Hypoglycemia — MCQs

10 questions

Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

Estimation of the blood sugar is relevant in all except –

A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

Beta blockers mask all effects of hypoglycemia except?

A one month old infant with a congenital cardiac lesion shows increased sweating during feeding. Which of the following is the sure sign of congestive cardiac failure in this infant?

A G1 P0 woman at 36 weeks presents with newly diagnosed gestational diabetes. What is the most appropriate initial management?

Which of the following conditions is most commonly associated with neonatal hypoglycemia?

All of these cause hyperglycemia except:

A 37-week small-for-date neonate is most likely to develop

Q10

In a 2-5 year-old child with DM, target HbA1C is:

Hypoglycemia Indian Medical PG Practice Questions and MCQs

Question 1: Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

A. Normal saline
B. Ringer lactate
C. 10% dextrose
D. Ringer lactate + 5% dextrose (Correct Answer)

Explanation: ***Ringer lactate + 5% dextrose*** - This combination provides both **electrolytes** (from Ringer lactate) to help correct **shock** and **glucose** (from 5% dextrose) to address **hypoglycemia** in a child with severe acute malnutrition (SAM). - Patients with SAM are at a high risk of **hypoglycemia** during shock, making glucose supplementation crucial. *Normal saline* - While suitable for initial fluid resuscitation in shock, it does **not contain glucose** and would not address the concomitant hypoglycemia. - Excessive use of normal saline can also lead to **hyperchloremic metabolic acidosis**, which is undesirable in already compromised patients. *Ringer lactate* - Ringer lactate provides **electrolytes** and is a good crystalloid for shock resuscitation, but it **lacks glucose** to correct hypoglycemia. - In SAM patients, where energy stores are depleted, simply providing Ringer lactate might not be sufficient to prevent or treat hypoglycemia. *10% dextrose* - 10% dextrose would effectively treat **hypoglycemia** but is not an appropriate fluid for fluid resuscitation in **shock**. - It would not adequately expand the intravascular volume or provide the necessary electrolytes for managing shock alone.

Question 2: Estimation of the blood sugar is relevant in all except –

A. Large for date baby
B. Birth asphyxia
C. Rh Incompatibility
D. Baby of hypothyroid mother (Correct Answer)

Explanation: ***Baby of hypothyroid mother*** - While maternal hypothyroidism can affect fetal development and lead to various complications, it does not directly cause **neonatal hypoglycemia** or **hyperglycemia**, making routine blood sugar monitoring less critical unless other risk factors are present. - The primary concerns for a baby born to a hypothyroid mother are related to thyroid function itself, such as **congenital hypothyroidism**, not blood glucose dysregulation. *Large for date baby* - **Macrosomic infants**, especially those born to mothers with gestational diabetes, are at increased risk for **hypoglycemia** due to chronic fetal hyperinsulinemia. - Close monitoring of blood glucose levels is essential to prevent neurological damage from sustained low sugar. *Birth asphyxia* - Infants who experience **birth asphyxia** are under significant stress, which can deplete their glycogen stores and impair gluconeogenesis, leading to **hypoglycemia**. - Monitoring blood glucose is a critical component of their post-resuscitation care and management. *Rh Incompatibility* - Severe **Rh incompatibility** can lead to **hydrops fetalis** and other complications, including liver dysfunction and extramedullary hematopoiesis, which can impair glucose regulation. - These infants are at risk for both **hypoglycemia** due to increased metabolic demand and **hyperglycemia** secondary to stress and liver involvement, necessitating blood sugar monitoring.

