Objective. Here we describe the clinical findings and legal outcomes in 12 prosecuted cases of infant and child starvation.
Methods. Medical records, investigation records, and transcripts of court testimony were reviewed in the cases of 12 infants and children from locations throughout Texas who had been starved deliberately. The children’s ages ranged from 2 months to 13 years. The caretakers of all children received both civil and criminal charges; cases were tried over an 11-year time span. Clinical presentations, examination findings, laboratory findings, symptoms of refeeding syndrome, and legal outcomes were examined. Two illustrative cases are presented in detail here.
Results. Of the 12 cases reviewed, the median age was 2.7 years, with a range of 2.25 months to 13 years 7 months. Half of the children died shortly before or soon after presentation for medical care or to law enforcement. Survival was more common in older children than in infants. Most of the children were secluded from others, and all had access to food denied or severely restricted. Caretakers claimed few, benign, or no past medical illnesses in the children. Based on weight and height measurements, 10 of the children had severe wasting and stunting, and 2 had mild or moderate wasting. There was a tendency toward more severe wasting in the fatal cases. All children manifested multiorgan effects of starvation. All survivors manifested complications with refeeding. Approximately half of the children had past or present injuries or history suggestive of physical or sexual abuse. Parental rights were terminated in all cases. A total of 25 individuals were charged criminally; 23 were found guilty or pled guilty, and trials for 2 individuals were pending at the time of this writing. The types of criminal charges and punishment varied from deferred adjudication to a life sentence.
Conclusions. Life-threatening criminal starvation of infants and children is a rare and severe form of child maltreatment. In our series, infants were more wasted at the time of presentation and less likely to survive prolonged starvation than were older children. As with other forms of child abuse, caretakers’ histories regarding the children’s illnesses were inconsistent with the severity and chronicity of the children’s degree of wasting. All victims in our series showed multiorgan effects of chronic malnutrition and deprivation, and all survivors developed refeeding complications and required prolonged periods of recovery.
Starvation affects >3 million children worldwide, primarily in developing countries with food shortage.1 In developed countries, deliberate starvation of an infant or child has been described as a rare and severe form of child maltreatment. The true incidence is not known, but several cases receive high-profile media coverage each year in the United States. A search of the Web-site archives of a prominent national news organization identified 6 cases of child starvation that received national media attention between July 2003 and June 2004 involving 5 fatalities and 4 survivors.2
Some articles focusing on child deaths from starvation in developed countries have been published in the medical literature. Most describe small case series and focus on autopsy findings.3–6 Outcomes in the criminal justice system of cases of infant or child starvation in the United States have been sparsely reported in either the scientific or the legal literature.
The purpose of this case series is to describe the medical findings, family and background information, criminal and civil charges, and responses to medical treatment of criminally prosecuted cases of infant/child starvation. Two illustrative cases are presented in detail.
This infant was born at term weighing 2.65 kg (6th percentile) with a length of 48 cm (17th percentile).§ The mother and infant were discharged after 2 days. Neonatal metabolic screens showed normal results (Fig 1 shows a photograph of this infant taken shortly after birth). When he was 74 days old, the mother called emergency medical services with a complaint of “infant not breathing.” She stated that the infant had had “sniffles” but had fed 1.5 hours earlier. She claimed that she had made a doctor’s appointment for the child’s sniffles, but investigators confirmed that the infant had received no medical care since hospital discharge. The infant was noted to be very underweight and malnourished, with lividity noted to the back. He was pronounced dead on arrival at a nearby emergency department.
The infant lived with his mother, father, and 3 siblings (ages 1, 2, and 3 years). The mother stated she breastfed him, but provided an inconsistent history of breastfeeding problems. The family’s income was below the poverty level. Neighbors and family members testified that they were either unaware or saw very little of the infant. One neighbor recalled the mother once stating that she did not want the infant.
The 3 surviving siblings were not considered to be malnourished. However, 1 sibling ate voraciously to the point of emesis after being placed in foster care. Another sibling had received medical care 1 month before the infant’s death.
