REVIEW ARTICLE

Eating disorders mothers and their children: a systematicreview of the literature

Maria Giulia Martini1,2 & Manuela Barona-Martinez1 & Nadia Micali1,3,4

Received: 30 July 2019 /Accepted: 7 January 2020# The Author(s) 2020

AbstractTo provide an overview of the impact of maternal eating disorders (ED) on child development in a number of domains includingfeeding and eating behaviour, neuropsychological profile and cognitive development, psychopathology and temperament.PubMed, Embase and PsychInfo were searched for studies exploring the impact of maternal ED on children between January1980 and September 2018. Initial search yielded 569 studies. After exclusion, 32 studies were reviewed. Overall, availableevidence shows that children of mothers with ED are at increased risk of disturbances in several domains. They exhibit moredifficulties in feeding and eating behaviours, display more psychopathological and socio-emotional difficulties, and they aremore likely to be described as having a difficult temperament. Maternal ED have an impact on child psychological, cognitive andeating behaviours, and might affect the development of ED in the offspring. Future research should focus on resilience and onwhich protective factors might lead to positive outcomes. These factors can be then used as therapeutic and preventative targets.

Keywords Eating disorder . Intergenerational effect . Children .Mothers

Introduction

Eating disorders (ED) are mental health disorders characterisedby severe disturbances in eating behaviour that significantlyimpact an individual’s emotional, psychosocial and physicalwell-being (Bannatyne et al. 2018). Current diagnostic classifi-cations of ED include anorexia nervosa (AN), bulimia nervosa(BN) and binge-eating disorder (BED) as full threshold ED. EDtypically affect women of reproductive age (Easter et al. 2014).

Early childhood is a crucial time for the development of themother–child relationship. It is during this time that children

develop psychosocially, engage in social learning and expresstheir temperament—which is a biological tendency within eachchild but it is shaped by complex interactions between genetic,biological and environmental factors (Shiner et al. 2012).

Risk for developmental problems in children of womenwith psychiatric disorder has been well documented in litera-ture and several aspects of children’s development can beaffected, including their physical, cognitive, social, emotionaland behavioural development (Ramchandani and Stein 2003).Fewer studies are available regarding the impact of ED onchild development.

However, the literature available suggests that children ofmothers with ED have an increased risk for negative develop-mental outcomes, including cognitive, social and emotionaldisturbances (Patel et al. 2002). Research has shown that chil-dren of mothers with ED are more likely to develop an emo-tional disorder at the age of 7 and 10 (Micali et al. 2014a), theyare more likely to show neurobehavioural dysregulation earlyafter birth and poorer language and motor development at1 year (Barona et al. 2017).

Furthermore, there is evidence that children of motherswith ED are more likely to develop ED themselves (Kothariet al. 2013).

Family and twin studies have consistently demonstratedthat ED have a strong genetic component (Mazzeo et al.

* Maria Giulia Martinim.martini@ucl.ac.uk; mgmartini@hotmail.it

1 Behavioural and Brain Sciences Unit, Institute of Child Health,University College London, 4th Floor, 30 Guilford Street,London WC1N 1EH, UK

2 South London and Maudsley, NHS Foundation Trust, London, UK3 Department of Psychiatry, University of Geneva,

Geneva, Switzerland4 Child and Adolescent Psychiatry Division, Department of Child and

Adolescent Health, University Hospital Geneva,Geneva, Switzerland

Archives of Women's Mental Healthhttps://doi.org/10.1007/s00737-020-01019-x

/Published online: 14 January 2020

(2020) 23:449–467

2005); however, the environment is likely to play a crucial rolein the expression of underlying genetic predispositions.

In 2005, Bulik et al. (2005) proposed a cycle of risk modelfor the development of AN, whereby the maternal effect ofAN on their children via perinatal complications ishypothesised as being influenced by environmental factors,genetic factors and environmental factors that are highly in-fluenced by maternal genotype (i.e. pregnancy nutrition,weight gain in utero, appearance focus and restrictive eatingduring childhood/adolescence). In 2009, Micali and Treasuresuggested a risk model for the impact of maternal ED on childdevelopment that embraces all ED focusing on in utero mech-anisms. In particular, the model explained the effect of a ma-ternal ED in pregnancy on the foetus via nutritional factors(including protein deficiency, low folate and low iron intake)and comorbid psychopathology (i.e. comorbid anxiety anddepression and in turn via increased glucocorticoids andcorticotrophin-releasing hormone) which both could lead toobstetric complications (Micali and Treasure 2009). The in-fluence of parental ED on child phenotype might likely be theresult of a complex interplay between genetic (maternal andchild) and environmental factors.

Understanding the mechanisms leading from maternal EDto adverse child development could help to determine bothrisk and protective factors that could be potentially targetedfor intervention.

To date, only one recent systematic review has been pub-lished on this topic in the last several years and the authors didfocus only on the most recent findings (2015 onwards) (Watsonet al. 2018). Previous reviews focusing on children of motherswith ED include (Patel et al. 2002) and (Park et al. 2003). Nosystematic reviews have been carried out so far covering theperiod between 2003 and 2015 and many relevant population-based studies have been carried out over this period.

The purpose of our paper is to provide an overview of theimpact of maternal ED on child development. Particularly, thisreview will focus on effects on developmental aspects, acrossthe spectrum of feeding and eating behaviour, neuropsycho-logical profile and cognitive development, psychopathologyand temperament.

Methods and materials

Data source

A systematic and comprehensive search of databases, includ-ing PsychInfo, Embase and Medline, was carried out for stud-ies published between January 1980 and September 2018. Thesearch was performed using the following mesh terms andkeywords: (‘maternal eating disorders’ or ‘maternal anorexianervosa’ or ‘maternal bulimia nervosa’ or ‘maternal bingeeating disorder’ or ‘mothers with eating disorders’ or ‘mothers

with anorexia nervosa’ or ‘mothers with bulimia nervosa’ or‘mothers with binge eating disorder’) and (‘child develop-ment’ or ‘child language development’ or ‘child feeding’ or‘child cognitive development’ or ‘child temperament’ or‘child psychopathology’).

Study selection

Inclusion criteria for the studies included (1) exposure(mothers) diagnosed with any ED (i.e. AN, BN and BED)either active or past, (2) the outcome was a measure of childdevelopment assessed from birth up until 12 years of age, (3)studies published in English and (4) primary studies.

Exclusion criteria for the studies included the following:studies were excluded if the aims were to investigate childeating pathology. Papers were also excluded if an interventionwas assessed such as video-feedback interactional treatment.

Quality assessment and data extraction

Two authors (M.G.M. and M.B.) independently screened, ex-tracted and cross-checked the data based on a priori exclusionand inclusion criteria. The quality of the final studies was alsoindependently checked by both authors using the Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses (Table 1). The abovescale includes case–control and cohort studies.

For each study, the following data were extracted whenavailable: demographic information, including participantcharacteristics (sample size ad mean age), ED type (AN,BN, BED), ED status (actual vs. recovered); measures usedto certain exposure and outcome. The identified studies inves-tigated a number of different child outcomes. After discussionbetween authors (M.B., M.G.M., N.M.), four domains werediscussed: feeding/eating, neuropsychological profile/cognitive development, psychopathology and temperament.However, a range of studies investigated more than one out-come and were included in more than one domain (Table 1).

Results

Search findings

A PRISMA flow diagram presents all phases of the review(Fig. 1) (Moher et al. 2009).

Most studies used case–control (n = 17) and cohort design(n = 16) and one early study used an uncontrolled design. Themajority of studies were published within the last decade (n =25) with 59% published within the last 5 years (2013–2018).

