REFERENCE: Meade, J. L. and Brissie, R. M., "Infanticide by Starvation: Calculation of Caloric Deficit to Determine Degree of Deprivation," Journal of Forensic Sciences, JFSCA, Vol. 30, No. 4, Oct. 1985, pp. 1263-1268.

ABSTRACT: A review of medical records and autopsy examination of a six-week-old male revealed the cause of death to be severe malnutrition with dehydration. Weight and caloric deficits were calculated to determine the degree of deprivation, which could be expressed as an interval of days for clear courtroom presentation. These calculations may be useful for quantifying the degree of malnutrition in a variety of child abuse cases.

KEYWORDS: pathology and biology, starvation, child abuse

The decedent was the 3010-g product of a 39-week uncomplicated gestation and delivery, to a 20-year-old, unmarried black female. The decedent was a male with a length of 51 cm, and a head circumference of 33.5 cm (Fig. 1).

Early feeding difficulty necessitated placement of an orogastric tube, which was used for a total of twelve feedings, over a one-and-one-half day interval. He was found to have a left choanal stenosis by barium contrast fluoroscopy. This was scheduled to be repaired at age twelve weeks. The orogastric feedings were followed by 24 peroral (PO) feedings, which were received without difficulty over a 3-day interval. The infant was discharged five days postdelivery at a weight of 2990 g.

A follow-up visit at three weeks of age revealed the child to have a weight of 2980 g, a length of 52 cm, and a head circumference of 35 cm (Fig. 1). The mother stated that the child had had no problems since discharge and was feeding well. He was also noted to have a slight inspiratory stridor and monilial diaper dermatitis.

At the age of 43 days, 24 days after the follow-up visit, he was found dead by his mother. He was found at 7:30 a.m. in her bed, where they normally slept. The mother claimed to have fed the child at midnight and again at 2:00 a. m. She stated that the child had had no vomiting, diarrhea, Or febrile illness.

At autopsy this six-week-old male was found to weigh 2300 g and have a length of 53 cm (Fig. 1). He was noted to be severely emaciated, essentially marasmic (Figs. 2 and 3). There was a total absence of grossly recognizable fat deposits in the chest and abdominal walls (Fig. 4). Muscle wasting was marked, with approximately 50% of muscle mass remaining. A small amount of fat was seen in the mesentery. The gastrointestinal tract was empty except for 2 mL of mucoid secretions in the colon. The decedent also had depressed fontanels, 2 + /4 skin tenting, and dryness of pleural, pericardial, and serosal surfaces.

Quantitation of caloric deficit is made by computing expected weight, subtracting actual weight, discounting dehydration (mild = 5%, moderate = 10%, severe = 15%), and then determining the conversion into calories.

An infant normally loses up to 10% of his body weight within the first three to four days of postnatal life. This loss is usually regained within ten days of delivery [4,5]. After the initial period of weight loss and recovery (:5 ten days), a normal full-term infant should gain 30 g/d [6]. The caloric requirements for normal growth and development are 50 to 100 kcal/kg/d during the first week, and 110 to 150 kcal/kg/d in the subsequent several months of life [6].

Using the minimum daily caloric requirement per kilogram for this child to grow and develop normally, one may calculate the average minimum daily caloric requirement. The growth curve of an infant is almost linear for the first two months of postnatal life [7]. Therefore, the mean of the two points (birth and death) will yield a figure remarkably close to the arithmetic average of daily needs (see Table 1). This child's average total daily caloric needs were at least 385 kcal/d.

In this 43-day-old child, we allow 10 days to regain birthweight, leaving 33 days of 30-g/d growth. This yields 990-g growth, or an expected weight at death of 4000 g. This conforms well with accepted growth curves.

The actual death weight was 2300 g. Adding in the moderate dehydration (10%) yields a hydrated death weight of 2556 g (2300 g = 0.9 X). This reveals a weigh deficit of 1444 g.

Adipose tissue is approximately 50% lipid [8], and fat contains 9 kcal/g. Muscle mass is 20% protein, and protein contains 4 kcal/g. Assuming 50% of the weight deficit is from adipose tissue and 50% from muscle mass, one figures caloric deficit from the fat compartment of 3249 kcal and from the protein compartment of 578 kcal (see Table 2). The total caloric deficit at time of death was calculated to be at least 3827 kcal. By dividing total caloric deficit by average daily caloric requirement, one sees this infant was deprived of at least 9.9 days of nutrition.

