After months of warnings over the risk of famine in Gaza under Israel’s bombardment, offensives and siege, children are starting to die.

Hunger is most acute in northern Gaza, which has been isolated by Israeli forces and has suffered long cutoffs of food supply deliveries. At least 20 people have died from malnutrition and dehydration at the north’s Kamal Adwan and Shifa hospitals, according to the Health Ministry. Most of the dead are children – including ones as old as 15 – as well as a 72-year-old man.

Particularly vulnerable children are also beginning to succumb in the south, where access to aid is more regular.

At the Emirati Hospital in Rafah, 16 premature babies have died of malnutrition-related causes over the past five weeks, one of the senior doctors told The Associated Press.

“The child deaths we feared are here,” Adele Khodr, UNICEF’s Middle East chief, said in a statement earlier this week.

Malnutrition is generally slow to bring death, striking children and the elderly first. Other factors can play a role. Underfed mothers have difficulty breastfeeding children. Diarrheal diseases, rampant in Gaza due to lack of clean water and sanitation, leave many unable to retain any of the calories they ingest, said Anuradha Narayan, a UNICEF child nutrition expert. Malnutrition weakens immune systems, sometimes leading to death from other diseases.

Israel largely shut off entry of food, water, medicine and other supplies after launching its assault on Gaza following Hamas’ Oct. 7 attack on southern Israel — allowing only a trickle of aid trucks through two crossings in the south.

Israel has blamed the burgeoning hunger in Gaza on U.N. agencies, saying they fail to distribute supplies piling up at Gaza crossings. UNRWA, the largest U.N. agency in Gaza, says Israel restricts some goods and imposes cumbersome inspections that slow entry. Also, distribution within Gaza has been crippled, U.N. officials say convoys are regularly turned back by Israeli forces, the military often refuses safe passage amid fighting, and aid is snatched off trucks by hungry Palestinians on route to drop-off points.

With alarm growing, Israel bent to U.S. and international pressure, saying this week it will open crossings for aid directly into northern Gaza and allow sea shipments.