Postpartum Depression and the Moderating Role of Empathy on Child Physiological Reactivity

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Perinatal maternal depression is a risk factor for the development of psychopathology in the offspring, probably by impacting its early physiological reactivity to stress and emotion regulation. The objective of this study is to evaluate the influence of postpartum depressive symptoms on the offspring’s physiological reactivity (heart rate variability -HRV) and the possible moderating effects of empathy and perinatal attachment. Methods. We recruited 24 mother-child dyads. The psychopathological profile and personal characteristics of pregnant women at 24–28 gestational weeks were evaluated by administrating the Perinatal Attachment Inventory (PAI) and the Empathy Quotient (EQ) questionnaire. Three weeks after childbirth, women completed the Edinburgh Postnatal Depression Scale (EPDS), and the offspring underwent an HRV recording. Results. Postpartum depression was a good predictor of the offspring’s HRV activity (b = 1.49, p = .045). Both perinatal attachment (r=-.463, p = .023, Fisher’s ES=-.501) and empathy (r=-.570, p = .004, Fisher’s ES=-.648) were negatively associated with postpartum depression. Finally, empathy showed a moderator effect on the association between postpartum depression and child’s HRV (b = 0.13, p = .03). We found no moderator effects for Perinatal Attachment. Conclusion. Despite the preliminary nature of our data, maternal depression showed predictive power on offspring's early regulatory mechanisms, with possible knock-on effects on emotional regulation and mother-child bond establishment. Interestingly, some maternal personality characteristics, such as empathy, can influence the development of depression symptoms, suggesting the presence of moderator factors modulating the association between maternal psychological status and child physiological reactivity. prenatal postnatal depression empathy heart rate variability attachment mother-child bond Figures Figure 1 Introduction Maternal perinatal depression has detrimental effects on child development. In particular, it has been associated with increased risk for wide-ranging adverse consequences, such as cognitive, social, and emotional disturbances, depression and anxiety, behavioral problems, and attachment insecurity [ 1 – 6 ]. Mechanisms underlying the associations between maternal depression and adverse infant and child developmental outcomes have been the object of research for years [ 6 , 7 ] and attention has been paid to the interference of depression with the creation of the bond between mother and child [ 8 – 13 ]. It has been documented that mothers with depression engage in less intense relationships with their children, experience more stress, and perceive their children in a more negative way [ 14 ]. This pattern of mother-child interplay has also been reported among children of mothers who have subclinical levels of depressive symptoms [ 15 – 17 ]. As a consequence of maternal depression, newborns show more dysregulated behavior, such as disturbed/disorganized sleep and difficult temperament [ 18 , 19 ], which can reciprocally further increase negative symptoms in the mother, thus determining a vicious, self-feeding cycle [ 20 ]. However, some maternal characteristics have a role in mediating/moderating the mother-child relationship. For example, women with a disorganized attachment style seem to be particularly at risk [ 21 ]. In contrast, maternal sensitivity, the ability to perceive and interpret accurately infant's signals and communications and then respond contingently and appropriately, favors an appropriate mother-child interplay[ 22 ] and helps regulate the infant's stress responsiveness and emotion regulation favoring long-lasting wellbeing[ 23 – 25 ]. In response to poor maternal interaction, infants may alter their behavior and exhibit poor emotional and behavioral state regulation, fewer positive and more negative facial expressions, avoidance, and greater fussiness [ 26 , 27 ]. An alteration in newborn behavioral regulation can be detected by recording the newborn's heart rate variability (HRV). HRV is a reliable estimate of the autonomic nervous system (ANS) functioning, and particularly of its vagal branch, and therefore, a good index of regulation capabilities and adaptation to the environment [ 28 , 29 ]. The parasympathetic (vagal) branch, reflected by the high frequencies component (HF) of the HRV, in particular, is a candidate marker of physiological stress regulation of autonomic response through top-down cognitive control across the lifespan [ 30 – 32 ]. As a confirmation, previous studies reported that HRV in the prenatal and neonatal period is predictive of various aspects of development, such as language skills and psychological development in early childhood [ 33 – 35 ]. Furthermore, a previous study exploring maternal HRV and child brain development showed an influence of maternal mental health on infant neurophysiology via alterations in autonomic stress regulation and dyadic physiological co-regulation [ 36 ]. To our knowledge, however, no studies investigated the effects of depressive symptoms in the postpartum on the HRV. We were specifically interested in the postnatal period, a period of great psychological vulnerability for the mother due to neurocognitive and neuroendocrine changes. These changes are supported by transitory high brain plasticity[ 37 ] that sustains behavior focused on the child, guaranteeing their centrality in neuroplastic changes[ 37 – 39 ]. The brain changes facilitate the mother to adapt to the child’s needs and development but also render her vulnerable to psychopathology[ 39 ]. Therefore, the first postpartum months are crucial because the same neurobiological modifications