Explaining infantile haemangioma, propranolol and safety-netting — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the clinic. A 2-month-old infant has a rapidly growing, bright-red raised haemangioma on the upper eyelid that appeared at three weeks of age and has enlarged over six weeks. The parents have read about propranolol on the internet and are anxious. [2]

Your tasks are: [2]

1. Explain what the lesion is and what the natural history will be, in plain language. [2]
2. Explain why this particular lesion needs treatment and why you will use oral propranolol. [1]
3. Explain the propranolol safety-netting — the hypoglycaemia risk and what to watch for. [7]
4. Explain the long-term plan and what may remain after the lesion has involuted. [11]

You are not expected to perform the PHACE imaging yourself in the station, but you should explain that further checks are part of the plan because the lesion is large on the face. [7]

Examiner prompt to the actor (parent)

"Will it ever go away? It was not there when she was born and it just keeps getting bigger. And the propranolol — I read it is a heart medicine, so is it safe for a baby? What should I watch for at home?" [7]

Marking domains

• Frame and natural history (3): explains that this is an infantile haemangioma — a benign growth of blood-vessel cells that appears after birth, grows fast for the first months, then shrinks over years — in plain, reassuring language; names that it was not present at birth because haemangiomas appear in the first weeks. [2]
• Why treat and why propranolol (3): explains that the upper-eyelid position threatens vision through pressure on the eye and amblyopia, so this lesion is treated rather than watched; names propranolol as the standard first-line medicine that halts growth and speeds shrinkage, at a weight-based dose, with a heart check first. [1]
• Safety-netting (2): explains clearly to maintain feeding during illness because the medicine can lower blood sugar, and to bring the infant in if she becomes pale, limp, off her feeds or lethargic; names holding the dose during significant respiratory illness. [7]
• Long-term plan (2): sets the expectation that treatment continues to around twelve months of age, that the lesion will shrink but may leave a paler patch or small residue that can be addressed later, and that further checks are arranged because the lesion is large on the face. [11]

Model answer — the explanatory script

"Thank you for bringing her in, and thank you for reading up — it helps us talk this through properly. What she has is called an infantile haemangioma. It is a benign overgrowth of tiny blood-vessel cells, and the reason it was not there when she was born is that these lesions appear in the first few weeks of life, then grow quickly for the first few months, and then — this is the reassuring part — they slowly shrink away over the next few years. So it is very likely to get much smaller, but we are not going to wait for that here, and let me explain why." [2]

"The reason we treat this one is where it is. Because it sits on her upper eyelid, as it grows it can press on the eye and change its shape, and a young baby's eye is learning to see, so pressure there can lead to a lazy eye and permanent reduced vision. That is a risk we do not take, so for an eyelid haemangioma we treat rather than watch. The medicine is propranolol — yes, it is also used as a heart and blood-pressure medicine in adults, but in babies with haemangiomas it is given at a careful, weight-based dose and it works extremely well. It halts the growth of the lesion and speeds up the shrinkage. We start it after a quick heart check to make sure her heart rate and rhythm are fine, and we build the dose up gradually." [1]

"Now, the most important thing I will teach you to watch for is low blood sugar, because propranolol can drop a baby's blood sugar, especially if she is unwell and not feeding well. The rule is simple — keep her feeding normally during any illness, do not let her go long without a feed, and bring her straight in if she becomes pale, floppy, off her feeds, or unusually sleepy or lethargic. Those can be signs of a low blood sugar and we would rather check her than have you wait. If she gets a heavy cold or chest infection, ring us, because we may hold the dose for a few days until she is over it." [7]

"The long-term plan is this. She will take the propranolol through her first year, because that is when these lesions are actively growing; once she is past that growth phase we taper it off. As the lesion shrinks it will leave skin that is paler, or sometimes a small soft lump or faint little blood vessels where it was, and if any of that bothers her later we can deal with it — but most children are left with very little. Because her lesion is large on the face, I have also arranged some further checks — a scan and a heart test and an eye review — to make sure there is nothing else going on alongside it, and I will go through those results with you. So the short version is: it will shrink, we are treating it now to protect her eye, the medicine is safe with a few sensible precautions, and we will walk through it with you the whole way." [11]