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Zhang L, Buonfiglio F, Fieß A, Pfeiffer N, Gericke A. Retinopathy of Prematurity-Targeting Hypoxic and Redox Signaling Pathways. Antioxidants (Basel) 2024; 13:148. [PMID: 38397746 PMCID: PMC10885953 DOI: 10.3390/antiox13020148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024] Open
Abstract
Retinopathy of prematurity (ROP) is a proliferative vascular ailment affecting the retina. It is the main risk factor for visual impairment and blindness in infants and young children worldwide. If left undiagnosed and untreated, it can progress to retinal detachment and severe visual impairment. Geographical variations in ROP epidemiology have emerged over recent decades, attributable to differing levels of care provided to preterm infants across countries and regions. Our understanding of the causes of ROP, screening, diagnosis, treatment, and associated risk factors continues to advance. This review article aims to present the pathophysiological mechanisms of ROP, including its treatment. Specifically, it delves into the latest cutting-edge treatment approaches targeting hypoxia and redox signaling pathways for this condition.
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Affiliation(s)
| | | | | | | | - Adrian Gericke
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; (L.Z.); (F.B.); (A.F.); (N.P.)
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2
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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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3
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Lee CW, Su H, Shiea J. Potential applications and challenges of novel ambient ionization mass spectrometric techniques in the emergency care for acute poisoning. Trends Analyt Chem 2022. [DOI: 10.1016/j.trac.2022.116742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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4
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Su H, Huang MZ, Shiea J, Lee CW. Thermal desorption ambient ionization mass spectrometry for emergency toxicology. MASS SPECTROMETRY REVIEWS 2022:e21784. [PMID: 35603997 DOI: 10.1002/mas.21784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/17/2021] [Accepted: 01/21/2022] [Indexed: 06/15/2023]
Abstract
In the emergency department, it is important to rapidly identify the toxic substances that have led to acute poisoning because different toxicants or toxins cause poisoning through different mechanisms, requiring disparate therapeutic strategies and precautions against contraindicating actions, and diverse directions of clinical course monitoring and prediction of prognosis. Ambient ionization mass spectrometry, a state-of-the-art technology, has been proved to be a fast, accurate, and user-friendly tool for rapidly identifying toxicants like residual pesticides on fruits and vegetables. In view of this, developing an analytical platform that explores the application of such a cutting-edge technology in a novel direction has been initiated a research program, namely, the rapid identification of toxic substances which might have caused acute poisoning in patients who visit the emergency department and requires an accurate diagnosis for correct clinical decision-making to bring about corresponding data-guided management. This review includes (i) a narrative account of the breakthrough in emergency toxicology brought about by the advent of ambient ionization mass spectrometry and (ii) a thorough discussion about the clinical implications and technical limitations of such a promising innovation for promoting toxicological tests from tier two-level to tier one level.
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Affiliation(s)
- Hung Su
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Min-Zong Huang
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Jentaie Shiea
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Medicinal and Applied Chemistry, Kaohsiung Medical University, Kaohsiung, Taiwan
- Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Wei Lee
- Institute of Medical Science and Technology, National Sun Yat-Sen University, Kaohsiung, Taiwan
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5
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Gokalp G, Nalbant T, Berksoy E, Bardak S, Demir G, Demir S, Sahin O, Hocaoglu N. Is hypoglycemia really observed in pediatric beta-blocker intoxications? A case-control study. Arch Pediatr 2021; 29:56-60. [PMID: 34848131 DOI: 10.1016/j.arcped.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/14/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beta-blocker (BB) intoxications are common in both childhood and adulthood. In the case of poisoning, bradycardia, hypotension, ventricular dysrhythmias, mental status changes, seizures, hypoglycemia, and bronchospasm may occur. Effects on the cardiovascular system are commonly seen, but hypoglycemia is not frequently observed in clinical practice. In this study, we aimed to answer the question, "Is hypoglycemia more commonly observed in BB intoxications than in other intoxications?" METHOD This was a case-control study conducted in a pediatric emergency department of a university hospital. The case group (Group 1) consisted of cases with BB poisonings and the control group (Group 2) consisted of cases with selective serotonin receptor inhibitor (SSRI) poisonings. Data were obtained from patient files. We recorded the blood glucose levels (BGLs) of all patients on admission to the emergency department and at the 1-, 6-, and 24-h follow-up. The amounts of BBs received by the cases were compared with the specific toxic doses of each drug. The data obtained were analyzed using the Statistical Package for the Social Sciences 22 (SPSS.22) program. Mean and standard deviation for numerical values and frequency for categorical data are reported; at test, chi-square test, and ANOVA tests were used for the analysis. RESULTS The study comprised 40 patients (Group 1) and 40 controls (Group 2). The mean serum BGLs of patients in Group 1 at admission and at the 1-, 6-, and 24-h follow-up were 107.2 ± 46.3 mg/dl, 86.3 ± 20.1 mg/dl, 88.6 ± 28.4 mg/dl, and 86.5 ± 23.7 mg/dl, respectively. The mean values of Group 2 cases were 100 ± 39.5 mg/dl, 92.1 ± 30 mg/dl, 91±28 mg/dl, and 127.8 ± 60.7 mg/dl, respectively, at admission and at the 1-, 6-, and 24-h follow-up (p = 0.4, p < 0.001, p = 0.7, and p < 0.001, respectively). The mean BGLs of patients who were exposed to propranolol at admission and at the 1-, 6-, and 24-h follow-up were significantly lower than those of the patients who had taken different BBs in Group 1. No linear correlation was found between the percentage of exposure to BB toxic doses and BGLs. CONCLUSION Our study showed that the BGLs of patients receiving BBs could be lower, but they were not at a level that would have serious consequences. Nevertheless, the BGLs of all cases of intoxication should be monitored closely.
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Affiliation(s)
- Gamze Gokalp
- Izmir Katip Celebi University Faculty of Medicine: Izmir Katip Celebi Universitesi Tip Fakultesi, Turkey; Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey.
| | - Tugce Nalbant
- Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir, Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Emel Berksoy
- Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir, Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Sefika Bardak
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Gulsah Demir
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Sule Demir
- Izmir Tepecik Egitim ve Arastirma Hastanesi: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik, Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi, Turkey
| | - Orhan Sahin
- Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey
| | - Nil Hocaoglu
- Dokuz Eylül University: Dokuz Eylul Universitesi Institute of Health Servises, Medical Pharmacology Depatment, Toxicology Devision, Turkey; Dokuz Eylul University: Dokuz Eylul Universitesi, Faculty of Medicine, Pharmacology Depatment, Medical Toxicology Devision, Turkey
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6
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Rikihisa N, Takatsuka H, Suzuki T, Shiko Y, Kawasaki Y, Hanawa M, Ishii I, Mitsukawa N. Efficacy and safety of propranolol gel for infantile hemangioma: A randomized, double-blind study. Biol Pharm Bull 2021; 45:42-50. [PMID: 34719577 DOI: 10.1248/bpb.b21-00500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We aimed to evaluate the efficacy and safety of propranolol gel at various concentrations with infantile hemangiomas after proliferative phases. We designed a single-center, randomized, double-blind, dose-dependent trial with placebo control and randomized patients to receive propranolol gel at 0%, 1%, or 5%, twice daily for 24 weeks. The primary efficacy endpoint was the percentage change in redness of the tumors. Safety endpoints were skin characteristics changes and systemic symptoms. We made two comparisons to evaluate the superiority of 1% and 5% propranolol gels against placebo for primary endpoint analysis and used the t-test to compare parents' satisfaction with these treatments. Initially, 19 patients were enrolled, but 8 were excluded from the analysis. We were underpowered to answer the question of efficacy. In the per-protocol set, we found similar results for the redness percentage change among the patients on placebo, 1% and 5% gel. However, the difference in redness before and after treatment suggested a slight decreasing trend of lesion's redness as the propranolol concentration increased. The difference in parents' satisfaction between the placebo and 5% propranolol gel groups was significant (p = 0.08). We observed no serious adverse events. We did not find an obvious dose-dependent effect for the propranolol gel treatment against infantile hemangiomas after the proliferative phase. However, external applications twice daily were less burdensome for parents and led to good compliances. It had a favorable safety profile in Japanese pediatric patients with infantile hemangiomas.
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Affiliation(s)
- Naoaki Rikihisa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University Hospital
| | | | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital.,Graduate School of Pharmaceutical Sciences, Chiba University
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital
| | - Michiko Hanawa
- Biostatistics Section, Clinical Research Center, Chiba University Hospital
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital.,Graduate School of Pharmaceutical Sciences, Chiba University
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University Hospital.,Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine
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7
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Farrell NM, Hamilton S, Gendron BJ, Corio JL, Lookabill SK. Presence of "One Pill Can Kill" Medications in Medication Organizers: Implications for Child Safety. J Pharm Pract 2021; 35:898-902. [PMID: 34000923 DOI: 10.1177/08971900211017491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if "one pill can kill" (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet. OBJECTIVE The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center. METHODS Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without. RESULTS A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs. CONCLUSION The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.
