Endocrine, Physiology, USMLE Step 1 - Full Vignette with Extended Explanations

Описание: A term newborn, large for gestational age, is born to a mother with late-pregnancy insulin-treated hyperglycemia and multiple autoimmune conditions. Shortly after birth, the infant displays low blood glucose but remains vigorous and stable on exam. What prevention-focused strategies should be considered for managing hypoglycemia risk in this well-appearing, at-risk term neonate? Which clinical factors guide optimal monitoring and interventions in the newborn nursery?

VIDEO INFO
Category: Endocrine, Physiology, USMLE Step 1
Difficulty: Hard - Advanced level - Challenges experienced practitioners
Question Type: Prevention - Preventive measures and screening
Case Type: Tricky Findings

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QUESTION
A term female neonate is born at 39 weeks 1 day by spontaneous vaginal delivery to a 28-year-old G2P2 mother with insulin-treated hyperglycemia in late pregnancy. Maternal conditions include Sjo gren s syndrome and rosacea. Medications in the third trimester were prenatal vitamins, low-dose aspirin 81 mg daily, insulin glargine at bedtime, pre-meal lispro, and topical azelaic acid; she used loratadine intermittently....

OPTIONS
A. Administer 40% oral dextrose gel at 200 mg/kg (0.5 mL/kg) massaged into the buccal mucosa in the newborn nursery, immediately initiate breastfeeding or expressed human milk, recheck capillary glucose in 30 minutes, and repeat a single gel dose if still below target while continuing skin-to-skin c...
B. Administer 40% oral dextrose gel 0.5 mL/kg in the nursery but defer breastfeeding for 1 hour to reduce rebound; recheck a glucose in 60 minutes and avoid an immediate feed until two values normalize.
C. Give 40% oral dextrose gel 1.0 mL/kg (400 mg/kg) once without an immediate feed, recheck a glucose after 2 hours, and proceed to additional gel doses only if the second value remains low.
D. Begin a prophylactic intravenous D10W infusion at 4-6 mg/kg/min and hold enteral feeds until euglycemia is documented on two checks; reserve oral dextrose gel for recurrent symptomatic episodes.

CORRECT ANSWER
A. Administer 40% oral dextrose gel at 200 mg/kg (0.5 mL/kg) massaged into the buccal mucosa in the newborn nursery, immediately initiate breastfeeding or expressed human milk, recheck capillary glucose in 30 minutes, and repeat a single gel dose if still below target while continuing skin-to-skin care.

EXPLANATION
At-risk, otherwise well term infants of diabetic mothers should be managed with noninvasive, nursery-based measures that prevent progression to symptomatic hypoglycemia and NICU transfer. The best prevention-focused strategy is to give 40% oral dextrose gel 200 mg/kg (0.5 mL/kg) rubbed into the buccal mucosa, immediately feed human milk, and recheck capillary glucose in 30 minutes, repeating a single gel dose if still below target while maintaining skin-to-skin care. This approach, supported by randomized trials and pediatric endocrine guidance, rapidly raises glucose, preserves rooming-in, decreases IV dextrose use and NICU admission, and supports breastfeeding. It pairs a precisely dosed, high-concentration glucose bolus with substrate delivery from the feed; 40% gel provides 400 mg/mL, so 200 mg/kg equals 0.5 mL/kg.

Deferring breastfeeding for an hour undermines the synergistic effect of gel plus feed and delays substrate delivery....


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