Treating an infantile hemangioma

If your infant is born with an infantile hemangioma,  your pediatrician's initial response will be patience. Many hemangionas will go away without being treated. But it also important to understand that these tumors can act quite differently from individual to individual.

There are a few steps most infantile hemangiomas will take1:
• they will emerge as a blemish a few days after birth
• they will experience a period of rapid growth
• they will begin a very slow period of self-resolution sometime after a child's first birthday
• they will disappear sometime before the child's 10th birthday

Because the vast majority of infantile hemangiomas go away on their own, it is entirely possible that your pediatrician will recommend against treatment.

But there are cases when treatment for infantile hemangiomas is required. When the tumor occurs in a place where it can lead to longterm problems or disfigurement--  for example by placing pressure on developing eyes, or by blocking air passages -- a more aggressive approach is warranted.

A few treatment approaches are available:

Laser therapy for infantile hemangioma

A 2010 study out of China looked at the use of a kind of laser known as intense pulsed light (IPL) with optimal pulse technology (OPT) in treating 62 patients with hemangioma. The study involved giving the infants four or five treatments over four-week intervals, and the reserachers reported marked improvement in 76% of cases. There were some adverse events reported, but these were called "transient" in nature.2

While the Chinese study showed good results using new generation lasers, laser therapy in the United States has been shown to result in scarring, and a 2007 case report out of Philadelphia showed unexplained freckling 11-years after a patient completed laser therapy for a hemangioma.3

Steroids for infantile hemangioma

For many years, the first choice for physicians treating troublesome hemangiomas has been sterioids. However the safety and efficacy of using sterioids in infants has long been a topic of concern for many researchers. A study released just two months ago from researchers at Boston Children's Hospital found that oral steroids can, in fact, be a safe and effective treatment for infantile hemangiomas.4

The researchers noted, however, that "the efficacy of oral corticosteroid therapy for problematic infantile hemangioma depends on dosage, duration of treatment, and definition of therapeutic response." In the study, 88% of the patient's tumors regressed, and 12% stabilized. In  the study, therapy began on infants at about three months, and they were on full treatment until 10 months before being tapered off of the sterioids.4

Propranolol for infantile hemangioma

Propranolol is quickly becoming the first choice for pedatric dermatologists treating troublesome infantile hemangiomas. The drug is a beta blocker that historically has been used to treat tremors, angina (chest pain), hypertension (high blood pressure), heart rhythm disorders, and other heart or circulatory conditions. However, in 2008 the New England Journal of Medicine published an amazing piece from three doctors in France who recognized the potential for the drug to treat hemangiomas.5

Then, in August 2011, a confirmatory study appeared in Pediatrics that showed that propranolol was effective, not only in infants, but in children up to five years old. In fact, the conclusion was telling: "Propranolol hydrochloride administered orally at 2 mg/kg per day reduced the volume, color, and elevation of focal and segmental IH in infants younger than 6 months and children up to 5 years of age."6

It should be noted that the study stressed the importance of monitoring children placed in this cardiac drug, and that small children were admitted to receive their first doses. Additionally, researchers noted other adverse events including bronchiolitis, gastroenteritis, streptococcal infection, cool extremities, dental caries, and sleep disturbance.6

Conclusion

Infantile hemangiomas are the most common pediatric soft-tissue tumor. There is absolutely no shortage of parents dealing with the hard questions of what to do for their baby's tumor. There are therapy options available for tumors if aggressive treatment is warranted, and parents should educate themselves with all of their options so that they can make the best choice for their baby and their situation.

References

1. Gontijo B, Silva CMR, Pereira LB. Hemangioma da infância. An Bras Dermatol. 2003;78:651-73.

2.  Li DN, Gold MH, Sun ZS, Tang AR, Wang HB, Sheng-Kang L. Treatment of infantile hemangioma with optimal pulse technology. J Cosmet Laser Ther. 2010 Jun;12(3):145-50. Available at http://www.ncbi.nlm.nih.gov/pubmed/20482239.