Weight was 2.4 kg (0.0 percentile), and length was 53 cm (0.1th percentile). The infant was noted to be emaciated, with sunken eyes and prominent ribs and other bones (Fig 2). There was no detectable subcutaneous fat, organs were smaller than expected, and the thymus was atrophied. The stomach contained a teaspoon of liquid, and a few pebble-sized portions of fecal material were found in the distal colon. Vitreous chemistries included a urea nitrogen level of 40 mg/dL and a sodium level of 127 mEq/L. The cause of death was listed as starvation, with moderate dehydration as a contributing factor.
Parental rights to the surviving children were terminated. The mother was tried and found guilty of capital murder and is currently serving a life sentence. The ruling was appealed to the state Supreme Court level and upheld. The father pled guilty to a charge of first-degree felony injury to a child and received a prison sentence of 25 years.
Emergency medical services received a call from an elementary school stating that a 7-year-old girl had collapsed. She was transported to a hospital where she was admitted for treatment of emaciation. She saw a physician twice within the 2 months before her collapse with complaints of sore feet and hands; during 1 visit, a bruise under her right eye was noted. Examination during the second visit revealed numerous open sores on her feet and ankles. Her extremities were noted to be cold with distal edema. She was not weighed. She was suspected of having a “connective tissue disease,” but her erythrocyte sedimentation rate and antinuclear antibody and rheumatoid factor levels were normal. No concerns for eating disorders or weight loss were documented.
The child lived with her father, stepmother, and infant stepsister. The family’s income was found to be $90000 per year. She was diagnosed with attention-deficit/hyperactivity disorder (ADHD) 14 months before admission, but medication and follow-up were discontinued after <1 year. She was home-schooled until ∼8 months before admission. At the time of the ADHD diagnosis, her height was recorded as 114 cm (23rd percentile) and weight as 19.9 kg (27th percentile).
In the 5 months preceding her collapse, school personnel had contacted the father and stepmother several times because the child was documented to be losing weight, eating food out of trash cans, begging for food, and hoarding food. Poorly healing skin lesions were noted. She always brought the same lunch to school: water and 3 sandwiches consisting of a teaspoon of peanut butter between 2 slices of bread. The school provided food to the child, but the parents refused to pay the cafeteria bill. They insisted that the school stop feeding the child because they claimed she had an eating disorder and they were trying to control her odd eating behaviors. Her collapse occurred on the day she returned to school after a 2-week vacation at home.
Her admission weight was 17.2 kg (0.2nd percentile), and her height was 114 cm (2.4th percentile). Tachycardia and dehydration were noted. Her hair was brittle and coarse, and subcutaneous fat was absent (Fig 3). There was marked hepatomegaly (Fig 4). Edema, erythema, and numerous open sores were noted on her distal lower extremities. Admission laboratory findings included elevated liver transaminase levels (alanine aminotransferase: 73 U/L; aspartate aminotransferase: 83 U/L) and a markedly elevated plasma triglyceride level (746 mg/dL). During a 9-day hospitalization she was found to have a bezoar (type unspecified). She developed refeeding syndrome manifested by low serum phosphate, potassium, and magnesium levels; hyperglycemia and marked increases in serum transaminases; diarrhea; and ST-T wave changes on electrocardiogram. No evidence of pancreatitis was recorded. Evaluations for congenital anomalies, metabolic diseases, toxic exposure, and malabsorption disorders were negative.
After hospitalization, the child and her stepsister were placed in foster care. She gained weight steadily, and within 3 months, her height was at the 20th percentile. Although her father and stepmother suggested that the child had an eating disorder, she displayed no unusual eating behaviors after hospital discharge (Fig 5).
Parental rights were terminated for both the father and stepmother. Both were found guilty of injury to a child by endangerment and sentenced to 2 years imprisonment.
The records of 12 infants and children who were suspected victims of intentional starvation were reviewed by the lead author (N.D.K.) at the request of criminal prosecutors and investigators. Court documents, photographs, medical records, depositions, testimony, and investigative reports were reviewed. All cases originated within the state of Texas between 1991 and 2003. Materials reviewed in this article are drawn from the public records of the legal proceedings. The study was approved by the University of Texas Health Science Center at San Antonio Institutional Review Board.
Weight for age, length or height for age, weight versus height for age, and BMI for age were calculated by using the nutrition anthropometry program NutStat.8 Using the same program, which is referenced on the 2000 Centers for Disease Control and Prevention growth charts,7 growth measurements were then converted into z scores (variations from means expressed as fractional standard deviations).