that enable the mother to care for her child and establish an appropriate mother-child relationship also make her vulnerable to psychopathology [ 40 ]. Based on the previous literature, the first aim of the study is to examine the relation between maternal postpartum depression and the regulatory abilities of their child (HF component of the HRV). The second aim is to evaluate the role of some protective factors, namely empathy and perinatal attachment, in moderating this relation. Considering the extant literature, we hypothesize that in the presence of maternal postpartum depressive symptoms, an alteration of the developing child's psychophysiology underlying its stress response and regulatory abilities could be detectable (Aim 1). Regarding the second aim of the study (Aim 2), we hypothesized that some maternal characteristics, such as empathy and perinatal attachment, could be associated with the development of postpartum depressive symptoms and that, thus, could moderate/mitigate the association between post-partum depression and offspring HRV. Methods Participants The study involved 24 mother-child dyads recruited during pregnancy in the period from March 2022 to February 2023 at the Gynecology and Obstetrics Unit of the Department of Women’s and Children’s Health, University Hospital of Padova. The inclusion criteria were as follows: a gestational period between 24 and 28 gestational weeks, actual absence of illnesses complicating pregnancy, delivery, perinatal period, and normal fetal medical records; at term birth; no use of corticosteroid medication with comprehensive and continuous tracking throughout the pregnancy; complete medical records as well as demographic, psychological, and lifestyle questionnaires for each expectant mother, and informed consent. The women recruited had a median age of 32 years (31; 36.7), and they were evaluated in the prenatal period at a median gestational age of 28 weeks (25.25; 29). None of the mothers assumed alcohol or smoked during pregnancy, and none had a psychiatric or neurological diagnosis; the socioeconomic status was medium for 20/24 women, low for 3/24, and high for 1/24 according to [ 41 ]. Complete data on demographic and clinical characteristics of the women are shown in the Supplementary Material. Children were born at a median gestational age of 38.5 weeks (38; 41), median birth weight of 2996 grams (2670; 3697); 14/24 were male. None of the children had perinatal complications or needed resuscitation. As for mothers, complete data on children's demographic and clinical characteristics are shown in the Supplementary Material. The study received approval from the Institutional Review Board (Prot.n 24139, 02.2022 Comitato Etico per la Sperimentazione Clinica dell’Azienda Ospedaliera di Padova, and 193-c, 01.2024 Comitato Etico della Ricerca Psicologica Area 17). It was conducted in accordance with ethical guidelines. Material Psychological measures in the mother Empathy Quotient (EQ) [ 42 ]The EQ is a self-report questionnaire that measures empathy's cognitive and affective aspects. The Italian version is a 60-item questionnaire with 40 questions regarding empathy and 20 filler items. The final score ranges between 0 and 80, with higher scores implying higher empathy. The Parental Attachment Inventory (PAI) [ 43 ] is a questionnaire that measures prenatal attachment in five dimensions: fantasy, affection, interaction, sensitivity, and differentiation of self from the fetus. It is composed of 21 Likert-type items, and the total score is the sum of the items and ranges from 21 to 84, with higher scores indicating higher levels of prenatal attachment. Edinburgh Postnatal Depression Scale (EPDS) [ 44 , 45 ]. The EPDS is a 10-item self-report scale to screen for Postnatal Depression. Each item has four answer choices indicating different levels of severity (0–3 points). Each item scores between 0 to 3, totaling 0 to 30 points overall. Higher scores denote more significant symptoms of postnatal depression. Autonomic measures – HRV in the child Autonomic functioning has been estimated by extracting HRV from an electrocardiogram (ECG). Ag/AgCl surface electrodes were positioned on the chest in a modified lead II configuration. The raw ECG signal was recorded with a LiveAmp system (Brain Products, Gilching, Germany) and amplified with a gain of 150, bandpass filtered (0.3–100 Hz), and digitized at 500 Hz (16 bit A/D converter, resolution 0.559 µV/LSB). The raw ECG signal was then exported to Kubios HRV Analysis Software 2.2 (The Biomedical Signal Analysis Group, Department of Applied Physics, University of Kuopio, Finland) to estimate the occurrence of each heartbeat and derive the series of inter-beat intervals (IBIs), calculated as the difference in milliseconds (ms) between two consecutive R-waves. Fast Fourier spectral analysis was conducted on the IBI series to compute frequency domain indexes and obtain the HF power (0.15–0.40 Hz) component. HF Frequency-domain index was logarithmically transformed to normalize its distribution. Procedure After the recruitment, at 24th -28th gestational weeks, the pregnant women underwent a structured interview about clinical and demographic information (complete data obtained are shown in the Supplementary Material) and filled out the Empathy Quotient (EQ) questionnaire and the Perinatal Attachment Inventory (PAI). The mothers were asked to return to our department with their sons once the baby was born between the third and fourth weeks of life. All appointments took place at our Department between 9–10 a.m. As the dyads came, children were prepared for the HRV recording by placing him/her on a crib and being undressed just enough to place the two electrodes. After the procedure, if the child became nervous, he/she was calmed down by the mother until the child reached