A Missed Opportunity: Severe Malnutrition in an Infant Despite Routine Care Access.

Severe malnutrition of an infant is rare in Canada but poses a major public health concern. This case report describes a 5-month-old male presenting with a rash, found to be severely malnourished with hypoglycemia, bradycardia, hypothermia, ketosis, and metabolic acidosis. Malnutrition was likely due to inadequate breastmilk supply and underfeeding. The infant was treated with intravenous fluids and carefully managed feeding plans while closely monitoring biochemical markers. His nutritional status gradually improved, normalizing symptoms and lab values. This case highlights the importance of early recognition of growth failure, timely referrals, and prevention of complications like refeeding syndrome.