Referral Score for Infantile Hemangioma Could Facilitate Early Treatment

By Will Boggs MD

March 13, 2020

NEW YORK (Reuters Health) - The newly validated Infantile Hemangioma Referral Score (IHReS) could facilitate timely referral and treatment of patients with infantile hemangioma, according to a new study.

"IHReS can be easily used during a visit, as scoring takes less than a minute," Dr. Christine Leaute-Labreze of Pellegrin Children's Hospital, in Bordeaux, France, told Reuters Health by email. "It can be used by all professionals working with young children, including doctors and even nurses and paramedics. In addition, a smartphone app is being developed to make it even more convenient."

Many infantile hemangiomas involute spontaneously, but a subset rapidly develop complications that result in pain, functional impairment, or permanent disfigurement. Early assessment of the severity of the infantile hemangioma is essential to determine the need for early appropriate treatment and reduce potential complications.

Dr. Leaute-Labreze and colleagues from eight European countries developed the IHReS and validated its use by nonexpert primary care physicians. The referral tool consists of 12 questions, a two-part algorithm, and 42 infantile hemangioma reference images representative of common cases seen by primary physicians.

Experts who assessed the 42 gold-standard cases using the IHReS correctly made 37 recommendations for specialist referral (but also recommended referral for five cases that required monitoring but not referral). The experts missed none of the cases that required referral.

ROC analysis identified an IHReS score of 5 as optimal for generating referral, with a sensitivity of 89.5%, a specificity of 69.5%, a positive predictive value of 48.1% and a negative predictive value of 95.4%, the researchers report in Pediatrics.

Ultimately, after changing the weighting of one question and reviewing discrepant cases, the task force settled on 4 or higher as the IHReS threshold for referral, which provided 96.9% sensitivity, 55.0% specificity, 40.5% positive predictive value, and 98.3% negative predictive value.

Patients with an IHReS score below 4 should not be referred to a specialist but should be monitored with the IHReS repeated at subsequent clinic visits, they say.

"The previous wait-and-see approach in infantile hemangioma is not always acceptable, because in a subgroup of infantile hemangiomas there may be complications and serious long-term disfigurement," Dr. Leaute-Labreze said. "That's why prompt recognition of at-risk infantile hemangiomas and referral to centers of expertise are essential."

Dr. Amor Khachemoune of State University Of New York and Veterans Affairs Hospital, in New York City, who recently reviewed treatment options for infantile hemangioma, told Reuters Health by email, "In clinical conditions like infantile hemangioma, with subsets or forms that have more serious complications if not managed earlier in life, knowing elements or danger signs/locations that warrant early referral to experts is very important, and having a use-friendly tool to help practitioners do so is very important."

"The IHReS could be made simpler in future studies and designs with visual pictures to target a wider range of practitioners, including general practitioners, family physicians, pediatricians, nurse practitioners, physician assistants, and other physician extenders," said Dr. Khachemoune, who was not involved in the research.

An electronic version of the IHReS, along with six sample training cases, is available at

SOURCE: Pediatrics, online March 11, 2020.