Question 3: A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

A. RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours
B. RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours
C. RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours
D. RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours (Correct Answer)

Explanation: ***RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours*** - The child shows signs of **some dehydration** (sunken eyes, skin pinch returning very rapidly). According to **WHO Plan B**, some dehydration requires **75 ml/kg over 6 hours** for rehydration. - For a 6 kg child: **75 × 6 = 450 ml total** - **Distribution:** 30 ml/kg in first hour (180 ml) + 45 ml/kg over next 5 hours (270 ml) - This option provides exactly **450 ml (180 + 270)**, perfectly matching WHO guidelines for some dehydration *RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours* - First hour: 120 ml = only **20 ml/kg**, which is **below the recommended 30 ml/kg** initial bolus for some dehydration - Total volume: **480 ml** exceeds the required **450 ml** for a 6 kg child - Incorrect fluid distribution pattern for WHO Plan B *RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours* - First hour volume is correct at **30 ml/kg (180 ml)** - However, next 5 hours: **480 ml = 80 ml/kg**, far exceeding the recommended **45 ml/kg** - Total: **660 ml** significantly exceeds **450 ml**, risking **fluid overload** in a small child *RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours* - Initial rate: **240 ml = 40 ml/kg** is appropriate for **severe dehydration (WHO Plan C)**, not some dehydration - This child shows **some dehydration** signs, not severe (no lethargy, unconsciousness, or very slow skin pinch) - Total: **600 ml** exceeds the **450 ml** requirement, indicating overtreatment for this clinical scenario

Question 4: Beta blockers mask all effects of hypoglycemia except?

A. Sweating (Correct Answer)
B. Palpitations
C. Dizziness
D. Tremors

Explanation: ***Sweating*** - **Sweating** is a **cholinergic symptom** mediated by the sympathetic nervous system acting on **muscarinic receptors** (via acetylcholine), NOT beta-adrenergic receptors. - Beta-blockers act on **adrenergic receptors only** and therefore **do not mask sweating**. - This makes **sweating the most reliable clinical sign** of hypoglycemia in patients on beta-blocker therapy. - Sweating remains the classic teaching point for symptoms that persist despite beta-blockade. *Palpitations* - **Palpitations** are an **adrenergic symptom** resulting from increased heart rate and contractility, mediated by **beta-1 adrenergic receptors**. - Beta-blockers effectively **mask** this symptom by blocking these receptors, preventing the cardiovascular response to hypoglycemia. *Dizziness* - **Dizziness** is a **neuroglycopenic symptom** resulting from insufficient glucose supply to the brain. - While technically not masked by beta-blockers (as it's not mediated by beta receptors), dizziness represents a **late and dangerous sign** of severe hypoglycemia. - Sweating is the more reliable and **earlier warning sign** that remains detectable in beta-blocked patients. *Tremors* - **Tremors** are an **adrenergic symptom** caused by stimulation of **beta-2 adrenergic receptors** in skeletal muscle. - Beta-blockers, especially non-selective ones, effectively **mask this symptom** by blocking these receptors.

Question 5: A one month old infant with a congenital cardiac lesion shows increased sweating during feeding. Which of the following is the sure sign of congestive cardiac failure in this infant?

A. JVP
B. Basal crepitations
C. Liver enlargement (Correct Answer)
D. Pedal oedema

Explanation: ***Liver enlargement*** - **Hepatomegaly** is a **cardinal sign** of **congestive cardiac failure** in infants due to venous congestion and fluid retention. - The infant's immature lymphatic system and pliable chest wall make other signs less reliable, while the liver quickly reflects increased systemic venous pressure. *JVP* - **Jugular venous pressure (JVP)** is notoriously difficult to assess accurately in infants due to their short necks and poorly developed neck muscles. - Therefore, it is **not a reliable indicator** of congestive cardiac failure in this age group. *Basal crepitations* - **Basal crepitations**, indicating pulmonary edema, can be a sign but are often subtle and can also be present in other respiratory conditions prevalent in infants. - The infant's small lung fields and rapid respiratory rate make the detection of crepitations challenging and less specific than liver enlargement. *Pedal oedema* - **Pedal edema** is less common in infants with congestive heart failure because they tend to retain fluid in the **extracellular space**, leading to generalized edema rather than localized peripheral swelling. - The distribution of fluid retention in infants often manifests as puffiness around the eyes or generalized anasarca rather than prominent pedal edema.