Severity of malnutrition was also calculated by using the Waterlow classification, under which wasting (normal height for age but decreased weight for height) is distinguished from stunting (decreased height for age and weight for age).1
Characteristics of fatalities were compared with survivors using the PEPI epidemiology statistics test package.9 Data grouped into 2 × 2 tables were compared by using Fisher’s exact test; other data were compared by using the Mann-Whitney U test.
The median age of the children was 2.7 years (range: 2 months to 13 years 7 months). Five cases involved children younger than 12 months at the time of presentation, and the rest were distributed across the childhood age spectrum (Fig 6). Seven were male, 6 were non-Hispanic white, 4 were Hispanic, and 2 were black. Two were siblings who were rescued at the same time. Six children survived. Five children were dead at the time of presentation. One child presented in bradycardia and shock and was resuscitated but died 13 days later from complications of shock. All the deceased children were autopsied.
Table 1 lists clinical, legal, and social findings by survival status. Initial laboratory values for the child who died 13 days after presentation are included with the survivors.
Age was the only statistically significant risk factor identified for death resulting from starvation: the fatality group had a median age of 8 months compared with the median age among survivors of almost 8 years (Fig 6).
Ten children had severe stunting, and 2 had mild or moderate wasting as defined by the Waterlow classification.1
For all 4 growth parameters analyzed, median z scores were lower in the fatality group than in the survivor group, but the differences did not achieve statistical significance.
Weight-for-age calculations showed that all children except 1 were moderately underweight (z scores below −2.0, or below 2 standard deviations below the mean), whereas 8 children were severely underweight (z scores below −3.0).
In all cases the lengths or heights for age were well below the mean. Nine had z scores below −2.0 (moderate stunting), and 4 had scores below −3.0 (severe stunting) for length (or height) for age.
Age-adjusted weight-for-height measurements were calculated for children younger than 9 years, and age-adjusted BMI was calculated for children 4 years or older. Six of the children had moderate wasting (z scores below −2.0), and all 5 children who were younger than 1 year met the criteria for severe wasting (z scores below −3.0).
Among the 6 children in whom fronto-occipital circumference was measured, 4 had measurements below the 5th percentile for age.
All 6 starvation survivors had been fed and given fluids of undetermined amounts at the time of rescue but before their clinical presentation. Nevertheless, clinical dehydration was noted in 4 survivors as well as in all fatal cases. Blood or vitreous urea nitrogen was elevated in 7 of these 10 children, suggesting that free water intake was being chronically restricted as well as caloric intake.
The only other laboratory abnormalities consistently noted were anemia in all 6 survivors (hematocrit was recorded for only 1 fatality); low prealbumin/albumin ratio in 6 of 7 patients tested; and elevated liver transaminases in 5 of 7 patients tested. No children had serum phosphorus levels drawn at the time of presentation. All deceased victims and 3 of the surviving victims were tested extensively for metabolic and genetic disorders; no such disorders were identified.
One child (described in case 2) had signs of kwashiorkor, evidenced by edema, hepatomegaly, low total serum protein, low prealbumin/albumin ratio, and high triglyceride levels.
Four survivors had cardiac dysrhythmias including tachycardia and/or bradycardia. Brain atrophy was documented on computed tomography scan in 3 survivors and in 2 children who died shortly after presentation. Two were infants, and 3 were aged 8 years or older. Delayed radiographic bone age was recorded in 2 of the children. Growth arrest lines were noted in 2 cases.
All survivors manifested complications with refeeding. Five of 6 surviving children had signs of gastric dysmotility. Gastric bezoars were found in 2 children that gave histories of gnawing on indigestible materials to sate their chewing urges. The types of bezoar were not recorded. Phosphate levels were low in all these children, and all of them required phosphate supplements during hospitalization. Serum amylase and lipase levels were not obtained from most children; the few levels that were obtained were all within the normal ranges. Children that required >10 days of hospitalization had difficulties with diarrhea, hyperglycemia resulting from insulin suppression, and fluid overload, manifested by edema or congestive heart failure.
