Growing up with a facial hemangioma: parent and child coping and adaptation

An analysis of information about infantile hemangiomas on TikTok: A cross-sectional study

The video app TikTok, a controversial platform, has increasingly been utilized for the dissemination of health-related topics. In this study, the quality of information on the top 50 most viewed TikTok videos on infantile hemangiomas (IHs) labeled #hemangioma was analyzed. The results showed that the videos were skewed toward more severe subtypes of IH, and most were directed at raising awareness about IH or combating stigmatizing attitudes toward birthmarks. Providers should be aware that social media applications such as TikTok are a commonly used venue for parents to cope and connect but may relay inaccurate or misleading information.

Mental Health of School-Aged Children Treated with Propranolol or Atenolol for Infantile Hemangioma and Their Parents

BACKGROUND

Infants with infantile hemangioma (IH) have been effectively treated with propranolol or atenolol. Concerns were raised about the mental health of these children at school age, due to central nervous system effects of propranolol and visible nature of IH.

OBJECTIVE

This study aimed to compare the mental health at school age of children treated with propranolol to children treated with atenolol for IHs and their parents.

METHODS

This two-centered cross-sectional study included children aged ≥6 years and treated with either propranolol or atenolol for IH during infancy. Children's outcomes were performance-based affect recognition (Dutch version of the Developmental Neuropsychological Assessment-II [NEPSY-II-NL]), parent-reported emotional and behavioral functioning (Child Behavioral Checklist [CBCL]), and health-related quality of life (KIDSCREEN-27). Parents' outcome was parenting stress (Parenting Stress Questionnaire [OBVL]).

RESULTS

Data of 105 children (36 propranolol, 69 atenolol; 6.0-11.8 years) were analyzed. Mental health outcomes did not differ between both β-blocker groups. Although overall functioning was in line with norms, children presented specific problems concerning affect recognition, parent-reported attention, and social quality of life. Parents showed increased physical symptoms, depressive symptoms, and parent-child relationship problems.

CONCLUSION

No difference in mental health at school age was found between children treated with propranolol or atenolol for IH. Although few overall mental health problems were found, specific problems require follow-up. Follow-up of children should be directed toward affect recognition, attention, and social functioning in daily life. Problems reported by parents could be ameliorated by mental health support during and after their infant's β-blocker treatment.

Feasible Removal of Facial Hemangiomas Under Local Anesthesia in Young Children

BACKGROUND

Facial Hemangiomas are often recommended to be removed exclusively in the operating room under general anesthesia, especially for children under the age of 4. Assumed parental and patient anxiety and possible blood loss pushes surgeons away from attempting excision under local anesthesia.

METHODS

A review was conducted to assess the outcomes of children who underwent excision of facial hemangiomas under local anesthesia alone by 1 plastic surgeon with a minimum of 3 months follow-up. Complications and hemangioma recurrence were recorded. A survey was given 3 to 6 months after treatment to assess parental satisfaction, anxiety, and thought process about anesthesia.

RESULTS

Eighteen children (9 males and 9 females) underwent in-office excision between 2020 and 2021. The mean age of this cohort was 12 months ( ranging 2-52 m). The average facial hemangioma size was 2.088 cm (ranging 1.0-3.2 cm). Ten patients experienced complete resolution (56%) at 12-month follow-up. There were no hospitalizations or cases of significant (>10 mL) blood loss, infection, dehiscence, hematoma, or scar hypertrophy. The average level of parental anxiety before the procedure was 3.3/10, and 1.6/10 after the procedure. Total 13/14 parents gave 4/4 ratings for satisfaction with the quality of care, team responsiveness, pain management, and management of expectations.

CONCLUSIONS

Facial hemangioma removal under local anesthesia alone is a safe and feasible alternative treatment method for patients younger than 4 years of age.

Analysis of Therapeutic Decisions for Infantile Hemangiomas: A Prospective Study Comparing the Hemangioma Severity Scale with the Infantile Hemangioma Referral Score

BACKGROUND

In view of the high incidence of infantile hemangioma (IH) in infants and young children, a comprehensive and reasonable evaluation scale for referral is urgently needed. This study compared the influence of the Hemangioma Severity Scale (HSS) and the Infantile Hemangioma Referral Score (IHReS) on treatment decisions for infantile hemangioma patients.

OBJECTIVE

We aimed to establish a reliable and effective evaluation method for referral.

METHODS

This was a prospective study to determine whether treatment was needed for IH patients after evaluation with the HSS and IHReS.

RESULTS

A total of 266 consecutive referred IH patients were evaluated for the risk of IH, and the treatment rate was 80.8%. The area under the curve (AUC) of the subject receiver operating characteristic curve (ROC) of treatment decision making after referral by the HSS was 0.703 (95% CI: 0.634-0.772), and after referral by the IHReS was 0.892 (95% CI: 0.824-0.960).