a drowsy state and the recording could begin. The electrocardiogram recordings have been recorded for sufficient time to obtain at least five minutes artifact-free. After the recordings, the mothers filled out additional questionnaires about the possible presence of postnatal depression, the Edinburgh Postnatal Depression Scale (EPDS). A structured interview has also collected information about delivery and the perinatal period. Questionnaires were administered using a computer interface and secure REDCap link ( https://www.projectredcap.org ). Statistical analysis At first, correlations between prenatal attachment (PAI), empathy (EQ), postpartum depression (EPDS) scores, and HF component of the child’s HRV were run using Pearson r. False discovery rate correction for multiple comparisons has been made. Independent linear regressions were conducted to evaluate the predictive power of postpartum depression on the HF component of the child's HRV. Subsequently, the moderator effects of perinatal attachment and empathy were evaluated by adding them to the regressions and evaluating the interactions between perinatal attachment and postpartum depression in one model, empathy and postpartum depression in the other, on the HF. Cronbach’s alpha measure of reliability has been performed to evaluate consistency between items. Statistics were determined using JASP (The JASP team 2018, version 0.19.2). Results Descriptive statistics At the reliability analysis of questionnaires, Cronbach’s alpha for EQ was 0.86, for PAI 0.88, and for EPDQ 0.89. Table 3 reports the scores obtained by the women in the questionnaires. Table 3 Median, 25- 75th percentiles, and number of clinical scores (where applicable) obtained by the mothers at questionnaires in the postpartum (EPDS) and in the prenatal period (EQ, PAI). PRENATAL POSTPARTUM Empathy (EQ) Perinatal Attachment (PAI) Depression (EPDS) Median 43.0 -0.23 5.5 25th percentile 38.0 -0.60 2.5 75th percentile 53.0 0.77 10 N clinical scores -- -- 9/24 Legend: EPDS: Edinburgh Postnatal Depression Scale; EQ: Empathy Quotient; PAI: Perinatal Attachment Inventory. The median HF percentage values in children were 8.200 Hz (3.425; 10.275), while the days of life at the recordings were 25 (20; 30 days). Correlations Correlations between the measures of interest were run (see Fig. 1). The HF scores of the child’s HRV were significantly correlated only with the postpartum depression score obtained in the Edinburgh Postnatal Depression Scale (r = .539, p = .007, Fisher’s ES = .603). Postpartum depression was inversely correlated both with the Empathy Quotient (r=-.570, p = .004, Fisher’s ES=-.648) and Perinatal Attachment Inventory (r=-.463, p = .023, Fisher’s ES=-.501). The correlations remained significant after correction for the false discovery rate. [INSERT FIGURE 1 HERE] Predictors of neonate’s HF component At first, a linear regression was run to examine the contribution of postpartum depressive symptoms to the neonate's HF component. Postpartum depressive symptoms significantly predicted the neonate's HF component (b = .13, p = .045). By adding in the regressions EQ and PAI, a moderation effect emerges between the Empathy Quotient and Postpartum Depression (b = 0.13, p = .03), while the principal effect of Postpartum Depression alone is no longer significant: higher levels of empathy predict lower symptoms of postpartum depression and stress, which in turn are associated with lower HF values (Fig. 2), suggesting that the association between variables is more complex than a simple principal effect. Therefore, empathy is shown to moderate the effect of depression and stress on the child's HRV by reducing them. We did not find moderation effects for Perinatal Attachment. Discussion The first aim of our study was to investigate the effects of postpartum depressive symptoms on the offspring’s HF component (parasympathetic) of HRV, which, being a measure of stress responsiveness and regulation ability, possibly represents a key mechanism in the establishment of psychological vulnerability (Aim 1). We also wanted to explore the association of maternal empathy and perinatal attachment to the fetus whose mothers had postpartum depressive symptoms and their possible moderating effects on HRV (Aim2). Regarding the first aim (Aim 1), we found that the development of depressive symptoms in postpartum is highly associated with an increase in the offspring’s HF component. The association between depressive symptoms and HRV suggests that the psychological state of the mother, probably acting on the interaction with the child, in some ways influences the early regulatory abilities of the baby, as reflected by the HF component of HRV, a well-known estimate of the parasympathetic branch of the ANS. By considering the effects on the offspring’s HRV of depression associated with pregnancy, we found a similar study in the literature, but evaluating the effect of prenatal depression on child’s autonomic measures [ 46 ]. In this research, the authors found that total HRV was significantly lower in children born by mothers reporting past major depressive disorder and life stressors. The effect of other maternal psychopathological symptoms during the prenatal period has also been investigated [ 47 – 50 ], mostly to explore the so-called “prenatal stress-immune programming” [ 51 , 52 ]. The women in our study have no previous diagnosis of depression or other psychopathology; therefore, to our knowledge, the present study is the first to evaluate the effect of postpartum depression on shaping the early regulatory ability of the child as reflected by the HRV. Interestingly, the presence of maternal postnatal depressive symptoms in the present study is associated with higher HF power. Under conditions of fetal stress, a reduction of the parasympathetic (HF measure) branch