TABLE 2.

Risk stratification when considering beta‐blocker treatment

Group 1 (Standard risk): May consider telemedicine initiation of oral or topical beta‐blocker therapy a as long as infant does not have additional features listed for Group 2 Adjusted gestational age > 5 wk Normal birthweight Recent documented weight (within 2 wk) Normal cardiovascular examination within previous 4 wk (including ≥ 1 documented HR after nursery discharge) Normal respiratory examination within previous 4 weeks Healthy in the 24‐48 h prior to scheduled telemedicine visit (especially, no respiratory and gastrointestinal signs and symptoms IH pattern and distribution does not confer risk of PHACE or LUMBAR syndrome Lack of ulceration or minimal/superficial ulceration Caregiver is able to understand instructions and demonstrate comprehension (eg, by repeating instructions provided during visit) Multiple IH with normal liver ultrasound and without cutaneous IH conferring risks noted in Group 2

Group 2 (Higher risk): Recommend in‐person evaluation unless local circumstances make this impossible prior to initiation of systemic beta‐blocker therapy b Corrected gestational age < 5 wk Abnormal cardiovascular examination or investigations OR those who lack documentation of this in the post‐natal period Medium‐to‐high risk of PHACE (ie, large segmental facial in segments S1, S3, S4 or scalp IH) Medium‐to‐high risk of LUMBAR syndrome (ie, segmental perineal and/or lumbosacral body IH ± visible associated anatomic abnormalities Significant IH ulceration Ongoing poor oral feeding or poor weight gain IH with symptoms of airway compromise (eg, stridor) or bilateral S3 (beard area IH at high risk for airway IH). Known pulmonary disease including ongoing respiratory compromise (eg, dyspnea, frequent wheezing or history of bronchospasm) Persistent or ongoing hypoglycemia Known or suspected congenital heart disease or suggestive symptoms Known or suspected aortic coarctation History of pathologic heart murmur or abnormal echocardiogram Ongoing diaphoresis Ongoing tachypnea Ongoing tachycardia History of syncope Extensive hepatic hemangiomas including those resulting in consumptive hypothyroidism or congestive heart failure Known brain malformation Family history in first degree relative of: Congenital heart disease Sudden death or arrhythmia Maternal history of connective tissue disorder (eg, systemic lupus, Sjogren syndrome, polymyositis, or other)

^a In ordinary circumstances, infants are being seen regularly for well‐child visits by primary care providers, who weigh and measure infants and perform heart and lung examinations as a standard part of their care. If these examinations are not occurring due to disruptions in healthcare, it becomes much more difficult to ascertain whether there is a normal cardiovascular or pulmonary examination, if normal growth is occurring and other baseline characteristics. In such cases, decisions about initiating therapy must be done on a case‐by‐case basis.

^b During this pandemic and other unusual circumstances, in‐person visits may not be possible in a timely fashion. In these settings, triage and management decisions need to be made on a case‐by‐case basis, ideally in conjunction with relevant specialists as needed (eg, ENT and cardiology).