Hemangioma in children When does it become dangerous and require urgent treatment

"Neonatal hemangioma in children is one of the most common tumors during infancy. Most of these tumors are harmless and gradually disappear as the child grows. However, in some cases, the tumor can be serious and requires urgent medical attention to prevent complications. In this Dely MyMedical article, we will discuss the warning signs, causes, and the most important treatment and prevention methods in a simple way for all parents."

Are all hemangiomas in children dangerous?
Most small hemangiomas are harmless and gradually disappear within 1–5 years. However, large hemangiomas or those located in sensitive areas such as the face or neck may cause complications, requiring careful medical follow-up or specialized treatment.

When does a hemangioma usually appear?
They typically appear within the first week to the first month after birth and can grow rapidly during the first three months, making early monitoring by a pediatrician very important.

What are the warning signs to watch for?

Very rapid growth of the hemangioma.
Bleeding or ulceration on the tumor.
Pressure on nearby organs, such as the eyes or mouth.
Breathing difficulties or heart failure in cases of large internal hemangiomas.

Does a hemangioma leave permanent marks on the child?
Most hemangiomas disappear completely, but large ones may leave loose skin or small scars after shrinking, sometimes requiring cosmetic surgery.

What are the treatment options for hemangiomas?

Observation: If the hemangioma is small and harmless, it is usually monitored until it gradually disappears.
Medication: Propranolol is commonly used to safely reduce the size of the hemangioma.
Laser therapy: Used to correct the color of the hemangioma or treat superficial ulcers.
Surgery: For large hemangiomas or to correct skin deformities after shrinkage.

Can hemangiomas be prevented?
There is no guaranteed way to prevent them, but early follow-up with a pediatrician helps detect small hemangiomas and manage them before complications occur.

Are hemangiomas associated with other problems?
In some large facial hemangiomas, they may be part of PHACE syndrome, which can involve the brain, arteries, heart, or eyes.

Are hemangiomas present at birth or do they appear later?
They are usually not visible at birth but appear within days to weeks afterward and begin rapid growth during the first few months.

Are hemangiomas painful?
Most hemangiomas are painless, but the child may feel pain if bleeding or ulceration occurs.

Can hemangiomas appear anywhere in the body?
Yes, they can appear on the face, head, neck, body, or even internal organs like the liver and lungs. The size and location vary depending on the case.

Can hemangiomas recur after disappearing?
It is very rare for a hemangioma to return after disappearing, especially if it was small and either treated or resolved naturally with the child’s growth.

Is hemangioma hereditary?
Usually not, but having a family history of hemangiomas may slightly increase the likelihood of a child developing one.

What is the difference between infantile hemangioma and other vascular tumors?

Infantile hemangioma: Grows rapidly in the first months of life, then gradually shrinks and disappears over the years.
Other vascular tumors: Grow with the child and do not regress on their own, requiring long-term follow-up.

Does the child need tests or investigations?

For small hemangiomas, a clinical examination is usually enough.
If the hemangioma is large, internal, or associated with syndromes, further tests may be needed, such as ultrasound, CT scan, or MRI.

Can laser therapy be used for infants?
Yes, laser treatment is safe for infants under specialized medical supervision, especially for superficial hemangiomas or to reduce redness and ulcers.

Do medications for hemangiomas have side effects?

Propranolol: Generally safe, but requires monitoring of blood pressure, heart rate, and blood sugar in infants.
Steroids: Have more side effects and are only used when necessary under close medical supervision.

When should parents seek urgent medical help?

Severe bleeding from the hemangioma.
Breathing or swallowing difficulties.
Eye or vision problems.
Signs of anemia, such as extreme paleness or persistent fatigue.

Does every hemangioma need surgery?
No, most hemangiomas in children disappear gradually without surgery. Surgery is only needed in very large cases or when complications affect nearby organs or cause significant cosmetic concerns.

Does hemangioma affect a child’s growth?
Usually, it does not affect overall growth, unless it is very large or linked to internal hemangiomas that impact the heart or other organs.

What is hemangioma in children?
A hemangioma is a type of benign (non-cancerous) tumor that appears in infants. It is formed by an abnormal cluster of small blood vessels on or under the skin.

It usually appears within 1–3 weeks after birth.
In the beginning, it may look like a faint skin mark, then becomes brighter red and grows during the first 2–4 months (proliferative phase).
Afterward, the growth stops and stabilizes (plateau phase).
Finally, it starts to shrink and fade gradually (involution phase).