of ANS is the most common result; however, increases have also been found. For example, perinatal asphyxia could determine bradycardia and consequent parasympathetic increase [ 30 , 53 ]. Similar effects have been reported in infants exposed to prenatal opiates and premature infants that developed apparent life-threatening events after discharge from the neonatal intensive care unit [ 54 , 55 ]. This confirms previous observations that the ANS reacts in different and complex ways depending on the maturation level and the stressor typology [ 52 ]. ANS is intricately connected to higher brain systems involved in emotion and cognition [ 56 ], and, at birth, it is still developing, particularly the parasympathetic branch (indexed by the HF component of HRV)[ 57 ]. This renders it vulnerable to being shaped by perinatal factors [ 58 , 59 ], and early adversities could significantly limit the ANS's capacity to respond to challenges and external needs [ 58 , 60 ], with consequences on neurodevelopment [ 61 , 62 ]. However, not all children exposed to maternal depression will be negatively affected [ 63 , 64 ], thus the association between maternal depression, maternal behavior, and child outcomes is probably complex and moderated by various factors [ 63 ]. Depression and its characteristics (e.g., severity, persistence) can be associated with personality traits and personal characteristics, such as empathy [ 65 ]. Therefore, we were interested in exploring if some maternal characteristics could moderate the development of psychopathological symptomatology and moderate the effects of depression on the child's HRV (Aim 2). We found that prenatal attachment, a construct that summarizes the crucial dimensions of maternal sensitivity, fantasy, interaction, affection, and differentiation of self from the fetus, negatively correlates with post-partum depressive symptoms, suggesting that the effects of a good prenatal attachment persist throughout the postnatal period. Previous works indicated prenatal maternal attachment as a key factor in promoting the development of maternal-child attachment [ 66 , 67 ], contributing to better mother-child bonding and supporting a more satisfactory interaction and self-efficacy in the mother, thus reducing the likelihood of developing depressive symptoms. However, the perinatal attachment was not associated with the child's HRV, and it has no moderator effects on the association between depressive symptoms and HRV. On the contrary, empathy was not only associated negatively with depressive and stress symptoms, but it also moderates the effects of depression and stress on HRV, which means that the effect of depressive symptoms on HRV was different for different levels of empathy. In particular, women experiencing higher empathy have lower depressive symptoms and, consequently, children with lower HF power. As sensitive parenting requires an accurate and empathic response to signals from the child, empathy could be a crucial mechanism allowing sensitivity in the mother. It allows us to hypothesize that imagining and empathizing with the incoming child allows them to regulate emotions better. From a neurobiological perspective, we know that cerebral plasticity mechanisms occurring in the woman’s brain are circuits associated with empathic mechanisms [ 68 ]. As confirmation, previous works found a correlation between empathy, depressive and remote maternal behavior in early postpartum women and that higher scores on an empathy test in the early postpartum period were associated with less remote and less depressive behavior [ 69 , 70 ]. This aspect opens important scenarios for the prevention of postnatal depressive symptoms, with cascading effects on the relationship with the child first and on the child's neurodevelopment later. If further research confirms the role of empathy in the development of depressive symptoms and in establishing the mother-child relationship, intervention programs enhancing empathy in the pregnant woman would perhaps make her better prepared to handle the intense demands of the early postpartum months. This study has several limitations. First, the numerosity is low and does not allow for generalization of results. It also does not highlight possible subthreshold effects, as in the case of the role of perinatal attachment. In addition, it would be important to have long-term follow-up data to better understand the clinical value of the differences in HRV found. Finally, our women did not have a clinical diagnosis of postpartum depression but variable symptomatology that only allowed for correlational measures and not case-control group comparisons. In conclusion, we found that postnatal depression can influence the autonomic functioning of the offspring, suggesting that maternal psychopathology may interfere with the child's early regulatory mechanisms, with possible knock-on effects on the responses to stress, mother-child bond, and emotional regulation later in development. However, some maternal personal characteristics, such as perinatal attachment and empathy, can influence the development of depressive symptoms, suggesting the presence of moderators/modulating factors in the association of maternal depression and child autonomic changes. A better understanding of how maternal characteristics may affect the development of psychopathology in the child may open up interesting possibilities for early intervention. Abbreviations ANS: autonomous nervous system EPDS: Edinburgh Postnatal Depression Scale EQ: empathy quotient HF: high frequency HRV: heart rate variability PAI: Parental Attachment Inventory Declarations Ethics approval and consent to participate . This study was performed in line with the principles of the Declaration of Helsinki. The Ethical Commitee of the Hospital (Comitato Etico per la Sperimentazione