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Affiliation(s)
- Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Bryan J Gendron
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jessica L Corio
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Sara K Lookabill
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
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8
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Adrienne Hughes
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
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9
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, de Gamarra-Martínez EF, Nogué-Xarau S. Availability in Spain of “one-pill killers” and other highly toxic drugs in infants. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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10
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, Fernández de Gamarra-Martínez E, Nogué-Xarau S. [Availability in Spain of "one pill killers" and other highly toxic drugs in infants]. An Pediatr (Barc) 2020; 93:380-395. [PMID: 32284232 DOI: 10.1016/j.anpedi.2020.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To prepare a list of highly toxic drugs in infants (HTDs) marketed in Spain, comparing those that reach the lethal dose in a child of 10kg with the ingestion of 1 to 3 units. METHOD HTDs are defined as those capable of causing severe or lethal poisoning in children less than 8-year-old. Severe poisoning is considered as that corresponding to Grade 3 in the Poisoning Severity Score classification and to the "major effects" category in publications in the American Association of Poison Control Centers. A literature review was carried out on the annual reports of the American Association of Poison Control Centers, as well as in PubMed, between January 2000 and February 2019 (Keywords "severe", "fatal", "life-threatening", "poisoning", "child", "paediatric", "toxicological emergency"). An observational, retrospective study was also conducted on infants less than 8-year-old that were seen in a Paediatric Emergency Department due to suspected drug poisoning between July 2012 and June 2018. The active ingredients responsible marketed in Spain were selected, and the lethal or highly toxic doses were determined. The number of units (pills) necessary to reach this dose in children of 10kg was calculated. RESULTS A total of 7 HTD groups were identified: analgesics; psychotropics and other medication used in neurological disorders; catarrh decongestants - cough -antihistamine - asthma drugs; cardiovascular drugs; antibiotics, topical preparations, and other drugs. In 29 active ingredients, the ingestion of a single pill could cause death in 10kg infant, in another 13, the ingestion of 2 pills could cause death, as well as the ingestion of 3 pills in 10 cases. CONCLUSION There are numerous HTDs marketed in Spain, some of which are available in potentially fatal presentations with few pills.
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Affiliation(s)
- Lidia Martínez-Sánchez
- Servicio de Urgencias, Hospital Sant Joan de Déu, Barcelona, España; Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España
| | - Raquel Aguilar-Salmerón
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España.
| | - Núria Pi-Sala
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Clínica Girona, Girona, España
| | - Maria Àngels Gispert-Ametller
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Urgencias, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - Milagros García-Peláez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital ASEPEYO Sant Cugat, Sant Cugat del Vallès, España
| | - Antoni Broto-Sumalla
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Consorci Sanitari de Terrassa, Barcelona, España
| | - Edurne Fernández de Gamarra-Martínez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Santiago Nogué-Xarau
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Unidad de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Barcelona, España
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Abstract
BACKGROUND Infantile haemangioma is one of the most commonly known benign vascular tumours of infancy and childhood, having an incidence of 3-10%. Most lesions regress spontaneously; however, some may require treatment owing to their clinical and cosmetic effects. Propranolol has become the treatment of choice for infantile haemangioma, but treatment protocols are largely institutional based without any specific consensus guidelines. Our aim was to evaluate the cost-effectiveness of propranolol use as inpatient versus outpatient therapy. METHODS A decision tree model was created depicting alternate strategies for initiating propranolol treatment on an inpatient versus outpatient basis combined with the option of a pretreatment echocardiogram applied to both strategies. Cost analysis was assumed to be based on treatment of haemangioma in patients who were born at term, had no chronic illnesses, a non-life-threatening location of the haemangioma, and those who were not taking any other medications that could potentiate the side effects of propranolol. A sensitivity analysis was performed to evaluate the probability of side effects. RESULTS The average cost incurred for inpatient treatment of infantile haemangioma was approximately $2603 for a single hospital day and increased to $2843 with the addition of an echocardiogram. The expected cost of treatment in the outpatient setting was $138, which increased to $828 after the addition of an echocardiogram. CONCLUSION Treating infantile haemangioma with propranolol is more cost-effective when initiated on an outpatient basis.
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Fogel I, Ollech A, Zvulunov A, Valdman‐Greenshpon Y, Atar Snir V, Friedland R, Lapidoth M, Ben‐Amitai D. Safety profile during initiation of propranolol for treatment of infantile haemangiomas in an ambulatory day‐care hospitalization setting. J Eur Acad Dermatol Venereol 2018; 32:2004-2009. [DOI: 10.1111/jdv.14955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 02/26/2018] [Indexed: 12/01/2022]
Affiliation(s)
- I. Fogel
- Department of Dermatology Northwestern University Chicago IL USA
| | - A. Ollech
- Department of Dermatology Northwestern University Chicago IL USA
| | - A. Zvulunov
- Pediatric Dermatology Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Ben Gurion University of the Negev Be'er Sheva Israel
| | - Y. Valdman‐Greenshpon
- Dermatology Unit Kaplan Hospital Rehovot Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - V. Atar Snir
- Pediatric Dermatology Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - R. Friedland
- Pediatric Dermatology Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - M. Lapidoth
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Laser Unit Rabin Medical Center ‐ Hasharon Hospital Petach Tikva Israel
| | - D. Ben‐Amitai
- Pediatric Dermatology Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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Kaempfen S, Neumann RP, Jost K, Schulzke SM. Beta-blockers for prevention and treatment of retinopathy of prematurity in preterm infants. Cochrane Database Syst Rev 2018; 3:CD011893. [PMID: 29499081 PMCID: PMC6494413 DOI: 10.1002/14651858.cd011893.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Retinopathy of prematurity (ROP) is a vision-threatening disease of preterm neonates. The use of beta-adrenergic blocking agents (beta-blockers), which modulate the vasoproliferative retinal process, may reduce the progression of ROP or even reverse established ROP. OBJECTIVES To determine the effect of beta-blockers on short-term structural outcomes, long-term functional outcomes, and the need for additional treatment, when used either as prophylaxis in preterm infants without ROP, stage 1 ROP (zone I), or stage 2 ROP (zone II) without plus disease or as treatment in preterm infants with at least prethreshold ROP. SEARCH METHODS We searched the Cochrane Neonatal Review Group Specialized Register; CENTRAL (in the Cochrane Library Issue 7, 2017); Embase (January 1974 to 7 August 2017); PubMed (January 1966 to 7 August 2017); and CINAHL (January 1982 to 7 August 2017). We checked references and cross-references and handsearched abstracts from the proceedings of the Pediatric Academic Societies Meetings. SELECTION CRITERIA We considered for inclusion randomised or quasi-randomised clinical trials that used beta-blockers for prevention or treatment of ROP in preterm neonates of less than 37 weeks' gestational age. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane and the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS We included three randomised trials (N = 366) in this review. Two of these studies were at high risk of bias. All studies reported on prevention of ROP and compared oral propranolol with placebo or no treatment. We found no trials assessing beta-blockers in infants with established stage 2 or higher ROP with plus disease.In one trial, study medication was started after one week of life, i.e. prior to the first ROP screening. The other two trials included preterm infants if they had stage 2 or lower ROP without plus disease. Based on the GRADE assessment, we considered evidence to be of low quality for the following outcomes: rescue treatment with anti-VEGF or laser therapy; and arterial hypotension or bradycardia requiring inotropic support. Evidence was of moderate quality for the following outcomes: progression to stage 2 with plus disease; progression to stage 3 ROP; and progression to stage 4 or 5 ROP.Meta-analysis of three trials (N = 366) suggested beneficial effects of oral beta-blockers on the risk of requiring anti-VEGF agents (typical risk ratio (RR) 0.32, 95% confidence interval (CI) 0.12 to 0.86; I² = 0%; typical risk difference (RD) -0.06, 95% CI -0.10 to -0.01; I² = 75%; number needed to treat for an additional beneficial outcome (NNTB) 18, 95% CI 14 to 84) and laser therapy (typical RR 0.54, 95% CI 0.32 to 0.89; typical RD -0.09, 95% CI -0.16 to -0.02; I² = 31%; NNTB 12, 95% CI 8 to 47). Meta-analysis of two trials (N = 161) demonstrated a beneficial effect of oral beta-blockers on progression to stage 3 ROP (typical RR 0.60, 95% CI 0.37 to 0.96; I² = 0%; typical RD -0.15, 95% CI -0.28 to -0.02; I² = 73%; NNTB 7, 95% CI 5 to 67). There was no significant effect of oral beta-blockers on progression to stage 2 ROP with plus disease or to stage 4 or 5 ROP. Although meta-analysis did not indicate a significant effect of beta-blockers on arterial hypotension or bradycardia, propranolol dosage in one study was reduced by 50% in infants of less than 26 weeks' gestational age due to severe hypotension, bradycardia, and apnoea in several participants. Analyses did not indicate significant effects of beta-blockers on complications of prematurity or mortality. None of the trials reported on long-term visual impairment. AUTHORS' CONCLUSIONS Limited evidence of low-to-moderate quality suggests that prophylactic administration of oral beta-blockers might reduce progression towards stage 3 ROP and decrease the need for anti-VEGF agents or laser therapy. The clinical relevance of those findings is unclear as no data on long-term visual impairment were reported. Adverse events attributed to oral propranolol at a dose of 2 mg/kg/d raise concerns regarding systemic administration of this drug for prevention of ROP at the given dose. There is insufficient evidence to determine the efficacy and safety of beta-blockers for prevention of ROP due to high risk of bias in two included trials and the lack of long-term functional outcomes. We would encourage researchers to conduct large, well-designed trials to confirm or refute the role of beta-blockers for prevention and treatment of ROP in preterm infants. Trials should report on long-term visual impairment. Researchers should consider dose-finding studies of systemic beta-blockers and topical administration of beta-blockers, in order to optimise drug delivery and minimise adverse events.