Studies included measured various aspects of child devel-opment: feeding/eating (n = 17), cognitive development/neuropsychological profile (n = 6), psychopathology (n = 12)

M. G. Martini et al.450

Table1

Studiesexploringtheim

pactof

maternalE

atingDisorder(ED)on

child

developm

ent

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

FEEDIN

G/EATIN

G1 Feeding/Eating

Steinetal.1994

Case–control

Totaln

=58

mothers

Cases

recruitedfrom

community

n=34;m

eanage28.3

12EDNOS,

6BNand16

subthreshold

Health

ycontrolsrecruitedfrom

community

n=24;m

eanage29.0

Exposure:MaternalE

D(Clinical

InterviewthroughEating

DisorderExamination—

EDE)

Outcome:infant

developm

ent:

BayleyScales

feedingand

grow

th:T

annerand

Whitehouse’sspecification

▪Negativeexpressedem

otionwas

morefrequent

amongthecase

motherscomparedto

controls

during

mealtimes

butn

otduring

play

▪Motherswith

EDwerelessfacilitatingduring

both

mealtimes

andplay,had

significantly

more

conflictw

ithinfants

▪Caseinfantswereratedas

less

happythan

the

controlsduring

both

mealtimeandplay

9/9

2 Feeding/Eating/Temperament

Evans

andleGrange1995

Case–control

Totaln

=20

Cases,A

NandBN

N=10,m

eanage=36.0(7.02)

Health

ycontrols

N=10,m

eanage=35.4(4.12)

Exposure:MaternalE

D(Clinical

InterviewDSM

III-RAPA

)Outcome:body

shape

questio

nnaire;sem

i-structured

interviewon

feeding

anddevelopm

ent

▪Positive

correlationfoundinbothcase

andcontrol

groups

betweenmothers’satisfactionwith

their

body

size

andtheirchild

ren’ssatisfactionwith

theirow

nweightand

shape

▪Mothersintheclinicalgroupreported

experiencing

emotionalp

roblem

swhenbreastfeedingtheir

child

ren

▪Infantsin

theclinicalgroupwereschedulefed—

thisrigidadherencecaused

someconfusionand

anxietyformotherswhentheirinfantsdisplayed

signsofhungeroutsidetherecommendedfeeding

times

▪Halfthechild

renof

EDmothersweredescribedas

displaying

difficultiessuch

ashyperactivity,

avoidant

behaviour,enuresis,insecure

attachment,depression,fears,personality

problems,stuttering,violent

temperamentand

oppositio

nald

efiant

behaviour

8/9

3 Feeding/Eating/Temperament

Agras

etal.1999

Case–control

Totaln

=194

Cases

N=41,m

eanage=32.1(4.4)

AN=2,BN=17,B

ED=22

Health

ycontrols

N=153,meanage32.9(3.8)

Exposure:maternalE

D(Clinical

InterviewDSM

III-R+Eating

DisorderInventory—

EDI)

Outcome:Infant

FeedingReport

(IFR

);Su

ckom

eter;C

hildren’s

Behaviour

Questionnaire

▪Fem

aleinfantsof

EDmotherssucked

morerapidly

than

otherinfants,butn

odifferencesin

caloric

intake

atthesefeedings

▪EDmothersbottlefedtheirdaughtersforamean

timeof

33.2

monthscomparedwith

infantsof

NEDmotherswith

23.6

months

▪EDmothersconsidered

theirfemalechild

rento

have

moredifficulty

inweaning

from

thebottle

(but

notfrom

thebreast)

than

NEDmothers

▪Infantsof

EDmotherswerereported

todawdle

morewhileeatin

gcomparedto

child

renof

NED

group

▪EDmothersreported

theirdaughtersas

vomiting

morefrequently

than

theirsons

(opposite

effect

forNEDmothers)

▪EDmothersreported

higher

concernfortheir

daughter’sweightthanNEDmothers

8/9

Eating disorders mothers and their children: a systematic review of the literature 451

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

▪Significant

maineffectfortheEDgroupforusing

food

asnon-nutritive

purposes

▪Significanteffectof

EDmothersreportingthey

fed

theirchildrenon

alessregularschedulethan

NED

mothers

▪Childrenof

motherswith

EDreported

asdemonstratingmorenegativ

eaffect(sadness,

crying,irritability)

than

childrenof

NEDmothers

4 Feeding/Eating

Steinetal.1999

Case–control

Totaln

=58

Cases

N=34,m

eanage=28.3

Health

ycontrols

N=24,m

eanage=29

Exposure:maternalE

D(Clinical

InterviewDSM

IIIR)

Outcome:Five-Point

Conflict/H

armonyScale

▪The

mostfrequentantecedenttoconflictw

asthe

mother’sconcernaboutthe

mannerof

eating;

disagreemento

verwho

fedtheinfant

andfood

refusal

▪Mothersin

theclinicalgrouponly

acknow

ledged

theinfant’ssignalsinathirdof

casescomparedto

over

ahalfin

theNEDmothersgroup

5/9

5 Feeding/Eating

Temperament

Waugh

andBulik

1999

Case–control

Totaln

=20

mothers

N=10,m

eanage30.1(3.1)

PastAN=6,pastBN=7

Health

ycontrolsrecruitedfrom

community

n=10,m

eanage30.8(3.6)

Exposure:maternalE

D(Clinical

InterviewDSM

III-R)

Outcome:To

ddlerTemperament

Scale(TTS);M

ealtime

Observatio

nSchedule(M

OS);

Food

Diary

▪Childrenof

wom

enwith

eatingdisordershad

significantly

lowerbirthweightsandlengthsthan

controlchildren

▪Nodifferencesobserved

inchildhood

temperament

ormothers’satisfactionwith

child

ren’s

appearance

▪Motherswith

EDmadesignificantly

fewerpositive

eatingcomments

8/9

6 Feeding/Eating

WhelanandCooper2000

Case–control

Totaln

=128mothers

Clin

icalgroup(any

EDdisorder)

Childrensplit

inthreegroups:

▪Clin

ical—feedingproblems

(1):42

▪Clin

ical—disturbedcomparisons

(2):79

▪Control:2

9

Exposure:maternalcurrentandpast

affectivedisorder

andcurrent

andpastED(EatingDisorder

Examination—

EDE+Clin

ical

InterviewDSM

IV)

Outcome:Sh

yness;Preschool

Behaviour

Checklist(PB

CL);

Behaviour

Screening

Questionnaire

(BSQ

);Feeding

ProblemsandEatingDisorders

InterviewSchedule

▪Childrenin

thefeedingproblem

groupwererated

assignificantly

moredisturbedthan

thecontrol

group(feeding

disturbances

such

asrefusal,

faddinessandspitting)

▪Severity

ofchild

disturbancewas

notrelated

tothe

relatio

nshipbetweenfeedingproblemsand

maternalE

D

8/9

7 Feeding/Eating

BlissettandMeyer

2006

Case–control

Totaln

=114mothers

and114child

ren

Meanmaternalage

33(5.5)

Meanchild

age29

months(13.77)

Exposure:MaternalE

D(Eating

DisorderInventory2—

EDE-2

questio

nnaire)

Outcome:Child

Feeding

Assessm

entQ

uestionnaire

(CFA

Q);Young

Schema

Questionnaire

▪Eatingpsychopathologydidnotexplain

mealtime

negativ

ityin

boys

▪Eatingpsychopathologyfailedtoexplainmealtime

negativ

ityin

girls

Food

refusal

▪Eatingpsychopathologyfailedto

explainfood

refusalinboys

Eatingpsychopathologyaddedsignificantly

tothe

variance

explainedin

food

refusalo

fgirls

6/9

8 Feeding/Eating

Cohort

Totaln

=12,050

ALSPAC

Exposure:MaternalE

D(self-report)

▪Motherswith

ahistoryof

EDweremorelik

elyto

startbreastfeeding

than

controls(83%

with

76%)

7/9

M. G. Martini et al.452

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

Micalietal.2009

Cases

N=441,AN=247andBN=194

Meanage,AN=29.1(5.0),

BN=28.3(4.6)

Health

ycontrols

N=10,461,m

eanage=28.2(4.8)

Outcome:feedingquestio

nnaires;

health

records

▪Alsoless

likelyto

stop

breastfeedingduring

the

firsty

earof

infant

life

▪Those

with

BNweremorelikelytocontinue

breast

feeding

Infant

feeding

▪ANmothersreported

moreearlyonsetp

ersistent

feedingdifficultiesin

alld

omains

except

refusal

totake

solid

s▪Infantsof

motherswith

BNdiffered

intherateof

refusaltotake

solid

sfrom

thoseANmothersin

theratesof

beingunsatisfied/hungryafterfeeding

9 Psychopathology/

Feeding/Eating

Reba-Harrelson

etal.2010

Cohort

Totaln

=13,006

MoB

a(N

orwegianmothersand

child

cohortstudy)