Clinica della Provincia di Padova, Prot.n 24139, February 2022) and of our Department (Comitato Etico della Ricerca Psicologica dell’Università di Padova, Prot.n 193-c, January 2024) approved the study. Informed consent to participate was obtained from all of the participants in the study. Consent for publication. Not applicable. Availability of data and materials. Data will be available on request. Competing interests. The authors declare that they have no competing interests. Funding. This work is funded by the European Union – NextGenerationEU and by the University of Padua under the 2021 STARS Grants@Unipd program (UTOPICO - In Utero and Postnatal Influences on Cerebral Organization - Exploring neurobiological mechanisms for advancing strategies fostering life-long wellbeing). Authors' contributions . EC conceived the research, coordinated the data collection, and wrote the first draft of the paper; BC supervised the data collection, interpreted the results, and critically reviewed the work; SP collected, analyzed, and interpreted the data and critically reviewed the work; FZ and PV collected and interpreted the data, and critically reviewed the work; DM and MD collaborated in analyzing the data and critically reviewed the work; AS interpreted the data, and critically reviewed the work. References Conroy S, Pariante CM, Marks MN, Davies HA, Farrelly S, Schacht R, et al. 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Available from: https://pubmed.ncbi.nlm.nih.gov/29517386/ Benvenuti P, Ferrara M, Niccolai C, Valoriani V, Cox JL. The Edinburgh Postnatal Depression Scale: validation for an Italian sample. J Affect Disord [Internet]. 1999 [cited 2024 Jun 18];53:137–41. Available from: https://pubmed.ncbi.nlm.nih.gov/10360408/ Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry [Internet]. 1987 [cited 2024 Jun 18];150:782–6. Available from: https://pubmed.ncbi.nlm.nih.gov/3651732/ Jacob S, Byrne M, Keenan K. Neonatal Physiological Regulation is Associated With Perinatal Factors: A Study of Neonates Born to Healthy African American Women Living In Poverty. Infant Ment Health J [Internet]. 2009 [cited 2024 Dec 10];30:82–94. Available from: https://pubmed.ncbi.nlm.nih.gov/20046545/ Schlatterer SD, du Plessis AJ. Exposures influencing the developing central autonomic nervous system. Birth Defects Res [Internet]. 2021 [cited 2025 Jan 8];113:845–63. Available from: https://pubmed.ncbi.nlm.nih.gov/33270364/ DiPietro JA, Hodgson DM, Costigan KA, Hilton SC, Johnson TRB. Fetal Neurobehavioral Development. Child Dev [Internet]. 1996 [cited 2025 Jan 8];67:2553–67. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-8624.1996.tb01874.x Dieter JNI, Emory EK, Johnson KC, Raynor BD. Maternal depression and anxiety effects on the human fetus: Preliminary findings and clinical implications. Infant Ment Health J [Internet]. 2008 [cited 2025 Jan 8];29:420–41. Available from: https://pubmed.ncbi.nlm.nih.gov/28636218/ Allister L, Lester BM, Carr S, Liu J. The effects of maternal depression on fetal heart rate response to vibroacoustic stimulation. Dev Neuropsychol [Internet]. 2001 [cited 2025 Jan 8];20:639–51. Available from: https://pubmed.ncbi.nlm.nih.gov/12002098/ Goldstein JM, Holsen L, Huang G, Hammond BD, James-Todd T, Cherkerzian S, et al. Prenatal stress-immune programming of sex differences in comorbidity of depression and obesity/metabolic syndrome. Dialogues Clin Neurosci [Internet]. 2016 [cited 2025 Jan 8];18:425–36. Available from: https://pubmed.ncbi.nlm.nih.gov/28179814/ Mulkey SB, Plessis A dú. The Critical Role of the Central Autonomic Nervous System in Fetal-Neonatal Transition. Semin Pediatr Neurol [Internet]. 2018 [cited 2023 May 22];28:29–37. Available from: https://pubmed.ncbi.nlm.nih.gov/30522725/ Reed S, Ohel G, David R, Porges S. A neural explanation of fetal heart rate patterns: a test of the Polyvagal Theory. Dev Psychobiol. 1999;108–18. Hambleton MT, Reynolds EW, Sithisarn T, Traxel SJ, Patwardhan AR, Crawford TN, et al. Autonomic nervous system function following prenatal opiate exposure. Front Pediatr [Internet]. 2013 [cited 2024 Dec 10];1. Available from: https://pubmed.ncbi.nlm.nih.gov/24400273/ Nino G, Govindan RB, Al-Shargabi T, Metzler M, Massaro AN, Perez GF, et al. Premature Infants Rehospitalized because of an Apparent Life-Threatening Event Had Distinctive Autonomic Developmental Trajectories. Am J Respir Crit Care Med [Internet]. 2016 [cited 2024 Dec 10];194:379–81. Available from: https://pubmed.ncbi.nlm.nih.gov/27479062/ Cainelli E, Vedovelli L, Bottigliengo D, Boschiero D, Suppiej A. Social skills and psychopathology are associated with autonomic function in children: a cross-sectional observational study. Neural Regen Res [Internet]. 2022 [cited 2021 Oct 11];17:920–8. Available from: https://pubmed.ncbi.nlm.nih.gov/34472494/ Mulkey SB, du Plessis AJ. Autonomic nervous system development and its impact on neuropsychiatric outcome. Pediatr Res [Internet]. 2019 [cited 2023 May 25];85:120–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30166644/ Faa G, Manchia M, Pintus R, Gerosa C, Marcialis MA, Fanos V. Fetal programming of neuropsychiatric disorders. Birth Defects Res C Embryo Today [Internet]. 2016 [cited 2019 Jul 12];108:207–23. Available from: http://doi.wiley.com/10.1002/bdrc.21139 Suppiej A, Vedovelli L, Boschiero D, Bolzon M, Cainelli E. Abnormal heart rate variability at school age in survivors of neonatal hypoxic-ischemic encephalopathy managed with therapeutic hypothermia. European Journal of Paediatric Neurology. 2020;29:66–70. Montagna A, Nosarti C. Socio-Emotional Development Following Very Preterm Birth: Pathways to Psychopathology. Front Psychol [Internet]. 2016 [cited 2022 Jul 12];7. Available from: https://pubmed.ncbi.nlm.nih.gov/26903895/ Thiriez G, Mougey C, Vermeylen D, Wermenbol V, Lanquart JP, Lin JS, et al. Altered autonomic control in preterm newborns with impaired neurological outcomes. Clin Auton Res [Internet]. 