A haemangioma, also known as a "blood sponge", is a always benign Proliferation of blood vessels. In infants, it often occurs in the head or neck area and usually appears as a reddish or bluish bump on or under the skin. In the vast majority of cases, infant haemangiomas do not require treatment. Treatment is only necessary if they are located in unfavourable areas or are very large.
When Lea was born, her little body still appeared clean. However, a red spot soon developed on her back. It grew rapidly over the course of her first weeks of life and gradually became strawberry red and slightly raised. A soft haemangioma had spread across her back. It was understandable that Lea's parents were worried, as the almost circular formation grew quite quickly.
According to the AWMF guideline "Infantile haemangiomas in infants and young children", Lea is one of the 4 to 5 percent of infants in Germany in whom a haemangioma appears in the first days or weeks of life. Other sources report up to 10 per cent of babies affected in the first year of life. Haematomas occur much more frequently in extremely premature babies (up to 20 per cent). Girls are affected by this phenomenon three times as often as boys. It usually forms on the face, scalp, neck and chest, but in rare cases haemangiomas also occur in internal organs such as the liver.
Of course, the paediatrician also noticed Lea's haemangioma on her back. However, she reassured the parents, emphasised once again the benign nature of such tumours and advised - as is usual in most cases and standard medical practice - to continue observing the tumour for the time being according to the principle of "wait and see". This is because the development of uncomplicated haemangiomas typically takes place in several phases: The appearance is followed by growth, then stasis - and finally often spontaneous regression! More on this later.
It is important to know that haemangiomas generally do not require any special care, but can be Very good sun protection need. But of course this always applies to all sensitive baby skin!
Not every haemangioma is harmless. It is therefore important that a haemangioma is examined by a doctor and its progress monitored so that any necessary treatment can be initiated in good time should it become necessary.
Because if treatment does become necessary, it is important not to miss the right time for therapy.
What are haemangiomas of the skin?
The upper and lower layers of the human skin are always criss-crossed by a fine network of blood vessels that supply the skin with oxygen and nutrients. Sometimes, for reasons that are as yet unknown, new blood vessels form in the upper layer of the skin, which are then recognised as cutaneous haemangiomas grow. These haemangiomas are therefore located on the surface of the skin or just below it. They are usually light to dark red in colour, as they consist of densely branched capillaries (blood vessels). These formations can be flat or raised and are often soft to the touch. Their round or oval shape is usually clearly defined. A good example of this is the so-called strawberry haemangioma. In our example, Lea is also affected by such a domed, bright red haemangioma. In the facial area, they are perceived as particularly disturbing for visual reasons, even if they don't bother the eyes or nose.
In contrast to the superficial haemangiomas, the subcutaneous haemangiomas significantly deeper under the skin. Due to this location, these blood vessels can shimmer through the skin above them in a bluish colour. They usually also feel firmer than superficial haemangiomas, are usually less clearly defined in shape and can cover larger, more diffuse areas.
And finally, the Mixed form of a cutaneous and subcutaneous haemangioma. This means that such a haemangioma spreads both on the surface of the skin and also grows deep under the skin. In this case, the appearance is a combination of red and bluish tones. In this type of benign proliferation of blood vessels, soft, spongy areas as well as firmer, deeper structures can be recognised. The shape is non-uniform with variable depth and size, resulting in a mixed appearance.
Why do children have haemangiomas?
The exact causes for the development of haemangiomas on or under the skin are still unknown. However, a child seems to be born with a predisposition to them, even if the changes on the skin only gradually become more apparent. In addition to the genetic disposition, anomalies of the Placenta to the risk factors. Premature babies are more frequently affected. Haemangiomas cannot be prevented prophylactically.
How do haemangiomas develop?
The development of a haemangioma in newborns typically occurs in several phases. These phases include the initial appearance of the haemangioma, growth, culmination and regression. Here is a detailed overview of this process:
First appearance: A haemangioma can (in rare cases) appear immediately after birth, usually as an initially pale, reddish spot. In the vast majority of cases, a haemangioma only becomes apparent in the first few weeks of the child's life, for example as small, reddish spots or flat patches.
Growth (proliferation phase) begins in the first month of life and can continue until the ninth, rarely even until the 12th month of life. Particularly at the beginning, a haemangioma grows relatively quickly, to the dismay of the parents. It often becomes somewhat more raised, can become intensely red and - depending on its depth and location - can vary in size and shape. The main growth takes place in the 2nd to 5th month of life. At three months, 80% of growth is already complete. With subcutaneous haemangiomas, this phase often lasts longer than with purely cutaneous haemangiomas.
The standstill (transition phase): The growth of the haemangioma has reached its peak and it will not get any bigger. This is followed by a phase of "stability", so the size and appearance do not change for the time being. How long this plateau lasts varies from child to child.