LIMITATIONS

This was a single-center study.

CONCLUSIONS

For decisions regarding the treatment of IH patients, the IHReS has a higher efficiency and sensitivity than the HSS. However, the specificity of the IHReS is lower than that of the HSS.

An exploration of the experiences of self-disgust in people with epilepsy

AIM

To explore the experiences of self-disgust in people with epilepsy and their understandings about this.

DESIGN

A qualitative study informed by thematic analysis.

METHOD

Ten adults (out of 43 individuals initially interested in taking part, with 38 of those with levels of self-disgust categorised as high) with epilepsy and uncontrolled seizures were recruited online and participated in a telephone semi-structured interview.

RESULTS

Three themes illustrated the development and experiences of self-disgust in adults with epilepsy and uncontrolled seizures, and how participants attempted to manage this. The first theme described the development of self-disgust as a result of the physical manifestations of seizures but also the experiences of others' disgust reactions to seizures and an expectation of rejection. The second theme described the enduring and often unescapable experiences of self-disgust, with the final theme illustrating how participants attempted to manage experiences of self-disgust, particularly through avoidance.

DISCUSSION

This study was the first to explore qualitatively the experiences of self-disgust in people with epilepsy. People with epilepsy experience disgust in reaction to the physical symptoms of seizures and these disgust-based feelings appeared to become internalized following others' disgust reactions. Avoidance as a strategy to manage self-disgust could be protective but might have inadvertently maintained feelings of self-disgust.

Development and validation of psychological status questionnaire for parents of infantile hemangiomas

BACKGROUND

Infantile hemangioma (IH) is the most frequent benign tumor of infancy which impacts the psychological status of parents of affected children. Parental psychological status has a significant effect on the therapeutic effect and long-term prognosis of IH children. However, no standard questionnaires had been established previously to assess the psychological status of Chinese parents of children with IH.

METHODS

This study prospectively developed and validated a psychological status instrument for the assessment of parents of patients with IH and to identify clinical features with effects on the psychological status. A total of 350 parents completed the 35-item Psychologic Status Questionnaire for parents of Infantile Hemangiomas (IH-PSQ) and provided demographic information. The IH-PSQ was refined via item analysis, validity analysis (including exploratory factor analysis and criterion-related validity) and reliability analysis (including internal consistency reliability, split half reliability, and test-retest reliability).

RESULTS

The dimensionality of the items was evaluated using factor analysis, with results suggesting 5 factors: anxiety, depression, psychological imbalance, disease shame, and disease fear. The final instrument consists of 4 scales with a total of 23 items. Construct validity was demonstrated and IH-PSQ showed good internal coherence (Cronbach's α: 0.957), good split half reliability (0.971), and good test-retest reliability (correlation coefficient: 0.967). The correlation coefficient between the Self-Rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) of children with IH was 0.874 and 0.754, respectively. Multiple linear regression analysis found that some characteristics will affect the score of IH-PSQ.

CONCLUSIONS

The IH-PSQ contains 5 dimensions and 23 entries, and with good reliability and validity, can objectively and effectively evaluate the psychological status of IH parents. Certain clinical characteristics of IH families, including parents' own factors (including their monthly income and cultural level) and disease-related factors of affected children (including the duration of illness, tumor size, with or without complications, single or multiple, whether being treated or not), were associated with a greater impact on IH-PSQ.

A Novel Approach in the Surgical Management of Nasal Tip Hemangiomas: A 26-Year Experience

Infantile hemangiomas are common benign tumors of infancy with a predilection for the face. Nasal-tip hemangiomas, termed the "Cyrano deformity," can have especially devastating psychological effects. The ideal surgical approach and timing for these patients is unclear, as numerous designs have been reported in the literature. The authors present a novel approach to nasal tip reconstruction involving an algorithmic approach to incision selection and leaving a thin rim of hemangioma tissue under the dermis after debulking to minimize skin envelope atrophy. Nineteen cases were treated with the senior author's preferred method, with a mean age of 3.3 years and follow-up of 2.5 years. At follow-up, 10 patients were deemed by the senior author to have a very good aesthetic result, and the remaining nine patients were deemed to have an excellent one. The results of this study suggest that surgical intervention as early as 3 to 4 years of age is safe and provides good aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Infantile Hemangioma: An Updated Review

BACKGROUND

Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life.

OBJECTIVE

To familiarize physicians with the natural history, clinical manifestations, diagnosis, and management of infantile hemangiomas.