Question 6: A G1 P0 woman at 36 weeks presents with newly diagnosed gestational diabetes. What is the most appropriate initial management?

A. Induction of labor
B. Oral hypoglycemics
C. Diet control (Correct Answer)
D. Insulin

Explanation: ***Diet control (Medical Nutrition Therapy)*** - For newly diagnosed gestational diabetes, **lifestyle modifications**, primarily **dietary changes**, are the **first-line treatment** per ACOG and ADA guidelines - Medical nutrition therapy (MNT) aims to control blood glucose levels through proper nutrition and should be attempted for **1-2 weeks** before considering pharmacologic interventions - Target goals: Fasting glucose <95 mg/dL, 1-hour postprandial <140 mg/dL, 2-hour postprandial <120 mg/dL *Induction of labor* - **Induction of labor** is typically considered for gestational diabetes if there are concerns about **fetal macrosomia** (EFW >4000-4500g), **poor glycemic control despite treatment**, or other maternal-fetal complications - Generally considered at **39-40 weeks** in well-controlled GDM or earlier with complications - Not the initial management for a new diagnosis at 36 weeks without additional concerning features *Oral hypoglycemics* - **Metformin** or **glyburide** may be used as second-line agents when **dietary management fails** to achieve adequate glycemic control after 1-2 weeks - Metformin is increasingly preferred as it does not cross the placenta as readily as glyburide - They are **not the initial step** in management *Insulin* - **Insulin therapy** is indicated when **dietary modifications alone** are insufficient in maintaining target blood glucose levels - Also preferred if oral agents are contraindicated or fail to achieve glycemic targets - Represents a **secondary intervention** when primary non-pharmacological methods are inadequate

Question 7: Which of the following conditions is most commonly associated with neonatal hypoglycemia?

A. Infants born to diabetic mothers (Correct Answer)
B. Infants with low birth weight
C. Infants born to mothers with toxaemia of pregnancy
D. Premature infants

Explanation: ***Infants born to diabetic mothers*** - Maternal hyperglycemia leads to fetal **hyperinsulinism**, which continues after birth when the glucose supply from the mother is interrupted. - This persistent hyperinsulinism rapidly consumes the available glucose in the neonate, leading to profound and often symptomatic **hypoglycemia**. - This is the **most common** association with neonatal hypoglycemia encountered in clinical practice. *Infants with low birth weight* - While **low birth weight (LBW)** infants are at increased risk for hypoglycemia due to limited glycogen stores and impaired gluconeogenesis, it is not the most common association compared to infants of diabetic mothers. - Their hypoglycemia tends to be due to limited metabolic reserves, whereas in infants of diabetic mothers, it's driven by **insulin excess**. *Infants born to mothers with toxaemia of pregnancy* - **Toxemia of pregnancy** (pre-eclampsia/eclampsia) is not directly associated with an increased risk of neonatal hypoglycemia. - However, severe pre-eclampsia can lead to **intrauterine growth restriction (IUGR)** and prematurity, which are indirect risk factors for hypoglycemia due to poor glycogen stores. *Premature infants* - **Premature infants** are at risk for hypoglycemia due to inadequate glycogen stores, immature enzyme systems for gluconeogenesis, and increased metabolic demands. - However, the incidence and severity are less compared to infants of diabetic mothers, where the mechanism involves **active hyperinsulinism** rather than just inadequate reserves.

