Starvation, Malnutrition, Dehydration, and Fatal Neglect

Abstract

Fatal starvation is a rare cause of death in industrialized countries but may be of major medicolegal importance if death results from deliberate withholding of food, especially in infants. Normally, the diagnosis of death as a result of starvation is a simple prima facie diagnosis. However, underlying diseases as causes of emaciation and concurrent diseases have to be ruled out. In cases of physical neglect, the forensic pathologist must not only clarify the cause of death but also give an expert opinion on the degree and duration of starvation. Several classification systems have been developed to estimate protein-energy-malnutrition (PEM) in third-world countries, especially the Waterlow classification. Following the Waterlow classification, a “stunted” (i.e., reduced weight for height) physical condition is calculated by using the ratio of the measured body height to the one expected for the actual age. Body weight can be used as a sign of acute malnutrition (“wasting”). However, body weight should be related to the expected weight for the actual height. The application of the Waterlow classification will be demonstrated using the author’s cases and on cases from the literature. The Waterlow classification is not only of importance for grading the final stage in cases of fatal starvation but also for the chronological development of the nutritional status if weight and height records of children are available. The diagnostic process both in deceased and living children will be addressed.

Acute dehydration may be also seen in young children due to physical neglect. In addition to classical autopsy findings such as poor skin turgor and sunken eyes, vitreous-humor chemistry may be helpful in making the diagnosis.