Ominous clinical characteristics that warrant immediate intervention
are (1) bradycardia, (2) reduced level of consciousness, (3) capillary refill
time greater than 2 seconds (according to the Advanced Pediatric
Life Support guidelines, rather than greater than 3 seconds, as recommended
by the World Health Organization), (4) a weak pulse, and (5) hypoglycemia. Other
clinical risk factors are severe anemia, hypothermia, acidotic breathing,
signs of dehydration, hyponatremia, hypokalemia, and lethargy.12 The
World Health Organization management approach consists of a 10-step program
that begins with initial stabilization and prevention of hypoglycemia,
hypothermia, and dehydration. During this initial phase of therapy,
antibiotic administration, vitamin therapy including vitamin A,
thiamine, and niacin may also be indicated. Initially, feedings with
a lower osmolality and caloric density are administered in small
volume (orally or by nasogastric tube) at frequent intervals; then
they are advanced to higher volumes through the first week. Since
these feedings contain added electrolytes and micronutrients, they
prevent and/or treat the electrolyte complications of refeeding
syndrome and start correcting micronutrient deficiencies. Simultaneously, concomitant infections
must be prevented or treated. This is followed by the commencement
of cautious feeding. Treatment of other infections including parasitic
infestations, malaria, tuberculosis, and human immunodeficiency
virus may also be needed. Subsequently, one enters a phase of rehabilitation
to achieve catch-up growth, achieve further micronutrient repletion
(multivitamin supplement, folic acid, zinc, copper, and iron), and
attention to assure sensory and emotional stimulation to compensate
for the developmental delays resultant from malnutrition. In children
older than 6 months of age, the caloric density of the feeding may
be increased. Iron is not given until the acute stabilization phase
is completed and the child has a good appetite, with the initiation
of weight gain (usually week 2) because giving iron can increase
infection risk. Subsequent follow-up monitoring ensues to assure
that the caretaker is capable of maintaining the child’s
health.