Hemangiomas are the most common benign tumors in children, and propranolol is the first-line treatment for infantile hemangiomas. 28 experts gathered in Chicago for a consensus meeting in December 2011, where experts reached a consensus on propranolol for the treatment of hemangiomas based on the available literature. This was published in the journal Pediatrics in January 2013. Infantile hemangioma (IH) is a common benign tumor consisting of actively proliferating endothelial-like cells. Their growth rate is unpredictable. Although most hemangiomas do not require treatment, children can develop a range of complications, including malformation, ulceration, bleeding, visual impairment, airway obstruction, congestive heart failure, and even death, requiring aggressive treatment. Propranolol is a beta-blocker that is rapidly effective in the treatment of hemangiomas, is well tolerated by patients, and induces hemangioma regression, but there is uncertainty and disagreement regarding the safety monitoring and dose increase of propranolol for IH. The most common complications were hypotension, hypoglycemia, bradycardia, hyperkalemia, and sleep disorders. 28 experts from 12 units and 5 specialties held a consensus meeting in December 2011. The experts attending the meeting treated more than 1000 cases and reached a consensus on issues related to propranolol treatment of hemangioma based on the available literature, the main points are as follows: Timing of treatment IH is diverse and complex. The greatest difficulty in treating IH is the need to determine which children are at high risk for complications and which children need systemic therapy. Internal therapy should be tailored to the child’s specific situation. Oral propranolol therapy needs to be considered when the child has ulcers, life dysfunction (visual impairment or airway obstruction), or is at risk for permanent malformations. Before treatment, the potential risks and benefits of adverse events from the application of propranolol therapy should be carefully weighed. Contraindications and history taking Prior to treatment, the potential risks of propranolol treatment for IH should be evaluated. Relevant contraindications include: cardiogenic shock, sinus bradycardia, hypotension, heart block greater than degree I, heart failure, bronchial asthma, and hypersensitivity to propranolol hydrochloride. The clinician should inquire about the child’s recent history of cardiovascular and pulmonary disease and perform an examination. The history should focus on feeding status, presence of dyspnea, shortness of breath, sweating, croup, heart murmur, heart block, or family history of arrhythmia. The examination should be performed by an experienced health care provider and should include heart rate, blood pressure, and cardiac and pulmonary conditions. Electrocardiogram (ECG) examination There is no consensus on whether to perform ECG examination in children with hemangioma treated with propranolol, but ECG examination may be considered for the following conditions: (1) newborns (1 month) with heart rate <70 beats/min; infants (1-12 months) with heart rate <80 beats/min; children (>12 months) with heart rate <70 beats/min; (2) children with congenital history of heart disease and arrhythmia disease (e.g., heart block, QT prolongation syndrome, sudden death); or mother's history of connective tissue disease; and (iii) history of arrhythmia or arrhythmia on auscultation examination. Because structural and functional heart disease can trigger complex IH, routine echocardiography is not required prior to treatment in the absence of abnormal clinical manifestations. Propranolol for PHACE PHACE syndrome is a cutaneous neurovascular syndrome that occurs in 1/3 of patients with large facial hemangiomas characterized by large, segmental hemangiomas of the head and neck, congenital brain, heart, eye, and/or chest wall malformations. In patients with PHACE syndrome, treatment with propranolol lowers blood pressure and reduces blood flow through obstructed, narrowed vessels, leading to an increased risk of stroke. In addition, the non-selective beta-blocker propranolol is more able to increase systolic blood pressure variability, which is a risk factor for stroke, than selective beta1-blockers. Cardiac and aortic arch malformations are common symptoms of PHACE syndrome and require echocardiography to assess cardiac anatomy and function. A cardiologist should be consulted regarding the use of propranolol in children with hemangiomas in combination with these symptoms. Children with PHACE syndrome who have large facial hemangiomas and are at high risk for comorbidities and permanent facial scarring are challenging to manage. children with PHACE syndrome are the best candidates for propranolol treatment, and the benefits of propranolol outweigh the risks associated with its use. In children with large facial hemangiomas at risk for PHACE syndrome, magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) of the head and neck and cardiac imaging are recommended before propranolol treatment. If the imaging results indicate that the patient is at high risk of stroke, a neurologist should be consulted. If the benefit of propranolol treatment outweighs the risk, consensus experts recommend the application of a minimal dose, gradual dose increases, and close observation, including hospitalization of high-risk children and gradual dose increases three times daily to minimize systolic blood pressure changes. Treatment regimen, target dose use and medication frequency Propranolol formulations currently available on the market include propranolol hydrochloride oral solution (20mg/5mL and 40mg/5mL). The consensus recommended target dose is 1 to 3 mg?kg-1?d-1, with most experts recommending 2 mg?kg-1?d-1. Because the dose of propranolol can be increased gradually, and because good results can be achieved with small