The regression (Evolution phase) is a great relief for parents of an affected child. This is because the haemangioma begins to shrink all by itself. This "reduction" can begin in the first year of life and continue into pre-school or school age (3 to 7 years). In around 80 to 90 % of affected children, the haemangioma has receded by the time they are four years old.
During regression, it is noticeable how the haemangioma slowly but steadily shrinks and also fades. The bright or glowing red colour gradually fades and the haemangioma becomes smaller. This regression is usually faster with cutaneous haemangiomas than with deeper subcutaneous tumours.
By the end of primary school at the latest, it will then become clear whether the haemangioma has completely disappeared and the skin appearance is completely normal. This is usually the case for small, uncomplicated and superficial haemangiomas. After larger and more complicated formations, small discolourations, a little excess skin or slight scars remain without therapy in 55 to 70 %. If this is functionally or visually disturbing, medical intervention may be necessary or desirable.
Diagnosing and treating haemangiomas (blood sponges)
As already mentioned: In many cases, treatment of the haemangioma is not necessary. Its development is merely monitored by a paediatrician, which in the case of Early detection examinationsThe skin is always inspected as well.
Up to 15 per cent of children who have a haemangioma require treatment. The choice of suitable therapy depends on the depth of the haemangioma, its location and the experience of the treating doctors.
Haemangiomas (blood sponges) on the face
Haemangiomas that are localised on the face usually require medical treatment. If they are located near the eye, nose, ear or lips, they can impair the function of organs such as vision, food intake, learning to speak, hearing, breathing or the regular growth of the nose.
Aesthetics also play a role in the decision in favour of or against treatment. This is because haemangiomas that are large or appear on the face affect the self-confidence of many sufferers.
In order to determine a haemangioma more precisely and also to gain clarity as to whether medical treatment is indicated, the haemangioma must be examined more closely. In many places, there are specialised haemangioma consultations for children that are attached to a clinic with a paediatric dermatology centre. Sometimes these consultations are also located in the Department of Oral and Maxillofacial Surgery, which varies from clinic to clinic. The depth of the benign tumour can also be precisely determined there by means of an additional ultrasound examination - in some cases also combined with colour Doppler.
Treatment of haemangioma with propranolol
"Treatment methods that are largely free of side effects are now available for the treatment of localised haemangiomas that require therapy," writes the Professional Association of Paediatricians and Adolescent Doctors online: "Their early use should no longer be avoided if necessary. The aim of any treatment is not primarily to remove the tumour immediately, but to stop it growing as quickly as possible with as few side effects as possible."
Older children are treated for cosmetic or functional problems before school entry at the earliest, if the haemangioma has not regressed on its own - which is rarely the case. For newborns and infants early treatment is indicated if the haemangioma grows rapidly, as in Lea's case, and/or threatens or already impairs vital functions. Appropriate treatment should ideally be started between the fifth week and fifth month of life, as the growth of the haemangioma can then be interrupted easily.
The use of the active ingredient Propranolol is the professionally recommended treatment for haemangiomas in healthy infants born at term with an unremarkable family history.
Propranolol is a so-called beta blocker, so it has been used since 1964 to lower high blood pressure. Also in infants and small children. But please don't be alarmed, dear parents of children with haemangioma! Propranolol also stops the growth of haemangiomas and can cause them to shrink. At the same time, the active ingredient has also been scientifically investigated in the treatment of haemangiomas in infants, is very safe and only rarely accompanied by side effects.
The fact that haemangiomas react to propranolol juice in this way was first discovered unintentionally by a French doctor in 2008. She was treating the diseased heart muscle of a baby who also happened to have a large haemangioma on her face. Treatment with propranolol not only improved the little heart, but also the haemangioma.
This effect of the active ingredient on the skin was then systematically researched and confirmed in various countries. In Germany, propranolol solution has been used since 2014 under the drug name Hemangiol® for the treatment of infantile haemangiomas in infants. With the approval of the Federal Institute for Drugs and Medical Devices (BfArM), a corresponding guideline for relatives and carers not only describes the application in great detail, but also refers to possible side effects and appropriate handling. For example, a treated infant's blood pressure may drop slightly, or sleeping and waking problems may occur. Cool hands and feet and gastrointestinal symptoms are also sometimes observed. Side effects are observed in around 30 % of treated cases. However, they are temporary, dose-dependent and predominantly harmless in nature, which is also emphasised in the AWMF guideline.
On the other hand, a serious side effect would be if the propranolol were to exacerbate an existing hypoglycaemia (also known as hypoglycaemia or low blood sugar levels) or conceal warning signs of approaching hypoglycaemia. Another complication would be a narrowing of the airways, which would make it harder for the treated baby to breathe - especially in the case of bronchial infections in winter.
Of course, doctors always weigh up the benefits against the risks of propranolol very carefully together with the parents of the baby concerned.
In order to rule out possible treatment risks, children are examined intensively before treatment begins to ensure that the heart is healthy and that no other underlying disease speaks against drug therapy for the haemangioma.
