Diagnosis and Management of Infantile Hemangioma

scans, had a sensitivity of 20 percent (95% CI: 3.30% to 71.19%), and the sensitivity of MRI was
100 percent (95% CI: 66.21% to 100%).
In a retrospective cohort study, 70 ultrasound was commonly used as the first imaging
technique and identified lesions in 42 of 44 patients (sensitivity of 95%). Ultrasound identified
direct shunts in 9 of 10 patients with shunts identified by angiography. Children with findings of
congestive heart failure or aortic tapering on imaging were more likely to require intervention for
their hepatic lesion. Given the small number of studies and heterogeneity of interventions and
outcomes, we considered SOE to be insufficient for all outcomes.
Key Question 2. Effectiveness and Harms of Corticosteroids
or Beta-Blockers
Network Meta-Analysis of the Effectiveness of Pharmacologic
Agents
Full and detailed methods and results of the network meta-analysis are available in Appendix
D. Effect measures (Table 4) reflect effects on the logit scale and are not immediately clinically
interpretable, but they demonstrate the nominal superiority of beta-blockers. Specifically, oral
propranolol had the highest estimated effect size, though there is overlap among the credible
intervals of the estimates. The estimated additive effect of intralesional delivery for propranolol
was -6.9 (95% Bayesian credible interval [BCI]: -11.9 to -2.5).
Table 4. Posterior estimates of effect size
Agent Mean Standard Error
95% Credible
Interval
Oral propranolol 6.0 0.7 [4.7 7.5]
Topical timolol 3.5 0.5 [2.4 4.6]
Intralesional triamcinolone 3.3 0.8 [1.7 4.9]
Oral steroid 2.6 0.5 [1.8 3.6]
Note: Table illustrates posterior estimates of effect size, on logit scale, relative to control, along with standard error and 95%
credible interval. Positive values indicate increased clearance relative to control, negative indicate decreased clearance.
More clinically interpretable are the clearance rates, presented in Figure 5, which presents
mean expected clearance rates and our confidence bounds around the estimates. The expected
efficacy of control arms was estimated to be 6 percent (95% BCI: 1% to 11%), i.e., we would
expect to see, on average, 6 percent clearance of IH in children who receive placebo or no
treatment during the study period. All non-control treatments were estimated to have a larger
expected clearance than control.
The largest mean estimate of clearance was for oral propranolol (95%, 95% BCI: 88% to
99%). Clearance associated with the use of oral steroids was 43% (95% BCI: 21% to 66%), thus
providing a clearance rate intermediate to control and use of beta-blockers. Triamcinolone, an
intralesional injectable steroid, had a higher clearance rate than oral steroids, with wide BCI
(58%; 95% BCI: 22% to 99%). Few data were available for intralesional propranolol, which is
reflected in its larger credible interval (estimated clearance: 9%, 95% BCI: 0 to 45%).
With fairly wide confidence bounds and limited data in some areas, the relative differences
among estimates are of greater importance than absolute effects in interpreting these results. The
estimates provide a relative ranking of anticipated rates of lesion clearance among treatment
options. Families and clinicians making treatment decisions should also factor in elements such
22