Cases

N=479,BED=634,BN=98,

AN=17

Health

ycontrols

N=12,257

Exposure:maternalE

D(self-report)

Outcome:Child

Feeding

Questionnaire;C

hild

Behaviour

Checklist(CBCL);Infant

ToddlerSo

cialEmotional

Assessm

ent(ITSE

A)

▪Motherswith

BNandBEDreported

higher

levels

ofdisordered

eatin

gbehavioursin

theirchild

ren

than

controls

▪Theyalso

reported

higher

levelsof

anxiety

symptom

sin

theirchildren

▪Motherswith

BNreported

higher

levelsof

OCD

symptom

sin

theirchildren

▪Maternally

reported

restrictivefeedingwas

significantly

associated

with

child

disordered

eatin

gdifficulties

8/9

10 Feeding/Temperament

Micalietal.2011

Cohort

Totaln

=10,902

ALSPAC

Cases

N=441,AN=166,BN=194,AN

+BN=81;m

eanage=28.7

(4.8)

Health

ycontrols

n=10,461;m

eanage=28.2(4.8)

Exposure:maternalE

D(self-report),maternal

depression,m

aternalanxiety

Outcome:maternalreports;C

arey

Infant

TemperamentS

cale;

DenverDevelopmentalS

cale

▪Maternallifetim

eEDpredictedfeedingdifficulties

at1month

and6months

▪EDsymptom

sin

pregnancyfoundto

predict

feedingdifficultiesat1month

▪Child‘difficult’

temperamentscorewas

associated

with

latefeedingdifficulties

8/9

11 Feeding/Eating

Easteretal.2013

Cohort

Totaln

=9423

ALSPAC

Cases

N=387,AN=140,mean

age=29.7(5.2),BN=170,

meanage=28.3(4.6),

AN+BN=71,m

eanage=29.6

(4.6)

Health

ycontrols

N=9037,m

eanage=28.8(4.8)

Exposure:maternalE

D(self-reported)

Outcome:Fo

odFrequency

Questionnaire

(FFQ

s);

nutritionalintake

▪Childrenofmotherswith

all3

EDgroups

(AN,B

NandAN+BN)hadhigher

scores

onthehealth

conscious/vegetarian

dietarypattern

across

all4

timepoints:3

,4,7

and9years*

▪Differences

persistedin

maternalA

NandBN

groups

afteradjustments—child

renscored

lower

onthetraditionaldietarypattern

across

all4

time

points

▪Trendsshow

edhigher

energy

intake

ofchild

ren

with

motherswith

BNandAN+BN

▪Childrenwith

motherswith

BNhadhigher

starch

intake

8/9

12 Feeding/Eating

Hoffm

anetal.2014

Cohort

Totaln

=50

Recruitedfrom

community

Cases

Exposure:maternalE

D(clin

ical

interviewSC

ID-I)

Outcome:anthropometric

data/in

fant

feedingstyle

▪Motherswith

historiesof

eatingdisordersscored

significantly

loweron

therestrictivefeedingstyle

subscalethan

controlm

others

7/9

Eating disorders mothers and their children: a systematic review of the literature 453

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

N=25;A

N=13;B

N=13;

EDNOS=2,meanage=32.7

(4.61)

Health

ycontrols=25,m

eanage

29.68(1.99)

questio

nnaire/Toddler

Diet

Questionnaire/EDE-Q

/BDI/BAI

▪Nosignificantdifferences

betweengroups

inchild

diet(i.e.durationof

breastfeeding,ageatsolid

food

introduction,daily

numberof

snacks

and

mealsetc)

▪Motherswith

eatin

gdisorder

historiesweremore

likelyto

reporttaking

arestrictivespecial

approach

tofeedingsuch

aslim

iting

processed

foodsor

feedingorganicfoodsonly

13 Feeding/Eating

deBarse

etal.2015

Cohort

Totaln

=4851

GenerationRstudy

Cases

N=415,meanage=30.8(5.0)

AN=121,BN=189,

AN+BN=105

Health

ycontrols

N=4436,m

eanage=30.8(4.8)

Exposure:maternalE

D(self-report

questio

nnaire)

Outcome:Child

Feeding

Questionnaire

(CFQ

);Child

EatingBehaviour

Questionnaire

(CEBQ);Children’sbody

mass

index

▪Motherswith

ahistoryof

EDused

lesspressureto

eatthanmotherswith

out

▪Motherswith

ahistoryof

ANwerelik

elyto

use

lowlevelsof

pressure

toeat

▪Childrenof

motherswith

anEDhadhigher

levels

ofem

otionalo

vereatingthan

controls—thiswas

strongestw

ithmotherswith

ahistoryof

AN

8/9

14 Feeding/Eating

Torgersenetal.2015

Cohort

Totaln

=49,045,m

eanage=29.6

(4.6)

MoB

a(N

orwegianmothersand

child

cohortstudy)

Cases

N=3013

AN=44,B

N=436,BED=2475,

EDNOS–

P=58

Health

ycontrols

N=46,032

Exposure:maternalE

D(Self-reported)questio

nnaire

Outcome:InfantDietQ

uestionnaire

4

▪Percentages

ofmothersbreastfeedingat6months:

BN(79%

),BED(76%

),EDNOS-P(59%

),AN

(58%

),no-ED(82%

)▪Infantsof

motherswith

BNhadsignificantly

lower

odds

ofbeingin

thehomem

adetraditional

food

classthan

thecommercial

jarred

baby

food

class

▪Infantsof

motherswith

BEDweresignificantly

lesslik

elytobe

inthehomem

adevegetarian

food

classthan

thecommercial

jarred

baby

food

7/9

15 Feeding/Eating

Saltzman

etal.2016

Case–control

Totaln

=260

Cases

N=36

motherswith

BED

Health

ycontrols

N=224

Exposure:frequencyof

BED

behavioursthroughself-report

questio

nnaire

EatingDisorder

Diagnostic

Scale(EDDS)

Exposure:Children’sNegative

Emotions

Scale;Com

prehensive

FeedingPractices

Questionnaire;

Child

BMI

▪MaternalB

EDpredicteduseof

more

nonresponsivefeedingpractices

(e.g.E

motion

Regulation,Restrictio

nforHealth

,Pressureto

Eat,and

Food

asRew

ard)

▪MaternalB

EDwas

associated

with

greateruseof

distress

responses,which

indirectly

predicted

higher

child

BMIpercentilethroughFo

odas

Rew

ardfeedingpractices

5/9

16 Feeding/Eating

Nguyenetal.2017

Cohort

Totaln

=6196

GenerationRstudy

Cases

N=591

Health

ycontrols

N=5605

Exposure:self-reportq

uestionnaire

Outcome:Fo

odFrequency

Questionnaire

(FFQ

),breastfeedingduration

▪Motherswith

ahistoryof

EDsseem

slightly

less

likelyto

initiatebreastfeeding,although

nolonger

statistically

significantafter

adjustment

▪Atthe

ageof

1year,infantsof

motherswith

ahistoryof

EDshadahigher

dietquality

7/9

17 Feeding/Eating

Martinietal.2018

Case–control

Totaln

=99

Cases

N=53;p

astE

D28,m

ean

age=33.3(5.5);currentE

D25,

meanage=29.0(5.4)

Exposure:clinicalinterview

(SCID

-I)

Outcome:

Infant

FeedingQuestionnaire

(IFQ

)/ParentalModellin

gof

▪Wom

enwith

P-EDandC-EDreported

higher

concerns

abouttheirinfant

being/becoming

overweightcom

paredwith

HC,respectively,at

8weeks

and6monthsand6monthsonly

post

partum

8/9

M. G. Martini et al.454

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

Health

ycontrols

N=46,m

eanage=34.0(3.8)

EatingBehaviours

Scale(PARM)