Most hemangiomas disappear by the age of 3–5 years, though some may leave behind loose skin or mild dilated blood vessels.

Important facts about hemangiomas in children:

They usually do not cause serious complications and resolve without treatment.
They occur in about 4%–10% of Caucasian infants.
They are 3–5 times more common in females with fair skin than in males.
Premature babies are at higher risk, while hemangiomas are rare in infants of African descent.

Types of Neonatal Hemangioma in Children

A neonatal hemangioma (vascular tumor) is an abnormal cluster of blood vessels that usually appears at birth or within the first few months of life. The type varies depending on the hemangioma’s shape, depth, and behavior.

1️⃣ Superficial Hemangioma

Appearance: Bright or dark red, slightly raised, similar to a birthmark.
Location: Most common on the face or scalp.
Behavior: Grows rapidly during the first 1–2 months, then gradually shrinks after the first year.
Note: Usually painless, but can cause cosmetic concerns if on the face.

2️⃣ Deep Hemangioma

Appearance: Bluish-purple under the skin, less visible than superficial types.
Location: Can occur anywhere on the body.
Behavior: May enlarge before shrinking, sometimes pressing on nearby organs if in sensitive areas.

3️⃣ Mixed Hemangioma

Appearance: Combination of superficial (red) and deep (blue) components.
Behavior: Grows faster and may be more complex to treat.

4️⃣ Segmental or Diffuse Hemangioma

Appearance: Spreads across a large skin area.
Complications: Sometimes linked with internal organ issues like the heart or liver.
Follow-up: Requires careful monitoring to prevent bleeding or severe health risks if very large.

5️⃣ Visceral Hemangioma

Appears inside organs such as the liver or lungs.
May occur alongside skin hemangiomas or alone.
Complications: Can cause heart failure or internal bleeding if large.

6️⃣ PHACE Syndrome

A rare condition associated with large facial hemangiomas.
PHACE = Posterior fossa brain malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye abnormalities.
Any large facial hemangioma may signal possible brain, heart, or eye problems.

Risk Factors for Neonatal Hemangioma in Newborns

1️⃣ Gender: More common in females (3:1 ratio).
2️⃣ Birth weight: Premature or low-birth-weight infants (<2500 g) are at higher risk.
3️⃣ Premature birth: Babies born before 37 weeks have increased risk.
4️⃣ Multiple pregnancy: Twins or triplets are more likely to develop hemangiomas.
5️⃣ Family history: A history of hemangiomas in parents or siblings increases the risk.
6️⃣ Pregnancy factors: Maternal hypertension, placental problems, or certain medications may contribute.
7️⃣ Ethnicity: More common in Caucasian infants than Asian or African infants.
8️⃣ Other factors: Rare congenital anomalies or syndromes may be linked to large or multiple hemangiomas.

Important note: Having risk factors does not mean a baby will definitely develop hemangiomas, but it increases the probability. Regular pediatric check-ups are essential for early detection.

Phases of Neonatal Hemangioma in Children

1️⃣ Proliferative Phase

Duration: Birth to 3–6 months (sometimes up to 12 months).
Features:
- Rapid growth of the hemangioma.
- Bright red if superficial, bluish if deep.
- Size increases quickly within weeks.
Risks: Pressure on nearby organs, ulceration, or bleeding in sensitive areas.

2️⃣ Plateau Phase

Duration: Around 6–12 months up to 2 years.
Features:
- Growth stops, size stabilizes.
- Color may start fading.
Risks: Usually minimal, but ulcers or infections must be monitored.

3️⃣ Involuting Phase

Duration: From about 1 year to 3–5 years or longer.
Features:
- Shrinks gradually in size and color.
- May leave behind loose skin or fine lines.
Risks: Rare, but large lesions may require surgical correction.

Not all hemangiomas follow the same timeline. Some disappear fully without treatment, while larger or complicated ones may need medical therapy (like propranolol) or laser.

Complications of Neonatal Hemangioma

1️⃣ Skin Complications

Ulceration (open sores).
Skin discoloration after shrinking (dark spots or pale streaks).
Scarring or deformities requiring cosmetic treatment.

2️⃣ Location-Related Complications

Face/eyes: Vision problems, eyelid involvement.
Head/neck: Rare pressure on brain or airways.
Internal organs (liver/lungs): May cause heart failure, internal bleeding, or breathing difficulties.

3️⃣ General Complications

Bleeding: If scratched or ulcerated.
Anemia: In very large hemangiomas due to blood loss.
Infection: Especially if ulcers develop.

