Case Report: Infantile Hemangioma Near Right Parotid Grows after Cessation of Breast Feeding by Mother Who Was Taking Propranolol

Abstract

A healthy four-week-old, full-term female presented to an outside emergency room with rapid swelling of the right parotid area, which was tentatively diagnosed as acute parotitis on ultrasound and discharged home with antibiotics. Within 72 hours the swelling had increased, and the patient presented to our Emergency Department. Imaging with ultrasound and MRI demonstrated homogenous vascularity consistent with hemangioma. History revealed that the patient’s mother had been on propranolol for congenital tachycardia pre- and post-natally. She had been breast-feeding up until a few days before the parotid swelling started but had been transitioning to formula. The infant was started on propranolol (goal dose 2mg/kg/day) with rapid improvement. This case raises the question of whether maternal propranolol consumption has an effect on hemangioma proliferation in the breast-fed newborn (and pre-natally). In review of the literature, propranolol is reported as the safest beta-blocker for treating hypertension in pregnant and lactating mothers as the plasma protein binding is upwards of 90%. Propranolol is metabolically transformed in the liver and excreted in the urine. The half-life of the medication, the pH of the breast milk, and the lipophilic nature of the breast milk affect the concentration of propranolol in breast milk. A study showed that if the mother took approximately 160mg/day of propranolol and the infant consumed the usual amount of breast milk (100-150ml/kg/day) the maximum propranolol load is presumed to be 32µ/24hours (8µ/kg in a 4kg infant). Infantile hemangiomas usually proliferate by two weeks of age. The proliferation in this child occurred later at approximately four weeks of age after the mother on propranolol weaned breast milk. When treating infants with hemangiomas, it is important to obtain maternal medication history, especially if treatment with propranolol is being considered. Corresponding Author: Lauren Sall, MD, 19751 East Kings Ct., Grosse Pointe Woods, MI 48236