▪Wom

enwith

P-EDshow

edless

awarenessof

infanthungerandsatietycues

comparedwith

HC

at8weeks

COGNITIV

EDEVELOPM

ENT/NEUROPS

YCHOLOGICALPR

OFILE

1 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Kotharietal.2014

Cohort

Different

samplesizesweretaken

into

account

Totaln

=982/852

Health

ycontrols:9

37/819

Cases

AN=14;B

N=18;A

N+BN=13

AN=11;B

N=12;A

Nand

BN=10

Exposure:self-reportq

uestionnaire

Outcome:GriffithsDevelopment

Scales;W

echslerPreschooland

Prim

aryScaleof

Intelligence–Revised

Griffithsdevelopm

entscales

▪Childrenof

wom

enwith

alifetim

eof

ANshow

edlower

scores

onthedevelopm

ento

flocomotor

andpersonal–socialdevelopmentthanchildrenof

unexposedmothers

WechslerPreschooland

Prim

aryScaleof

Intelligence–Revised

▪Childrenof

wom

enwith

alifetim

eof

ANshow

edlower

scores

onperformance

subtestsof

geom

etricdesign

andblockdesign

▪Theyalso

show

edlower

scores

onvernaltestsof

comprehension

andsimilarities

Theyalso

show

edlower

verbalIQ

scores

incomparisonto

thecontrols

7/9

2 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Kotharietal.2013

Cohort

Totaln

=11,088

Cases=446

Meanage=29.17(4.49)

AN=194,BN=171and

AN+BN=81

Health

ycontrols

N=10,642,

meanage=29.10(4.5)

Exposure:maternalE

D(self-report)

questio

nnaire

Outcome:WechslerIntelligence

ScaleforChildren(W

ISC-III);

TestsforEverydayAttentionfor

Children;

CountingSp

anTask;

Stop-SignalP

aradigm

Intelligenceandglobalcognition

▪Childrenof

ANmothersshow

edhigher

full-scale

IQandperformance

IQthan

comparedwith

NED

mothers

▪Childrenof

ANmothersshow

edhigh

picture

arrangem

entscoreson

theWISCsubtestw

hereas

child

renof

BNmothersshow

edlowobject

assemblyscores

Working

mem

ory(W

M)

▪Childrenof

ANmothersshow

edslightly

better

WM

span

scores

afteradjustments

▪Childrenof

AN+BNmothersshow

edbetter

globalWM

scores

7/9

3 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Koubaaetal.2013

Cohort

Totaln

=112

Cases

N=47;A

N=24;B

N=20;

EDNOS=3,

meanage=29.3(4.6)

Health

ycontrols=65,

meanage30

(3.7)

Exposure:maternalE

D(clin

icalinterview)

Outcome:anthropometric

measurement/M

aternal

Adjustm

entand

Maternal

Attitude

Questionnaire

(MAMA)/Five

toFifteen(FTF)

▪Childrenborn

tomotherswith

EDhadalower

birthweightb

utdisplayedan

earlycatch-up

inweight

▪The

averagehead

circum

ferencewas

foundto

bedelayedup

toatleast1

8monthsof

age

▪Childrenof

motherswith

ANor

BNhad

significantly

higher

FTFscores

than

controls

reflectin

gdifficultiesinlanguage

andsocialskills

8/9

4 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Kotharietal.2015

Cohort

Totaln

=1128

Cases

N=266

AN–R

=58

AN–B

P=66

BED=72

Exposure:clinical

interview(SCID

)Outcome:So

cialCom

munication

DisordersChecklist(SC

DC);

Diagnostic

Analysisof

Non-VerbalA

ccuracy

Socialcognition

▪Childrenof

wom

enwith

abingingphenotypehad

higher

odds

ofapoor

socialcommunication

▪Those

with

abingingandpurgingphenotypehad

child

renwith

higher

odds

ofhaving

poor

social

communication

8/9

Eating disorders mothers and their children: a systematic review of the literature 455

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

Purge=70

Health

ycontrols

N=862

(DANVA);EmotionalT

riangles

Task

DANVA

▪Childrenof

motherswith

abingingandpurging

phenotypehadlowerodds

ofmakingerrorswhen

recognisingem

otionalfrom

high-intensity

faces

andlower

odds

ofmisattributingfacesas

sad***

Emotionaltriangle

Binging

andpurgingphenotypemothers’infants’

show

edpoorer

recognition

offear

5 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Sadeh-Sh

arvitetal.2016a

Case–control

Totaln

=58

Cases

N=29;A

N=14,B

N=13,

EDNOS=2,

meanage31

(4.20)

Health

ycontrols

N=29,m

eanage=33.1(4.64)

Exposure:self-reported

questio

nnaire

(EDI-2)

Outcome:BayleyScales

ofInfant

Development(BSID)

▪The

child

renof

motherswith

eating

disordersshow

eddelayedmentaland

psychomotor

developm

ent

▪Severity

ofmaternaleatingdisordersymptom

sem

ergedas

asignificantp

redictor

ofchild

developm

ent,buto

ther

maternal

psychopathologydidnot

7/9

6 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

Baronaetal.2017

Case–control

Totaln

=65

Cases

N=37;activeED=18,m

eanage

30.17(5.74);pastE

D=19,m

ean

age34.47(3.96)

Health

ycontrols

N=28,m

eanage=34.00(3.34)

Exposure:clinical

interview(SCID

-I)

Outcome:Brazelto

nNeonatal

BehaviouralAssessm

entS

cale

(NBAS)/BayleyScales

ofInfant

andTo

ddlerDevelopment

(BSID-III)

•Exposed

childrenhadpoorer

neurobehaviour

atbirthandworse

language

andmotor

developm

ent

at1year

8/9

PSYCHOPA

THOLOGY

1 Feeding/Eating/

Psychopathology

Evans

andleGrange1995*

Case–control

Totaln

=20

Cases,A

NandBN

N=10,m

eanage=36.0(7.02)

Health

ycontrols

N=10,m

eanage=35.4(4.12)

Exposure:maternalE

D(clinicalinterview?)

Outcome:BodySh

ape

Questionnaire;sem

i-structured

interviewon

feedingand

developm

ent

▪Positive

correlationfoundinbothcase

andcontrol

groups

betweenmothers’satisfactionwith

their

body

size

andtheirchild

ren’ssatisfactionwith

theirow

nweightand

shape

▪Mothersintheclinicalgroupreported

experiencing

emotionalp

roblem

swhenbreastfeedingtheir

child

ren

▪Infantsin

theclinicalgroupwereschedulefed—

thisrigidadherencecaused

someconfusionand

anxietyformotherswhentheirinfantsdisplayed

signsofhungeroutsidetherecommendedfeeding

times

▪Halfthechild

renof

EDmothersweredescribedas

displaying

difficultiessuch

ashyperactivity,

avoidant

behaviour,enuresis,insecure

attachment,depression,fears,personality

problems,stuttering,violent

temperamentand

oppositio

nald

efiant

behaviour

8/9

2 Psychopathology

Barbinetal.2002

Case–control

Totaln

=65,m

eanage=33.2(3.1)

Cases:N

=44

EDgroup(N

=22),depressed

group(N

=20)

Exposure:maternalE

D(self-report

questio

nnaire)

Outcome:Child

Behaviour

Checklist(CBCL);Children’s

▪Nodifferencesin

term

sof

psychological

adjustmentinchild

renof

motherswith

EDand

controls.E

Dmothersreported

higher

numberof

problemsduring

pregnancyandchild

birth

8/9

M. G. Martini et al.456

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

Health

ycontrols

N=23

EatingBehaviour

inventory

(CEBI);P

arentC

hild

RelationshipInventory(PCRI)

▪Childrenof

motherswith

depression

had

significantly

greaterpsychologicalp

roblem

scomparedwith

child

renof

motherswith

EDand

controls

3 Psychopathology/

Feeding/Eating

Reba-Harrelson

etal.2010*

Cohort

Totaln

=13,006

Cases

N=479,BED=634,BN=98,

AN=17

Health

ycontrols

N=12,257

Exposure:maternalE

D(self-reported)

Outcome:Child

Feeding

Questionnaire;C

hild

Behaviour

Checklist(CBCL);Infant

ToddlerSo

cialEmotional

Assessm

ent(ITSE

A)

▪Motherswith

BNandBEDreported

higher

levels

ofdisordered

eatin

gbehavioursin

theirchild

ren

than

controls

▪Theyalso

reported

higher

levelsof

anxiety

symptom

sin

theirchildren

▪Motherswith

BNreported

higherlevelsof

anxiety

andOCDsymptom

sin

theirchildren

▪Maternally

reported

restrictivefeedingwas

significantly

associated

with

child

disordered

eatin

gdifficulties

8/9

4 Psychopathology

Cim

inoetal.2013

Case–control

Totaln

=64,

meanage=33.2(3.1)

