Non-Selective Beta-Blocker (Infantile Haemangioma / SVT / Hypertension) Pregnancy: Avoid first trimester — beta-blockers associated with IUGR, neonatal bradycardia. If essential for maternal indication (arrhythmia, hypertension) — use with foetal monitoring. Paediatric indication not applicable in pregnancy.

Propranolol (Infantile Haemangioma / Paediatric Arrhythmias)

Brand names: Hemangiol (infantile haemangioma), Inderal (general)

Adult dose

Dose: Arrhythmia: 40 mg two to four times daily. Hypertension: 80–160 mg daily in divided doses. Thyrotoxicosis: 10–40 mg three times daily

Route: Oral

Frequency: Two to four times daily

Max: 320 mg/day

Adult indications for reference. Main paediatric focus — infantile haemangioma and SVT. Source: BNF 90.

Paediatric dose

Dose: Infantile haemangioma (Hemangiol): start 1.5 mg/kg/day in 2 divided doses for 1 week → 3 mg/kg/day in 2 divided doses. SVT: 0.25–0.5 mg/kg/dose IV under cardiac monitoring; oral 1–4 mg/kg/day in 3–4 divided doses. Hypertension: 1–4 mg/kg/day in 2–4 divided doses mg/day/kg

Route: Oral (Hemangiol oral solution 3.75 mg/mL). IV (SVT emergency only)

Frequency: Twice daily (haemangioma); three to four times daily (SVT/hypertension)

Max: 3 mg/kg/day (haemangioma); 4 mg/kg/day (SVT/hypertension)

Hemangiol licensed for infantile haemangioma from 5 weeks corrected gestational age to 5 months (treatment start window). Duration: 6 months total. Take during or just after feeding — prevents hypoglycaemia. Withhold if infant is sick (vomiting/not feeding) — hypoglycaemia risk. Source: BNF for Children 2024; MHRA SPC Hemangiol.

Dose adjustments

Renal

No dose adjustment required in paediatric renal impairment.

Hepatic

Severe hepatic impairment: reduce dose — first-pass metabolism reduced → higher systemic exposure.

Paediatric weight-based calculator

Patient weight (kg)

Clinical pearls

Infantile haemangioma — transformative indication: Hemangiol (propranolol 3.75 mg/mL solution) is licensed for proliferating infantile haemangioma (IH) requiring treatment. Before propranolol, IH treatment was limited to oral steroids (side effects) or laser. Propranolol causes rapid involution of IH via vasoconstriction + anti-angiogenic effects (reduces VEGF, bFGF). Response rate >95% — most haemangiomas regress within 4–8 weeks.
MHRA hypoglycaemia warning for Hemangiol: propranolol blocks sympathetically mediated glycogenolysis — infants are particularly vulnerable. MANDATORY rule: ALWAYS give Hemangiol dose during or immediately after feeding. NEVER give if infant is sick, vomiting, or refusing feeds — withhold dose. Blood glucose testing before discharge from initiation visit. Parents must be counselled on hypoglycaemia signs in infants (jitteriness, pallor, sweating, seizures) and emergency glucose management (oral glucose gel).
Treatment start window: Hemangiol should be started between 5 weeks and 5 months corrected gestational age — when haemangiomas are actively proliferating. Starting too late (after 5 months) misses the proliferative phase. Duration: 6 months. Most haemangiomas treated from 1–3 months corrected age show complete or near-complete resolution by 12 months.
SVT management in infants: propranolol is used for prevention of SVT (particularly WPW-related SVT and AVNRT) in infants and young children. Onset of oral action is 30–60 minutes. For acute SVT — adenosine (vagal manoeuvre first) is first-line; propranolol IV is second-line in haemodynamically stable SVT. IV use requires continuous cardiac monitoring.
Asthma absolute contraindication: non-selective beta-blockade in any degree of airway hyperresponsiveness can precipitate fatal bronchospasm — even at the low doses used for haemangioma. Always ask parents about family history of asthma, wheeze, atopy, or breathing difficulties in the infant before prescribing. Source: BNF for Children 2024; Léauté-Labrèze et al. NEJM 2008 (haemangioma discovery); Léauté-Labrèze et al. NEJM 2015 (HEMANGIOL trial); MHRA SPC Hemangiol.

Contraindications

Asthma or bronchospasm (non-selective beta-blockade — absolute CI in asthma; avoid even in history of wheeze)
Cardiogenic shock, decompensated heart failure
Sinus bradycardia, AV block greater than first degree (without pacemaker)
Phaeochromocytoma without adequate alpha-blockade
Hypoglycaemia-prone infants (premature, IUGR — hypoglycaemia risk at Hemangiol doses)

Side effects

Bradycardia (most common cardiovascular effect — monitor HR, especially in neonates)
Hypoglycaemia (MHRA warning for Hemangiol — propranolol blocks glycogenolysis and gluconeogenesis; always give with or after feeding; withhold if not feeding)
Hypotension
Bronchospasm (avoid in any respiratory disease; even at low doses for haemangioma)
Sleep disturbances, nightmares, vivid dreams (central CNS penetration)
Cold extremities, Raynaud phenomenon (peripheral vasoconstriction)

Interactions

Calcium channel blockers (verapamil, diltiazem): profound bradycardia and AV block — avoid combination or close monitoring
Antidiabetic agents (insulin, sulphonylureas): propranolol masks hypoglycaemia symptoms (except sweating) — very dangerous in hypoglycaemia-prone infants on Hemangiol
Lidocaine: beta-blockade reduces lidocaine clearance — monitor for lidocaine toxicity if used concomitantly
NSAIDs: reduce antihypertensive effect of propranolol
Adrenaline: risk of rebound hypertension if used (alpha-uncountered vasopressor effect)

Monitoring

Heart rate and blood pressure before first dose and after dose increases
Blood glucose at 1–2h after first dose (hypoglycaemia — Hemangiol indication)
Feed tolerance at each dose (withhold if not feeding — hypoglycaemia protocol)
Haemangioma response at 4, 8, 12 weeks (photographic documentation — size, colour, texture)
Respiratory assessment (bronchospasm at each visit)
ECG at baseline (SVT indication — assess for WPW, AV block)

Reference: BNF for Children 2024; Léauté-Labrèze et al. NEJM 2015 (HEMANGIOL trial); MHRA SPC Hemangiol; American Heart Association Paediatric Advanced Life Support 2020. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways