[size=20px]A 3 month old infant with a growing ulcerated scalp infantile hemangioma (IH) is started on propranolol therapy at a dose of 1 mg/kg/d. After one week the dose is increased to 2 mg/kg/d and within 24h the infant experiences an episode of severe wheezing, without associated infectious symptoms, that requires pediatric ICU admission and nebulized bronchodilator therapy.

 

The next appropriate step in the care of this child is:

 

A Bronchoscopy with bronchoalveolar lavage

 

B Discontinuation of propranolol

 

C Allergy testing

 

D Oral amoxicillin for 1 week

 

E Budesonide (Pulmicort) inhaler therapy[/size]

B

B

B

B

B

B

B

B

B

Correct Answer

B Discontinuation of propranolol

 

Infantile hemangiomas (IH) are the most common benign vascular tumor in childhood with an estimated prevalence of 5–10%. Although most IHs resolve spontaneously, approximately 20% require treatment based on their location or the development of complications. In severe cases, early treatment is warranted to arrest the growth of the IH, prevent functional impairment and improve quality of life.

 

Propranolol is now the first line of therapy for IH with features not amenable to observation. Although generally well tolerated, systemic therapy with propranolol may be associated with significant adverse effects in about 2% of treated patients. Adverse effects, thought to be due to non-selective β-blockade, can occur in the central nervous system (agitation, sleep disturbance), the respiratory system (bronchospasm, bronchial hyperreactivity), cardiovascular system (bradycardia and hypotension) and can result in significant hypoglycemia.

 

Decisions to discontinue propranolol therapy should take into account the severity of the adverse effect and the likelihood that it is due to propranolol. Bronchial hyperreactivity resulting in wheezing in a child with a viral infection is clearly different from a child without URI symptoms who experiences life threatening bronchospasm. Children experiencing mild symptoms can be maintained on propranolol with consideration given to reducing the dose. The occurrence of a life-threatening adverse effect such as severe bronchospasm should prompt discontinuation of therapy with awareness of the possibility for rebound growth of the IH.