IH2

Question 1

What is the typical clinical course of an infantile hemangioma (IH)?

Answer 1

IHs proliferate rapidly in the first 5–6 months, plateau by 9–12 months, and then involute slowly over years.

Question 2

What are the risk factors for developing IHs?

Answer 2

• Female sex
• Premature birth
• Low birth weight
• Advanced maternal age
• Placental abnormalities (e.g., placenta previa, pre-eclampsia)

Question 3

What are the types of IHs based on morphology and distribution?

Answer 3

• Superficial IH – Bright red, raised lesion (strawberry-like)
• Deep IH – Bluish, subcutaneous swelling
• Mixed IH – Combination of superficial and deep features
• Segmental IH – Large, patterned growth along developmental units (higher risk of complications)

Question 4

How do you differentiate IHs from congenital hemangiomas?

Answer 4

• IHs appear after birth, grow rapidly, and then involute.
• Congenital hemangiomas are fully formed at birth and follow either:
  
  • RICH (Rapidly Involuting Congenital Hemangioma) – Shrinks quickly
  • NICH (Non-Involuting Congenital Hemangioma) – Persists without regression

Question 5

What features classify an IH as high-risk?

Answer 5

• Beard area IHs → Airway involvement (risk of subglottic hemangioma)
• Periocular IHs → Risk of amblyopia & visual impairment
• Lumbosacral IHs → Spinal dysraphism (LUMBAR syndrome)
• Large segmental hemangiomas → Risk of PHACE syndrome
• Ulcerated lesions → Pain, bleeding, secondary infection

Question 6

What is PHACE syndrome, and when should you suspect it?

Answer 6

• PHACE stands for:
  
  • Posterior fossa anomalies
  • Hemangiomas (large segmental)
  • Arterial anomalies
  • Cardiac anomalies (coarctation of aorta)
  • Eye abnormalities
• Suspect PHACE in large segmental hemangiomas (>5 cm) on the face or scalp.

Question 7

What is LUMBAR syndrome?

Answer 7

• Lower body IH
• Urogenital anomalies
• Myelopathy
• Bony deformities
• Anorectal malformations
• Renal anomalies

Question 8

What are the potential complications of untreated IHs?

Answer 8

• Ulceration (most common complication, occurs in ~16%)
• Airway obstruction (if in the beard area)
• Visual impairment (if periocular)
• Hearing loss (if ear involvement)
• Scarring & disfigurement (cosmetic concerns)
• Functional impairment (e.g., feeding difficulties if perioral)

Question 9

What are the indications for treating IHs?

Answer 9

• Life-threatening IHs → Airway, liver, cardiovascular involvement
• Functional impairment → Visual, feeding, respiratory obstruction
• Ulceration → Pain, bleeding, infection, scarring
• Risk of disfigurement → Large facial lesions
• Syndromic associations → PHACE, LUMBAR

Question 10

What is the first-line treatment for problematic IHs?

Answer 10

Oral propranolol (non-selective β-blocker).

Question 11

What pre-treatment assessments are needed before starting propranolol?

Answer 11

• Cardiovascular & respiratory exam (auscultation, pulses, liver size)
• ECG (if arrhythmia or segmental hemangioma)
• ECHO (if PHACE syndrome or cardiac history)
• Baseline glucose (if hypoglycemia risk)
• Paediatric cardiology review (if significant comorbidities)

Question 12

How is propranolol dosed for IH treatment?

Answer 12

• Start: 1 mg/kg/day in 2–3 divided doses
• Target dose: 2–3 mg/kg/day
• Duration: 6–12 months, adjust for weight gain
• Tapering: Over 2–4+ weeks to prevent rebound growth

Question 13

What are the contraindications for propranolol in IH treatment?

Answer 13

• Absolute:
  
  • Heart block (2nd/3rd degree)
  • Symptomatic bradycardia
  • Persistent hypoglycemia
  • Hypersensitivity to propranolol
• Relative (use caution or monitor closely):
  
  • Frequent wheezing/asthma
  • Significant hypotension or bradycardia
  • Extensive hepatic hemangiomas (risk of heart failure)

Question 14

What are the monitoring requirements for propranolol therapy?

Answer 14

• First dose: Monitor HR/BP for 2 hours post-dose
• Stable treatment phase: Monitor HR/BP every 4–8 weeks
• Discontinue temporarily if: Poor feeding, intercurrent illness, wheezing

Question 15

What are the alternatives to propranolol for IH treatment?

Answer 15

• Atenolol (selective β1-blocker) – Fewer CNS & respiratory side effects
• Topical timolol – For small, superficial IHs
• Oral corticosteroids – If β-blockers are contraindicated
• Laser therapy (Pulsed Dye Laser – PDL) – For ulcerated or residual lesions
• Surgery – Rare, used for functionally impairing or refractory IHs

Question 16

What is the role of topical timolol in IH management?

Answer 16

Used for superficial, small hemangiomas (<2 cm).

Question 17

What should be done if an IH shows rebound growth after stopping propranolol?

Answer 17

• Mild regrowth: Monitor and consider restarting propranolol for a few months
• Significant regrowth: Resume full-dose propranolol and reassess duration

Question 18

What is involved in the management of segmental head/neck hemangiomas?

Answer 18

• MDT (Multidisciplinary Team)
• Screen for associated PHACE syndrome (30% risk):
  
  • Pediatric neurologist + brain MRI with contrast before 12 weeks of age (no need for GA)
  • Pediatric cardiologist, Echocardiogram
  • Ophthalmologist – consider TSH for hypo/hyperthyroidism

Question 19

What screening is needed for large IHs in the lumbosacral area?

Answer 19

• MDT (Multidisciplinary Team)
• Involve pediatrician
• US of abdomen and pelvis (urogenital defects)
• US of spine – < 4 months prior to ossification
• If abnormal, involve pediatric neurologist and spine MRI