2015 [cited 2024 Dec 10];25:233–42. Available from: https://pubmed.ncbi.nlm.nih.gov/26253935/ Fox NA. Maturation of autonomic control in preterm infants. Dev Psychobiol. 1983;16:495–504. Pearson RM, Evans J, Kounali D, Lewis G, Heron J, Ramchandani PG, et al. Maternal Depression During Pregnancy and the Postnatal Period: Risks and Possible Mechanisms for Offspring Depression at Age 18 Years. JAMA Psychiatry [Internet]. 2013 [cited 2024 Dec 10];70:1312–9. Available from: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1748838 Stein A, Netsi E, Lawrence PJ, Granger C, Kempton C, Craske MG, et al. Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trial. Lancet Psychiatry. 2018;5:134–44. Yan Z, Zeng X, Su J, Zhang X. The dark side of empathy: Meta-analysis evidence of the relationship between empathy and depression. Psych J [Internet]. 2021 [cited 2024 Dec 27];10:794–804. Available from: https://pubmed.ncbi.nlm.nih.gov/34494388/ Bloom K. The development of attachment behaviors in pregnant adolescents. Nurs Res. 1995;44:289-289. Condon JT, Corkindale C. The correlates of antenatal attachment in pregnant women. Br J Med Psychol [Internet]. 1997 [cited 2024 Dec 10];70 ( Pt 4):359–72. Available from: https://pubmed.ncbi.nlm.nih.gov/9429755/ Hoekzema E, Tamnes CK, Berns P, Barba-Müller E, Pozzobon C, Picado M, et al. Becoming a mother entails anatomical changes in the ventral striatum of the human brain that facilitate its responsiveness to offspring cues. Psychoneuroendocrinology. 2020;112:104507. van ’t Hof SR, Straathof M, Spalek K, Hoekzema E. Theory of mind during pregnancy and postpartum: A systematic review. J Neuroendocrinol [Internet]. 2023 [cited 2025 Jan 8];35. Available from: https://pubmed.ncbi.nlm.nih.gov/37094082/ MacKinnon AL, Gold I, Feeley N, Hayton B, Carter CS, Zelkowitz P. The role of oxytocin in mothers’ theory of mind and interactive behavior during the perinatal period. Psychoneuroendocrinology [Internet]. 2014 [cited 2025 Jan 8];48:52–63. Available from: https://pubmed.ncbi.nlm.nih.gov/24995584/ Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 15 Jul, 2025 Read the published version in Italian Journal of Pediatrics → Version 1 posted Editorial decision: Major revision 29 May, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers invited by journal 30 Mar, 2025 Editor assigned by journal 26 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6302974","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435881020,"identity":"570ad946-d98f-45ae-8215-125078081428","order_by":0,"name":"Elisa Cainelli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYDACdsYGMM3GwMB44IGBDQMDMwODBIMBHi3MCC0MBxIM0mBa8OhhRmIfSGA4DGZIMOCxhp+ZufnDDwY7eT7p5gMHEgrOJ25n5z14g6HgD04tks2MbZI9DMmGbTLHEoAOu524s5kv2QKfwwwOM7Yx8DAcYGyTyDEAa9lwmMcMr1/sDzM2f/zDcMC+TSL/A1DLOcJaDIAhJg20JRFoCyjEDhDWIgF0mLSMQXJym0QayGHJxhsOA/2SYGCMUwt/e/vjj28q7Gznz0h++ODDHzvZDefPHrzx4Y8cTi1Q56HweBgYEghoQAc8JKofBaNgFIyC4Q4A26ZQKB5+mb8AAAAASUVORK5CYII=","orcid":"","institution":"Università degli Studi di Padova","correspondingAuthor":true,"prefix":"","firstName":"Elisa","middleName":"","lastName":"Cainelli","suffix":""},{"id":435881021,"identity":"95db53ef-995b-4ca0-948b-c26c70cba9ed","order_by":1,"name":"Barbara Carretti","email":"","orcid":"","institution":"University of Padova","correspondingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Carretti","suffix":""},{"id":435881022,"identity":"67c7ac7a-6a3b-4135-8434-d9bf905d9ad7","order_by":2,"name":"Sara Puddu","email":"","orcid":"","institution":"University of Padova: Universita degli Studi di Padova","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Puddu","suffix":""},{"id":435881023,"identity":"21c4b4e6-c1be-45c5-ae4a-67d9b9a596ef","order_by":3,"name":"Filippo Zemin","email":"","orcid":"","institution":"University of Padova: Universita degli Studi di Padova","correspondingAuthor":false,"prefix":"","firstName":"Filippo","middleName":"","lastName":"Zemin","suffix":""},{"id":435881024,"identity":"9ceec265-8b52-4679-958b-a50e9cfb48f3","order_by":4,"name":"Paola Veronese","email":"","orcid":"","institution":"University of Padova: Universita degli Studi di Padova","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"","lastName":"Veronese","suffix":""},{"id":435881025,"identity":"31dbb2c9-2c33-4f51-ace8-97378b16c4a6","order_by":5,"name":"Damiano Menin","email":"","orcid":"","institution":"University of Ferrara","correspondingAuthor":false,"prefix":"","firstName":"Damiano","middleName":"","lastName":"Menin","suffix":""},{"id":435881026,"identity":"87df1552-c014-4451-8cfb-2d4d3899430e","order_by":6,"name":"Marco Dondi","email":"","orcid":"","institution":"University of Ferrara","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Dondi","suffix":""},{"id":435881027,"identity":"d3a051d3-5d95-48b7-80cf-75d3282224a5","order_by":7,"name":"Agnese Suppiej","email":"","orcid":"","institution":"University of Ferrara: Universita degli Studi di Ferrara","correspondingAuthor":false,"prefix":"","firstName":"Agnese","middleName":"","lastName":"Suppiej","suffix":""}],"badges":[],"createdAt":"2025-03-25 10:51:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6302974/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6302974/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13052-025-02063-y","type":"published","date":"2025-07-15T16:05:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81022883,"identity":"5744a69e-99a2-4ebe-b7c5-07b5e9344d04","added_by":"auto","created_at":"2025-04-21 10:05:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38225,"visible":true,"origin":"","legend":"\u003cp\u003ePearson r heatmap represents the associations between postpartum depression, perinatal attachment, empathy, and HF component of the child’s HRV.