Cases

N=31;A

N=16,B

N=15

Health

ycontrol

N=33

Exposure:maternalE

D(clin

icalinterviewSC

ID-I)

Outcome:

Symptom

Checklist-90–R

evised

(SCL-90-R)

Child

Behaviour

Checklist(CBCL)

Children’slongitu

dinalp

rofiles

▪Emotional-adaptiv

eprofilesweresignificantly

higher

inchildrenin

theexposedgroupon

all

CBCLdimensionsacross

allthree

assessment

timepoints

Powerof

maternalE

Dson

thechild

’spsychological

profile

▪Mother’spsychoticism

scorewas

relatedto

the

child

’sanxiety/depression

andT1andT2

8/9

5 Psychopathology

Micalietal.2014a

Cohort

Totaln

=9443

Cases

AN=126,BN=156and

AN+BN=62

Health

ycontrols

N=9099

ALSPAC

Exposure:self-reported

questio

nnaire

(EDE-Q

)Outcome:Developmentand

Well-beingAssessm

ent

(DAWBA);Strengths

andDifficulties

Questionnaire

(SDQ)

MaternalE

Dandoffspringpsychopathology

atage7

▪MaternalE

Dpredictedem

otionald

isorders,

particularly

astrong

associationbetween

maternalA

NandAN+BNforoffspring

emotionald

isorders

MaternalE

Dandoffspring

psychopathologyatage10

▪MaternalE

DpredictedoffspringDSM

-IVor

ICD-10disorder

▪MaternalA

NandAN+BNstrong

associated

with

emotionaland

anxietydisorders**

7/9

6 Psychopathology

Micalietal.2014b

Cohort

Totaln

=8622

Cases

N=351,

AN:n

=193,

meanage=29.5(4.9)

BN:n

=158,

meanage=28.4(4.3)

AN+BN=81

Health

ycontrols

N=8271,m

eanage=28.7(4.6)

Exposure:self-reported

questio

nnaire

Outcome:StrengthsandDifficulties

Questionnaire

(SDQ);Carey

Infant

TemperamentS

cale;

DenverDevelopmentalS

cale;

LifeEventsQuestionnaire;

obstetricrecords

Childhood

psychopathology

▪Genderwas

predictiv

eof

having

conduct

problems,hyperactivity

/inattentionbutn

otof

emotionalp

roblem

s▪Childrenof

wom

enwith

AN(bothgenders)and

boys

ofwom

enwith

BNweremorelikelytohave

emotionalp

roblem

s▪Childrenof

wom

enwith

BNweremorelik

elyto

presentw

ithconductp

roblem

s

7/9

Eating disorders mothers and their children: a systematic review of the literature 457

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

ALSPAC

▪Girlsof

ANmothersweremorelik

elyto

have

emotional,conductand

hyperactivity

problems

▪Girlsof

BNmothersweremorelik

elyto

have

hyperactivity

/inattentionproblems

▪Boysof

ANmothersweretwiceas

likelyto

have

emotionalproblem

swhereas

boys

ofBNmothers

weretwiceas

likelyto

have

emotionaland

conductp

roblem

s7 Psychopathology

Cim

inoetal.2015

Case–control

TotalN

=251families,m

ean

age=33.2(3.1)

Anxiety

disorder

(N=42)

Depressivedisorder

(N=39)

Eatingdisorder(N

=44)

Health

ycontrol

N=126

Exposure:MaternalE

D(clinical

interviewSC

ID-I)

Outcome:symptom

schecklist9

0(SCL-90-R);The

Child

Behaviour

Checklist(CBCL)

▪Children’sexternalisingproblemstended

toincrease

over

timeonly

inthegroups

ofmothers

with

anED

▪Interpersonalsensitivity

andpsychoticism

significantly

predictedexternalizingproblems

8/9

8 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

and

Temperament

Baronaetal.2016*

Cohort

Totaln

=48,403

Cases

N=2197;A

N=906;

BN=931;

AN+BN=360

Health

ycontrols

N=46,206,

meanage=29.4(4.16)

DNBC

Exposure:self-reportq

uestionnaire

Outcome:Developmental

MilestoneInterview;C

hild

Temperament;Looking

after

Child;S

DQ

▪Girlsof

wom

enwith

lifetim

eANhadhigherodds

ofhaving

emotionalp

roblem

s▪Girlsof

wom

enwith

lifetim

eBNof

having

conductp

roblem

scomparedwith

childrenof

healthywom

en▪Boysof

wom

enwith

lifetim

eANhadhigherodd

oftotal,em

otionaland

conductp

roblem

s▪B

oysof

wom

enwith

lifetim

eBNhadhigherodds

oftotal,conduct,hyperactivity

andpeer

difficultiescomparedto

childrenof

wom

enwith

outanED

▪Boysof

wom

enwith

lifetim

eANandBNhad

higherodds

oftotal,em

otionaland

peerproblems

comparedto

child

renof

healthywom

en

8/9

9 Psychopathology

Cim

inoetal.2016

Case–control

Totaln

=408parents

Cases

Bothparentswith

BEDN=102,

child

ren=51

Onlymotherswith

BEDN=104,

child

ren=52

Onlyfatherswith

BEDN=100,

child

ren=50

Health

ycontrols

N=102parents,child

renN=51

Exposure:maternalE

D(clin

ical

interviewthroughDSM

-5criteria)

Outcome:ScalefortheAssessm

ent

ofFeedingInteractions

(SVIA

)/Child

Behaviour

Checklist

(CBCL)

▪The

groups

with

oneor

both

parentsdiagnosed

with

BEDshow

edhigherscoreson

theSV

IAand

ontheCBCLinternalisingandexternalising

scales,indicatingpoorer

adult–child

feeding

interactions

andhigher

emotional–behavioural

difficulties

▪Adirectinfluenceof

parentalpsychiatricdiagnosis

onthequality

ofmother–infant

andfather–infant

interactions

was

also

found,both

atT1andT2

8/9

10 Psychopathology

Sadeh-Sh

arvitetal.2016b

Case–control

Totaln

=notspecified

Cases

N=29;A

N=14;B

N=13;

EDNOS=2,meanage=31

(4.20)

Health

ycontrols

Exposure:self-reportq

uestionnaire

(EDI-2)

Outcome:CBCL/2–3;v

ideo

recordingof

mother/child

interaction

▪Motherswith

eatingdisorderswerelesssensitive

totheirchildren,triedto

controltheirchildren’s

behavioursmore,andwereless

happyduring

mother–child

interactions

▪The

child

renin

thematernaleatingdisordergroup

wereratedas

lessresponsive

totheirmothersand

8/9

M. G. Martini et al.458

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

N=notspecified,

meanage,33.1(4.64)

theirmothersalso

reported

morebehavioural

problemsthan

thosein

thecontrolg

roup

11 Psychopathology

Cim

inoetal.2018

Case–control

Totaln

=150families

Cases

F+/M

+N=50

M−/F+

N=50

F+/M

−N=50

Health

ycontrols

N=50

Exposure:maternalE

D,clin

ical

interview(SCID

-I)

Outcome:Italianadaptio

nof

FeedingScale(SVIA

)/CBCL

▪Childrenwith

both

parentswith

BEDshow

edthe

highestaffective,anxiety,oppositio

nal/defiant

andautism

spectrum

problems,butn

oinfluence

ofpaternaldiagnosiswasfoundon

theoffspring’s

psychopathology

▪MaternalB

EDhadan

influenceon

children’s

affectiveandautism

spectrum

problems

▪Diagnosisof

BEDinbothparentshadan

effecton

infants’affectiveproblems

▪PaternalB

EDhadan

effecton

oppositio

nal/d

efiant

problemsthroughthequality

offather–infant

interactions

▪MaternalB

EDhadan

effecton

theoffspring’s

affectiveandanxietyproblemsthroughthe

mediatio

nof

mother–infant

interactions

7/9

TEMPE

RAMENT

1 Feeding/Eating/Temperament

Agras

etal.1999*

Case–control

Totaln

=194

Cases

N=41,m

eanage=32.1(4.4)