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Affiliation(s)
- Siree Kaempfen
- University of Basel Children's Hospital (UKBB)Department of NeonatologyBaselBaselSwitzerlandCH‐4031
| | - Roland P Neumann
- University of Basel Children's Hospital (UKBB)Department of NeonatologyBaselBaselSwitzerlandCH‐4031
| | - Kerstin Jost
- University of Basel Children's Hospital (UKBB)Department of NeonatologyBaselBaselSwitzerlandCH‐4031
| | - Sven M Schulzke
- University of Basel Children's Hospital (UKBB)Department of NeonatologyBaselBaselSwitzerlandCH‐4031
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Korkmaz L, Karaca C, Akin MA, Bastug O, Sahiner M, Ozdemir A, Gunes T, Ozturk MA, Kurtoglu S. Short-term Refractive Effects of Propranolol Hydrochloride Prophylaxis on Retinopathy of Prematurity in Very Preterm Newborns. Curr Eye Res 2017; 43:213-217. [PMID: 29135357 DOI: 10.1080/02713683.2017.1390769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Retinopathy of prematurity (ROP) is one of the major problems of surviving premature infants with several ophthalmic morbidities such as increased risk of refractive errors, strabismus, and cortical visual impairment. Use of propranolol hydrochloride (PH) for the prevention of ROP is a new promising treatment modality. However, long-term effects are still to be defined. In our study, we aimed to investigate the short-term refractive effects of PH used for ROP prophylaxis in very preterm newborns. METHODS This is a prospective, randomized, double-blind, placebo-controlled study. Very preterm newborns with a birthweight less than or equal to 1500 g and/or born prior to 32 gestational weeks were included in the study. The subjects were randomly divided into two groups: control group (CG, n = 37) given placebo and PH group (PHG, n = 34) given PH starting from 4 weeks after birth (27.1 ± 2.1 day). PHG patients received PH therapy for about 1 month (25.7 ± 7.8 day). Anthropometric measurements including weight, length, and head circumference were recorded before PH treatment (at birth) and during eye control (at corrected age). Cycloplegic refraction values were measured by retinoscopy at corrected age (CG: 10.3 ± 4.3 months, PHG: 11.4 ± 4.8 months). RESULTS Anthropometric measurements including gestational age, weight, length, and head circumference were similar at birth and corrected age in both groups. The mean level of spherical refraction was significantly less hyperopic in the PHG than in the CG (CG: 1.37 ± 1.40 D, PHG: 0.37 ± 1.44 D) (p = 0.005). CONCLUSION PH may lead to myopic shift by affecting the beta-adrenergic receptors in the choroid or ciliary body of the developing eye. Long-term refractive follow-up is required in order to elucidate the effects of PH on emmetropization process of these very preterm infants.
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Affiliation(s)
- Levent Korkmaz
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Cagatay Karaca
- b Department of Ophthalmology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Mustafa Ali Akin
- c Division of Neonatology , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Osman Bastug
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Mustafa Sahiner
- b Department of Ophthalmology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Ahmet Ozdemir
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Tamer Gunes
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Mehmet Adnan Ozturk
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Selim Kurtoglu
- a Division of Neonatology , Erciyes University Medical Faculty , Kayseri , Turkey
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15
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Mei-Zahav M, Blau H, Hoshen M, Zvulunov A, Mussaffi H, Prais D, Stafler P, Steuer G, Lapidoth M, Amitai DB. Propranolol treatment for infantile hemangioma does not increase risk of childhood wheezing. Pediatr Pulmonol 2017; 52:1071-1075. [PMID: 28267266 DOI: 10.1002/ppul.23683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/25/2017] [Accepted: 02/08/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Propranolol is the treatment of choice for infantile hemangiomas requiring medical intervention. Although contraindicated in asthma, its bronchoconstrictive effect in infants and children has not been extensively studied. We aimed to assess the incidence of wheezing episodes in infants and children treated with propranolol for infantile hemangiomas. STUDY DESIGN A retrospective case-control study. SETTING a tertiary pediatric hospital. PATIENTS All Children followed for infantile hemangioma between 2009 and 2014. Children followed conservatively served as control group and were matched 1:1 for gender and month of birth by random matching to children treated with propranolol. INTERVENTIONS All respiratory episodes (asthma, wheezing, stridor, and pneumonia) and respiratory associated hospitalizations were recorded from hospital records, from the primary care physician visits records and pharmacy prescriptions. The main outcome measure was the incidence of respiratory episodes in the treatment and the control groups. RESULTS A total of 1828 clinic visits were reviewed for 683 children. In addition, primary care physician visits records were available in 80% of them. Two hundred and sixteen children were treated with propranolol. Incidence of respiratory episodes and recurrent respiratory episodes was similar in the propranolol and control groups (8.3% vs 12%, P = 0.265; 3.7% vs 6.5%, P = 0.274, respectively). Time to first episode was similar in the treatment and control groups (5.03 ± 3.32 vs 4.45 ± 3.21 months, respectively, P = 0.09). Respiratory hospital admission rate was similar in both groups. CONCLUSIONS Propranolol treatment does not exacerbate wheezing episodes in infants and children.
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Affiliation(s)
- Meir Mei-Zahav
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Hannah Blau
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Alex Zvulunov
- Pediatric Dermatology Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Faculty of Health Sciences, Medical School for International Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Huda Mussaffi
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Dario Prais
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Patrick Stafler
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Guy Steuer
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Moshe Lapidoth
- Sackler School of Medicine, Tel Aviv University, Israel.,Laser Unit, Department of Dermatology, Rabin Medical Center, Petah Tikva, Israel
| | - Dan Ben Amitai
- Sackler School of Medicine, Tel Aviv University, Israel.,Pediatric Dermatology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
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Gupta A, Verma A, Dhua A, Bhatnagar V. Vascular Anomalies: A Pediatric Surgeon's Perspective. Indian J Pediatr 2017; 84:612-617. [PMID: 28466404 DOI: 10.1007/s12098-017-2355-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
Abstract
Anomalies affecting the capillary and venous channels form the bulk of the spectrum of vascular anomalies. As per International Society for the Study of Vascular Anomalies (ISSVA) classification, these are referred to as hemangiomas and venous malformations respectively. The present article is a descriptive note of their management and outcomes. Retrospective records of patients over 17 y (January 2000 through December 2016) were reviewed for presentation, management and outcomes. Outcomes were graded into 3 subgroups based on subjective assessment of clinical images: Group A = near-total response (>90%); Group B = 50-90% and Group C = <50% reduction. Among 90 cases of hemangioma, majority were located in head and neck (86.7%). Outcomes recorded in children who received steroids (n = 36) were: Group A = 61.1%, B = 25% and C = 13.9%; steroids and beta-blockers (n = 8): Group A = 62.5%, B = 25% and C = 12.5%; only beta-blockers (n = 4): Group A = 75% and B = 25%; intralesional sclerotherapy (n = 32): Group A = 55.2% and B = 44.8%; steroids followed by sclerotherapy (n = 7): Group A = 28.6% and B = 71.4%; excision (n = 3): Group A = 100%. Among 171 cases of venous malformation, majority were located in head and neck (49.6%). Outcomes recorded in children who received sclerotherapy (n = 165) were Group A = 20.7%, B = 51% and C = 28.3%; steroids (n = 3): Group A = 100%; beta-blockers (n = 1): Group C = 100%; excision (n = 2): Group A = 100%. Better outcome was noted in smaller-sized lesions and those who required lesser volume of sodium tetradecyl sulfate (STS) injection. Thus, to conclude, the decision regarding the choice and timing of each therapeutic modality should be individualized based on location, size and type of the lesion. The goal of management in these lesions should be to improve the quality of life rather than elimination of the lesion.