\u003c/p\u003e\n\u003cp\u003eLegend: HF: high frequency\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6302974/v1/7c62bfaf61677bc01aba7691.jpg"},{"id":87220512,"identity":"5d753f89-beb6-4535-871e-906916dcc4b3","added_by":"auto","created_at":"2025-07-21 16:12:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":641146,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6302974/v1/4990e9a0-e414-41bf-b03f-8efab169bd47.pdf"},{"id":81022885,"identity":"93e2bc0e-dde0-47fb-b9c2-ab978530f110","added_by":"auto","created_at":"2025-04-21 10:05:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":306233,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6302974/v1/e4e91729370e13ae0448da2d.docx"}],"financialInterests":"","formattedTitle":"Postpartum Depression and the Moderating Role of Empathy on Child Physiological Reactivity","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMaternal perinatal depression has detrimental effects on child development. In particular, it has been associated with increased risk for wide-ranging adverse consequences, such as cognitive, social, and emotional disturbances, depression and anxiety, behavioral problems, and attachment insecurity [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMechanisms underlying the associations between maternal depression and adverse infant and child developmental outcomes have been the object of research for years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and attention has been paid to the interference of depression with the creation of the bond between mother and child [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It has been documented that mothers with depression engage in less intense relationships with their children, experience more stress, and perceive their children in a more negative way [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This pattern of mother-child interplay has also been reported among children of mothers who have subclinical levels of depressive symptoms [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs a consequence of maternal depression, newborns show more dysregulated behavior, such as disturbed/disorganized sleep and difficult temperament [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which can reciprocally further increase negative symptoms in the mother, thus determining a vicious, self-feeding cycle [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, some maternal characteristics have a role in mediating/moderating the mother-child relationship. For example, women with a disorganized attachment style seem to be particularly at risk [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In contrast, maternal sensitivity, the ability to perceive and interpret accurately infant's signals and communications and then respond contingently and appropriately, favors an appropriate mother-child interplay[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and helps regulate the infant's stress responsiveness and emotion regulation favoring long-lasting wellbeing[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn response to poor maternal interaction, infants may alter their behavior and exhibit poor emotional and behavioral state regulation, fewer positive and more negative facial expressions, avoidance, and greater fussiness [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. An alteration in newborn behavioral regulation can be detected by recording the newborn's heart rate variability (HRV). HRV is a reliable estimate of the autonomic nervous system (ANS) functioning, and particularly of its vagal branch, and therefore, a good index of regulation capabilities and adaptation to the environment [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The parasympathetic (vagal) branch, reflected by the high frequencies component (HF) of the HRV, in particular, is a candidate marker of physiological stress regulation of autonomic response through top-down cognitive control across the lifespan [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. As a confirmation, previous studies reported that HRV in the prenatal and neonatal period is predictive of various aspects of development, such as language skills and psychological development in early childhood [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Furthermore, a previous study exploring maternal HRV and child brain development showed an influence of maternal mental health on infant neurophysiology via alterations in autonomic stress regulation and dyadic physiological co-regulation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, however, no studies investigated the effects of depressive symptoms in the postpartum on the HRV. We were specifically interested in the postnatal period, a period of great psychological vulnerability for the mother due to neurocognitive and neuroendocrine changes. These changes are supported by transitory high brain plasticity[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] that sustains behavior focused on the child, guaranteeing their centrality in neuroplastic changes[\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The brain changes facilitate the mother to adapt to the child\u0026rsquo;s needs and development but also render her vulnerable to psychopathology[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Therefore, the first postpartum months are crucial because the same neurobiological modifications that enable the mother to care for her child and establish an appropriate mother-child relationship also make her vulnerable to psychopathology [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the previous literature, the first aim of the study is to examine the relation between maternal postpartum depression and the regulatory abilities of their child (HF component of the HRV). The second aim is to evaluate the role of some protective factors, namely empathy and perinatal attachment, in moderating this relation. Considering the extant literature, we hypothesize that in the presence of maternal postpartum depressive symptoms, an alteration of the developing child's psychophysiology underlying its stress response and regulatory abilities could be detectable (Aim 1). Regarding the second aim of the study (Aim 2), we hypothesized that some maternal characteristics, such as empathy and perinatal attachment, could be associated with the development of postpartum depressive symptoms and that, thus, could moderate/mitigate the association between post-partum depression and offspring HRV.