AN=2,BN=17,B

ED=22

Health

ycontrols

N=153,meanage32.9(3.8)

Exposure:maternalE

D(clin

ical

interviewDSM

III-R+Eating

DisorderInventory—

EDI)

Outcome:Infant

FeedingReport

(IFR

);Su

ckom

eter;C

hildren’s

Behaviour

Questionnaire

▪Fem

aleinfantsof

EDmotherssucked

morerapidly

than

otherinfantsbutn

odifferencesin

caloric

intake

atthesefeedings

▪EDmothersbottlefedtheirdaughtersforamean

timeof

33.2

monthscomparedwith

infantsof

NEDmotherswith

23.6

months

▪EDmothersconsidered

theirfemalechild

rento

have

moredifficulty

inweaning

from

thebottle

(but

notfrom

thebreast)than

NEDmothers

▪Infantsof

EDmotherswerereported

todawdle

morewhileeatin

gcomparedto

child

renof

NED

group

▪EDmothersreported

theirdaughtersas

vomiting

morefrequently

than

theirsons

(opposite

effect

forNEDmothers)

▪EDmothersreported

higher

concernfortheir

daughter’sweightthanNEDmothers

▪Significant

maineffectfortheEDgroupforusing

food

asnon-nutritive

purposes

▪Significanteffectof

EDmothersreportingthey

fed

theirchildrenon

alessregularschedulethan

NED

mothers

▪Childrenof

motherswith

EDreported

asdemonstratin

gmorenegativeaffect

(sadness,crying,irritability)

than

childrenof

NEDmothers

8/9

Eating disorders mothers and their children: a systematic review of the literature 459

Tab

le1

(contin

ued)

Authors

Study,design

Participants:n

,age

(SD),

diagnosesandrecruitm

ent

Measures

(exposureandoutcom

e)Results

NOSratin

g

2 Feeding/Eating/Temperament

Waugh

andBulik

1999*

Case–control

Totaln

=20

mothers

N=10,m

eanage30.1(3.1)

PastAN=6,PastBN=7

Health

ycontrolsrecruitedfrom

community

n=10,m

eanage30.8(3.6)

Exposure:maternalE

D(clin

icalinterview)

Outcome:To

ddlerTemperament

Scale(TTS);M

ealtime

Observatio

nSchedule(M

OS);

Food

Diary

▪Childrenof

wom

enwith

eatingdisordershad

significantly

lowerbirthweightsandlengthsthan

controlchildren

▪Nodifferencesobserved

inchildhood

temperament

ormothers’satisfactionwith

child

ren’s

appearance

▪Motherswith

EDmadesignificantly

fewerpositive

eatingcomments

8/9

3 Cognitiv

edevelopm

ent/

Neuropsychologicalp

rofile

and

Temperament

Baronaetal.2016*

Cohort

Totaln

=48,403

Cases

N=2197;A

N=906;

BN=931;

AN+BN=360

Health

ycontrols

N=46,206,

meanage=29.4(4.16)

Exposure:self-reportq

uestionnaire

Outcome:Developmental

MilestoneInterview;C

hild

Temperament;Looking

after

Child;S

DQ

▪Girlsof

wom

enwith

lifetim

eANhadhigherodds

ofhaving

emotionalp

roblem

s▪Girlsof

wom

enwith

lifetim

eBNof

having

conductp

roblem

scomparedwith

childrenof

healthywom

en▪B

oysof

wom

enwith

lifetim

eANhadhigherodds

oftotal,em

otionaland

conductp

roblem

s▪B

oysof

wom

enwith

lifetim

eBNhadhigherodds

oftotal,conduct,hyperactivity

andpeer

difficultiescomparedto

childrenof

wom

enwith

outanED

▪Boysof

wom

enwith

lifetim

eANandBNhad

higherodds

oftotal,em

otionaland

peerproblems

comparedto

child

renof

healthywom

en

8/9

4 Temperament

Zerwas

etal.2012

Cohort

Totaln

=48,964

Cases

N=3013,

AN:n

=44

meanage=26.5(4.7)

BN:n

=436mean

age=29.6(4.7)

BED:n

=2475,

meanage=30.1(4.6)

EDNOS:

n=58

meanage=27.8(5.2)

Health

ycontrols

N=45,964

Exposure:maternalE

D(self-report

questio

nnaire)

Outcome:Fu

ssy/Difficult

Subscale–InfantC

haracteristics

Questionnaire

▪Motherswith

anEDhadgreaterodds

ofreporting

moredifficultinfanttem

peramentratings

▪Wom

enwith

ANandEDNOS-Pwere2.3–2.8

times

morelikelyto

ratetheirchild

ren’s

temperamentasdifficult

9/9

AN,anorexianervosa;BED,binge-eatingdisorder;B

N,bulim

ianervosa;ED,eatingdisorder;S

CID

,StructuredClin

icalInterviewforDSM-IV

*Studies

fitting

morethan

onedomain

M. G. Martini et al.460

and infant temperament (n = 4). Five studies fit more than onedomain.

Characteristics of the 34 articles included in the systematicreview are shown in Table 1.

Quality assessment

The research design and content of studies was well executedwith over 90% rated as strong. The four studies rated as mod-erate were due to (1) poor representativeness of cases, poorlydefined controls and ascertainment of exposure; (2) lack ofcomparability of cases and controls on the basis of design oranalysis (Blissett and Meyer 2006); (3) one study being un-controlled (Hodes et al. 1997); and (4) no description of con-trol group, no mention of history of outcome (Saltzman et al.2016). It is worth noting that sample size was not accountedfor as some studies rated as strong included small sample sizesof less than 10 (Evans and le Grange 1995). Therefore, astrong and positive overall assessment should be interpretedwith caution.

Study results

Feeding outcomes (n = 17)

Given its relevance, the impact of maternal ED on children’sfeeding and mealtimes is an area that has received consider-able attention. Feeding the infant is a crucial task of parentingnot only because it can absorb considerable part of the day inthe early stages of life but also because it is one of the mostimportant means of communication between mother and child(Silva et al. 2016).

Review of the present studies showed that mothers with EDmight exhibit problems in feeding behaviours with their off-spring starting from breast feeding. A number of population-based studies investigated the impact of ED on breast feeding,yielding discrepant findings (Micali et al. 2011, 2009). A largepopulation-based study showed that women with a history ofED were more likely to start breast feeding and less likely tostop during the first year of the infant life. More specifically,mothers with BN were more likely to continue breast feedingand these differences persisted even after adjusting for

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Reasons:

-Inves�gated Ea�ng problems in mothers with ED 14

-Inves�gated child weight or growth 2

-Interven�ons were assessed 3

-Inves�gated birth or perinatal outcomes 16

-Uncontrolled study 1

Fig. 1 PRISMA flow diagram showing study selection process

Eating disorders mothers and their children: a systematic review of the literature 461

confounding factors (Micali et al. 2009). A similar studyfound that women with ED started breast feeding their infantsas often as controls; however, they were more likely to inter-rupt early (Torgersen et al. 2010). Conversely, Nguyen andcolleagues found that mothers with a history of ED wereslightly less likely to initiate breast feeding, although no lon-ger significant after adjustment (socio-demographics, bodymass index (BMI), maternal psychiatric symptoms) (Nguyenet al. 2017).

Although feeding difficulties are common in early stages ofthe infant’s life, mothers with AN reported increased feedingproblems including exhaustion during feeding, slow feedingand no established feeding routine (Micali et al. 2011, 2009).On the other hand, infants of women with BN had higherlevels of refusal to take solids in comparison to controls(Micali et al. 2009). Blisset and Meyer found similar resultswith some gender specificity, showing that maternal eatingpsychopathology predicted food refusal in girls but not boys.Symptoms of low maternal depression combined with highbulimic scores were significantly associated with food refusalin girls (Blissett and Meyer 2006). Conversely, Whelan andCooper did not find the gender of the child to be related tomaternal ED history, nor did it moderate the relationship be-tween feeding difficulties and maternal ED (Whelan andCooper 2000).