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Affiliation(s)
- Alisha Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ajay Verma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anjan Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Kim KH, Choi TH, Choi Y, Park YW, Hong KY, Kim DY, Choe YS, Lee H, Cheon JE, Park JB, Park KD, Kang HJ, Shin HY, Jeong JH. Comparison of Efficacy and Safety Between Propranolol and Steroid for Infantile Hemangioma: A Randomized Clinical Trial. JAMA Dermatol 2017; 153:529-536. [PMID: 28423174 DOI: 10.1001/jamadermatol.2017.0250] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance There are limited data from randomized clinical trials comparing propranolol and steroid medication for treatment of infantile hemangioma (IH). Objective To determine the efficacy and safety of propranolol compared with steroid as a first-line treatment for IH. Design, Setting, and Participants This randomized clinical noninferiority trial tested the efficacy and safety of propranolol vs steroid treatment for IH at a single academic hospital. All participants were diagnosed with IH between June 2013 and October 2014, had normal heart function, and had not been previously treated for IH. Interventions The participants were randomly assigned to either the propranolol group or the steroid group. In the propranolol group, the patients were admitted, observed for adverse effects for 3 days after treatment initiation, and then released and treated as outpatients for 16 weeks (2 mg/kg/d). In the steroid group, the patients were seen as outpatients from the beginning and were also treated for 16 weeks (2 mg/kg/d). Main Outcomes and Measures The primary efficacy variable was the response to treatment at 16 weeks, which was evaluated by the hemangioma volume using magnetic resonance imaging before and at 16 weeks after treatment initiation. While comparing the effect of medication between the groups, we monitored the adverse effects of both drugs. Results A total of 34 patients (15 boys, 19 girls; mean age, 3.3 months; range, 0.3-8.2 months) were randomized to receive either propranolol or steroid treatment (17 in each treatment group). Guardians for 2 patients in the steroid group withdrew their consent, and 1 patient in the propranolol group did not complete the efficacy test. The intention-to-treat analysis, applying multiple imputations, found the treatment response rate in the propranolol group to be 95.65%, and that of the steroid group was 91.94%. Because the difference in response rate between the groups was 3.71%, propranolol was considered noninferior. We found that there was no difference between the groups in safety outcomes. Conclusions and Relevance Our trial demonstrated that propranolol was not inferior to steroid with respect to therapeutic effects in IH. Trial Registration clinicaltrials.gov Identifier: NCT01908972.
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Affiliation(s)
- Kyu Han Kim
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea2Institute of Human-Environment Interface Biology, Seoul National University Medical Research Center, Seoul, Republic of Korea3Laboratory of Cutaneous Aging and Hair Research, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae Hyun Choi
- Department of Plastic and Reconstructive Surgery, Institute of Human-Environment Interface Biology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Woon Park
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Young Kim
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea2Institute of Human-Environment Interface Biology, Seoul National University Medical Research Center, Seoul, Republic of Korea3Laboratory of Cutaneous Aging and Hair Research, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun Seon Choe
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyunjung Lee
- Department of Plastic and Reconstructive Surgery, Institute of Human-Environment Interface Biology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Bin Park
- Department of Medicine, Seoul National University School of Medicine (Master Course), Seoul, Republic of Korea
| | - Kyung Duk Park
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jae Hoon Jeong
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
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18
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Is Propranolol Safe and Effective for Outpatient Use for Infantile Hemangioma? A Prospective Study of 679 Cases From One Center in China. Ann Plast Surg 2017; 76:559-63. [PMID: 26101993 DOI: 10.1097/sap.0000000000000506] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The protocol for the treatment of infantile hemangioma with propranolol varies among different clinical centers. METHODS Six hundred seventy-nine patients who were 1 to 12 months old were recruited in this prospective study to receive propranolol treatment. The response to the propranolol therapy was classified as 4 levels. The results were primarily evaluated using color Doppler ultrasound examinations before and after propranolol treatment. RESULTS The response was excellent in 176 (25.9%), good in 492 (72.5%), stable in 5 (0.7%), and poor in 6 (0.9%) of the patients. The mean age at the initiation of the therapy was 3.3 months (range, 1 to 10.9 months) and the mean duration of the therapy was 7.1 months (range, 3-17 months). The mean duration of the follow-up time after the discontinuation of the therapy was 5.3 months (range, 3-17 months). Regrowth of the hemangioma was observed in 92 cases (13.5%). Seventy-nine (11.6%) of the parents complained of their child's minor discomfort during the therapy. CONCLUSIONS Propranolol (2 mg/kg per day) may significantly reduce the size of a hemangioma. As an outpatient therapy, propranolol was found to be safe for Chinese children and to have minor side effects.
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19
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Love JN, Howell JM, Klein-Schwartz W, Litovitz TL. Lack of toxicity from pediatric beta-blocker exposures. Hum Exp Toxicol 2016; 25:341-6. [PMID: 16866192 DOI: 10.1191/0960327106ht632oa] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The risk of toxicity in a child who is unintentionally exposed to a beta-blocking drug remains uncertain. The current study further defines this risk, particularly in the common scenario of ingestion of one or two tablets. A prospective cohort of 208 pediatric patients, 6 months to 6 years of age, reported to two regional poison centers serves as the study population. Data were collected with a standardized instrument during the care of each patient and for a minimum of 24 hours after exposure. No instances of serious toxicity typical of beta-blocker intoxication, such as ‘shock-like’ states, arrhythmias or seizures were observed in this series. Furthermore, there were no reported episodes of hypoglycemia, symptomatic bradycardia or bronchospasm. Nine instances of altered mental status or behavioral changes were reported. All appeared to be minor in nature. The most serious outcome was charcoal aspiration during gastrointestinal decontamination. This study adds to a growing body of evidence suggesting that exposure to one or two beta-blocker tablets places children at very little, if any, risk of toxicity.
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Affiliation(s)
- J N Love
- Department of Emergency Medicine, Georgetown University Hospital, Ground Floor CCC bldg, 3800 Reservoir Rd, NW, Washington, DC 20007, USA.
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20
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Gondi JT, Gazula S, Rajasekhar A, Usharani G. Excellent response of infantile orofacio-orbital hemangioma to propranolol-pictorial depiction and literature review. Contemp Clin Dent 2016; 7:269-72. [PMID: 27307684 PMCID: PMC4906880 DOI: 10.4103/0976-237x.183060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Infantile hemangiomas (IHs) are common, benign vascular tumors of infancy, with more than half affecting the head and neck region. IHs involving the lips and oral cavity can often present to the oral surgeon and the pedodontist. Till date, several doubts exist among clinicians regarding the use of propranolol to treat infantile hemangiomas in neonates and small infants, appropriate dose, treatment duration, side effects, response, and long-term follow-up. We present a 2-month-old male infant with extensive hemangioma involving the face, orbit, buccal mucosa and palate with feeding difficulties, and risk of life-threatening complications such as airway compromise, aspiration, and visual loss which showed excellent response with high-dose propranolol and had no side effects. We also reviewed literature for the mechanism of action of propranolol and possible minor and serious side effects.
