To the Editor: The response of infantile hemangiomas to propranololreported in the letter by Léauté-Labrèzeet al. (June 12 issue)1 catapulted the use of this treatmentto first-line status among physicians managing this disease.Not included in their letter was a discussion about initiatingand monitoring propranolol use, or about potential risks, whichmay be unique among these patients. The most common seriousadverse effects are bradycardia and hypotension. Infants withvery large hemangiomas or miliary hemangiomatosis are at riskfor high-output cardiac compromise.2 Propranolol may mask theclinical signs of early cardiac failure and diminish cardiacperformance. Propranolol may also blunt the clinical featuresof hypoglycemia. Sustained hypoglycemia in infancy has beenassociated with long-term neurologic sequelae.3 We know of twoinfants who had unrecognized side effects from propranolol.
We developed a treatment protocol to optimize safety: baselineechocardiography and 48-hour hospitalization or home nursingvisits to monitor vital signs and blood glucose levels. Medicationis given every 8 hours, with an initial dose of 0.16 mg perkilogram of body weight. If the vital signs and glucose levelsremain normal, the dose is incrementally doubled to a maximumof 0.67 mg per kilogram (to a maximum daily dose of 2.0 mg perkilogram). Propranolol should be gradually tapered over a periodof 2 weeks.
Elaine C. Siegfried, M.D. William J. Keenan, M.D. Saadeh Al-Jureidini, M.D. Saint Louis University School of Medicine St. Louis, MO 63104 siegfried{at}kidsderm.com
References
Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo J-B, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649-2651. [Free Full Text]
Gottschling S, Schneider G, Meyer S, Reinhard H, Dill-Mueller D, Graf N. Two infants with life-threatening diffuse neonatal hemangiomatosis treated with cyclophosphamide. Pediatr Blood Cancer 2006;46:239-242. [CrossRef][Web of Science][Medline]
Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics 2008;122:65-74. [Free Full Text]
The authors reply: After more than 40 years of clinical usein infants, there is no documented case of death or seriouscardiovascular disease as a direct result of exposure to a beta-blocker.1Side effects of beta-blockers are well known; these includetransient bradycardia and hypotension that warrant close monitoringat the onset of treatment. Bronchospasm is usually seen as anexacerbation in patients with underlying reactive airways; afamily history with regard to atopy or repeated wheezing shouldbe obtained. Beta-blockers decrease lipolysis, glycogenolysis,and gluconeogenesis that predispose patients to hypoglycemia.They also mask some beta-sympathetic–related hypoglycemicsymptoms. The first week of life is a critical period when neonatesgradually reach their optimal milk intake and spontaneous hypoglycemiais more likely to develop; beta-blockers clearly should be avoidedduring this period. Most infants treated for an infantile hemangiomaare older and have a normal food intake, and the conditionsdescribed in the article by Burns et al.2 do not apply.
A large multicenter study is in the planning stage. We hopethat this study will lead to elaborate, reasonable, and objectiverecommendations concerning the use of beta-blockers in thisindication.
Christine Léauté-Labrèze, M.D. Eric Dumasde la Roque, M.D. Alain Taïeb, M.D. Bordeaux Children's Hospital 33 076 Bordeaux, France christine.labreze{at}chu-bordeaux.fr
References
Love JN, Sikka N. Are 1-2 tablets dangerous? Beta-blocker exposure in toddlers. J Emerg Med 2004;26:309-314. [CrossRef][Web of Science][Medline]
Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics 2008;122:65-74. [Free Full Text]
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