Use of Propranolol for Capillary Haemangioma of Infancy

Children’s Services Colchester General Hospital Turner Road Colchester CO4 5JL

Children’s Elective Care Unit 01206 744237

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A haemangioma is a collection of small immature blood vessels. They are sometimes called ‘strawberry marks’ because the surface of some haemangiomas look a bit like a strawberry. Hemangiomas can be superficial or deep in the skin. Some haemangiomas are a combination of the two, seen as a raised red area on the surface of the skin, and as a bluish swelling deeper in the skin. Very occasionally hemangiomas may occur internally.

Haemangiomas are not usually obvious at birth but become apparent within a few days or weeks. They grow rapidly in the first three months, increasing in size and sometimes in redness. It is unusual for haemangiomas to grow after six to ten months of age, when most haemangiomas tend to have a ‘rest period’ and then begin to shrink.

Propranolol is a beta-blocker. Some nerves release a chemical called noradrenaline when they are stimulated, which in turn stimulates beta adrenergic receptors’. These can cause a variety of effects. For instance, if the beta adrenergic receptors in the heart are stimulated, the heart pumps harder and faster than before, so more blood is pumped around the body. Beta- blocker medicines block the beta adrenergic receptors and stop them being stimulated.

By blocking the beta adrenergic receptors, propranolol can make blood vessels narrower, reducing the amount of blood flowing through them. This is particularly effective in hemangiomas, by reducing the colour and making them softer.

Growth of the haemangioma cells is also limited by propranolol so that the haemangioma starts to reduce in size More research is needed to fully understand how propranolol works. The beneficial effects are usually seen very quickly.

Propranolol may be associated with a number of side effects, which happen very rarely. However, you should report any of the following to your doctor as the dose of propranolol may need to be altered or, on very rare occasions, stopped: bradycardia (slow heart rate) hypotension (low blood pressure) bronchospasm (temporary narrowing of the airway, leading to wheezing and coughing) peripheral vasoconstriction (reduced blood flow to the extremities, such as fingers and toes, making them feel cold and blue) weakness and fatigue, showing as floppiness and disinterest in surroundings sleep disturbance hypoglycemia (low blood sugar) gastro-intestinal disturbances such as constipation or diarrhoea.

If you have any concerns about these side effects, please discuss them with your doctor, nurse or pharmacist.

Occasionally we will suggest some tests to check that your child can safely take the medicine. These may include blood and urine tests, an electrocardiogram (ECG) and echocardiogram (ECHO). If your child has multiple haemangiomas visible on the skin, we may also carry out an abdominal ultrasound scan to look for any hemangiomas in the liver.

Some infants will be monitored for two hours after the first dose. This monitoring allows the doctors to be absolutely sure your child can tolerate the prescribed dose. The procedure is occasionally repeated after one week when the dose is increased, although the dose is normally increased at home.

Your child’s dose is worked out depending on their weight.

This will mean that the dose may change over time as your child grows. At Colchester hospital, we supply propranolol as a 10mg/5ml liquid – that is 5ml of liquid contains 10mg of the active ingredient.

Propranolol is usually given three times a day, eight hours apart.

We advise giving your child at least 2oz of milk with the evening dose. Babies must also have a milk feed during the night.

Your child should not have the anti-wheezing medicine salbutamol (by inhaler or nebuliser) while taking propranolol as the two medicines have opposing effects.

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