doses of propranolol for IH, clinicians can determine the optimal target dose for each patient based on the patient's response. Because the heart is responsive to beta blockers, doses should be increased gradually, even in hospitalized patients, starting with low doses. After weighing treatment safety, efficacy, and convenience, consensus experts recommend applying propranolol at 3 doses/d with a minimum interval of 6 h. Initiation of propranolol for IH Some providers can safely monitor all outpatients, and some primary care physicians make every effort to admit all children. The following recommendations address potential adverse reactions to oral propranolol for suspected IH. There are increasing data on the safe use of the drug in outpatients but relatively limited data for this condition. The consensus recommends dividing children into 2 groups based on age. Inpatient medication recommendations are as follows (see Figures 1 and 2): ①Inpatient treatment is recommended for infants ≤8 weeks of age with poor social security or with other concomitant conditions affecting the cardiovascular system, respiratory system (including respiratory angiomas), or who require maintenance of blood glucose levels. ② For infants aged >8 weeks with good social security and no serious concomitant diseases, outpatient treatment with regular monitoring is recommended. Cardiovascular system monitoring Changes in heart rate and blood pressure are most pronounced 1 to 3 h after application of propranolol. Monitor changes in heart rate and blood pressure before treatment and at 1h and 2h after starting the drug, at each increasing dose (0.5 mg?kg-1?d-1), including at least one test when the target dose is reached. If heart rate and blood pressure are abnormal, monitor until heart rate and blood pressure return to normal. Treatment effects are usually most pronounced after the first dose; therefore, repeated cardiovascular monitoring is not necessary without dose changes unless the patient is too young or has concomitant disease affecting the cardiovascular system or respiratory system, including symptomatic airway angiomas. Accurate detection of blood pressure in children is not easy, so early detection of bradycardia is important. Whereas measuring heart rate is relatively simple, the standard values for bradycardia have been clarified and are determined as follows: (1) newborns (<1 month), <70 beats/min; (2) infants 1 to 12 months, <80 beats/min; and (3) children >12 months, <70 beats/min. At 1 to 6 months of age, infant blood pressure is highly variable and there are no uniform standard data. Moreover, most normal blood pressure measurements in children are based on auscultatory measurements for the evaluation of hypertension or hypotension. Oscillometric instruments are easy to use and have minimal observational error, but the readings do not agree with auscultation; therefore, obtaining accurate blood pressure values in newborns and infants is difficult and requires the assistance of an experienced specialist. Age-based standard parameters for systolic blood pressure in infants are difficult to obtain; as a general rule, systolic blood pressure below the following should be considered abnormal (systolic blood pressure below the 5th percentile as measured by oscillometry (i) newborns: <57 mmHg (<5th percentile) or 64 mmHg (2 standard deviations below normal); (ii) 6-month-old infants: <85 mmHg (<5th percentile) or 65 mmHg (2 standard deviations below normal); (iii) 1-year-old infants: <88 mmHg (<5th percentile) or 66 mmHg (2 standard deviations below normal). percentile) or 66 mmHg (2 standard deviations below normal). Children whose heart rate and systolic blood pressure fall below these targets during the initiation of medication or increase in drug dose should be considered at high risk and monitored closely. Follow-up monitoring Heart rate and blood pressure should be measured before treatment and 1h and 2h after each increase in drug dose (0.5 mg?kg-1?d-1), including at least once after reaching the target dose. Ambulatory electrocardiographic monitoring (Holtermonitoring) is not used as a routine monitoring after propranolol application. No information is available on the use of ambulatory ECG monitoring in children with hemangioma treated with propranolol for bradycardia or arrhythmias, and this expert consensus does not recommend ambulatory ECG monitoring as a routine monitoring tool. Prevention of hypoglycemia Early intervention is needed when signs and symptoms of hypoglycemia appear, and measures should also be taken to reduce the risk of hypoglycemia. Random glucose monitoring in the study did not detect asymptomatic hypoglycemia and the timing of hypoglycemic events is variable and unpredictable, so routine glucose testing is not recommended. Propranolol should be administered immediately after daytime feeding. Children should be supervised to ensure that they are taking the medication regularly and avoid prolonged fasting. In healthy children, the risk of hypoglycemia is age-dependent and can occur after 8 h of fasting in children 0 to 2 years of age. Infants at 6 weeks should be fed at least once for 4 h, those at 6 weeks to 4 months at least once for 5 h, and those at 4 months at least once for 6 to 8 h. Propranolol should be discontinued if serious illness occurs while taking the drug, especially if the illness restricts feeding via the mouth. When fasting is required for sedation and surgical operations or imaging are performed, supplementation with Pedialyte electrolyte solution (Pedialyte) or sedation with glucose-containing fluids may be indicated. Preoperative medication and anesthesia may hide the child's symptoms; however, preoperative monitoring of blood glucose levels may improve this phenomenon. Special care should be taken with propranolol in premature infants or those taking other medications that affect blood glucose levels.