There is a well-known relationship between specific par-enting styles in women with EDs and feeding problems intheir offspring. An early study found that negative expressedemotions and more intrusive behaviours were more frequentamong mothers with ED compared to controls during bothmealtime and play (Stein et al. 1994). Mealtime interactionin offspring (ages 1–4) and mothers with ED compared tocontrols was also investigated by Waugh and Bulik (1999)who found that control mothers made more positive eatingcomments while mothers with ED tended to be more negative.

Differences between ED diagnoses and their impact oninfant feeding problems are worth noting. Saltzman and col-leagues found that maternal BED predicted use of more non-responsive feeding practices (i.e. emotion regulation, restric-tion for health, pressure to eat and food as reward), indirectlythrough more distress responses to children’s negative emo-tions. Maternal BED was associated with greater use of dis-tress responses, which indirectly predicted higher child BMIpercentile through food as reward feeding practices (Saltzmanet al. 2016). Also, mothers with BN or BED were more likelyto report higher levels of restrictive feeding styles compared tocontrols (Reba-Harrelson et al. 2010), and mothers with ahistory of AN were more likely to use less pressuring feedingstrategies compared to controls (de Barse et al. 2015).

Maternal ED can also influence nutritional intake, dietarypatterns and diet quality in infants.

Easter and colleagues found that children of mothers withED reported higher scores on the ‘health conscious/

vegetarian’ dietary pattern (diet high in vegetarian foods, nuts,salad, rice, pasta and fruits) across all four time periods (ages3, 4, 7 and 9) when compared with controls (Easter et al.2013). Furthermore, they showed less adherence to the ‘tradi-tional’ dietary pattern across all four time points. Energy in-take was higher in the BN and AN +BN group, and this intakeincreased significantly over time for children of mothers withBN (Easter et al. 2013). In another study, Torgersen et al.(2015) found that mothers with BN and BED were less likelyto use ‘homemade traditional food’ than ‘commercial jarredbaby food’ when compared with mothers without ED; how-ever, in women with BED, the associations were significantonly before controlling for relevant confounders (Torgersenet al. 2015). Nguyen and colleagues found that children ofmothers with life-time ED had higher diet quality at 1 year(Nguyen et al. 2017). Mothers with histories of ED may alsobe more likely to take ‘special approaches’ to feeding theirchildren, such as limiting the amount of processed foods oreliminating other types or classes of foods (Hoffman et al.2014).

Body image distortion, core symptoms of both AN and BNcan also have an impact on feeding practices. In a recent studyconducted by our team, we found that women with both pastand current ED reported higher concerns about their infantbeing/becoming overweight compared with controls, respec-tively, at 8 weeks and 6months and 6 months only postnatally.Also, women with past ED showed less awareness of infanthunger and satiety cues compared with HC at 8 weeks(Martini et al. 2018).

Cognitive development and neuropsychological profile (n =6)

There is a growing evidence to suggest that ED arecharacterised by a specific neurocognitive profile includingalterations in attention, visuospatial ability, memory, socialcognition and executive functions, encompassing set shiftingand central coherence (Giombini et al. 2018; Lang et al. 2014;Westwood et al. 2016). These profiles observed during activeillness were thought to be a complex interplay between riskand protective factors, given the genetic profile and the driveto high educational achievement and perfectionism, commonfeatures of ED profile (Bardone-Cone et al. 2010). Also, thesemight be intermediate phenotypes, an early risk marker thatare thought to lie between genetic/biological risk and actualphenotypical manifestations (Micali and Dahlgren 2016).

Research on neuropsychological profiles in children ofwomen with ED aimed mainly at understanding both the im-pact of maternal ED on their children and to obtain a betterunderstanding of intermediate endophenotypes of ED.

In the study carried out by Kothari et al. (2013), the inves-tigation of neuropsychological profiles showed that childrenof mothers with AN had high full-scale and performance IQ,

M. G. Martini et al.462

increased working memory (WM) capacity, better visuospa-tial functioning and decreased attentional control when com-pared to controls (Kothari et al. 2013). Another study investi-gating the early cognitive development (18 months and4 years) in a sub-set of these children showed that childrenof women with lifetime AN had difficulties with social under-standing, poorer motor skills, planning and abstract reasoning(Kothari et al. 2014). In a recent longitudinal study of childrenof mothers with ED, we recently found that infants of motherswith ED had poorer language and motor development com-pared to control mothers. Interestingly, after studying differ-ential outcomes based on active versus past ED, we found thatchild cognitive difficulties were associated both with maternalactive ED and past ED (Barona et al. 2017). Overall, thesefindings highlight early developmental difficulties in motorand cognitive development in offspring of ED mothers.

The study of later cognitive characteristics suggests a morespecific pattern of strengths and difficulties across several do-mains of cognition, for example, higher IQ, better visuospatialperformance and WM in children of mothers with lifetimeAN, and poorer visuospatial functioning in children ofmothers with lifetime BN (Barona et al. 2017).

Only one study to date has investigated social cognition inchildren of mothers with ED in mid-childhood and early ado-lescence, with some evidence of differences between at-riskoffspring and controls. In particular, differential facial emotionprocessing, poorer recognition of fear, and higher scores onthe social communication disorders checklist were present inchildren of mothers with binge eating and purging behaviours,the latter also present in children of mothers with lifetimeBED (Kothari et al. 2015).

Finally, in a small longitudinal cohort study, Koubaa andcolleagues found that children born to mothers with AN or BNhad significantly higher Five to Fifteen (validated parent ques-tionnaire assessing neurocognitive development) scores thancontrols reflecting difficulties in language and social skills(Koubaa et al. 2013).

Psychopathology (N = 12)

There is strong evidence that parental mental illness is associ-ated with psychopathology in offspring, establishing that chil-dren of parents with psychiatric disorders are at higher risk ofdeveloping psychopathology themselves (Rasic et al. 2013).Research has also shown that familiar risk is only partlydiagnosis-specific meaning that children might develop thesame parental diagnosis (homotypic transmission) but maybe also at risk for a range of other psychiatric disorders (het-erotypic transmission) (Siegenthaler et al. 2012). However,the effect of maternal ED on their offspring psychopathologyhas received less attention.

Of the studies in this domain, five specifically investigatedpsychological/emotional development (Barbin et al. 2002;

Cimino et al. 2016, 2013, 2015; Sadeh-Sharvit et al. 2016b) andseven explored general psychopathology (Barona et al. 2016;Cimino et al. 2018; Evans and le Grange 1995; Hodes et al.1997; Micali et al. 2014a, 2014b; Reba-Harrelson et al. 2010).

A large longitudinal cohort study identified a higher riskfor emotional and behavioural disorders in offspring of EDmothers at an early age (3.5 years). Specifically, the authorsidentified associations between maternal ED type (AN vs.BN) and child psychopathology (emotional vs. behaviouralproblems), as well as gender differences (Micali et al.2014b). Emotional difficulties were found in both girls andboys of mothers with AN, while more hyperactivity and peerdifficulties were found in both girls and boys of mothers withBN. This study also aimed to understand risk mechanisms andhighlighted a mediating role for maternal anxiety and depres-sion in the postpartum. These findings were confirmed andextended in a later study when the same children were aged7, 10 and 13, where maternal EDs (both AN and BN) stronglypredicted emotional and anxiety disorders (Micali et al.2014a). A recent longitudinal study showed that maternalED was associated with childhood psychopathology in girlsand boys at age 7, both emotional and behavioural problems.Disorder and gender-specific findings across studies point toan effect of maternal lifetime AN on emotional disorders, inparticular anxiety, across ages; while maternal BN seems to beassociated with hyperactivity, conduct and peer problems(Barona et al. 2016).

These findings support those of case–control studies. Intwo longitudinal studies using the Child Behaviour Checklist(CBCL), the authors found that children of mothers with EDreported higher externalising and internalising scores fromthe CBCL compared to controls (Cimino et al. 2015,2018). The emotional-adaptive profiles of children in theclinical group of mothers with ED scored significantly higherin all dimensions of the CBCL (Cimino et al. 2013). Morespecifically, externalising problems increased over time(Cimino et al. 2015).

