The American Academy of Pediatrics' first infantile
hemangioma clinical practice guideline discourages the traditional "wait
and see" approach. Instead, the report calls for early identification of
certain hemangiomas that may cause scarring or medical problems. The goal:
prompt treatment - when needed - for best outcomes.
In its first-ever clinical practice guideline
for infantile hemangiomas, the American Academy of Pediatrics (AAP) calls for a
shift in approach to the common, bright red or bruise-like birthmarks that
appear shortly after a baby is born. Infantile hemangiomas, the most common
benign (non-cancerous) tumor of childhood, usually are harmless and start to go
away on their own after a period of rapid growth. The AAP emphasizes that early
identification and monitoring is essential, however, to allow for timely
treatment that can prevent medical complications or permanent disfigurement.
The report, "Clinical Practice Guideline for the Management of Infantile Hemangiomas," will be published
in the January 2019 Pediatrics (available online Dec. 24). It marks the
first time the AAP has developed guidelines for these birthmarks, clusters of
extra blood vessels that appear on up to 5 percent of infants. While some can
form inside a child’s body, most form on or within the skin. Superficial
hemangiomas may look like rubbery, bumpy red “strawberry” marks, while those
deeper in the skin may resemble bruised swelling.
“The traditional approach to infantile hemangiomas was very
hands-off, since most begin to go away on their own without causing problems,”
said Dr. Ilona Frieden, MD, FAAP, vice-chairperson of the multidisciplinary AAP
subcommittee that spearheaded the new guidelines.
“But for some hemangiomas, waiting until they cause problems
misses a critical window of opportunity for treatments that can prevent
significant complications such as permanent scarring, skin breakdown, or
medical problems,” she said.
The AAP guideline emphasizes which infantile hemangiomas are
most likely to pose problems and may need treatment. Hemangiomas located on
certain parts of the body are more likely to become open sores, bleed, become
infected and scar, for example. Those near the child’s eyes, nose or mouth may
affect the child’s ability to see, eat, or breathe well. Large hemangiomas on
facial features, such as the nose or lip, can also distort growth. In rare
cases, especially when there are five or more hemangiomas, others may grow
inside the body and need to be monitored with imaging tests.
Infantile hemangiomas typically grow most rapidly between 1
and 3 months of age and tend to stop growing by about 5 months of age,
according to the guidelines. This benchmark was determined after an extensive
review of research, and is earlier than once believed, said Daniel P. Krowchuk,
MD, FAAP, chairperson of the clinical practice guideline subcommittee.
“This is why the AAP recommends treating problematic
hemangiomas ideally by 1 month of age,” Dr. Krowchuk said. “The goal is to keep
them from getting any bigger during their period of rapid growth, or to make
them shrink more quickly,” he said.
The guidelines also outline the best treatments for problem
hemangiomas. The recommended treatment of choice is propranolol, a beta blocker
medication used for many years to treat high blood pressure that is now
commonly given by mouth to slow the growth of hemangiomas. Oral steroids have
been largely replaced by safer and more effective options but may still be used
in select cases. Topical medications applied directly on, or injected
into, the skin may be used for small, superficial hemangiomas.
“Because surgery will always leave a scar itself--and
because most hemangiomas get better with time--early surgery is only
recommended for a small minority of cases,” Dr. Krowchuk said.
The subcommittee was composed of infantile hemangioma
experts in the fields of dermatology, cardiology, hematology-oncology,
otolaryngology-head and neck surgery, plastic surgery, radiology and
epidemiology, as well as general pediatrics, policy implementation and a parent
representative. The practice guideline underwent comprehensive review by the
AAP, including AAP councils, committees and sections and select outside
AAP offers information for parents on “strawberry marks” and
other types of infantile hemangiomas in a new article on HealthyChildren.org,
the AAP website for parents. The article will be posted December 24 at this
The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit www.aap.org and follow us on Twitter @AmerAcadPeds