METHODS

A Pubmed search was conducted in November 2019 in Clinical Queries using the key term "infantile hemangioma". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

The majority of infantile hemangiomas are not present at birth. They often appear in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches. Then, they grow rapidly in the first 3 to 6 months of life. Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated. Deep lesions are bluish and dome-shaped. Infantile hemangiomas continue to grow until 9 to 12 months of age, at which time the growth rate slows down to parallel the growth of the child. Involution typically begins by the time the child is a year old. Approximately 50% of infantile hemangiomas will show complete involution by the time a child reaches age 5; 70% will have disappeared by age 7; and 95% will have regressed by 10 to 12 years of age. The majority of infantile hemangiomas require no treatment. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration in areas where serious complications might ensue, interference with vital structures, life- or function-threatening complications, and significant disfigurement.

CONCLUSION

Treatment should be individualized, depending upon the size, rate of growth, morphology, number, and location of the lesion (s), existing or potential complications, benefits and adverse events associated with the treatment, age of the patient, level of parental concern, and the physician's comfort level with the various treatment options. Currently, oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas. Topical timolol may be considered for superficial infantile hemangiomas that need to be treated and for complicated infantile hemangiomas in patients at risk for severe adverse events from oral administration of propranolol.

Infantile Hemangioma: A Review of Current Pharmacotherapy Treatment and Practice Pearls

Infantile hemangioma (IH) is the most common vascular tumor of infancy, affecting as many as 5% to 10% of all infants. The exact cause is unclear, but specific risk factors, such as low birth weight, prematurity, female sex, white race, and family history are associated with IH development. Most IHs are benign and self-resolving, but a small subset of patients with IHs are at risk of severe or life-threatening outcomes. Systemic and topical β-blockers are effective and safe for use in pediatric patients and considered first-line treatment for both complicated and uncomplicated IHs. Recently published guidelines provide a thorough review of IH and management. This article focuses on IH pharmacotherapy and provides practice pearls to support health care providers in IH medication management.

Diagnosis and Management of Infantile Hemangiomas in the Neonate

Infantile hemangiomas (IH) are a common benign tumor of infancy, most being uncomplicated and not requiring therapy. Some IH may require treatment; the pediatric provider must be familiar with morphology, distribution, natural history, and associations of IH. Several treatment options are available for IH: current standard of care, oral propranolol. Other therapies include wound care; topical beta-blocker therapy for small, superficial, and uncomplicated IH; treatment of IH residua. In addition to functional compromise and other complications, potential for permanent deformity and eventual psychosocial stigmatization are important when considering the need for treatment of IH in a neonate or infant.

Clinical Practice Guideline for the Management of Infantile Hemangiomas

Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

Efficacy of Propranolol Between 6 and 12 Months of Age in High-Risk Infantile Hemangioma

BACKGROUND AND OBJECTIVES

There is no consensus on optimal treatment duration for propranolol in infantile hemangioma (IH). We evaluated the efficacy and safety of oral propranolol solution administered for a minimum of 6 months up to a maximum of 12 months of age in high-risk IH.

METHODS

This single-arm, open-label, phase 3 study was conducted in patients aged 35 to 150 days with high-risk IH in 10 hospitals between 2015 and 2017. The study comprised a 6-month initial treatment period (ITP) plus continuation up to 12 months of age if complete success was not achieved, a follow-up, and a retreatment period. Patients received oral propranolol twice daily (3 mg/kg per day). The primary end point was the success rate at the end of the ITP. Furthermore, the persistence of IH response and efficacy of retreatment was evaluated.

RESULTS

The success rate after 6 months of treatment was 47%, increasing to 76% at the end of the ITP. Of the patients who achieved success, 68% sustained success for 3 months without treatment, and 24% required retreatment. Of the 8 patients who were retreated, 7 achieved success. Adverse events, reported by 80% of patients, were mild, which were expected in this population or known propranolol side effects.

CONCLUSIONS

Oral propranolol administered beyond 6 months and up to 12 months of age meaningfully increases the success rate in high-risk IH. Success was sustained in most patients up to 3 months after stopping treatment. Retreatment was efficacious, and the safety profile satisfactory.

Oral propranolol for infantile hemangiomas beyond the proliferative phase

Infantile hemangiomas grow rapidly during infancy followed by gradual involution. After involution, residual lesions sometimes remain. Despite the prognosis for eventual involution, infantile hemangiomas often cause great psychosocial morbidity that affects patients and their parents. Oral propranolol usually induces earlier involution and redness reduction in infantile hemangiomas in the proliferative phase. However, to evaluate the effectiveness of oral propranolol for infantile hemangiomas beyond the proliferative phase is difficult because of spontaneous regression. We report five Japanese patients treated with 2 mg/kg per day of oral propranolol for infantile hemangiomas beyond the proliferative phase and compared with three untreated patients. After the oral propranolol treatment for 25 weeks, all the treated patients exhibited earlier color fading than untreated patients. Four patients reached nearly complete resolution. Adverse events occurred in three patients: cold, exanthema subitum and suspected of bronchial asthma, respectively. The propranolol treatment for the patient with suspected of bronchial asthma was suspended for 4 months. Recurrence after termination of treatment was not seen. Oral propranolol (2 mg/kg per day) is a safe and effective treatment for Japanese patients with infantile hemangiomas beyond the proliferative phase.

Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas

BACKGROUND

Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps.

METHODS

According to the deformities and patients' wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods.

RESULTS

From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation.

CONCLUSION

Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary.

Use of propranolol in a remote region of rural Guatemala to treat a large facial infantile haemangioma

We present a female infant with a right-sided facial and neck haemangioma, from a remote, resource-poor community in rural Guatemala. She received first-line treatment, propranolol, with marked reduction in tumour size and erythema. Treatment was stopped after 35 weeks due to recurrent diarrhoea and sustained weight loss. Propranolol can be used to safely treat infants with haemangiomas in remote, rural communities if there is adequate follow-up, education and communication. Periocular haemangiomas should be treated promptly to avoid visual impairment. Infants with large facial haemangiomas should be screened for Posterior fossa anomalies, Hemangioma, Arterial anomalies, Cardiac anomalies, and Eye anomalies (PHACE) syndrome, and specialists should be involved. The case also highlights the difficulty of providing treatment for a complex illness when basic health needs, such as food security and water sanitation, are limited.

Burden of Infantile Hemangioma on Family: An International Observational Cross-Sectional Study

BACKGROUND/OBJECTIVES

Infantile hemangioma (IH) is the most frequent benign tumor of infancy resulting from vascular proliferation. Data regarding the burden on families of children with IHs are limited. This study aimed to characterize IHs and provide a comprehensive evaluation of the burden of IHs on parents of children requiring systemic treatment in the United States and Europe.

METHODS

This noninterventional cross-sectional study included infants with newly diagnosed IH requiring systemic treatment. A parent or family member completed two questionnaires (Family Member questionnaire; Hemangioma Family Burden [HFB] questionnaire).

RESULTS

A total of 693 individuals were evaluable in five countries. IHs were observed in more girls than boys (66%-83% female) and the mean age at inclusion was 0.44 to 1.4 years. Approximately half of patients had superficial IHs, approximately 70% of cases affected the head, and approximately 80% of cases were moderate or severe. Most patients received propranolol treatment. Their child's IH affected more than 70% of parents in each country, but fewer than 10% were offered psychological support. Approximately half of all parents reported that their child's IH affected their professional life. The global HFB score was significantly (p < 0.001) greater with greater IH severity. More than 90% of parents in each country were satisfied with the care of their child's disease.

CONCLUSIONS

This international study using the validated HFB questionnaire provides further insight into the burden of IH and highlights potential areas for future focus in assisting families with affected children.

Evidence-Based Medicine in the Treatment of Infantile Hemangiomas

Over the past decade, the treatment of infantile hemangiomas has undergone dramatic breakthroughs. This review critically evaluates the latest literature that supports the myriad treatment options for infantile hemangiomas. It chronicles the fading role of steroid therapy and evolution of propranolol use as the major treatment modality. Although propranolol is helping this disease become more of a medical disease and less of a surgical dilemma, the report also reveals a continued search to find nonsystemic treatment options. In summary, this is an evidence-based medicine review for the treatment of infantile hemangiomas.

Vascular Anomalies in Pediatrics

A standardized classification system allows improvements in diagnostic accuracy. Multidisciplinary vascular anomaly centers combine medical, surgical, radiologic, and pathologic expertise. This collaborative approach tailors treatment and management of vascular anomalies for affected individuals.

Pulsed dye laser therapy for infantile hemangiomas: a systemic review and meta-analysis

BACKGROUND

Infantile hemangiomas (IH) are common pediatric tumors. This meta-analysis was performed to review the therapeutic efficacy and safety of pulsed dye laser (PDL) in the treatment of IH.

METHODS

Seven databases were searched, including PubMed, OvidSP, Karger, Elsevier, EMBASE, Web of Science and Wiley Online Library. The review collected the characteristics of year of publication, hemangiomas cases, prior treatment, laser parameters, adverse side, pretreatment symptom, and number of response from all articles.

RESULTS

A total of 1580 studies were identified, the first round search retrieved 39 articles met inclusion criteria. Of those, only 13 articles with 1529 hemangiomas were included in the meta-analysis. This meta-analysis demonstrated an overall resolution rate of 89.1% with 6.28% incidence of adverse effect.

CONCLUSION

PDL may be the effective modality to decrease the proliferative phase and accelerate rates of involution and resolution with few adverse events.

