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Treatment for haemangiomas with beta blockers

  • Haemangiomas (he-man-gee-omas) are a common type of birthmark that are sometimes called a strawberry mark because of their bright, red strawberry colour. They often develop shortly after birth and grow fast in the first few months of life. They then stop growing and very slowly shrink and fade away over several years, even without treatment. One in 15 babies will develop a haemangioma.

    Haemangiomas usually don’t cause any problems, with most disappearing completely on their own.

    As many haemangiomas typically tend to resolve by themselves, most do not need any treatment. However, a haemangioma will need urgent treatment if:

    • it is pressing on or obstructing an important structure, such as the eyes, nose, lips, ears, genitals or windpipe
    • it is very large
    • it bleeds or becomes an open sore that is painful and does not heal
    • its appearance may cause problems for your child’s self-esteem and social development when they reach school age

    Treatment should be given when the benefits of treatment outweigh the risks involved. All treatments have side effects that your doctor and nurse practitioner will discuss these with you.

    How do beta blockers work?

    Beta blockers are the first line of treatment for haemangiomas. They may be in the form of either gel drops (timolol) applied to the skin or as tablets or a liquid (propranolol or atenolol) taken by mouth. It is not understood how beta blockers work in haemangiomas but in most children, beta blockers will stop further growth of the haemangioma and reduce the size and redness.

    Beta blockers are commonly used in children to treat other problems including migraine, glaucoma, high blood pressure and some heart problems. Beta blockers have been used in paediatric health for more than fifty years and have an excellent safety record in young children. 

    Topical beta blockers (timolol) - drops applied onto the skin

    Timolol XE 0.5 per cent gel-forming drops may be used on flat or small haemangiomas. A prescription is required for this medication. Follow the prescribed dose (usually one drop applied morning and evening) – your doctor or nurse practitioner will confirm this with you. Use a clean finger to spread the timolol over the surface of the haemangioma. There is no need to cover the haemangioma with anything afterwards. If the haemangioma develops into an open wound, stop the timolol and contact your doctor or nurse practitioner.

    Oral beta blockers (propranolol or atenolol) - taken by mouth as syrup or tablets

    Oral beta blockers can be used to treat larger haemangiomas. The dose is calculated according to your child’s weight. Usually treatment will start on a lower dose and will be increased to the full dose after a few days. The medicine is usually given twice a day with feeds. As your baby grows, the doctor or nurse practitioner may choose to adjust the dose.

    Propranolol is available with a prescription as 10mg tablets (many children can take these crushed in a little water or milk, or taken in food for older children), or as a syrup made up by the pharmacist.

    The strength is often 5 mg/ml but your doctor may use a different strength, so always follow their instructions.

    Atenolol is available with a prescription as a syrup strength of 5mg/ml. 

    Care at home when taking oral beta blockers

    • If your child is wheezy, is not feeding normally, is unwell, or is vomiting, stop giving the oral medicine and contact your doctor or nurse practitioner. In most instances, oral beta blockers can be safely restarted when your child is feeding well again.
    • Oral beta blockers should be given with feeds (just before, during or just after).
    • Oral beta blockers may need to be discontinued for two days prior to any planned surgery – discuss this with the surgeon and anaesthetist.
    • If a dose of beta blockers is accidentally missed, do not give an extra dose.
    • Routine immunisations can continue to be given while on beta blockers.

    Possible side effects of oral beta blockers

    Many children will have cold hands and feet when taking a beta blocker. This is not a problem.

    Occasionally a child may develop sleep disturbance, diarrhoea or vomiting when taking oral beta blockers. If this occurs, stop the medicine and consult your doctor or nurse practitioner.

    Serious side effects are very rare and include low blood sugar, lowered heart rate and wheezing or worsening of asthma. If your child is drowsy or lethargic stop, the medicine and attend your local GP or your local Emergency Department.

    If your child is not feeding normally, stop giving the medicine and contact your doctor or nurse practitioner.

    Follow-up and monitoring of treatment

    If the haemangioma is responding well, there may be no need to increase the beta blocker dose as your child’s weight increases. Treatment may continue for up to 24 months but in most cases stops around 12 months of age. Beta blockers can be stopped safely without the need for reducing the dose

    Some haemangiomas will grow again after stopping treatment. This is often minimal and temporary. However, in some children, the regrowth can be significant and your specialist may recommend restarting treatment for an additional few months

    Laser therapy and surgery are other treatment options if beta blockers are unsuccessful or not appropriate for your child. For more information see the Haemangiomas of infancy (strawberry naevus) fact sheet.

    Key points to remember

    • Give the medication to your child strictly as directed.
    • Give your child oral beta blockers with feeds. If your child is not feeding normally, or is vomiting, do not give the medicine. Call your doctor or nurse practitioner.
    • If your child has a wheeze when they breathe, do not give the oral beta blocker. Call your doctor or nurse practitioner.
    • If a dose is missed, do not give an extra dose of the topical or oral beta blockers.
    • Do not use topical beta blockers on skin with an open wound.

    For more information

    Common questions our doctors are asked

    Should I give the dose of oral beta blockers during or after a feed?

    As long as your infant is feeding well, this doesn’t matter. If your infant or child is not feeding normally, stop giving the oral beta blocker (see above).

     

    Developed by The Royal Children's Hospital Dermatology Department, Plastic & Maxillofacial Surgery, and Department of General Medicine. We acknowledge the input of RCH consumers and carers.

    Reviewed May 2021

    Kids Health Info is supported by The Royal Children’s Hospital Foundation. To donate, visit www.rchfoundation.org.au.


Disclaimer  

This information is intended to support, not replace, discussion with your doctor or healthcare professionals. The authors of these consumer health information handouts have made a considerable effort to ensure the information is accurate, up to date and easy to understand. The Royal Children's Hospital Melbourne accepts no responsibility for any inaccuracies, information perceived as misleading, or the success of any treatment regimen detailed in these handouts. Information contained in the handouts is updated regularly and therefore you should always check you are referring to the most recent version of the handout. The onus is on you, the user, to ensure that you have downloaded the most up-to-date version of a consumer health information handout.