HEMANGEOL prevents the response of endogenous catecholamines to correct hypoglycemia and masks the adrenergic warning signs of hypoglycemia, particularly tachycardia, palpitations and sweating. HEMANGEOL can cause hypoglycemia in children, especially when they are not feeding regularly or are vomiting; withhold the dose under these conditions.
Hypoglycemia may present in the form of seizures, lethargy, or coma. If a child has clinical signs of hypoglycemia, parents should discontinue HEMANGEOL and call their health care provider immediately or take the child to the emergency room. Concomitant treatment with corticosteroids may increase the risks of hypoglycemia. Monitor heart rate and blood pressure after treatment initiation or increase in dose. Interrupt treatment in the event of a lower respiratory tract infection associated with dyspnea and wheezing.
It has recently been used in the treatment of infantile hemangiomas IHs after growth arrest of an infant's hemangioma was incidentally noted when propranolol was started for obstructive hypertrophic myocardiopathy. We describe 3 children receiving treatment with oral propranolol for IHs who experienced life-threatening events in association with hypoglycemia and hypothermia.
Our purpose is to highlight this idiosyncratic reaction and increase awareness for both the prescribing physician and the emergent care provider who may be caring for the child in an acute setting.
A healthy month-old girl presented with an unresectable, vision-threatening IH on the upper eyelid. She was taking no other medications and had no history of hypoglycemia. The night before hospitalization she was fussy but was otherwise well and ate a normal dinner.
On the day of the event she ate breakfast and had no fever, nausea, vomiting, or diarrhea. Because of fussiness she received 1 dose of ibuprofen and a small amount of benzocaine gel to her gums for teething. Two hours after receiving her morning dose of propranolol she became pale, cold, clammy, and increasingly unresponsive, and her father called She was taken by paramedics to the hospital and given intravenous IV fluids before arrival at the emergency department ED.
To convert glucose to millimoles per liter, multiply by 0. She was rapidly revived with glucose-containing IV and oral fluids. Findings from a computed tomographic scan of the head were normal. She was discharged from the hospital within 24 hours and has done well off all medications, with no apparent sequelae or similar clinical episodes to date 10 months as of time of writing. A healthy month-old girl with a nasal tip IH, previously treated with topical clobetasol propionate at age months was started on propranolol for continued growth of her hemangioma.
There was no history of hypoglycemia or other medications. The initial dose of propranolol hydrochloride, 0. After 2 months there was minimal change in the size of the IH, and the propranolol hydrochloride dosage was increased to 1.
During an intercurrent illness fever, nausea, vomiting , propranolol was withheld. After 4 days she began eating normally, and propranolol was restarted. The day prior to hospitalization, she ate dinner at 5 PM , had propranolol at 6 PM , and went to bed. The mother found her 13 hours later in bed, cold, clammy, and unresponsive.
A minute seizure occurred prior to transport by ambulance to the ED. Her rectal temperature was Thirty minutes after arrival, she had another seizure and was given lorazepam. She was admitted to the hospital and had no further episodes of hypoglycemia or seizures for the next 48 hours fingerstick glucose level checked every hours. Her organic and amino acid levels were normal. A healthy 5-week-old, full-term girl presented with a nasal tip IH that was increasing in size rapidly.
At 10 months of age, 2. She was given dextrose intravenously and taken to the ED, where her rectal temperature was Her parents noted that she had developed a cough and runny nose 1 day prior, but that they felt she had been eating normally. A nasopharyngeal swab for respiratory syncytial virus was taken, and the findings were positive.
She was admitted to the pediatric unit, and her propranolol hydrochloride dosing was decreased to twice daily 1. Albuterol nebulizer treatments and IV fluids were administered. The parents were instructed to give the propranolol only twice daily until follow-up with the dermatology and cardiology departments was arranged.
Treatment of IHs is designed to control growth, minimize deformity, preserve function, and minimize psychological and emotional stress. Systemic pharmacotherapy is most often used to treat large IHs that present a surgical challenge or those causing functional or life-threatening problems. Well-designed studies evaluating the efficacy and safety of various treatments are lacking, with anecdotal reports and case series leading to currently accepted treatments. Agents traditionally used in treating IHs include oral and intralesional corticosteroids, but other treatments, such as interferon alfa and vinca alkaloids, have also been used.
Propranolol has recently been used in the treatment of IHs after improvement in color, softening, growth arrest, and even regression of an IH was incidentally noted when propranolol was started for treatment of hypertrophic myocardiopathy. Propranolol has been used in children for many years both for cardiac and noncardiac diseases.
Although it has been well studied in adults, experience in infants and children has been mainly anecdotal. The most common serious adverse effects of propranolol include bradycardia and hypotension. Bronchospasm can be seen in patients with reactive airway disease. Other adverse effects include congestive heart failure, depression, nausea, vomiting, abdominal cramping, sleep disturbance, and night terrors. Interestingly, even today, newer indications of this age-old drug are being discovered.
Moreover, propranolol treatment has been found to be cost-effective when compared to other corresponding treatment options for individual indications. In this article, we attempt to recount the journey of propranolol right from its inception to the present day.
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