Vascular endothelial growth factor expression and pathological changes in the local tissue of facial hemangiomas following injections with pure alcohol

The aim of the present study was to investigate the association between the formation of hemangioma and the expression of vascular endothelial growth factor (VEGF) following local injections of pure alcohol in patients exhibiting hemangioma. Ten healthy subjects (control group) and 10 hemangioma patients (treatment group) were included in the study population, with the hemangioma patients receiving one injection of pure alcohol. The VEGF levels were evaluated in the treatment and control group subjects prior to and following the injection using enzyme-linked immunosorbent assay; furthermore, local tissue was excised to perform pathological analysis one week after the injections. The VEGF levels of the healthy group were identified to be significantly lower when compared with those of the treatment group prior to the injections (P<0.01) and one week after the injections (P<0.01), however, were not significantly different when compared with the treatment group one month after the injections (P>0.01). Therefore, serum VEGF concentrations in the peripheral blood may be a clinical indicator of the efficacy of clinical treatment and aid with determination of the prognosis.

Versatility of tissue expansion in abdominal wall reconstruction after removal of vascular malformations in children

BACKGROUND

Children who have had extensive abdominal wall vascular anomalies (VAs) face 3 common reconstructive options: either tolerating the complications of these lesions, exposure to repeated laser therapy session with its sequelae, or excision followed by a color-matched skin graft. The use of serial tissue expansion and excision of the affected skin offers a potentially better option under the right circumstances. Tissue expanders (TEs) have broad applicability but are not without complications.

OBJECTIVE

To study the versatility of use of TEs in the management of children who had extensive VAs in their abdominal wall with special emphasis to the complications and children and parental satisfaction.

MATERIALS AND METHODS

Retrospective data collection of 12 patients' charts, operative data of 84 operative procedures, and follow-up visits. Statistical analysis done using Student t test significance and P<0.05 was considered statistically significant.

RESULTS

Using 35 different sizes of TEs and 84 operative procedures in 9 boys and 3 girls aged from 2 to 12 years with different types of abdominal wall VAs revealed an overall complications rate of 20%. Child and parental satisfaction was found to be good overall.

CONCLUSIONS

Tissue expander is a useful and feasible tool for reconstruction of the abdominal wall with extensive VAs in children; parents and children were satisfied and body image is acceptable.

Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment

Non-accidental trauma (NAT) is a leading cause of childhood traumatic injury and death in the United States. It is estimated that 1,400 children died from maltreatment in the United States in 2002 and abusive head trauma (AHT) accounted for 80% of these deaths. This review examines the epidemiology and risk factors for NAT as well as the general presentation and required medical work up of abused children. In addition, potential algorithms for recognizing cases of abuse are reviewed as well as outcomes in children with NAT and potential neurosurgical interventions which may be required. Finally, the evidence for seizure prophylaxis in this population is addressed.

Educational paper: parenting a child with a disfiguring condition-how (well) do parents adapt?

Studies indicate serious levels of stress among parents of children with a medical condition. Moreover, adaptation seems to be a specific challenge for parents of children with a disfiguring condition because of the visible nature of the condition. In the present overview, we performed a literature search in PubMed, Embase, and PsycINFO to identify both qualitative and quantitative studies concerning psychological distress among parents of children with a disfiguring condition. Two of the authors critically appraised the retrieved citations. A total of 1,459 publications were identified, of which 21 qualitative and 22 quantitative studies met our inclusion criteria. Most qualitative studies infer that the birth of a child with a disfiguring condition starts an adaptation process in which parents experience a range of negative emotions and have concerns related to the visible nature of the condition. The results of quantitative studies are mixed and contradictory, and together suggest that some, but not all parents of a child with a disfiguring condition experience stress. Methodological limitations of the quantitative studies and potential stressors are discussed, and recommendations for future research are made.

CONCLUSION

The present overview neither shows that the existing literature is conclusive about the perceived strain among the parents of children with a disfiguring condition nor does it provide evidence for a relationship between visibility and parental strain.

Periocular hemangiomas and lymphangiomas

Infantile hemangiomas are the most common benign tumor of childhood. Lymphangiomas are benign hamartomatous vascular tumors. Both lesions can be problematic when located in the periocular region. Pediatricians must be familiar with the characteristics of each which would necessitate referral to an ophthalmologist or other subspecialist for evaluation, including obstruction of the visual axis which can lead to amblyopia of the affected eye. Additional potential complications include proptosis, ocular motility limitation, optic nerve injury, and poor eyelid closure with or without corneal surface disease. All children with periocular hemangiomas or lymphangiomas should be referred to an ophthalmologist for further evaluation.

Haemangioma: clinical course, complications and management

Despite their high incidence, most infantile haemangiomas (IH) do not require treatment as they regress spontaneously and most do not leave significant sequelae. For the subset of haemangiomas that require treatment, indications for intervention can be divided into three main categories: ulceration, disfigurement and impairment of function or vital structures. In addition, certain IH have a risk of associated structural anomalies. Given the wide heterogeneity of haemangiomas, deciding which haemangiomas need intervention and when to intervene requires a detailed knowledge of natural history and clinical indicators of increased risk.

