On the first day the 4-year-old girl ate regular food by mouth in over two years, doctors found out she liked french fries.
The girl had been fed only through feeding tubes and IVs since she was a year-and-a-half old because her mother, Katie Ripstra, consistently told doctors her daughter would vomit whenever she ate. As a result, the girl developed an oral aversion. She hated the idea of food coming near her mouth. So the doctors coaxed her with something greasy—a common practice with children like her.
“Humans like salt and fat,” said Dr. Marcella Donaruma, a child abuse pediatrician at Texas Children's Hospital, “so we tempt them with french fries.”
The girl would come to like ice cream and pizza, applesauce and especially bananas. She didn't like Jello.
Donaruma testified in court yesterday that her official diagnosis of the 4-year-old had nothing to do with vomiting or any gastrointestinal issues, but that instead the girl suffered from medical child abuse for most of her life. The mother, Ripstra, now faces a maximum sentence of life in prison for two counts of intentionally causing bodily injury to a child. She's accused of salt poisoning, blood letting and deliberately causing infections in her daughter's feeding lines.
The case jurors have heard this week centers largely around one near-fatal event on August 6, 2013. Ripstra's daughter had just been discharged from Texas Children's in good condition the previous afternoon, but at 5:45 the next morning, Ripstra brought her back, saying she had diarrhea, had been vomiting all night and had a fever.
Doctors rushed the girl to the ICU. Her sodium level was at 182; a normal level would have been around 135.
Donaruma and several other doctors who testified at Ripstra's trial this week said that a sodium level this high could have easily killed the child. At the time, doctors were puzzled by the source of the spike—she had left the hospital perfectly fine less than 24 hours earlier with a stable sodium level, 138. At first, they thought that, somehow, she had rapidly lost a lot of fluids, perhaps by diarrhea or vomiting.
So they called Dr. Michael Brown, the chief kidney specialist at the hospital who often sees patients with this condition, called “hyperneutremia.” Brown testified that, to find out how much fluid such a patient needs, doctors often use a simple equation to determine how much has been lost. Brown testified that the toddler would have had to lose seven pounds of fluids—either through diarrhea or vomiting—in a matter of mere hours. Yet when they put the girl back on the scale, she weighed the same as that previous afternoon: 38 pounds. “It didn't make mathematical sense, and it didn't make physiological sense,” Brown testified.
The case had already been on Donaruma's radar since that May. The toddler's gastrointestinal doctor, Eric Chioux, had consulted with her after earlier cases of sodium spikes, unexplained drops in blood level, a myriad of multi-bacteria infections in the girl's feeding IV—relatively uncommon problems, Donaruma said—and unusual symptoms that never got better, no matter the treatment.
From the time the child was an infant, doctors had been searching and searching for the proper diagnosis. A geneticist, Dr. Frank Probst, testified in court that he ordered seven genetic tests, searching the girl's blood, even for some of the rarest diseases in the world. Donurama, who specializes in identifying child abuse, entered the picture when doctors could come up with no explanation for the girl's illnesses and test results consistently turned up normal. Instead, Donaruma searched for signs of medical child abuse.
At the time the girl was hospitalized on August 6, 2013, just hours after she'd been discharged in good condition, Donaruma was ready to try something new. The following week, she ordered a “therapeutic separation,” a diagnostic test in which the mother isn't allowed contact with the child so doctors can observe any differences. By September 10, the girl showed no sign of any of the previous symptoms, didn't have any unexplained sodium spikes or blood level drops, no line infections, and, most importantly, tolerated food just fine. That's when Donaruma decided that Ripstra's daughter didn't suffer from any disease or ailment, but rather from medical child abuse. As for a medical explanation that had previously eluded other doctors, Donaruma suspected salt poisoning.
“I believe her mother was the cause of her illness,” she said.
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But Ripstra's defense argues that the doctors did not search hard enough for the correct diagnosis. They insist the girl suffered from something called mitochondrial disease, which causes dysfunction in the body's cells responsible for generating energy. The symptoms Ripstra reported are consistent with the disease—along with some earlier medical tests doctored ordered, such as a delay in the time it took for her stomach and intestines to digest food and severe reflux, when she was a baby. Both are signs of mitochondrial disease.
Probst, the geneticist, however, says he tested the girl for the disease multiple times. On Thursday he testified in court that it wouldn't be possible for someone to recover as rapidly as Ripstra's daughter had if mitochondrial disease was truly the cause.
Still, Ripstra's defense attorneys believe that doctors jumped to the conclusion of salt poisoning without any concrete proof. To show that Ripstra wasn't just lying or exaggerating about her daughter's symptoms, defense attorney Charles Peckham went through medical records with Donaruma showing that nurses themselves were reporting diarrhea, sometimes multiple times a day. It was not solely Ripstra who was seeing these problems, he argued.
Rather than jumping to child abuse as the only explanation for the girl's medical problems, the defense claims Ripstra's daughter's illness can instead be explained by faulty medical decision-making. And while Donaruma testified Thursday that salt poisoning and blood letting appeared to be the only explanations for the girl's recurring illness, the defense continues to emphasize that there's no smoking gun—nothing to prove that Ripstra directly put salt into her daughter's IV or taking blood from her.