The same authors carried out other two longitudinal studiesaimed at investigating the emotional and behavioural profileof children of one or both parents with BED and adult–childfeeding interaction (Cimino et al. 2016, 2018). They foundthat the children with one or both parents diagnosed withBED had higher scores on the internalising and externalisingscales, and higher levels of emotional and behavioural diffi-culties (Cimino et al. 2016). Furthermore, children with bothparents with BED showed the highest affective, anxiety, op-positional/defiant, and autism spectrum problems versus chil-dren of families with only one BED diagnosed father.Maternal BED was associated with children’s affective andautism spectrum problems, and diagnosis of BED in bothparents had an effect on infants’ affective problems. PaternalBED had an effect on oppositional/defiant problems throughthe quality of father–infant interactions, and maternal BED

Eating disorders mothers and their children: a systematic review of the literature 463

had an effect on the offspring’s affective and anxiety problemsthrough the mediation of mother–infant interactions (Ciminoet al. 2018).

On the contrary, Barbin et al. did not find any difference interms of psychological adjustment on both subscales ofinternalising and externalising in children of mothers withED compared to healthy controls (Barbin et al. 2002).

In two early small studies, authors found that half ofchildren of mothers with ED displayed psychiatric problemssuch hyperactivity, avoidant behaviour, enuresis, insecureattachment, depression, fears, personality problems,stuttering, violent temperament and oppositional defiant be-haviour (Evans and le Grange 1995) and OCD (Hodes et al.1997), respectively.

The latter association has also been found in a more recentlarge cohort study conducted by Reba-Harrelson and col-leagues. The authors found that children of mothers withbinge BED or BN were significantly more likely to exhibitsymptoms of anxiety compared to children of control groupmothers. Children of mothers with BN were also significant-ly more likely to exhibit obsessive-compulsive symptomsthan children of non-eating-disordered mothers. All thosewith AN, BN or BED were significantly more likely to havechildren who exhibited symptoms of depression (Reba-Harrelson et al. 2010).

Likewise in a small recent study, mothers with ED reportedhigher levels of behavioural problems in their children com-pared to control mothers (Sadeh-Sharvit et al. 2016b).

Temperament (N = 4)

Temperament is defined as early appearing, biologicallyrooted, basic personality dimension (Bates et al. 1995).Although temperament is said to be a biological tendencywithin each child, environmental contexts, especially the so-cial context, interrelate with the genetic tendencies of eachchild (Shiner et al. 2012).

Mothers with EDs have been shown to be more likely todescribe their infant as having a difficult temperament.Compared to womenwith no history or current EDs, they tendto rate their children as having high levels of difficult temper-ament (Zerwas et al. 2012) and perceive them as having great-er negative affect, that is, demonstrating more sadness, irrita-bility and crying compared to controls (Agras et al. 1999). In amore recent large longitudinal study, we found that motherswith ED were more likely to perceive their children as havinga ‘difficult temperament’ characterised by the child being lesshappy and active than other children their age, more restlessand as having more tantrums and as being less cautious andguarded than other children their age (Barona et al. 2016). Onthe contrary in an early study, the authors did not observe anydifference in childhood temperament between children bornfrom ED mothers and controls (Waugh and Bulik 1999).

Discussion

The literature regarding the impact of maternal ED onchild development has expanded in the last decade.Albeit earlier studies focusing on small clinical samples,larger population-based samples have recently increasedour knowledge on the topic.

Overall, the literature suggests that maternal ED im-pact on child cognitive, psychological and feeding andeating development.

Regarding feeding and eating, research shows that childrenof mothers with ED tend to experience more difficulties infeeding their children both in infancy and childhood.Although studies on breast feeding yield mixed results, wom-en with ED often report difficulties with this. Throughouttoddler years, difficulties such as slow feeding, small quanti-ties feeding and not having established feeding routinesemerged as common among ED mothers. Restricting parentalfeeding styles, negative expressed emotions and intrusive be-haviours also appeared to be more frequent in ED motherscompared to controls. The most recent findings (Martiniet al. 2018; Saltzman et al. 2016) are in line with earlier re-search (Stein et al. 1994). To date, it is not possible to disen-tangle the influence of genetic predisposition versus environ-mental factors, though likely both have a role. Future researchinvestigating genotype–environment interface is warranted toprovide further insight.

Although the current literature is less prominent, availablefindings shows that a maternal lifetime history of ED mayhave a negative impact also on children’s cognitive, psycho-logical development and psychopathology.

Interestingly, recent studies have identified shared geneticrisk between ED and other psychiatric disorders, i.e. schizo-phrenia and BED (Solmi et al. 2019) and AN and obsessivecompulsive disorder (OCD) but also other positive geneticcorrelations between AN and schizophrenia and AN and neu-roticism (Duncan et al. 2017; Yilmaz et al. 2018). These find-ings suggest that the genetic risk transmitted will impact onthe behavioural, physiological and medical phenotypesexpressed in children. Therefore, we might assume that chil-dren of AN women have a higher genetic risk of developing awide range of phenotypes and psychiatric disorders such aspsychosis, neuroticism, educational attainment but also lowerBMI and lower risk of diabetes. Less is known on cognitionand neuropsychological characteristics in offspring of EDmothers prior to the onset of psychopathology, and thesemight be an important focus of study in at-risk offspring, help-ing future prevention and early interventions.

Strengths and limitations

This systematic review has several strengths. First, it is thefirst systematic review summarising the existing findings from

M. G. Martini et al.464

1980 until 2018 on the impact of maternal ED on child devel-opment, and its findings can be valuable in deriving futurehypothesis.

Second, the majority of studies relied on community-basedor register-based samples rather than clinical samples; there-fore, selection bias in the original studies is likely to be small.

Moreover, if an association between maternal ED and childdevelopment has been established in population-based stud-ies, which are more likely to include less severe case of ED,our results are liable to be an underestimation of the effect.

However, some limitations should also have to be takeninto account. Some of the studies reviewed above are singlefindings and need replication. Also, the vast majority of thestudies explored mother–child dyad and did not involve thefathers. Although ED have a higher incidence in women thanin men, gender ration is less skewed in BED than BN and AN(Hudson et al. 2007) and paternal ED can also have an impacton child development.

Studies showed a high degree of heterogeneity in the waythe ED diagnosis is established, ranging from self-reportedquestionnaires (used in cohort studies such as ALSPAC(Easter et al. 2013; Micali et al. 2009, 2011, 2014a, 2014b,), DNBC (Barona et al. 2016), Generation R study (de Barseet al. 2015; Nguyen et al. 2017), MoBa (Torgersen et al.2015)) to structured interviews using both the Diagnosticand Statistical Manual (Agras et al. 1999; Cimino et al.2016; Evans and le Grange 1995; Stein 1999; Waugh andBulik 1999; Whelan and Cooper 2000) and SCID I (Baronaet al. 2017; Cimino et al. 2015, 2018; Hoffman et al. 2014;Kothari et al. 2015; Martini et al. 2018).

It is important to point out that parental psychopathologydoes not always impact on child development in a negativeway. This might be due to numerous factors including protec-tive family network, child resilience, early access to mentalhealth services, parenting abilities etc.

Future research should focus on the protective factors thatmoderate the relationship between maternal ED and adversechild outcomes leading to a healthy development of the child.This would shed light into mechanisms that could be poten-tially directed for intervention. For example, further researchcould introduce fathers and explore their roles in the familydynamics and in ameliorating, exacerbating or acting indepen-dently of the possible influence of a mother with ED.

Conclusion

In summary, maternal ED have an impact on child psycholog-ical, cognitive and eating development, and might affect thedevelopment of ED in the offspring. Despite this evidence,little is known on how genetic and environmental factors in-terplay and affect risk. As maternal psychopathology not al-ways negatively affect child development, future research

should focus on resilience and on which protective factorshave impact on positive outcome. These factors can be thenused as therapeutic and preventative targets.

Compliance with ethical standards

Conflict of interest The authors declare that they have no competinginterests.

Ethical approval The article does not contain any studies with humanparticipants performed by any of the authors.

Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing, adap-tation, distribution and reproduction in any medium or format, as long asyou give appropriate credit to the original author(s) and the source, pro-vide a link to the Creative Commons licence, and indicate if changes weremade. The images or other third party material in this article are includedin the article's Creative Commons licence, unless indicated otherwise in acredit line to the material. If material is not included in the article'sCreative Commons licence and your intended use is not permitted bystatutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/.

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