At the start of therapy, children are usually monitored in hospital for three days. It is observed how the child reacts to propranolol. Accordingly, the active ingredient is initially dosed at a very low level, i.e. the child is more or less "sneaked in". The child receives the medicinal juice twice a day - with careful monitoring of blood pressure, heart rate, respiration and blood sugar levels. If the child tolerates propranolol well, the dosage is usually increased to the target dose on the second day of hospitalisation - but still under close monitoring. During the inpatient stay, the accompanying adult receives intensive training on how to administer propranolol to the infant (dosage and method of administration shortly before or after meals). If the days are uneventful, the child goes home, where treatment is continued on an outpatient basis. A first check-up at the paediatrician's practice takes place after about one to two weeks. The paediatrician will then adjust the dose individually. The recommended duration of treatment is currently six months.
Initially, it can be observed that the growth of the haemangioma is stopped. As the therapy progresses, the haemangioma fades and is usually no longer visible.
In around 15 to 20 % of all cases, a new growth (rebound) of the haemangioma is observed after the end of propranolol therapy. However, this is limited in its extent and rarely necessitates a resumption of treatment.
Treatment options for infantile haemangioma
Even though propranolol is now the drug of choice for treating haemangiomas, there are situations in which other treatment options are used.
Before propranolol therapy became common, affected infants had been treated with systemic (oral) Corticosteroids treated. This is no longer recommended today due to the expected side effects. Only in rare exceptional cases - e.g. if propranolol is not effective or in an immediately life-threatening situation - is this therapy still used.
Rarely do smaller ones, on haemangiomas growing on the skin Cold treatments is an option. This so-called cryotherapy is intended to slow down the further growth of a superficial (cutaneous) haemangioma by briefly freezing it.
The use of special Lasering has been pushed into the background by the success of propranolol therapy. Laser treatment is only an option in cases of intolerance or failure of propranolol to work.
If, contrary to expectations, an uncomplicated haemangioma does not regress spontaneously or has later left residual skin, an operation can be carried out in older children (from around the age of five). Laser treatment or also a surgical procedure (both under general anaesthetic).
How do the parents of a child with a haemangioma feel?
Although infantile haemangiomas of the skin are always benign and in the vast majority of cases self-regressing, they can cause considerable distress to the parents of an affected child. This can manifest itself on several levels:
Firstly, there is the emotional stress: Affected parents are often Fear and worry The baby's parents may be worried about the appearance of their child and the possible development of the haemangioma - especially if it enlarges quickly or appears in a prominent place such as the face or head. Also the Uncertainty about the progression and possible disappearance of the haemangioma can be stressful. Questions like "Will it get bigger?" - "Will it disappear again?" - "Will it leave scars?" "Will my child need an operation?" are common. It is also not uncommon for parents to fear that their child will need an operation because of a visible haemangioma. Stigmatisation experiences. They simply worry whether their child will be teased later at nursery or school.
The Practical load is not insignificant for parents: Because in any case Regular visits to the doctor paediatricians, dermatologists or specialised clinics. This can therefore be time-consuming and sometimes stressful and may cost working time and days of holiday. If treatments are necessary, such as propranolol therapy, this can also require additional time and organisational effort - not to mention the agitation that usually accompanies it. And finally, constant monitoring of the haemangioma for changes or complications (such as ulcerations or infections) also requires the parents' full attention.
We should also not forget the financial burden: Even if most treatments are covered by health insurance, additional costs may be incurred for non-refundable treatments, medication, travel costs to specialists or additional therapies.
It is often forgotten that affected parents also social burdens can be exposed to. For example through the Interaction with others: This is because parents often have to respond to questions or comments from relatives, friends and strangers - which can be uncomfortable or at least stressful. In addition, in some families with children affected by haemangioma, the need for support from family and friends can also increase, especially if additional care is required.
And finally, affected parents often also have long-term concerns: For example, they worry about the subsequent impact of the haemangioma on their child's well-being and self-perception, especially if scars or cosmetic changes are left behind. And they often have concerns about whether the haemangioma could affect the normal growth and development of the affected area.
To reduce all these possible stresses, parents can, for example
- speak to the midwife. Midwives look after the physical and emotional well-being of the parents. They guide affected parents to expert medical help and also support the parents and the child during the treatment period of the haemangioma.
- It is also advisable to have regular discussions with the paediatrician or specialised doctors to clarify questions and ensure the best possible treatment.
- It can also be helpful:
- to exchange ideas with other affected parents, which can strengthen them emotionally and often leads to many practical tips.
- to seek professional psychological support in the event of considerable emotional stress.
Let's give Lea's mother the last word here: "Good information about haemangiomas and their typical progression and treatment helped me to reduce my fears and set realistic expectations. I have learnt for myself not to see the haemangioma as a flaw in my child. And I learnt to observe the haemangioma without immediately becoming anxious at every change. That was exhausting. But since then I've been able to deal with the haemangioma well."
