Diagnosis and Management of Infantile Hemangioma

Results
We present results for Contextual Questions (CQ) followed by those for our network metaanalysis,
which includes studies of beta-blockers and steroids. We then present results for each
Key Question (comparative effectiveness questions).
We identified 966 publications potentially relevant to the CQ in our database searches. We
also flagged studies for potential relevance to CQ in our screening of studies for Key Questions.
We included 68 studies in the narrative summary of information addressing CQ.
CQ1. Natural History of Untreated IH and Adverse Outcomes
of Untreated IH
Natural History of IH
IH have been estimated to occur in around 5 percent of neonates and infants. 2 IH may be
classified into subtypes including localized, segmental, indeterminate, and multifocal. Several
studies have shown most IH to be of the localized type, and regardless of type, most IH involute
with time; 30-33 however, the presentation and course of IH in individual children are
heterogeneous. 34 IH usually present within the first month of life and undergo rapid proliferation
over the first several months of life. 35,36 One study found that IH reached 80 percent of their final
size by 5 months of age. 9 Many experts recommend referral at an early age (as early as 4 to 8
weeks of life) to subspecialists given this rapid proliferation. 9
Segmental IH are more likely to have more prolonged growth, defined as after 9 months of
age. 9,37 Involution typically starts by 1 year of age, but the timing of involution varies
markedly. 38,39 In one large retrospective review of 1109 referred patients (median age=8 months)
conducted in the pre-propranolol era, 769 were returned to the care of their primary provider
without subspecialty followup, and only 102 (9%) required intervention. 40
Most lesions involute by age 5 to 7, 41,42 though timing varies, and disfigurement may
remain. 22,38,43,44 The majority (80%) of lesions involuting after age 6 years in one series resulted
in residual scarring or telangiectasia, compared with 38 percent involuting before age 6. 35 In
studies of referred populations, residual lesions (e.g., telangiectasias, atrophy, fibrofatty tissue,
hypopigmentation) were reported in 25 to 69 percent of untreated IH. 38,45 Lesions affecting
visual cortex development may result in lasting deficits in vision even after resolution of the
IH. 46
Indications for Treatment
The major indications for treatment of IH include risks of ulceration, disfigurement, and
functional impact. 39,47-52 While psychological impact on the child also plays a role in treatment
decisions, data on the effects of IH on quality of life for the child suggest minimal impact. Such
data are often limited by the necessity to parent-report in this young population. 22,53,54 Estimates
of complications from IH vary but are generally noted to occur in approximately 30 percent of
the studied population. 31,32,55 One study found higher initial complication rates for patients
referred to a surgical center, potentially due to the higher likelihood of more advanced lesions
being referred. 56 Given that the literature typically includes children treated at referral centers, it
is likely that the overall complication rate may be higher in study populations than in the general
population.
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