Results from the 3 cohorts studied follow the typical pattern of what is already known about eating disorders clinically, with presentation during adolescence, a marked female predominance and presentation with low median body weights or %IBWs. Although there were a small proportion of cases with avoidant restrictive food intake disorder (ARFID), or other specific feeding and eating disorders (OSFED), most were for children with anorexia nervosa.

Consistent with national findings [6], referral rates significantly increased post-pandemic. Bodywhys, the ED association of Ireland, also reported an increased demand for their online support groups [9]. In line with the findings of Driscoll and colleagues in CAMHS setting, there was no difference in comorbid mental health difficulties. In our CAMHS cohort, available data suggested that significantly fewer children (19% vs. 43%, p = 0.011) were prescribed psychotropic medication post-COVID-19, perhaps linked to earlier recognition as reflected by a shorter duration of illness and faster referral rate.

School closures due to COVID were associated with huge lifestyle changes, parental home working, and closure of sporting facilities and opportunities [10]. The public health messaging at this time encouraged healthy eating and physical activity during lockdown. This is understandable given the high rates of obesity, and against a recognition that during the pandemic nearly half of American adults gained weight, especially those already overweight [11]. Weight gain was also linked to high rates of stress, depression, and anxiety [11]. However, potential adverse effects of weight stigma [12] were also noted and this calls for more careful public health messaging. Given the recognition that Ireland ranks as one of the highest levels for obesity in Europe, addressing this important health topic needs sensitive messaging to avoid increased disordered eating.

To what extent the increase in ED presentations post-COVID-19 is due to overzealous public health messaging in vulnerable groups, or is linked with a direct effect, is unknown. Although a bidirectional association between COVID-19 and psychiatric disorders, has been established, particularly linked to anxiety and mood disorders, eating disorders were not included [13]. A recent systematic review highlights several ways the pandemic may have indirectly adversely affected eating behaviours and disorders [14]. This included a preoccupation on weight/body shape, an over-reliance of dieting to manage weight following physical activity restrictions, reduced surveillance by primary care services linked to restriction or changes in healthcare provision, social isolation increasing stress and anxiety, and exacerbating symptoms in patients with EDs, and difficulty accessing certain food products. Qualitative studies are beginning to outline the myriad of lived experiences during COVID-19 for individuals and families who developed an ED or experienced a deterioration in a prior ED [15].

Findings from these 3 ROI cohorts mirror the international view, suggesting that COVID-19 has had a specific impact on referral rates of children with ED [6, 16, 17]. Some studies have further suggested an increase in illness severity, characterised by lower weights, increased medical instability, and increased requirement of hospitalisation [18, 19] as well as atypical case presentations [20]. Although our data reflect increased numbers of EDs, unlike previous suggestions, and in accordance with the NCPED data [6], our findings do not show any significant increase in medical compromise or complexity. Despite this, there was a shorter duration of weight loss prior to referral to the CAMHS specialist ED service. Further investigation of this may be warranted, and perhaps qualitative studies could assess whether clinicians became more alert to eating disorders and mental health difficulties among patients during the pandemic, leading to faster referrals to CAMHS services.

A strength of this study is the inclusion of children with eating-related difficulties across multiple clinical settings covering large catchment areas and the inclusion of clinical profiles. In addition, patient statements whether COVID-19 was a contributory factor to their illness were recorded at the CAMHS specialised ED service setting. The ED CAMHS service is a publicly funded service responsible for a catchment area of 260,560 children or 12.7% of all the children living in Ireland. Both paediatric hospitals are not confined to any catchment area. CHI Crumlin operates as an acute paediatric hospital with a 24-h emergency department as well as being the national centre for several paediatric specialties. CHI Temple Street located in Dublin inner city provides both quaternary and tertiary paediatric services. Limitations include a failure to capture children attending primary care or private services and admissions to specialist psychiatry inpatient units which were not captured in the 3 services examined. The time frame across each of the 3 settings is different, preventing combining all data. In addition, this study does not include data from the 3rd CHI hospital, CHI Tallaght.