Many people are familiar with a birthmark commonly known as a "strawberry," literally named for the lesion's raised and red appearance. The medical term for these lesions is infantile hemangiomas and they are one of the most common forms of vascular anomaly that affect nearly 4%-10% of infants (Buckmiller, Munson, Dyamenahalli, Dai, & Richter, 2010). If hemangiomas are present in an inconspicuous site, they are frequently left untreated and allowed to follow a natural course of proliferation to resolution. Without complication and the right amount of patience from family members, this course of treatment will allow the lesion to typically resolve with minimal deformity.

An important nursing consideration, when developing a treatment plan for hemangiomas, is to understand and to educate the patient's family regarding the lifespan of the lesion. Infantile hemangiomas are characterized by three clinical stages: a proliferation phase, an involuting phase, and an involuted phase (Menezes, CcCarter, Greene, & Bauman, 2011). The proliferation phase is further divided into a rapidly proliferative phase that usually peaks around 4 months of age, and a slower proliferative phase that may persist until 8-12 months, and sometimes 24 months for larger lesions (Menezes et al., 2011). At the completion of this proliferative phase, the involution phase begins. In this phase, the lesion begins to decrease in size. According to Menezes et al. (2011), it is generally believed that 90% of infantile hemangiomas are fully involuted by th e age of 9 years. However, some hemangiomas can be problematic and can cause serious complications. Complications of infantile hemangiomas can include ulceration, permanent disfigurement due to their massive growth, and airway obstruction, and can affect normal function, depending on their location and size; for example, a lesion near the eye can cause obstruction leading to visual loss (Martin et al., 2013). Problematic infantile hemangiomas may require intervention during the rapidly proliferative or proliferative phase (Martin et al., 2013). Primary treatment options that have been available in the past for complicated hemangiomas include systemic or intralesional corticosteroids, chemotherapeutic agents, laser treatment, surgery, or a combination of therapies, all of which can include associated side effects (Buckmiller et al., 2010). Currently, there is no medication that is approved by the Food and Drug Administration for the treatment of infantile hemangiomas (Martin et al., 2013). In 2008, a baby was treated for cardiomyopathy with propranolol who incidentally also had an infantile hemangioma. During treatment, it was noted that the lesion decreased in size while on the medication (Blatt et al., 2011). Further studies at the institution where the effect of propranolol was identified confirmed the observation in 10 other babies with infantile hemangiomas (Blatt et al., 2011). Since publishing this discovery, propranolol has become a first-line treatment option for infantile hemangiomas. (Blatt et al., 2011).

In 2010, Arneja et al. (2010) described the introduction of propranolol as the potential drug to "create a paradigm shift for the treatment of complicated hemangiomas" (p. 895). Propranolol has been used for at least 50 years for the treatment of a variety of cardiac disorders including hypertension, migraine headaches, hyperthyroidism, glaucoma, anxiety, hyperhidrosis, and portal hypertension (Arneja et al., 2010). Propranolol has a general tolerable side-effect profile; more severe complications can include bradycardia, hypotension, hypoglycemia, seizures, rash, and bronchospasm (Arneja et al., 2010). According to Arneja et al. (2010), "these complications are generally rare in the pediatric population and found with doses higher than 2 mg/kg per day" (p. 893). Another side effect noted by Martin et al. (2013) is a change in sleep pattern including an increase/decrease in sleep and nightmares. Unfortunately, because of the limited literature and research available on the use of propranolol in hemangiomas, a precise protocol for its clinical use does not exist (Buckmiller et al. 2010). According to Blatt et al. (2011), specific "dosing frequency, setting (inpatient or outpatient) for initiation, clinical and laboratory monitoring or duration of treatment" all vary from facility to facility (p. 757). Many vascular anomaly centers, including Nemours/DuPont Hospital for Children, have developed a facility-specific protocol in conjunction with the pediatric cardiology team for the initiation of propranolol therapy for the treatment of infantile hemangiomas.

In 2011, a meeting was held in Chicago, IL, which included 28 members from 12 institutions, representing five specialties to discuss their various experiences with propranolol use in infantile hemangiomas (Martin, et al., 2013). All members recognized the importance of educating the providers and parents regarding the proper use of propranolol as well as potential side effects (Martin et al., 2013). The recommended education included teaching families how to take their child's pulse to monitor for signs of bradycardia, monitoring for signs/symptoms of allergic reaction, and monitoring signs/symptoms of hypoglycemia with instructions given on how to avoid low blood sugar levels (Martin et al., 2013). Teaching should include monitoring for breathing/wheezing problems as propranolol may need to be held during respiratory illness due to potential for bronchospasm (Martin et al., 2013). In addition, education should be included regarding the effect propranolol may have on sleeping patterns and how to adjust administration times to decrease adverse effect (Martin et al., 2013).

In summary, propranolol is not approved by the Food and Drug Administration for this off-label use for treatment of infantile hemangiomas and there is a continued need for further research regarding best practice for administration/monitoring perimeters. It is, however, clear that most institutions that are familiar with the therapy have found it to be a highly effective agent against potentially disfiguring childhood lesions, infantile hemangiomas.

REFERENCES