Infantile haemangiomas and quality of life

OBJECTIVE

To determine the quality of life (QOL) and self-esteem of children with infantile haemangiomas using objective measures.

DESIGN

Twenty-one children, 5-8 years old, with a diagnosis of head or neck haemangioma measuring 2 cm or more, were compared with 22 children with no history of haemangioma.

SETTING

A tertiary medical centre in the north of Israel.

INTERVENTIONS

Demographic and clinical details were collected, followed by two questionnaires-Paediatric Quality of Life Inventory (PedsQL) and Harter pictorial scale of Perceived Competence and Social Acceptance for young children-answered by children and parents of the two groups.

MAIN OUTCOME MEASURES

QOL and self-esteem of the children in the two groups.

RESULTS

There were no significant differences in QOL indices or self-perception scores between children with and without haemangioma (86.6±10.3 vs 80.1±15.07, p=0.23 and 3.62±0.2 vs 3.72±0.21, p=0.17, respectively). Interestingly, parents of children with haemangioma reported higher QOL of their children than parents of children without haemangioma (86.4±9.6 vs 77.1±14.9, p<0.03). Likewise, a positive correlation between parents' scored PedsQL and children's scored PedsQL was found (0.56, p=0.008).

CONCLUSIONS

The findings raise a question about aggressive as opposed to more conservative treatment, especially in the era of propranolol.

Propranolol in use for treatment of complex infant hemangiomas: literature review regarding current guidelines for preassessment and standards of care before initiation of therapy

In 2008, the positive effects of propranolol on infantile hemangiomas (IH) have been discovered serendipitously by Léauté-Labrèze and her coworkers. Since then, propranolol has been in use in allday clinical practice worldwide for treatment of IH. It even caused some kind of paradigm shift in the overall management of these lesions, though propranolol is still not FDA approved, respectively, in “off-label” use for this indication in the majority of institutions. Thus, the aim of this communication is to evaluate the literature for current evidence regarding guidelines for preassessment and standards of care before initiation of therapy.

Treatment of infantile hemangiomas

1.Recognize infantile hemangiomas that are associated with a higher risk for complications and associated anomalies.2.Appreciate the typical timing of growth and involution of infantile hemangiomas.3.Become familiar with recently reported treatments for infantile hemangiomas.Infantile hemangiomas are common proliferations of endothelial tissue that affect approximately 4% to 5% of infants.1 Lesions represent a broad clinical spectrum and their management has to be individualized. Fortunately, most infantile hemangiomas do not require active therapy and may be managed with "active nonintervention";2 however, it is important to recognize those that do require therapeutic intervention and to be familiar with the therapeutic options.

Treatment with propranolol for infantile hemangioma in 13 Taiwanese newborns and young infants

BACKGROUND

Hemangioma in infants has a benign self-limited course, but the 10% of cases with complications need further treatment. Successful treatment with propranolol in western countries has been reported over the past few years. We evaluated the efficacy of propranolol for treating infantile hemangioma in Taiwanese newborns and young infants.

METHODS

Patients below 1 year of age treated with propanolol between November 2009 and March 2011 were enrolled. Demographic data, clinical features, imaging findings, treatment regimens of propranolol, and outcome were investigated.

RESULTS

Thirteen patients were treated with propranolol at a dose of 2-3 mg/kg/day. Seven (53.8%) patients had solitary hemangioma and six had multiple ones. The indications for treatment were risk of local event in nine patients, functional risk in four, local complication in one, and life-threatening complication in one. The median age for starting propranolol was 4 months (range: 1-11 months). Responses to propranolol, such as decolorization, regression in tumor size, or improvement of hemangioma-associated complications were observed in all patients within 1-2 weeks after treatment. Propranolol-associated adverse effects occurred in two patients. One infant had occasional tachypnea, and the other had occasional pale-looking appearance. The symptoms resolved after dosage tapering.

CONCLUSION

Propranolol may be a promising therapeutic modality for infantile hemangioma. Therapeutic strategies are needed to evaluate the optimal treatment protocol and long-term adverse effects.

Parents' emotional and social experiences of caring for a child through cleft treatment

Little is known about the experiences of parents caring for a child through long-term treatment for cleft lip and/or cleft palate. We conducted in-depth interviews with 35 parents with children between the ages of 20 weeks and 21 years to explore experiences across the treatment program. We analyzed the data using a constructivist grounded theory approach and present in detail in this article one subcategory from the analysis: managing emotions. Throughout childhood and adolescence, parents experienced conflicting emotions about their child's impairment, uncertainty about cleft treatment, and stigmatizing attitudes. Although parents attempted to manage emotional tensions by pursuing cleft treatments, the interventions could themselves be a source of conflict for them. We suggest that routine assessment of parents' emotional and social well-being should be included in cleft treatment programs, and access to psychosocial support made available.