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Affiliation(s)
- Jonathan Theodore Gondi
- Department of Head and Neck Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Suhasini Gazula
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
| | - A Rajasekhar
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
| | - G Usharani
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
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21
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Thompson AM, Franco Palacios CR, Henriksen MN. Intravenous lipid emulsion and high-dose insulin as adjunctive therapy for propranolol toxicity in a pediatric patient. Am J Health Syst Pharm 2016; 73:880-5. [DOI: 10.2146/ajhp150594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Carlos R. Franco Palacios
- Nephrology Department, Rice Memorial Hospital, Willmar, MN and Affiliated Community Medical Centers, Willmar, MN
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Lee CW, Su H, Wu KD, Shiea J, Wu DC, Chen BH, Shin SJ. Rapid point-of-care identification of oral medications in gastric lavage content by ambient mass spectrometry in the emergency room. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2016; 30:1295-1303. [PMID: 27173111 DOI: 10.1002/rcm.7557] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 06/05/2023]
Abstract
RATIONALE Acute poisoning should be handled with high efficiency in order to minimize morbidity and mortality in the emergency room. Unfortunately, history-taking and physical examination are not always reliable. Mis-swallowing of oral medications is common in the pediatric group. This study aimed at developing a rapid point-of-care ambient mass spectrometric method for the early identification of ingested oral medications in gastric lavage content. METHODS Four different types of oral medications that are most commonly mis-swallowed by children were diluted to different concentrations. Each of these chemical solutions was mixed with human gastric lavage content. A direct metallic sampling probe was dipped into the solution. It was then inserted promptly into the thermal desorption electrospray ionization source to carry out ionization and subsequent mass spectrometric analysis of the medications. The corresponding compounds were identified through matching of the obtained mass spectrometric data with those provided by well-established databases. RESULTS Since no pretreatment of the specimen was required, the sampling step, and the subsequent thermal desorption electrospray ionization and mass spectrometric detection of the medications were completed within 30 s. Mass spectra were obtained for four different kinds of oral medication. The limit-of-detection of the four tested oral medications in gastric lavage content is at sub-ppm level, which is sensitive enough for emergency medicine applications since the quantities of medications ingested by pediatric patients are usually much higher. CONCLUSIONS Thermal desorption electrospray ionization mass spectrometry, with informational support provided by an online mass spectral database, allows for early point-of-care identification of mis-swallowed oral medications in the evacuated gastric lavage contents obtained from gastric lavage of patients in the emergency room, and it is promising in providing important toxicological information to ensure the appropriateness of the subsequent medical management. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Chi-Wei Lee
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung Su
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Kun-Da Wu
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Jentaie Shiea
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Deng-Chyang Wu
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Bai-Hsiun Chen
- Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shyi-Jang Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Turhan AB, Bör Ö, Özdemir ZC. Treatment with propranolol for infantile hemangiomas: single-center experience. J Cosmet Dermatol 2016; 15:296-302. [DOI: 10.1111/jocd.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Ayşe Bozkurt Turhan
- Division of Pediatric Hematology and Oncology; Faculty of Medicine; Eskişehir Osmangazi University; Eskişehir Turkey
| | - Özcan Bör
- Division of Pediatric Hematology and Oncology; Faculty of Medicine; Eskişehir Osmangazi University; Eskişehir Turkey
| | - Zeynep Canan Özdemir
- Division of Pediatric Hematology and Oncology; Faculty of Medicine; Eskişehir Osmangazi University; Eskişehir Turkey
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Yun YJ, Gyon YH, Yang S, Lee YK, Park J, Park M. A prospective study to assess the efficacy and safety of oral propranolol as first-line treatment for infantile superficial hemangioma. KOREAN JOURNAL OF PEDIATRICS 2015; 58:484-90. [PMID: 26770224 PMCID: PMC4705329 DOI: 10.3345/kjp.2015.58.12.484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 11/27/2022]
Abstract
Purpose To determine the efficacy and safety of oral propranolol as a first-line treatment for superficially located infantile hemangioma (IH) and propose an assessment tool to measure treatment response. Methods Patients with superficial IH under 1 year of age were prospectively recruited between May 2012 and December 2013 at the Department of Pediatrics of Chungbuk National University Hospital. Propranolol was administered to 12 infants (median age, 3.8 months) while monitoring cardiovascular and adverse metabolic effects. If a patient showed no adverse events, the dosage was gradually increased up to 3 mg/kg/day and maintained for 1 year. We used our own scoring system to assess treatment response using parameters like change in color, and longest diameter, and thickness of the IH. Results Eleven out of 12 patients completed the protocol with consistent improvement of hemangiomas during therapy. Patients on propranolol showed a more than 50% involution in the first 3 months, with additional steady involution until 1 year. Patients with the highest scores at 1 month maintained their score and showed better responses until treatment termination. The patient with the lowest score at 1 month did not show any further regression and stopped propranolol treatment 4 months after initiation. In two children with recurrences after successful therapeutic regression, propranolol was effective after being reintroduced. Propranolol treatment was not interrupted in any patient due to adverse events. Conclusion Oral propranolol at 3 mg/kg/day showed a consistent, rapid, and therapeutic effect on superficial IHs without significant adverse events.
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Affiliation(s)
- Yeong Ju Yun
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yun Hee Gyon
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sohyoung Yang
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Youn Kyung Lee
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joohyun Park
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Meerim Park
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Kaempfen S, Neumann RP, Jost K, Schulzke SM. Beta-blockers for prevention and treatment of retinopathy of prematurity in preterm infants. Hippokratia 2015. [DOI: 10.1002/14651858.cd011893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Siree Kaempfen
- University of Basel Children's Hospital (UKBB); Department of Neonatology; Basel Basel Switzerland CH-4031
| | - Roland P Neumann
- University of Basel Children's Hospital (UKBB); Department of Neonatology; Basel Basel Switzerland CH-4031
| | - Kerstin Jost
- University of Basel Children's Hospital (UKBB); Department of Neonatology; Basel Basel Switzerland CH-4031
| | - Sven M Schulzke
- University of Basel Children's Hospital (UKBB); Department of Neonatology; Basel Basel Switzerland CH-4031
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Propranolol versus corticosteroids: what should be the treatment of choice in infantile hemangiomas? Ann Plast Surg 2015; 74:237-41. [PMID: 24051459 DOI: 10.1097/sap.0b013e318299cd4e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infantile hemangiomas (IHs) are common and benign vascular tumors and usually involute spontaneously. Nevertheless, in some cases, treatment with systemic corticosteroids or propranolol is required. No randomized controlled studies, in which both treatment options were compared, have been performed. METHODS A systematic literature review and a retrospective cohort study in the Academic Medical Centre of 56 patients (mean age, 5.5 months; range, 0-40 months; SD, 7.6) with IHs were carried out. These patients were treated with either systemic corticosteroids or propranolol. The outcomes of both treatment options were evaluated and compared. RESULTS The literature review showed that propranolol resulted in an involution in 100% of the patients, whereas corticosteroids only reached involution in 89%. The mean first response of the IH to propranolol was 3.2 days and of corticosteroids was 8.5 days. In our study sample, the patients treated with propranolol showed a faster and better response than the patients treated with corticosteroids. This is in line with literature findings. CONCLUSIONS Systemic propranolol treatment is more effective for IHs than systemic corticosteroid treatment. Secondly, propranolol elicits a faster response than corticosteroids.
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Jacks SK, Kertesz NJ, Witman PM, Fernandez Faith E. Experience with Holter monitoring during propranolol therapy for infantile hemangiomas. J Am Acad Dermatol 2015; 73:255-7. [DOI: 10.1016/j.jaad.2015.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/29/2015] [Accepted: 05/10/2015] [Indexed: 10/23/2022]
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Treatment with propranolol for infantile hemangiomas: A case series of 106 infants. Exp Ther Med 2015; 10:51-54. [PMID: 26170911 DOI: 10.3892/etm.2015.2485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 04/28/2015] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the clinical benefit and side effects of propranolol treatment in 106 children with infantile hemangiomas (IHs). A retrospective chart review was conducted on all children who attended the clinic between September 16, 2009 and November 11, 2013. Propranolol was administered in a progressive schedule reaching 1.0-1.5 mg/kg/day, divided into three doses. Demographic data, clinical features, imaging, treatment regimens and outcomes were investigated. Any adverse effects following medication were evaluated and managed accordingly. Preliminary analysis of the data showed the inclusion of 106 children (71 female and 35 male) with a mean age and weight at onset of treatment of 5.1 months and 7.3 kg, respectively. All 106 patients responded positively to treatment. Side effects that required intervention and/or close monitoring included diarrhea (n=10), hypotension (n=7), nightmares (n=2), agitation (n=1) and cold extremities (n=1). No long-term adverse effects were observed in any of the patients. In conclusion, propranolol administered orally at 1.0-1.5 mg/kg/day had a rapid therapeutic effect for resolving IHs with few complications.
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A novel topical nano-propranolol for treatment of infantile hemangiomas. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1109-15. [DOI: 10.1016/j.nano.2015.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 01/27/2015] [Accepted: 02/17/2015] [Indexed: 01/08/2023]
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You HS, Kim HS, Kim BS, Kim MB, Ko HC. Propranolol to treat infantile hemangioma (IH) in patients with congenital heart disease. J Am Acad Dermatol 2015; 72:912-4. [PMID: 25890462 DOI: 10.1016/j.jaad.2015.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/23/2015] [Accepted: 01/24/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Hyang-Suk You
- Department of Dermatology, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hoon-Soo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Yangsan, Korea
| | - Byung-Soo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Yangsan, Korea; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon-Bum Kim
- Department of Dermatology, School of Medicine, Pusan National University, Yangsan, Korea; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, School of Medicine, Pusan National University, Yangsan, Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Busan, Korea.