3.  Bayliss SJ, Berk DR. Freckling 11 years after pulsed dye laser therapy for an infantile hemangioma: coincidence or a previously unrecognized complication? Clin Pediatr (Phila). 2008 Mar;47(2):189-90. Epub 2007 Dec 5.

4.  Greene AK, Couto RA. Oral prednisolone for infantile hemangioma: efficacy and safety using a standardized treatment protocol. Plast Reconstr Surg. 2011 Sep;128(3):743-52.

5. Léauté-Labrèze, Christine and de la Roque, Eric Dumas and Hubiche, Thomas and Boralevi, Franck and Thambo, Jean-Benoît and Taïeb, Alain. Propranolol for Severe Hemangiomas of Infancy. NEJM. 2008; 358(24): 2649-2651. Available at http://www.nejm.org/doi/full/10.1056/NEJMc0708819#t=article

6. Hogeling M, Adams S, Wargon O. A randomized controlled trial of propranolol for infantile hemangiomas. Pediatrics. 2011 Aug;128(2):e259-66. Epub 2011 Jul 25.

So, what is an infantile hemangioma?

Plain, and simple: a hemangioma is a benign tumor. Most people know this type of tumor by a different name, strawberry birthmark. But an infantile hemangioma is a mass of tissue and living blood cells. It has veins that deliver blood to it, and it has veins that return that blood to the heart. They appear, often several days after birth, and they grow, sometimes for the first 18 to 24 month's of a child's life.

Hemangiomas are also quite common. According to Medscape, "Infantile hemangiomas occur in 10-12% of white non-Hispanic infants, 1.4% of black infants, and 0.8% of Asian infants." This is a point that leads to some misunderstanding about them. In most babies that have hemangiomas they are small, and occur in an innocuous spot like an arm or a leg. Here they are seen by most pediatricians as harmless, and they are left to go away on their own, often between the child's 5th and 9th year.

But some babies are not so lucky. Their hemangiomas appear on their faces, throats, or heads. As they grow they can cause a wide range of problems, they can constrict airways, place pressure on developing eyes, cause disfigurement, or even place pressure on the brain through a baby's soft spot.

Not all hemangiomas grow at the same rate. Some are extremely aggressive, expanding by inches within months, while others remain small. Some, hemangiomas have another bad habit -- they ulcerate, or open up, creating an open wound and scars on the child.

Most pediatricians have a wait-and-see approach to hemangiomas, chosing to delay any therapy until the path of tumor becomes clear. There are typically three cases when doctors take them more seriously:

When they appear on a part of the body that can impair the child in some way
When they grow especially rapidly
When they ulcerate, creating an open wound

My daughter hit the trifecta. Her hemangioma grew amazing quickly, as can be seen below. It sits above her soft spot, and it opened up, creating a large scab on her head. But it wasn't until that wound showed signs of infection that our pediatrician chose to refer us to a specialist to treat the tumor more aggressively. That may have been because of another truth about hemangiomas, there is no treatment for the tumor that doesn't require some serious education and soul-searching. Next, time I'll talk about hemangioma treatment.

Until then, thank you for stopping by and learning more.

A Hemangioma Grows

This week my four-month old began treatment for an infantile hemangioma (IH) on her head. In the next few weeks I will post more information about hemangiomas because I hope to help other parents and families who are faced with these birthmarks.

To begin, however I wanted to share a series of photos that show how a hemangioma grows, from almost nothing at birth, to a swollen, scary tumor on your baby. The dramatic nature of this tumor's growth can be understood in that all of this growth happened over four months. One physician told us that without treatment it could grow for a year and a half two years.

 

Spiny, the black swallowtail from the dill

Introducing @educatingdaddy !

This April two amazing things will happen. My son will turn four, and my second-born will enter the world. In four years of fatherhood I have learned many things, and the education continues daily. There is not a day that goes by that I am not awed by something my son says or does.

The smiles are limitless, the wisdom incredible, and the journey not for the faint of heart.

And so, I have created a twitter feed to share bits of my experience. In time, I will also use it to share some of my writing. So, follow me today. @educatingdaddy!