Parents' experiences of caring for a child with a cleft lip and/or palate: a review of the literature

This review brings together for the first time the existing quantitative and qualitative research evidence about the experiences of parents caring for a child with a cleft. It summarizes salient themes on the emotional, social and service-related experiences of parents and critiques the literature to date, comparing it with wider, selected literature from the field of children's long-term conditions, including disability. The review suggests that there are similarities and differences between the literatures, in terms of research focus and approach. Similarities are found across children's conditions in the perspectives of parents on emotional, social and service-related aspects, although much of the cleft literature is focused on the early stages of children's lives. However, the quality of cleft research to date about parents' experiences has also been variable, with a narrow emphasis on cross-sectional, deficit-orientated psychological approaches focused mainly on mothers. Despite a substantial literature, little qualitative research has examined parents' perspectives in-depth, particularly about their child's treatment journey. This contrasts with the wider children's literature, which has traditionally drawn not only on psychological approaches but also on the broader perspectives of sociology, social policy, nursing and health services research, using both qualitative and quantitative methods, often in integrated ways. Such approaches have been able to highlight a greater range of experiences from both mothers and fathers, about caring for a child with a long-term condition and views about treatment. The review identifies a lack of comparable research in the cleft field to examine parents' experiences and needs at different stages of their children's lives. Above all, research is needed to investigate how both mothers and fathers might experience the long-term and complex treatment journey as children become older and to elicit their views about decision making for cleft treatments, particularly elective surgeries.

Surgical treatment of infantile hemangioma in a multidisciplinary vascular anomalies clinic

OBJECTIVE

(1) Discuss indications for surgical treatment of infantile hemangioma (IH); (2) describe outcomes, management of complications and long term surveillance of surgically treated IH.

STUDY DESIGN

Retrospective.

SUBJECTS AND METHODS

The charts of children seen in a dedicated vascular anomalies center at a tertiary pediatric hospital were reviewed.

RESULTS

Out of 1012 patients diagnosed with IH over 27 months, 92 patients, predominantly caucasian female, with an average age of 36 months, underwent surgery for 94 lesions. Head and neck lesions accounted for 67% of the population and 51 lesions were located on the face. Surgical indications included bleeding, functional impairment, ulceration and cosmetic disfigurement. Mean surface area was 7.75 cm². Although lesions requiring additional procedures were larger (median 5.5 cm²) than single-stage excisions, this difference was not statistically significant (P=0.09). Head and neck lesions were more likely to require multiple modality treatment (P=0.003). There was no identified objective criteria to predict head and neck lesions that are more likely to be associated post-operative complications.

CONCLUSIONS

Most IH do not require treatment. The majority of infantile hemangioma occurred on the head and neck. When significant functional impairment, ulceration, bleeding, cosmetic deformity is encountered or anticipated, surgical therapy can be performed at any clinical phase with few complications and favorable outcomes.

New developments in the management of periocular capillary hemangioma in children

The authors describe the theories of pathogenesis for capillary hemangioma and discuss the benefits and side effects of current treatment options, such as systemic and intralesional corticosteroids, laser therapy, and surgical excision. They also evaluate the recent systemic and topical applications of beta-blockers to treat infantile hemangioma. Although no major adverse events from beta-blocker treatment have been reported, the incidence of potential side effects such as bronchospasm, hypoglycemia, heart block, bradycardia, and congestive heart failure is unknown due to the novelty of the treatment. It has been postulated that topical application for localized superficial tumor may reduce systemic effects. Further research is necessary to compare the effectiveness of different treatments and to find the optimal dosing and delivery methods to minimize adverse effects in the treatment of this disorder.

Hemangiomas revisited: the useful, the unusual and the new. Part 2: endangering hemangiomas and treatment

Hemangiomas, although benign tumors, can when located in particular regions threaten vital structures or in certain clinical circumstances be associated with other abnormalities, carrying significant morbidity and mortality. We review these endangering hemangiomas. We also discuss briefly the treatment with emphasis on the recent use of propranolol.

Clinical review of periorbital capillary hemangioma of infancy

PURPOSE

To explore the role of intralesional steroid injections (ILSI) and oral steroids in the management of periocular hemangioma of infancy (HOI).

METHODS

In this retrospective study, treatment options studied were observation, ILSI, and oral steroids. All children received adjunctive amblyopia treatment if required. The main indications for treatment were cosmetic, worsening astigmatism, and visual axis obscuration. Success was defined as complete HOI regression before the age of 5 years (cosmetic group), reduction of astigmatism of at least 1 diopter cylinder (DC) (astigmatism group), or no evidence of amblyopia at the last follow-up (visual axis obscuration group).