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Tan CE, Itinteang T, Leadbitter P, Marsh R, Tan ST. Low-dose propranolol regimen for infantile haemangioma. J Paediatr Child Health 2015; 51:419-24. [PMID: 25187156 DOI: 10.1111/jpc.12720] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2014] [Indexed: 11/27/2022]
Abstract
AIMS Propranolol, now the preferred treatment for problematic proliferating infantile haemangioma (IH), at an empirical cardiovascular dosage of 2-3 mg/kg/day is associated with variable complication rates. A meta-analysis shows complications in 31% of patients at a mean dosage of 2.12 mg/kg/day. This study reports on the minimal dosage and duration of treatment to achieve accelerated involution and side effects using a stepwise escalation regimen. METHODS Consecutive patients with problematic proliferating IH treated with propranolol were identified from our vascular anomalies database. Propranolol was commenced at 0.5 mg/kg/day in two divided doses and increased to 1 mg/kg/day after 24 h. The patients were reviewed after 1 week, and the dosage was increased to 1.5 mg/kg/day. The dosage was further increased by 0.5 mg/kg/day, if necessary, to achieve accelerated involution. RESULTS Forty-four patients, aged 3 weeks to 11 months (mean, 3.8 months), received propranolol therapy for problematic proliferating IH. The minimal dosage required to achieve accelerated involution was 1.5-2 mg/kg/day. Treatment was maintained for an average of 9.3 months and discontinued at an average age of 14.2 months. Rebound growth occurred in the first patient of this series when propranolol was withdrawn at 7.5 months of age, requiring reinstitution of treatment. Slight rebound growth following cessation of treatment was observed in four other patients, but reinstitution of propranolol was not required. Minor complications were observed in three (6.8%) patients. CONCLUSIONS Propranolol at 1.5-2 mg/kg/day, administered in divided doses with stepwise escalation, is safe and effective for treating problematic proliferating IH. Treatment is continued to an average age of 14.2 months.
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Affiliation(s)
- Cherise Es Tan
- Gillies McIndoe Research Institute, Wellington, New Zealand
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Song H, Shi H, Zhang X, Wang J, Yu Y, Chen W, Zhou H. Safety profile of a divided dose of propranolol for heart rate in children with infantile haemangioma during 16 weeks of treatment. Br J Dermatol 2014; 172:444-9. [PMID: 25041341 DOI: 10.1111/bjd.13250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2014] [Indexed: 11/30/2022]
Affiliation(s)
- H. Song
- Ningxia Medical University; Yinchuan China
| | - H. Shi
- Department of Dermatovenereology; Ningxia Medical University General Hospital; Yinchuan 750004 China
| | - X. Zhang
- Department of Dermatovenereology; Ningxia Medical University General Hospital; Yinchuan 750004 China
| | - J. Wang
- Department of Dermatovenereology; Ningxia Medical University General Hospital; Yinchuan 750004 China
| | - Y. Yu
- Department of Dermatovenereology; Ningxia Medical University General Hospital; Yinchuan 750004 China
| | - W. Chen
- Department of Dermatovenereology; Ningxia Medical University General Hospital; Yinchuan 750004 China
| | - H. Zhou
- Ningxia Medical University; Yinchuan China
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Wolter JK, Wolter NE, Blanch A, Partridge T, Cheng L, Morgenstern DA, Podkowa M, Kaplan DR, Irwin MS. Anti-tumor activity of the beta-adrenergic receptor antagonist propranolol in neuroblastoma. Oncotarget 2014; 5:161-72. [PMID: 24389287 PMCID: PMC3960198 DOI: 10.18632/oncotarget.1083] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Neuroblastoma (NB) is a pediatric tumor of the sympathetic nervous system, which is often associated with elevated catecholamines. More than half of patients with metastatic NB relapse and survival is extremely poor with current therapies. In a high-throughput screen of FDA-approved drugs we identified anti-NB activity for the nonselective β-adrenergic receptor antagonist propranolol hydrochloride. Propranolol inhibited growth of a panel of fifteen NB cell lines irrespective of MYCN status, and treatment induced apoptosis and decreased proliferation. Activity was dependent on inhibition of the β2, and not β1, adrenergic receptor, and treatment resulted in activation of p53 and p73 signaling in vitro. The majority of NB cell lines and primary tumors express β2 adrenergic receptor and higher mRNA levels correlate with improved patient survival, but expression levels did not correlate with in vitro sensitivity to propranolol. Furthermore, propranolol is synergistic with the topoisomerase I inhibitor SN-38 and propranolol inhibits growth of NB xenografts in vivo at doses similar to those used to treat infants with hemangiomas and hypertension. Taken together, our results suggest that propranolol has activity against NB and thus should be considered in combination treatments for patients with relapsed and refractory NB.
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Affiliation(s)
- Jennifer K Wolter
- Departments of Pediatrics and Medical Biophysics, University of Toronto
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Schneider M, Reimer A, Cremer H, Ruef P. Topical treatment with propranolol gel as a supplement to the existing treatment of hemangiomas. World J Pediatr 2014; 10:313-7. [PMID: 25515804 DOI: 10.1007/s12519-014-0509-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 01/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Systemic treatment with propranolol is proven to be effective for patients with hemangiomas with less side-effect. We used a propranolol gel for topical use on hemangiomas. METHODS In this retrospective study, we analyzed 148 patients who had been treated topically with propranolol gel for 12 weeks. We analyzed the data of patients and clinically gave each hemangioma a "hemangioma score" to determine the treatment success. RESULTS In 147 of the 148 patients, strong signs of resolution under treatment included lightening, paling, and less vascularization. The hemangioma score showed a significant decrease during the treatment. Relevant serum levels of propranolol were not found. Adverse effects were rare and not related to propranolol. CONCLUSION Topical treatment with propranolol gel is suitable for specific hemangiomas in addition to cryotherapy and systemic treatment with propranolol.
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Schneider M, Cremer HJ, Ruef P. A retrospective analysis of systemic propranolol for the treatment of complicated infantile haemangiomas. Acta Paediatr 2014; 103:977-83. [PMID: 24837972 DOI: 10.1111/apa.12691] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/08/2014] [Accepted: 05/13/2014] [Indexed: 11/26/2022]
Abstract
AIM A small percentage of complicated infantile haemangiomas need early, safe and effective treatment, and the option of off-label systemic propranolol treatment has been in existence since 2008. The aim of this study was to provide greater insight into the drug's efficacy and side effects. METHODS We report our retrospective experiences of 207 paediatric patients treated with systemic propranolol for complicated infantile haemangiomas, which were photographed and analysed with a specific haemangioma score. RESULTS Systemic treatment was successful in 99.5% of the patients. The haemangioma score before treatment was 8.3 ± 3.3 and the score at the end of the treatment was 1.5 ± 1.4. The reduction in the haemangiomas was significant and did not show any differences when distributed according to different localisations or to the patients' ages. Relevant side effects that may have made it necessary to discontinue the treatment were not observed. However, there was a statistically significant reduction in heart rate during the first six in-hospital drug applications. CONCLUSION Our study demonstrates that systemic propranolol treatment is a highly effective treatment that is nearly always safe. These findings are a milestone for particularly complicated haemangiomas and provide highly valuable information on this drug treatment.
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Affiliation(s)
- M Schneider
- Children's Hospital Heilbronn; Heilbronn Germany
| | - HJ Cremer
- Children's Hospital Heilbronn; Heilbronn Germany
| | - P Ruef
- Children's Hospital Heilbronn; Heilbronn Germany
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Phillips RJ, Lokmic Z, Crock CM, Penington A. Infantile haemangiomas that failed treatment with propranolol: clinical and histopathological features. J Paediatr Child Health 2014; 50:619-25. [PMID: 24905852 DOI: 10.1111/jpc.12600] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2014] [Indexed: 12/28/2022]
Abstract
AIM To describe the clinical and histopathological characteristics of infantile haemangiomas that failed treatment with oral propranolol . DESIGN This study is a case series from the vascular birthmarks clinic at Royal Children's Hospital, Melbourne. PATIENTS The patients for this study were infants who commenced treatment with oral propranolol before 6 months of age and who were treated for at least 4 months without a satisfactory result. For histology and immunohistochemistry, tissue from the four non-responding patients who subsequently underwent surgical excision was matched with four historical controls. OUTCOME MEASURES Based on medical record review and photographic assessments, infants were defined as having failed treatment with oral propranolol if the infantile haemangioma either continued to grow or showed 20% improvement or less. Tissue sections were examined for tissue structure, mast cells, sympathetic innervations and beta-2 adrenergic receptor expression, and the number of mast cells and beta-2 adrenergic positive cells. RESULTS From a group of 135 infants who met the inclusion criteria, 14 infants failed propranolol treatment. Eleven of these infants had focal facial haemangiomas. No difference was seen in tissue morphology, tissue innervations, beta-2 adrenergic receptor expression, cell number or mast cell distribution, and number between non-responding and control haemangiomas. CONCLUSION We report a treatment failure rate of 10%, which is higher than previously reported. Focal facial lesions failed to respond twice as frequently as other types of haemangioma. No histopathological reason was identified to indicate why some haemangiomas failed to respond.
