Oral propranolol remains the primary systemic treatment for infantile hemangioma with no superior alternativesPropranolol Remains the Standard Treatment for Infantile Hemangioma

UNLABELLED: The purpose of the study is to compare the efficacy and safety of available interventions for infantile hemangioma against oral propranolol and to evaluate the certainty of the comparative evidence. We conducted a Bayesian network meta-analysis in accordance with PRISMA-NMA guidelines and systematically searched PubMed, Embase, the Cochrane Library, and CNKI from January 2008 to June 2026. A random-effects consistency model was fitted using the BUGSnet package. Evidence certainty was assessed using the CINeMA framework, and risk of bias was evaluated using the revised Cochrane RoB 2 tool. Thirty randomized controlled trials (RCTs) including 2,639 patients across nine treatment nodes were included in the efficacy analysis, and 12 RCTs involving 1,143 patients across eight nodes were included in the safety analysis. Using oral propranolol as the reference treatment, no active intervention demonstrated statistically significant superiority in efficacy, whereas placebo was significantly inferior. Corticosteroids were the only intervention associated with substantially higher adverse event rates, whereas atenolol showed a trend toward fewer adverse events. By anchoring all comparisons to oral propranolol and integrating CINeMA certainty assessments with inconsistency testing, these findings are consistent with the continued role of oral propranolol as the reference systemic treatment for infantile hemangioma. For patients intolerant to propranolol, atenolol may represent a reasonable alternative. CONCLUSIONS:  By anchoring all comparisons to oral propranolol and integrating CINeMA certainty assessments with inconsistency testing, these findings are consistent with the continued role of oral propranolol as the reference systemic treatment for infantile hemangioma. For patients intolerant to propranolol, atenolol may represent a reasonable alternative. WHAT IS KNOWN: • Oral propranolol is the established first-line systemic therapy for infantile hemangioma. • Previous network meta-analyses have reported treatment rankings, but the clinical meaning of these rankings relative to oral propranolol remains uncertain. WHAT IS NEW: • Despite favorable point estimates for combination therapy and nadolol, this benchmark-anchored analysis found no included active intervention statistically superior to oral propranolol. • Certainty assessment showed that treatment rankings were limited by heterogeneity, inconsistency, risk of bias, and imprecision; atenolol had the largest body of direct comparative evidence among the alternatives.