Key Action Statement 3A: Clinicians should use oral propranolol as the first-line agent for IHs requiring systemic treatment (grade A, strong recommendation).

Aggregate Evidence QualityGrade A
BenefitsImprove IH treatment; avoid adverse effects associated with oral steroid therapy
Risks, harm, costOccurrence of adverse effects associated with propranolol use (see KAS 3D); medication cost and cost of hospitalization if drug is initiated while infant is an inpatient
Benefit-harm assessmentBenefits outweigh harms
Intentional vaguenessNone
Role of patient preferenceParents should be involved in shared decision-making regarding treatment.
ExclusionsCaution (but not exclusion) in infants <5 wk of age, postconceptional age of <48 wk; potential exclusions that require appropriate subspecialty evaluation and/or clearance; evidence of cardiogenic shock or heart failure; sinus bradycardia; heart block greater than first degree; known or suspected PHACE syndrome, including presence or risk of coarctation of the aorta and cerebrovascular anomalies; known asthma and/or reactive airway disease; known hypersensitivity to propranolol
StrengthStrong recommendation
Key references3,46,5961