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Affiliation(s)
- Roderic J Phillips
- Vascular Biology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Paediatrics, Monash University, Melbourne, Victoria, Australia
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Hetterich N, Lauterbach E, Stürer A, Weilemann LS, Lauterbach M. Toxicity of antihypertensives in unintentional poisoning of young children. J Emerg Med 2014; 47:155-62. [PMID: 24746907 DOI: 10.1016/j.jemermed.2014.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 01/09/2014] [Accepted: 02/09/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Knowledge is limited about the toxicity of unintentional exposure to antihypertensives in young children (0-6 years of age). OBJECTIVE Our aim was to research symptoms and poisoning severity in unintentional poisonings in this group of age and determine adequate poisoning management. METHODS We performed a 10-year retrospective, explorative analysis of the Mainz Poison Center/Germany database with regard to circumstances of poison exposure, dosage, symptoms, and treatment. To be able to relate drug exposure with reported symptoms, analyses were restricted to single drug exposures. Written follow-up information was obtained in about 50% of all cases. RESULTS A total of 1489 cases were analyzed, of which 957 were single drug exposures with 421 exposures to beta-blocking agents, 364 to inhibitors of the renin-angiotensin system, 122 to calcium channel blockers, and 50 to antiadrenergic drugs. No severe (Poisoning Severity Score [PSS]=3) or fatal poisonings (PSS=4) were reported and, with the exception of atenolol, propranolol, irbesartan, isradipin, clonidine, and moxonidine, no poisonings with a PSS>1. We did not find a significant relationship between dosage, release formulation and symptoms, or PSS. All patients fully recovered without specific treatment. CONCLUSIONS In young children with unintentional, single drug exposure to the most popular antihypertensive medication (i.e., metoprolol, bisoprolol, ramipril, enalapril, lisinopril, captopril, candesartan, valsartan, amlodipine, and verapamil), only mild symptoms occurred, and hospital evaluation is not a must. However, children with recent exposure to clonidine or moxonidine should be evaluated at a hospital due to an increased likelihood of poisonings of at least moderate severity.
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Affiliation(s)
- Nicole Hetterich
- Mainz Poison Center, Mainz, Germany; 2(nd) Medical Clinic, University Medical Center Mainz, Germany
| | | | - Andreas Stürer
- Mainz Poison Center, Mainz, Germany; 2(nd) Medical Clinic, University Medical Center Mainz, Germany
| | - Ludwig S Weilemann
- Mainz Poison Center, Mainz, Germany; 2(nd) Medical Clinic, University Medical Center Mainz, Germany
| | - Michael Lauterbach
- Mainz Poison Center, Mainz, Germany; 2(nd) Medical Clinic, University Medical Center Mainz, Germany; Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
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Haider KM, Neely DE, Plager DA. Hemangiomas treated with propranolol: do the rewards outweigh the risks? ACTA ACUST UNITED AC 2014; 63:2-5. [PMID: 24260800 DOI: 10.3368/aoj.63.1.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Recent reports of propranolol for the treatment of hemangiomas have led many physicians to question the best treatment strategy for children with vision-threatening hemangiomas. Although propranolol has potential side effects, including hypoglycemia and hypotension, early studies suggest it is more efficacious than systemic cortico steroids with a lower incidence of adverse side effects.
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McSwiney E, Murray D, Murphy M. Propranolol therapy for cutaneous infantile haemangiomas initiated safely as a day-case procedure. Eur J Pediatr 2014; 173:63-8. [PMID: 23933667 DOI: 10.1007/s00431-013-2105-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 07/15/2013] [Indexed: 11/29/2022]
Abstract
Propranolol is emerging as the treatment of choice for high-risk infantile haemangiomas. Current protocols recommend overnight admission for initiation of propranolol as well as baseline investigations including electrocardiography (ECG) and echocardiography (ECHO). Our study examined the safety profile of propranolol for the treatment of infantile haemangiomas using a simplified day-case initiation protocol. We evaluated 20 consecutive patients commencing propranolol as a day case for the treatment of an infantile haemangioma over an 18-month period. Investigations were carried out according to our local protocol. Cardiac investigations were not routinely performed. Patients were observed for 2 h following administration of the first dose of propranolol (0.5 mg/kg orally). If no adverse effects were observed, patients were discharged on a daily dose of propranolol of 1 mg/kg, increased to 2 mg/kg on day 4. Patients were reviewed on the day ward on day 8. All haemangiomas requiring treatment were small to moderate in size (median maximum diameter 2.35 cm). Except for capillary blood glucose measurement, no patient required venepuncture for additional blood investigations. As all patients had a normal clinical examination, none required ECHO. An ECG was performed on just one patient. No adverse reactions were observed following administration of propranolol. All patients were discharged home on the same day. No serious adverse events were reported at follow-up. We demonstrate that with targeted cardiac screening, propranolol can be safely initiated on a day-case basis for the treatment of small- to moderate-sized infantile haemangiomas.
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Affiliation(s)
- Edward McSwiney
- Department of Paediatrics, Cork University Hospital, Cork, Ireland,
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Hermans DJJ, Bauland CG, Zweegers J, van Beynum IM, van der Vleuten CJM. Propranolol in a case series of 174 patients with complicated infantile haemangioma: indications, safety and future directions. Br J Dermatol 2013; 168:837-43. [PMID: 23278381 DOI: 10.1111/bjd.12189] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Infantile haemangioma (IH) is a benign, common and self-limiting tumour of infancy; only a minority of cases need active treatment. Currently, propranolol appears superior to classic treatments. OBJECTIVES To document in a prospective study indications and side-effects of propranolol for complicated IH in a large patient group. METHODS Analysis of prospectively collected data was performed on 174 patients with IH treated with propranolol in a tertiary referral centre from September 2008 to January 2012. RESULTS The group consisted of children with a potentially threatening and/or complicated IH; the girl/boy ratio was 123/51, and the mean age at the start of treatment was 4·8 months. In 173 cases (99·4%), treatment was successful, as assessed nonquantitatively by clinical observation. This striking effect was characterized by immediate cessation of growth, softening, fading of the erythema and rapid induction of regression. The mean duration of treatment was 10·7 months. The most important adverse effects were hypotension (3·4%), wheezing (9·2%), nocturnal restlessness (22·4%) and cold extremities (36·2%). In one patient, propranolol was stopped. In 15 patients it was necessary to reduce the dose, although the lower dose was still effective. CONCLUSIONS In this study, propranolol was effective and safe in almost all patients with complex IH. Administration of systemic medication to an infant with a benign condition requires careful consideration, as only a minority of patients with IH require an active medical intervention. A shift of the indication of propranolol for IH is evident, expanding its application for life-threatening situations or severe functional impairment to early prevention of disfigurement or cosmetically permanent sequelae. However, the indication for such an active approach should be determined by experienced physicians.
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Affiliation(s)
- D J J Hermans
- Department of Dermatology, Hecovan Team for Haemangioma and Vascular Malformations, Radboud University Nijmegen Medical Centre, PO Box 9101, 6525 GL Nijmegen, The Netherlands
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Liu LS, Sokoloff D, Antaya RJ. Twenty-four-hour hospitalization for patients initiating systemic propranolol therapy for infantile hemangiomas--is it indicated? Pediatr Dermatol 2013; 30:554-60. [PMID: 23829941 DOI: 10.1111/pde.12182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In recent years, oral propranolol has risen from serendipitous discovery to first-line, albeit off-label, therapy for infantile hemangiomas (IHs). This retrospective study explored the utility of a 24-hour hospitalization for the initiation of propranolol therapy in children with problematic IHs by evaluating the effects of systemic propranolol on hemodynamics and blood sugar levels. Thirty-one children were admitted to the hospital to begin oral propranolol at a dose of 2 mg/kg/per day. Heart rate (HR), blood pressure (BP), and blood glucose (BG) measurements were obtained at baseline and 1 to 3 hours before and after each dose of propranolol. No caregivers reported any adverse effects during the hospitalization. On average, HR decreased by 5 beats per minute (bpm) (p < 0.01) and systolic BP decreased by 4 mmHg (p < 0.01) after propranolol administration. There was no statistically significant change in diastolic BP or BG with propranolol therapy. Over the first three doses of propranolol we saw statistically significant attenuation of the effects of propranolol on HR, with HR approaching baseline values during the hospitalization (p = 0.04). We did not see statistically significant changes in BP over the course of three doses of propranolol. This study suggests that 24-hour hospitalization with hemodynamic monitoring may not be necessary for safe initiation of propranolol therapy in otherwise healthy infants. Parental education on frequent feedings to decrease the chance of hypoglycemia may be as effective as 24-hour hospitalization.
