Summary of Key Action Statements (KASs) for the Management of IHs

In Managing IH, Recommendations for CliniciansEvidence Quality; Strength of Recommendation
1. Risk stratification
 1A. Classify an IH as high risk if there is evidence of or potential for the following: (1) life-threatening complications, (2) functional impairment or ulceration, (3) structural anomalies (eg, in PHACE syndrome or LUMBAR syndrome), or (4) permanent disfigurementX; strong
 1B. After identifying an IH as high risk, facilitate evaluation by a hemangioma specialist as soon possibleX; strong
2. Imaging
 2A. Do not perform imaging unless the diagnosis of IH is uncertain, there are ≥5 cutaneous IHs, or associated anatomic abnormalities are suspectedB; moderate
 2B. Perform ultrasonography as the initial imaging modality when the diagnosis of IH is uncertainC; weak
 2C. Perform MRI when concerned about associated structural abnormalities (eg, PHACE syndrome or LUMBAR syndrome)B; moderate
3. Pharmacotherapy
 3A. Use oral propranolol as the first-line agent for IHs requiring systemic treatmentA; strong
 3B. Dose propranolol between 2 and 3 mg/kg per d unless there are comorbidities (eg, PHACE syndrome) or adverse effects (eg, sleep disturbance) that necessitate a lower doseA; moderate
 3C. Counsel that propranolol be administered with or after feeding and that doses be held at times of diminished oral intake or vomiting to reduce the risk of hypoglycemiaX; strong
 3D. Evaluate patients for and educate caregivers about potential adverse effects of propranolol, including sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotensionX; strong
 3E. May prescribe oral prednisolone or prednisone to treat IHs if there are contraindications or an inadequate response to oral propranololB; moderate
 3F. May recommend intralesional injection of triamcinolone and/or betamethasone to treat focal, bulky IHs during proliferation or in certain critical anatomic locations (eg, the lip)B; moderate
 3G. May prescribe topical timolol maleate as a therapy for thin and/or superficial IHsB; moderate
4. Surgical management
 4. May recommend surgery and laser therapy as treatment options in managing selected IHsC; moderate
5. Parent education
 5. Educate caregivers of infants with an IH about the condition, including the expected natural history and its potential for causing complications or disfigurementX; strong