Synopsis
Distinguish a proliferating infantile vascular tumour from a congenital vascular malformation, identify site- and syndrome-specific threats early, and coordinate propranolol, imaging and anomaly-directed intervention safely.
- Infantile haemangioma is usually absent or faint at birth, becomes evident in the first weeks, proliferates rapidly during early infancy and then involutes over years.
- Vascular malformations are structural channel abnormalities present at birth, although sometimes subtle; they grow with the child, expand with hormonal or traumatic change and do not follow spontaneous tumour involution.
- Superficial infantile haemangioma is bright red and raised, deep disease is skin-coloured or blue and compressible, and mixed lesions show both levels across every skin tone.
- Referral urgency depends on function and future distortion, not diameter alone: eyelid, nose, lip, ear, airway beard distribution, perineum, scalp and segmental patterns are high risk.
- Five or more cutaneous infantile haemangiomas should prompt specialist consideration of liver ultrasound because diffuse hepatic disease can cause high-output heart failure or hypothyroidism.
- A large segmental facial or scalp haemangioma raises PHACE concern; extensive lumbosacral or perineal disease raises spinal, genitourinary and anorectal anomaly concern.
- First-line active treatment for a problematic proliferating infantile haemangioma is oral propranolol started early through a paediatric specialist protocol, usually before the fastest growth window closes.
- Give propranolol during or immediately after a feed and withhold it during poor intake, vomiting or significant illness to reduce hypoglycaemia risk.
- Capillary malformations use laser, venous and lymphatic malformations may use sclerotherapy or surgery, and arteriovenous malformations need flow imaging and staged embolisation or surgery rather than propranolol.
- Kasabach–Merritt consumptive coagulopathy is associated with kaposiform haemangioendothelioma or tufted angioma, not an ordinary infantile haemangioma.
Key red flags
Stridor, eye occlusion, ulceration, severe pain, poor feeding, failure to thrive, recurrent bleeding, palpable thrill, bruit, limb overgrowth, neurological signs, five or more cutaneous haemangiomas or a large segmental facial or lumbosacral lesion requires expedited specialist assessment.
Warmth, pulsation, bruit, thrill, rapid expansion, pain or bleeding indicates arteriovenous shunting and makes unplanned biopsy hazardous.
Periocular, airway-distribution, nasal-tip, lip, ear, ulcerated, large segmental or perineal lesions need early specialist review during proliferation.
Investigation priorities
Distinguish infantile tumour proliferation from a malformation or congenital tumour.
Management branches
An infant or child presents with a vascular-appearing birthmark or swelling.
- Establish presence and completion at birth, postnatal onset, speed and trigger-related expansion using dated photographs and pregnancy and birth history.
- Examine surface, depth, compressibility, warmth, pulse and bruit and assess vision, airway, feeding, hearing, ulceration, bleeding, pain and limb growth.
- Diagnose clinically when classic, obtain expert Doppler for uncertainty and refer high-risk sites or flow features promptly rather than waiting to observe the natural history.
A small uncomplicated infantile haemangioma is away from functional and high-distortion sites.
- Explain proliferation and involution honestly, including possible residual skin, and give photographs and measurements a scheduled review interval during early growth.
- Use bland emollient and protect from friction; provide an ulcer contact plan and avoid folk remedies, ligation or trauma to the lesion.
- Escalate immediately if growth accelerates, surface breaks, pain develops or eye, airway, feeding, hearing or anatomy becomes threatened.