The evidence applies to pediatric patients diagnosed with infantile hemangioma who have not received treatment for this pathology.

It does not apply to patients with contraindications to beta-blockers, including a history of allergy or hypersensitivity, heart disease, arrhythmias, asthma, and/or bronchial obstruction.

Outcomes of complete remission, post-treatment relapse, adverse effects, and severe adverse effects were included, as these are the most important outcomes for patients and their caregivers, according to the authors of this review.

Despite being a secondary outcome, we evaluated the outcome decrease in the Hemangioma Activity Score since it is associated with a better response to treatment.

The outcomes included in the summary are those considered relevant for decision-making by the authors, which coincide with those reported by the included systematic reviews.

When comparing the benefits and risks between both therapies, the use of atenolol compared to the use of propranolol could result in little or no difference in terms of the probability of complete remission of infantile hemangioma, the decrease in the Hemangioma Activity Score, the probability of relapse after treatment, and the risk of presenting adverse and/or severe adverse events (low certainty of evidence).

However, it is impossible to perform a correct risk/benefit assessment, given the uncertainty in the evidence, so further aspects should be considered for decision-making.

The included systematic reviews did not perform a cost-effectiveness analysis between the two treatments.

Atenolol and propranolol, however, are low-cost and widely available drugs, so a formal economic analysis does not seem necessary for clinical decision-making.

Based on the evidence provided by this summary, it is unclear whether patients' caregivers and treating physicians should favor or oppose the use of atenolol, considering the uncertainty of its superiority compared to propranolol monotherapy.

The ideal dose and duration of atenolol treatment for infantile hemangioma have not yet been studied or defined. However, the once-daily dosing of atenolol may represent an advantage over the use of propranolol.

The conclusions of this summary are in tune with the nine included systematic reviews [2–4,9,10,13–16] because, given the existing uncertainty in the evidence, it is not yet possible to establish the superiority of a treatment.

When comparing with international clinical guidelines, it is observed that both the Clinical Practice Guideline for the Management of Infantile Hemangioma of the American Academy of Pediatrics [26] and the Spanish Consensus on Infantile Hemangioma of the Spanish Association of Pediatrics [27] still establish propranolol as the first line of treatment for infantile hemangioma. However, in both guidelines, atenolol is mentioned as a potential valid therapeutic alternative, according to the emergence of new evidence.

Consequently, new randomized comparative studies are still needed, which can be extrapolated to the results of this review.

The likelihood that future evidence will change the conclusions of this summary is high due to the existing uncertainty.

A systematic review was identified in the PROSPERO (International Prospective Register of Systematic Reviews) platform that compares the use of atenolol monotherapy against other therapeutic alternatives for infantile hemangioma, including propranolol monotherapy [28]. This systematic review could shed new light on the subject.

No new trials were found in recruitment on the ClinicalTrials.gov platform of the National Institutes of Health (NIH), comparing the use of atenolol versus propranolol as monotherapy for infantile hemangioma.