Medical and Social History
In each case, the parental history was characterized by either minor complaints, allegations of unusual eating habits, or lack of acknowledgment of the child’s poor condition. In all but 1 case, other children who were not malnourished were residing in the victim’s home.
The 6 infants were all described by their caretakers as having minor or no symptoms before death or rescue. All were reported to have consumed at least 90 mL of formula within hours of clinical presentation. However, autopsies of the 4 deceased infants failed to demonstrate any evidence of recent or substantial intake preceding death.
Caretakers of the older victims justified withholding food for various reasons: corporal punishment was ineffective; the child had ADHD and was difficult to control; the child had aberrant eating behaviors, including “an unnatural appetite” or “eating dog food or garbage”; and a perception that the child was evil.
None of the 5 infants in the series had seen a physician except for newborn care. Of the 7 older children, 6 had not seen a physician in the year before their death or rescue. One child (case 2) had had 3 physician visits in the year before her rescue. Except for the child described in case 2, all of the school-aged children were either home-schooled or kept from school around the time of their rescue or demise.
The father was either unknown or uninvolved in the child’s life in 6 cases; in 1 case, the mother was uninvolved in the child’s care.
The youngest infant in the series had a cleft palate. None of the other children were found to have congenital anomalies.
Legal and Investigative Outcomes
Six children had histories or physical findings indicative of recent physical abuse. One child was confirmed, and another was suspected, to be a victim of recent sexual abuse. Five victims had previously been reported to Children’s Protective Services (CPS) for suspected abuse. Two had previously been confirmed to be victims of physical abuse. One had been referred for neglectful supervision, but the charge was not validated. One had been reported to CPS but not investigated because the family could not be located, and 1 was a victim of in utero maternal drug abuse.
When possible, statements or testimony from siblings were obtained. Statements from neighbors or relatives residing outside the victim’s home typically demonstrated that the victims’ families kept the children secluded from others and when in public concealed their appearances with clothing and blankets. In 3 cases, statements from school personnel described deprivation-related behaviors such as stealing or hoarding food and rummaging through garbage for food; often these statements were substantiated further by similar observed behaviors during hospitalization after rescue. In 4 cases, parents admitted or were overheard stating that food withholding was being used as a form of punishment.
Photographs of the victims were shown for all cases that went to trial. Testimony about the photographs emphasized that reasonable adults would recognize the poor conditions of the victims. Photographs of food and garbage found at the victims’ homes were used to demonstrate that food was available. Pictures of siblings and adults in the home showed that other family members were fed adequately and that caretakers were knowledgeable about how to keep other children from starving.
Defense arguments at trial included lack of resources (eg, poverty or no health insurance), an undetected genetic disorder that compromised food absorption, and an eating disorder. No defendants claimed insanity. Arguments that some of the children had eating disorders were countered by documented observations of survivors’ ravenous appetites and sustained weight gain after rescue.
In 1 of the infant cases (case 1), poverty was claimed as a reason for starvation. Trial testimony pointed out that the mother was overweight. This same mother also claimed breastfeeding difficulties, but formula was found in the home. Lack of access to medical care was countered with documentation of physician visits by siblings of the victim.
Parental rights were terminated in all cases. Criminal charges were filed in all 12 cases against a total of 25 individuals. The most common charge was “injury to a child by omission.” Twenty-three individuals were either found guilty or pled guilty to the charges. Criminal trials for 2 individuals were pending at the time of this writing. One parent received deferred adjudication without a jail sentence, but all other convicted individuals received prison sentences, including life sentences for 3 parents, 1 stepparent, and 1 grandparent.