4️⃣ Psychological and Social Impact

Cosmetic concerns if located on the face or hands.
Parental anxiety and stress due to size or location.

5️⃣ Rare Syndrome-Related Complications

Part of PHACE syndrome, involving brain, arteries, heart, or eyes.

Comparison: Infantile Hemangioma vs Vascular Malformation

Feature	Infantile Hemangioma	Vascular Malformation
Onset	Appears days to weeks after birth	Present at birth or develops gradually
Growth	Rapid growth (1–3 months), then regresses by 1–5 years	Grows with the child, does not regress
Color/Shape	Red or blue, raised above skin	Varies: blue, red, purple, usually flat or slightly raised
Types	Superficial, deep, mixed, segmental	Arterial, venous, lymphatic, mixed
Complications	Possible bleeding, ulceration, organ compression	May cause pain, bleeding, bone deformities, organ compression
Treatment	Observation, propranolol, laser, or surgery if needed	Depends on type: laser, surgery, sclerotherapy
Prognosis	Usually resolves with age	Persists for life, requires ongoing care
Spread	Usually localized, one or few lesions	Can be widespread or localized

Medical Treatment for Neonatal Hemangioma

1️⃣ Propranolol

Description: A heart and blood pressure medication, now the first-line treatment for hemangiomas.
How it works: Oral administration under pediatric supervision.
Duration: Several months to a year, depending on response.
Effectiveness: Reduces size and redness within weeks.
Monitoring: Requires follow-up for blood pressure, heart rate, and blood sugar.

2️⃣ Corticosteroids

Description: Previously common before propranolol, now used for resistant cases.
How given: Orally or sometimes via injection.
Effectiveness: Slows hemangioma growth.
Side effects: Weight gain, bone fragility, high blood pressure, sleep issues.

3️⃣ Other Medications (rare cases)

Sirolimus or Vincristine: For very large, complex, or unresponsive hemangiomas.
Always managed by a pediatric oncologist.

Key tips for medical treatment:

Never start medication without medical supervision.
Monitor the child’s growth and hemangioma regularly.
Stopping medication should always be gradual under a doctor’s guidance.

When is Surgery Needed?

Surgery is not the first option but may be required when:

Very large or diffuse hemangiomas press on vital organs (eyes, nose, mouth).
Hemangiomas unresponsive to medication or laser.
Residual deformities (loose skin, scarring) after involution.
Persistent bleeding or deep ulcers.

Types of Surgery

1️⃣ Direct Excision: Removal of the hemangioma (partially or completely). Usually considered after involution or when severe complications exist.
2️⃣ Reconstructive Surgery: Corrective procedures to repair cosmetic deformities, tighten loose skin, or restore normal appearance.

Advantages of Surgery:

Immediate relief from organ compression or bleeding.
Cosmetic improvement after regression.

Potential Risks of Surgery

Bleeding during or after the procedure.
Infection at the surgical site.
Scarring or new skin deformities.
Recurrence of the hemangioma if it is not completely removed (rare cases).

How to Manage Infantile Hemangioma Syndrome in Children

1️⃣ Regular Medical Follow-Up

Routine visits to a pediatrician to monitor the growth of the hemangioma and detect any complications early.
Referral to dermatologists or pediatric oncologists may be necessary for large or complex hemangiomas.

2️⃣ Observation (Watchful Waiting)

Most hemangiomas shrink and disappear gradually within 1–5 years without treatment.
Regular monitoring is essential to ensure the lesion is not growing rapidly or pressing on vital organs.

3️⃣ Medication

Propranolol: A widely used and effective treatment for reducing hemangioma size, especially large ones or those near the eyes and face.
Other medications: Steroids or specialized drugs may be considered in rare cases when propranolol is not effective.

4️⃣ Surgical or Laser Treatment

Laser therapy: Helps correct skin discoloration, treat ulcerations, or manage small superficial hemangiomas.
Surgery: Reserved for very large lesions or to correct skin deformities that remain after involution.

5️⃣ Skin Care

Keep the skin around the hemangioma clean.
Avoid friction or scratching to prevent ulceration or bleeding.
Use moisturizers or medicated creams if there is dryness or ulcer formation.

6️⃣ Psychological and Social Support

Educate parents about realistic expectations regarding hemangioma growth and involution.
For visible facial hemangiomas, provide psychological support to the child to help reduce anxiety and improve self-confidence later in life.

7️⃣ Monitoring for Warning Signs

Immediate medical attention is required if symptoms such as severe bleeding, large ulcerations, breathing difficulties, vision problems, or poor growth appear.