Question 8: All of these cause hyperglycemia except:

A. Catecholamines
B. Insulin (Correct Answer)
C. Cortisol
D. GH

Explanation: ***Insulin*** - Insulin's primary function is to **lower blood glucose levels** by facilitating glucose uptake into cells and promoting glycogen synthesis. - It counters the effects of hormones that elevate blood sugar, directly leading to a **decrease in hyperglycemia**. *Catecholamines* - **Catecholamines** (e.g., epinephrine, norepinephrine) increase blood glucose by promoting **glycogenolysis** and **gluconeogenesis**. - They also **inhibit insulin secretion**, further contributing to elevated blood sugar. *Cortisol* - **Cortisol** is a **glucocorticoid** that raises blood glucose by increasing **gluconeogenesis** and reducing peripheral **glucose utilization**. - It can also decrease insulin sensitivity, leading to **hyperglycemia**. *GH* - **Growth hormone (GH)** can induce **insulin resistance** in peripheral tissues, which leads to reduced glucose uptake. - It also promotes **gluconeogenesis**, both contributing to elevated blood glucose levels.

Question 9: A 37-week small-for-date neonate is most likely to develop

A. Hypoglycaemia (Correct Answer)
B. Hyaline membrane disease
C. Hypocalcaemia
D. Hypothermia

Explanation: ***Hypoglycaemia*** - **Small-for-date** neonates have reduced **glycogen stores** due to chronic fetal stress or placental insufficiency. - Their increased metabolic demands relative to limited energy reserves make them prone to **low blood glucose**. - This is the **most immediate metabolic complication** requiring urgent screening and management. *Hyaline membrane disease* - This condition, also known as **respiratory distress syndrome**, primarily affects **premature neonates** due to surfactant deficiency. - **Small-for-date infants** at term (37 weeks) typically have **accelerated lung maturity** due to chronic intrauterine stress, making them **less susceptible** to RDS compared to appropriately grown preterm infants. *Hypocalcaemia* - While neonates can experience hypocalcemia, it is particularly common in infants of **diabetic mothers**, those with **asphyxia**, or those born **prematurely**. - Small-for-date status alone isn't the primary risk factor for **neonatal hypocalcaemia**. *Hypothermia* - **Small-for-date** infants have a larger **surface area to body mass ratio** and reduced **subcutaneous fat**, which significantly increases heat loss. - This is indeed a **major risk** requiring immediate attention at birth (thermal protection, skin-to-skin care). - However, **hypoglycemia** is considered the **most characteristic metabolic derangement** and "most likely" complication specifically associated with SGA status, making it the best answer for this question.

Question 10: In a 2-5 year-old child with DM, target HbA1C is:

A. < 8% (Correct Answer)
B. < 7%
C. < 7.5%
D. < 6.5%

Explanation: ***< 8%*** - For children aged **2-5 years** with diabetes mellitus, the target **HbA1c** is **< 8%** (some guidelines recommend < 8.5%) to balance glycemic control with the significant risk of hypoglycemia. - This age group is at **critical neurodevelopmental stage**, and severe hypoglycemia can have lasting cognitive effects, hence a more lenient target is recommended. - The higher target accounts for **unpredictable eating patterns, variable activity levels**, and difficulty in recognizing hypoglycemic symptoms at this young age. *< 7%* - An **HbA1c** target of **< 7%** is too stringent for very young children (2-5 years) and significantly increases the risk of **severe hypoglycemia**. - This target may be appropriate for **adults** or older adolescents with good awareness and self-management skills, but not for this vulnerable age group. - Achieving this target in toddlers would require intensive monitoring and could compromise safety and quality of life. *< 7.5%* - An **HbA1c** target of **< 7.5%** is the recommended target for **older children (6-12 years)** and **adolescents (13-19 years)**, not for children aged 2-5 years. - While more achievable than < 7%, this target is still too aggressive for the 2-5 year age group and increases hypoglycemia risk without proportional long-term benefit. *< 6.5%* - An **HbA1c** target of **< 6.5%** is far too aggressive for children aged 2-5 years and would pose an **unacceptable risk of severe and frequent hypoglycemia**. - This target approaches near-normal glycemia and is only considered in select adult patients who can achieve it safely with minimal hypoglycemia risk. - In young children, such tight control could result in seizures, developmental harm, and psychological stress for families.

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