Clinical presentations of malnutrition in developed countries vary along a broad spectrum, from insufficient weight gain managed as an outpatient to prolonged starvation and death. Malnutrition in children may be intentional or unintentional and is often multifactorial. Inadequate care by 1 or several caretakers may result from lack of knowledge regarding nutritional needs or formula preparation, incapacitation caused by mental illness or substance abuse, or poverty. Other causes of malnutrition include breastfeeding difficulties, congenital anomalies that interfere with feeding, and organic disease such as cardiac defects or cystic fibrosis. Neglectful care and purposefully withholding food as forms of punishment or parental rejection can also occur.10
The physiologic effects of severe starvation have been described among internment camp survivors,11,12 inhabitants of regions with food shortage,13–15 and adolescents with anorexia nervosa.16–19 The first and most apparent effects of starvation are weight loss and changes in overall body appearance.1 The Waterlow system for grading the degree of malnutrition is frequently used in international settings, because it distinguishes between wasting (low weight for height), stunting (low height for age), and combined wasting and stunting. Severe wasting is defined as being <75% of predicted weight for height, and severe stunting is defined as being <85% of predicted height for age.1
Calculation of z scores allows for more detailed quantification of growth abnormalities and for comparison among groups. The use of weight-for-height z scores for classifying the degree of wasting in starving children is now commonly accepted by international relief organizations. Moderate wasting is usually defined as a weight-for-height z score between −2.0 and −3.0, whereas a score below −3.0 is termed severe wasting.20
Starved individuals have an overall gaunt appearance and bony prominence, particularly of the ribs and scapula.21 Changes in facial appearance make the individual appear older than his or her actual age.1 Individuals with kwashiorkor may present with edema and a protuberant abdomen resulting from hepatomegaly.13 In children, a sustained period of malnutrition results in decreases in height velocity. Eventually, brain growth and head circumference may be adversely effected in younger children.22 Long-term studies of children who have survived famine and concentration camps12,15,22 demonstrate lower attainment of weight and height growth as well as long-term cognitive defects when compared with children who did not suffer from famine or internment. Permanent alterations in cognitive functioning have been reported among children who were starved when they were younger than 2 years.15,22
Severe malnutrition impacts nearly every organ system. Compromises in immune system functioning result in an increased risk for opportunistic infections.23 Epidermal skin layers manifest atrophy, causing fissuring as well as poorly healing sores and lesions.23 Depletion of available body fuels result in electrolyte imbalances.24 Gastrointestinal dysmotility and atrophy impair absorption of food and nutrients.25 Color and texture changes of hair, skin, and nails result from sustained protein deficiency.14 Anemia and hypoproteinemia also occur because of inadequate nutrient intake.23 Changes in heart rate and rhythm occur with severe malnutrition and during refeeding.17,23 Thymus atrophy results from stress or shock.3 Undernutrition can also affect pulmonary function, renal function, bone marrow production, insulin secretion, and brain growth and development.22,23
In our series, the most striking finding was the occurrence of profoundly reduced weight for age in nearly all subjects. Most of the children were both wasted and stunted, and all were noted to have absent subcutaneous fat. Physiologic derangements present in nearly all cases included dehydration, cardiac abnormalities, anemia, and hypoproteinemia.
Psychological effects of starvation have been described, mostly in adult survivors of internment camps and famines.11 The behavioral responses of child survivors of famine are varied, ranging from “defiance, distrust and withdrawal”26 to displaying a restricted range of emotions.12 Psychological responses also vary with the circumstances of starvation: victims of famine were more open in expressing their desire for food, whereas prisoners repressed all concerns because outbursts were often punishable by death.11
The psychological effects of starvation on the surviving victims in our series were profound in most cases. These children initially did not trust hospital staff and regularly stole food during their inpatient stays. Some obsessed constantly about their next meal or food in general. One child became defiant and threatened to run away from the hospital when oral intake was withheld from him in preparation for an endoscopy procedure. Although hoarding and food obsessions have also been reported in concentration-camp survivors,11 the psychological effect of starvation on children in our study was compounded by other factors such as physical abuse, sexual abuse, and, most importantly, the fact that food was available to everyone but them.
Complications of refeeding after sustained periods of starvation were documented in studies published after World War II,27 when starved prisoners continued to die even after rescue. A recent definition of refeeding syndrome is “the metabolic and physiologic consequences of the depletion, repletion, compartmental shifts and interrelationships of the following: phosphorus, potassium, magnesium, glucose metabolism, vitamin deficiency, and fluid resuscitation.”28 In starvation, fat and muscle are catabolized, leading to loss of muscle mass, water, and minerals. Extracellular shifts and compensatory mechanisms maintain normal intravascular levels of depleted components, including phosphorus, potassium, and magnesium.29 With refeeding, carbohydrate repletion and insulin release cause intracellular shifts of glucose, phosphorus, potassium, and other components, resulting in lower serum levels.30
All the surviving patients in this study had hypophosphatemia with refeeding, most had hypokalemia, and half had hypomagnesia. Half had hyperglycemia, reflecting limited ability to diminish nitrogen loss and to metabolize glucose.30,31 In addition, 1 patient developed hepatomegaly in the month subsequent to his rescue; the suspected etiology was fatty liver resulting from conversion of excess glucose to fat.32 Other complications of refeeding, including fluid overload problems, arrhythmias, and gastrointestinal dysmotility were documented in several of the patients in this study.
