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Initial experience with a multidisciplinary strategy for initiation of propranolol therapy for infantile hemangiomas
Sharon L Cushing1, Robert J Boucek, Scott C Manning
1Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington 98105-0371, USA.
Insights
Initiating propranolol for infantile hemangiomas as an outpatient is safe for most children. This protocol ensures careful monitoring and parent education, reducing costs while maintaining safety.
Area of Science:
- Pediatric dermatology
- Cardiology
- Pharmacology
Background:
- Infantile hemangiomas (IH) are common vascular tumors in infants.
- Propranolol is an effective treatment for IH, but requires careful initiation.
- Outpatient initiation may offer cost and convenience benefits over inpatient strategies.
Purpose of the Study:
- To establish a safe and standardized protocol for initiating propranolol therapy for infantile hemangiomas in an outpatient setting.
- To evaluate the safety and feasibility of this outpatient protocol.
Main Methods:
- Retrospective review of 49 patients with infantile hemangiomas at a pediatric hospital.
- Inclusion criteria excluded patients requiring hospital admission.
- Pretreatment included cardiology evaluation (ECG, echocardiography if needed).
- Initial propranolol dosing (2-3 mg/kg/d) monitored for blood pressure and heart rate at 1, 2, and 3 hours.
- Standardized parent education on home monitoring and side effects was provided.
Main Results:
- Outpatient propranolol initiation was successful in 89% (39/44) of eligible patients.
- Five patients required brief hospital admission for reasons including heart failure signs, airway involvement, or social factors.
- Propranolol caused transient blood pressure reduction, necessitating a 3-hour monitoring point.
- No patients experienced symptomatic hypotension, bradycardia, or heart failure.
Conclusions:
- Outpatient initiation of propranolol for infantile hemangiomas is generally safe and effective for most children.
- Comprehensive cardiovascular evaluation, close monitoring post-dose, and thorough parent education are crucial.
- This standardized protocol offers a cost-effective alternative to inpatient initiation while ensuring patient safety.
Objectives:
To outline a safe, standardized protocol for outpatient initiation of propranolol therapy for infantile hemangiomas.
Study Design:
Retrospective review.
Setting:
Academic tertiary care pediatric hospital.
Subjects And Methods:
Forty-nine infantile hemangioma patients were offered propranolol therapy and included in the study. Any patients requiring hospital admission were excluded. Screening consisted of cardiology evaluation, including electrocardiography and, when indicated, echocardiography. Target initiation dose was 2 to 3 mg/kg/d divided into 3 doses. Blood pressure and heart rate were initially monitored at baseline and 1 and 2 hours in clinic following initial dosing. A 3-hour time point was later added. Families received standardized instructions regarding home heart rate monitoring, side effects, and fasting.
Results:
Outpatient propranolol therapy was safely initiated in 39 of 44 patients (89%). Five patients required brief admission: 1 with clinical signs/symptoms of heart failure, 3 having airway involvement, and 1 for social reasons. Propranolol administration transiently reduced blood pressure; the maximal decrease occurred at 2 hours, prompting addition of a 3-hour time point to ensure recovery. No patients exhibited symptomatic hypotension, bradycardia, or heart failure.
Conclusions:
In most children with infantile hemangiomas, propranolol therapy can be safely initiated as an outpatient. Careful cardiovascular evaluation by an experienced clinician is essential for pretreatment evaluation, inpatient admission (when necessary), blood pressure and heart rate monitoring following initial dosing, and parent education. This standardized multidisciplinary outpatient initiation plan reduces the cost of initiating therapy compared with inpatient strategies while still providing appropriate monitoring for potential treatment complications. Further evaluation of propranolol therapy efficacy at the current dosing and duration of treatment continues.
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