruptly, though a gradual taper over 2–4 weeks may be used to monitor for rebound growth.