RESULTS

Twenty-four of 41 children (58.5%) had amblyopia at presentation. Eighteen children formed the observation group, 17 children received ILSI, and 6 children received oral steroids. Successful outcome was achieved in all except 2 patients in the cosmetic group and 6 of 7 in the visual axis obscuration group. Mean astigmatic correction of all cases was 1.65 ± 1.34 DC before treatment and 0.91 ± 1.17 DC after treatment, the change being statistically significant (P < .001).

CONCLUSION

Observation appears to be a highly effective strategy if coupled with amblyopia therapy, especially for mild cases. Intralesional and oral steroids appear to be equally effective for lesions requiring treatment, but their exact role cannot be clearly determined in the presence of a spontaneously resolving lesion.

Visual outcomes of treated periocular capillary haemangiomas in childhood: a 10-year review

PURPOSE

To report our experiences of treating periocular capillary haemangioma with particular emphasis on visual outcomes.

METHODS

Patients who underwent treatment for periocular capillary haemangioma were identified, and a chart review was performed.

RESULTS

There were seventeen patients in the study. The main indications for treatment were increased size of lesion with threat of amblyopia and partial or full pupil occlusion. Seven patients required more than one type of treatment. Fourteen patients had intralesional steroid treatment and six patients had oral steroids. Intralesional steroids gave variable results with minimal side-effects, oral steroids were very effective but 4 out of 6 patients developed side-effects. The average pretreatment astigmatism was 2.4D and post treatment this had reduced to 1.3D. Final visual outcomes were available for 15 patients, 13 had visual acuity of 6/7.5 or better, two were amblyopic with vision of 6/9-2 and 6/18.

CONCLUSION

In this study, intralesional steroids were used for localized lesions and oral steroids for diffuse haemangiomas with orbital involvement. Treatment especially with oral steroids was found to halt the proliferative phase and assist early haemangioma regression reducing ocular sequelae.

Infantile haemangioma: part II. Risks, complications and treatment

Because of their spontaneous involution, most infantile haemangiomas (IH) do not require therapeutic intervention. However, in 10 to 15% of cases such as segmental and multifocal IH, locations in the periocular, airway and perineal areas, or complications of ulceration, treatment is necessary. Moreover, the risk of permanent scarring and disfigurement associated with IH, even if involution is complete, has been increasingly recognized as a rationale for treatment. Treatments for IH currently include topical, intralesional, systemic therapies, laser and surgical modalities depending on the clinical scenario. However, clinicians must carefully weigh the risks and benefits for each treatment. Recently, the efficacy of propranolol, a non-cardioselective beta-blocker, was reported and has been revolutionary in the management of IH.

Intense Pulsed-Light Therapy for Proliferative Haemangiomas of Infancy

Infantile haemangioma therapy has long been a wait-and-see policy. Since recent development of laser and light therapy, pulsed dye laser has been successfully used for treating superficial haemangiomas. Few studies have been published about treatment with intense pulsed light (IPL) to assess the risk/benefit of IPL in the treatment of infantile haemangiomas during their early proliferative phase. In the present retrospective cohort study, we retrieved data about a series of 14 Caucasian children (median age: 4.8 months) with infantile haemangiomas treated with Photoderm Vasculight flash lamp. All patients experienced a rapid regression of the haemangiomas after 3 treatments on average. Few adverse events were noted, including ulceration and crusts. No residual scarring and cosmetic damages were noticed. Fast growing haemangiomas should be treated with light therapy as soon as possible. This technology is safe, efficient, inducing regression, and preventing any further functional and aesthetic complications. The benefit-risk ratio favours the treatment of most types of haemangiomas which are out of the scope of betablocker administration.

Current management of infantile hemangiomas

During the past several years, there have been new advancements in the management of infantile hemangiomas (IHs). In many patients, no treatment is ever necessary--because IHs are well known for their natural history of spontaneous involution. However, a significant minority of hemangiomas do require treatment. Moreover, they are very heterogeneous, making the decision of when, how, and why to intervene quite variable. The least common but most important rationale for intervention is the presence of a life- or function-threatening complication, where prompt therapeutic intervention is a necessity. A much more common scenario is ulceration, where appropriate management is needed to expedite healing and control pain. Increasingly, the life-altering aspects of hemangioma are being recognized as a rationale for treatment because permanent scarring and disfigurement can result even if involution is complete. Treatments for IHs currently include topical, intralesional, and systemic therapies. Laser and surgical modalities are also sometimes used depending on the clinical scenario. In the absence of rigorous evidence-based studies, clinicians must carefully weigh the risks and benefits of medical or surgical treatments versus observation alone in tailoring management to the specific clinical situation at hand.