 FIG. 2-This view shows the wizened face, well-demarcated ribs, and leathery folds of the skin. The scaphoid abdomen is another feature not expected in a six-week-old child.

FIG. 3-Especially apparent in this view is the shriveled, prune-like appearance of the buttocks. This is due to the near complete lack of the gluteal fat pad.

FIG. 4-Notice the complete lack of subcutaneous fat, as well as the intercostal and abdominal wasting. There was an estimated 50% loss of muscle tissue.

Conversion of grams to calories must entail a few assumptions: (1) failure to put on mass is qualitatively equivalent to the body's self-reabsorption, (2) the self-digestion is 100% efficient and (3) 50% of the deficit will be from the fat compartment, and 50% from the protein compartment. The first assumption states that if a child is expected to gain a kilogram, but in actuality loses a kilogram, then the net weight deficit is 2 kg. This premise should be self-evident.

If the second assumption is false, the caloric deficit would be even higher than calculated. Since utilization of the body's stores as energy would most assuredly not be 100% efficient, this is another factor to ensure conservative estimates.

If the third assumption is incorrect, it is in underestimating the contribution of the fat compartment. A 3000-g infant is 12% by weight fat (equivalent to 24% adipose tissue), and 12% by weight protein (equivalent to 60% wet muscle mass) [3,9]. This percentage of fat increases quickly after birth to as much as 28% [9]. This would be equivalent to 56% adipose tissue, by weight. This yields an adipose: muscle ratio of approximately 1: 1. Cahill states that there is a "preferential and almost exclusive utilization of fat and fat-derived fuels during starvation" [10]. The body's metabolic machinery adapts during starvation to conserve protein. In a starving patient, the supply of as little as 150 g of dextrose per day avoids the necessity of turning to protein for gluconeogenesis.

This child lacked almost all body fat, and his muscle mass was approximately 50% depleted. This indicates a period of minimal caloric support which prevented proteolysis, followed by a period of absolute starvation and fluid restriction.

[1] Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., and Silver, H. K., "The Battered-Child Syndrome," Journal of the American Medical Association, Vol. 181, No. 1, 7 July, 1962, pp. 17-24.

[2] Adelson, L., "Homicide by Starvation: The Nutritional Variant of the Battered Child'," Journal the American Medical Association, Vol. 186, 2 Nov. 1963, pp. 458-460.

[3] Hughes, E. A., Stevens, L. H., and Wilkinson, A. W., "Some Aspects of Starvation in the Newborn Baby," Archives of Disease in Childhood, Vol. 39, No. 208, Dec. 1964, pp. 598-604.

[4] Meredith, H. F., Human Body Growth in the First Ten Years of Life, State Printing Co., Columbia, SC, 1978, p. 31.

[5] Pipes, P. L., Nutrition in Infancy and Childhood, 2nd ed., C. V. Mosby Co., St. Louis, 1981, p. 3.

[6] Weinsier, R. L. and Butterworth, C. E., Handbook of Clinical Nutrition, C. V. Mosby Co., St. Louis, 1981, p. 183.

[7]  Foman, S. J., Infant Nutrition, 2nd ed., W. B. Saunders Co., Philadelphia, 1974, pp. 52-53, 508-513.

[8] Baker, G. L., "Human Adipose Tissue Composition and Age," The American Journal of Clinical Nutrition, Vol. 22, No. 7, July 1969, pp. 829-835.

[9] Widdowson, E. M. and Spray, C. M., "Chemical Development in utero, " Archives of Disease in Childhood, Vol. 26, No. 127 June 1951, pp. 205-214.

[10] Cahill, G. H., Jr., "Starvation in Man," The New England Journal of Medicine, Vol. 282, No. 12,19 March, 1970, pp. 117-126.

[11] Saudek, C. D. and Felig, P., "The Metabolic Events of Starvation," The American Journal of Medicine, Vol. 60, Jan. 1976, pp. 117-126.

[12] Schmitt, B. D. and Kempe, C. H., "Abuse and Neglect of Children," in Nelson Textbook of Pediatrics, 12th ed., R. E. Behrman and V. C. Vaughn, 111, Eds., W. B. Saunders Co., Philadelphia, 1983, pp. 99-105.

[13] Hansen, J. D. L., Buchanan, N., and Pettifor, J. M., "Protein Energy Malnutrition," in Textbook of Pediatric Nutrition, 2nd ed., D. S. McLaren and D. Burman, Eds., Churchill Livingstone, Edinburgh, 1982, p. 133.