The families of all children in our series had access to medical care and resources, and all victims had siblings to whom food and medical care was provided, many within the period of time that the victim was starving. Some caretakers claimed to have appointments or plans to take the victim to a doctor, often for minor complaints. Investigators were able to verify false claims of appointments for 2 of these cases. Although infants were entirely dependent on caretakers to provide sufficient nutrition, ambulatory victims, who could have obtained food if permitted, were denied access by either restraint or seclusion.
Although most of the children in this case series were secluded from relatives, neighbors, medical care, and school personnel, opportunities for earlier detection and intervention occurred in at least 2 cases. In case 2, a physician examined the child ∼6 weeks before her collapse for an acute complaint of foot pain and swelling; she was not weighed at that time. School personnel documented that she was thin and demonstrating deprivational behaviors at school for several months, but they did not report their concerns to CPS. A CPS worker saw the youngest child in this series, aged 2 months, on the morning of her demise after a referral from the birth hospital for an abnormal maternal urine drug screen. During a home visit, the infant was noted to be wrapped in clothing but was not unwrapped or examined and died a few hours later. These examples suggest that training investigators to inspect infants and children for signs of starvation and reinforcing the practice of plotting growth parameters at all medical encounters may be beneficial in earlier detection and treatment of such victims.
In this series, all caretakers faced criminal child abuse charges, and all of them lost their parental rights. However, the specific criminal charges and the final sentences varied widely.
There are limitations to this case-series report. First, only 12 cases were analyzed, and results may not be applicable to all infants and children who show signs of starvation. Second, several clinical parameters and serological findings were not documented for all cases. These missing data would have been useful in assessing the chronicity and severity of the starvation in these infants and children.
Starvation is an uncommon but potentially lethal presentation of child maltreatment in the United States. A careful history, including documentation of food availability and intake, is helpful in distinguishing intentional from unintentional starvation. Clinicians must remember that starvation affects many organ systems and can present with a wide variety of chemical and physiologic derangements, both at the time of presentation and during convalescence. They also must be alert to the potentially lethal consequences of rapid nutritional resuscitation. Children and infants should be rehabilitated slowly and carefully, with frequent monitoring of electrolytes, gastrointestinal function, signs of fluid overload, and cardiac dysrhythmias.
Protection of the survivors and their siblings from additional injury is an important goal of medical treatment. To achieve this goal, clinicians must accurately communicate the severity of the medical findings to CPS workers, law enforcement investigators, and attorneys involved in such cases.
We thank Anjenean B. Bolster, RN, MSN, C-PNP, and Ms Lucy Cavazos for assistance in preparing this manuscript.
- Accepted February 14, 2005.
- Reprint requests to (N.D.K.) Department of Pediatrics, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail:
No conflict of interest declared.
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- ↵Latham MC. Protein-calorie malnutrition in children and its relation to psychological development and behavior. Physiol Rev.1974;54 :541– 565
- ↵Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Vol 2. Minneapolis, MN: University of Minnesota Press; 1950:131
- ↵Klein S. Protein-energy malnutrition. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 21st ed. Philadelphia, PA: WB Saunders; 2000:1150–1152
- ↵Friedman P. The effects of imprisonment. Acta Med Orient.1948;7 :163– 167
- ↵Martin BK, Slingerland AW, Jenks JS. Severe hypophosphatemia associated with nutritional support. Nutr Supp Serv.1985;5 :33– 38
- ↵Defronzo RA, Jacot E, Jequier E, Maeder E, Wahren J, Felber JP. The effect of insulin on the disposal of intravenous glucose: results from indirect calorimetry and hepatic and femoral venous catheterization. Diabetes.1981;30 :1000– 1007
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