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Affiliation(s)
- Lucinda S Liu
- School of Medicine, Yale University, New Haven, Connecticut
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Engberg Damsgaard T, Vandborg Bjerre J. Haemangioma and propranolol. J Plast Surg Hand Surg 2013; 48:86-8. [PMID: 23837510 DOI: 10.3109/2000656x.2012.754622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A slow-involuting segmental haemangioma was initially treated conventionally. Proliferation recurred when treatment was stopped. When the effect of propranolol on haemangiomas was published, we treated this 2.5- year- old girl with it. The haemangioma finally regressed recorded on magnetic resonance imaging and at clinical follow-up.
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Xiao Q, Li Q, Zhang B, Yu W. Propranolol therapy of infantile hemangiomas: efficacy, adverse effects, and recurrence. Pediatr Surg Int 2013; 29:575-81. [PMID: 23519547 PMCID: PMC3657346 DOI: 10.1007/s00383-013-3283-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2013] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the efficacy, adverse effects, and recurrence of oral propranolol for treatment of infantile hemangioma. METHODS Participants were treated with oral propranolol three times daily, with inpatient monitoring of adverse effects. The starting dosage was 2 mg/kg per day, which had been for the remaining duration of treatment. Therapy duration was planned for 4-6 months; if there was significant relapse, the period of treatment was extended. A photograph based severity scoring assessment was performed by three observers to evaluate efficacy by visual analog scale (VAS). RESULTS Sixty-one infants [median age 3.3 (1.2-8.1) months] were included in the study. The median follow-up-time was 15 (6-20) months and 53 patients completed treatment at a median age of 10.3 (8.4-18.1) months, after a duration of 8.5 (4.5-14) months. In all patients, there was significant fading of color [with a VAS of -9 (-6 to -9) after 6 months] and significant decrease in size of the infantile hemangiomas [with a VAS of -8 (-3 to -10) after 6 months]. We did not observe any life-threatening adverse effects. The therapy was interrupted due to temporary aggravation of pre-existing bronchial asthma in one child. Four cases presented partial recurrences. CONCLUSIONS Oral propranolol 2 mg/kg per day was a well-tolerated and effective treatment, mild adverse effects, and low recurrence for infantile hemangiomas. Propranolol should now be used as a first-line treatment in hemangiomas when intervention is required. Also, prospective studies should be needed in determining the most effective treatment dosage, optimum treatment duration, and exact mechanism of action of propranolol in future.
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Affiliation(s)
- Qiang Xiao
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Qin Li
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Bin Zhang
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
| | - Wenlin Yu
- Department of Plastic Surgery, General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liu Hua Road, Yue Xiu District, 510010 Guangzhou, People’s Republic of China
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Propranolol in use for treatment of complex infant hemangiomas: literature review regarding current guidelines for preassessment and standards of care before initiation of therapy. ScientificWorldJournal 2013; 2013:850193. [PMID: 23766715 PMCID: PMC3673324 DOI: 10.1155/2013/850193] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 04/28/2013] [Indexed: 02/05/2023] Open
Abstract
In 2008, the positive effects of propranolol on infantile hemangiomas (IH) have been discovered serendipitously by Léauté-Labrèze and her coworkers. Since then, propranolol has been in use in allday clinical practice worldwide for treatment of IH. It even caused some kind of paradigm shift in the overall management of these lesions, though propranolol is still not FDA approved, respectively, in “off-label” use for this indication in the majority of institutions. Thus, the aim of this communication is to evaluate the literature for current evidence regarding guidelines for preassessment and standards of care before initiation of therapy.
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Propranolol as a first-line treatment for diffuse infantile hepatic hemangioendothelioma. J Pediatr Gastroenterol Nutr 2013; 56:e17-20. [PMID: 22331019 DOI: 10.1097/mpg.0b013e31824e50b7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Treatment of infantile capillary hemangioma of the eyelid with systemic propranolol. Am J Ophthalmol 2013; 155:165-170.e2. [PMID: 22967870 DOI: 10.1016/j.ajo.2012.06.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 06/23/2012] [Accepted: 06/14/2012] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the efficacy and safety of systemic propranolol for infantile capillary hemangiomas of the eyelid. DESIGN Prospective, interventional cases series. METHODS All patients with eyelid infantile capillary hemangiomas at risk of developing amblyopia seen between January 2009 and January 2012 at the University Federico II, Naples, Italy, were treated with systemic propranolol (2 mg/kg body weight per day). Maximum length of treatment was 4 months, and propranolol was suspended when complete regression of lesions was obtained or in case of collateral effects. Minimum follow-up was 6 months. RESULTS Of 17 patients with eyelid infantile capillary hemangiomas, 3 were excluded for asthma and 14 (7 males, 7 females; mean age, 20.85 ± 29.7 months; range, 1 to 72 months) underwent treatment with systemic propranolol. Capillary hemangiomas involved the upper eyelid in 10 cases and the lower eyelid in 4 cases. Propranolol was stopped in 1 case for hypotension and in 1 case for allergy. Treatment was administered over a mean of 2.5 ± 1.3 months (range, 1 to 4 months); the mean follow-up was 10.64 ± 8.7 months (range, 6 to 39 months). Ten patients were younger than 1 year and demonstrated complete regression. Two patients older than 5 years also benefited from treatment. In 4 cases, amblyogenic astigmatism was present and decreased from 1.25 ± 0.5 diopters before treatment to 0.25 ± 0.2 diopters after treatment. No regrowth was observed. CONCLUSIONS Four months of treatment with oral propranolol for eyelid infantile capillary hemangiomas led to complete regression of the lesion in patients younger than 1 year. No major collateral effects were observed. Treatment also may be considered in patients older than 5 years to reduce astigmatism and for aesthetic purposes.
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Kozanoglu I, Yandim MK, Cincin ZB, Ozdogu H, Cakmakoglu B, Baran Y. New indication for therapeutic potential of an old well-known drug (propranolol) for multiple myeloma. J Cancer Res Clin Oncol 2012; 139:327-35. [DOI: 10.1007/s00432-012-1331-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
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Oral Propranolol for Treating Infantile Hemangiomas: A Case Series of 57 Patients. ACTAS DERMO-SIFILIOGRAFICAS 2012. [DOI: 10.1016/j.adengl.2012.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Can a Poison Center Overdose Guideline Safely Reduce Pediatric Emergency Department Visits for Unintentional β-Blocker Ingestions? Am J Ther 2012; 19:346-50. [DOI: 10.1097/mjt.0b013e3181ff7aaf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Oral propranolol for treating infantile hemangiomas: a case series of 57 patients. ACTAS DERMO-SIFILIOGRAFICAS 2012; 103:708-17. [PMID: 22853960 DOI: 10.1016/j.ad.2012.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 12/27/2011] [Accepted: 03/04/2012] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Infantile hemangiomas (IH) are a frequent vascular tumor. In recent years, propranolol has emerged as an alternative in the treatment of IH. The objective of the present study was to evaluate the effectiveness of propranolol for the treatment of IH. MATERIALS AND METHODS Patients with IH requiring treatment were included. Cardiologic evaluation was made to every patient and electrocardiogram (ECG) and echocardiogram were done. Oral propranolol was started in an ambulatory way at a dose of 2mg/kg daily divided in two doses. At ten days all the patients were evaluated with a 24-h rhythm holter. Evaluation of effectiveness: In clinical controls and by images IH were formally analyzed, without blindness. Response was categorized as complete response (CR), partial response (PR) and no response (NR). Adverse events: Adverse events were registered in a special category of the formulary. RESULTS 57 patients were included. Mean age was 9.7 months. There were 80.8% females. Mean duration of treatment was 7.3 months (1-24 months). EFFICACY 50.6% had CR, 49.3% had PR. There were a 7% of adverse events. No differences in response rate exist according to age or location. No rhythm holter was altered at ten-day control. CONCLUSION Our study highlights the possibility of starting propranolol in an ambulatory way, establishes a dose of 2mg/kg/day and confirms the security profile of the drug. We consider propranolol as a first line treatment for IH.
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