Neonatal hypoglycaemia — structured oral station (12 minutes)

Opening prompt — "What is your threshold to treat, and what do you do first?"

Model response: ^[1]

• "There is no single glucose number that defines brain injury — I use an operational threshold. In the first 48 hours, under 2.6 mmol/L is my treatment threshold. This baby is 1.9 and symptomatic, so the hypoglycaemia is critical."^[7][1]
• "I give 40% glucose gel 0.5 mL/kg — that is 200 mg/kg — massaged into the buccal mucosa, followed by a feed, and recheck at 30 minutes, while establishing other treatments — because he is symptomatic, gel eligibility fails and intravenous access is the treatment."^[7][2]

Examiner is listening for: the operational-threshold framing, the correct gel dose, and the recognition that symptomatic means critical. ^[1]

Probe 1 — "What evidence supports the gel?"

• "The Sugar Babies trial: 40% dextrose gel 200 mg/kg reduced treatment failure from 24% to 14% — relative risk 0.57 — with no serious adverse events, in late-preterm and term babies in the first 48 hours."^[2]
• "The Cochrane review concluded oral dextrose gel is probably an effective and safe first-line treatment; it also reduced mother-infant separation and increased exclusive breastfeeding after discharge."^[3]

Probe 2 — "The glucose is still low after gel and a feed. What now?"

• "That is critical hypoglycaemia. I start a 10% glucose infusion at 60 mL/kg/day — 80 mL/kg/day because he is symptomatic — with a 1 mL/kg (100 mg/kg) 10% glucose bolus, and recheck at 30 minutes."^[7]
• "If access is difficult or delayed beyond 15 minutes I give glucagon 200 microgram/kg intramuscularly or subcutaneously. I increase volume before concentration, and anything above 12% goes through a central catheter, umbilical vein catheter or PICC."^[7]

Probe 3 — "How do you counsel the mother who wants to keep breastfeeding?"

This is a scored domain. Demonstrate it out loud: ^[1]

• "I reassure her the gel and the feeding plan are exactly how we protect breastfeeding — the evidence shows gel increases exclusive breastfeeding at discharge, and immediate breastfeeding after gel improves subsequent feeds. I would encourage expressed colostrum and skin-to-skin, keep her and the baby together, and avoid separation."^[7][3]

Probe 4 — "What is the prognosis if you treat promptly?"

• "The CHYLD cohort showed that hypoglycaemia treated to maintain at least 2.6 mmol/L was not associated with neurosensory impairment at 2 years — risk ratio 0.95. The reassurance holds for recurrent and severe episodes once the threshold is maintained."^[4]
• "HypoEXIT tested a lower threshold of 2.0 mmol/L and found it non-inferior — but only in well, asymptomatic term babies, so it does not change what I do for this symptomatic preterm baby."^[5]

Probe 5 — "When would you investigate for persistent disease?"

• "If the glucose infusion rate exceeds 8 mg/kg/minute, or the hypoglycaemia is recurrent, prolonged or refractory. I draw the full panel during an episode, before treatment — blood gas, insulin, cortisol, acyl-carnitine profile, growth hormone, amino acids, ammonium, pyruvate, beta-hydroxybutyrate, plus a urine metabolic screen. A glucose that needs more than 8 mg/kg/minute is the signature of hyperinsulinism."^[7]