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe study involved 24 mother-child dyads recruited during pregnancy in the period from March 2022 to February 2023 at the Gynecology and Obstetrics Unit of the Department of Women\u0026rsquo;s and Children\u0026rsquo;s Health, University Hospital of Padova. The inclusion criteria were as follows: a gestational period between 24 and 28 gestational weeks, actual absence of illnesses complicating pregnancy, delivery, perinatal period, and normal fetal medical records; at term birth; no use of corticosteroid medication with comprehensive and continuous tracking throughout the pregnancy; complete medical records as well as demographic, psychological, and lifestyle questionnaires for each expectant mother, and informed consent.\u003c/p\u003e \u003cp\u003eThe women recruited had a median age of 32 years (31; 36.7), and they were evaluated in the prenatal period at a median gestational age of 28 weeks (25.25; 29). None of the mothers assumed alcohol or smoked during pregnancy, and none had a psychiatric or neurological diagnosis; the socioeconomic status was medium for 20/24 women, low for 3/24, and high for 1/24 according to [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Complete data on demographic and clinical characteristics of the women are shown in the Supplementary Material.\u003c/p\u003e \u003cp\u003eChildren were born at a median gestational age of 38.5 weeks (38; 41), median birth weight of 2996 grams (2670; 3697); 14/24 were male. None of the children had perinatal complications or needed resuscitation. As for mothers, complete data on children's demographic and clinical characteristics are shown in the Supplementary Material.\u003c/p\u003e \u003cp\u003e The study received approval from the Institutional Review Board (Prot.n 24139, 02.2022 Comitato Etico per la Sperimentazione Clinica dell\u0026rsquo;Azienda Ospedaliera di Padova, and 193-c, 01.2024 Comitato Etico della Ricerca Psicologica Area 17). It was conducted in accordance with ethical guidelines.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMaterial\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePsychological measures in the mother\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEmpathy Quotient (EQ)\u003c/span\u003e [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]The EQ is a self-report questionnaire that measures empathy's cognitive and affective aspects. The Italian version is a 60-item questionnaire with 40 questions regarding empathy and 20 filler items. The final score ranges between 0 and 80, with higher scores implying higher empathy.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe Parental Attachment Inventory (PAI)\u003c/span\u003e [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] is a questionnaire that measures prenatal attachment in five dimensions: fantasy, affection, interaction, sensitivity, and differentiation of self from the fetus. It is composed of 21 Likert-type items, and the total score is the sum of the items and ranges from 21 to 84, with higher scores indicating higher levels of prenatal attachment.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEdinburgh Postnatal Depression Scale (EPDS)\u003c/span\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The EPDS is a 10-item self-report scale to screen for Postnatal Depression. Each item has four answer choices indicating different levels of severity (0\u0026ndash;3 points). Each item scores between 0 to 3, totaling 0 to 30 points overall. Higher scores denote more significant symptoms of postnatal depression.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAutonomic measures – HRV in the child\u003c/h3\u003e\n\u003cp\u003eAutonomic functioning has been estimated by extracting HRV from an electrocardiogram (ECG). Ag/AgCl surface electrodes were positioned on the chest in a modified lead II configuration. The raw ECG signal was recorded with a LiveAmp system (Brain Products, Gilching, Germany) and amplified with a gain of 150, bandpass filtered (0.3\u0026ndash;100 Hz), and digitized at 500 Hz (16 bit A/D converter, resolution 0.559 \u0026micro;V/LSB). The raw ECG signal was then exported to Kubios HRV Analysis Software 2.2 (The Biomedical Signal Analysis Group, Department of Applied Physics, University of Kuopio, Finland) to estimate the occurrence of each heartbeat and derive the series of inter-beat intervals (IBIs), calculated as the difference in milliseconds (ms) between two consecutive R-waves. Fast Fourier spectral analysis was conducted on the IBI series to compute frequency domain indexes and obtain the HF power (0.15\u0026ndash;0.40 Hz) component. HF Frequency-domain index was logarithmically transformed to normalize its distribution.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eAfter the recruitment, at 24th -28th gestational weeks, the pregnant women underwent a structured interview about clinical and demographic information (complete data obtained are shown in the Supplementary Material) and filled out the Empathy Quotient (EQ) questionnaire and the Perinatal Attachment Inventory (PAI). The mothers were asked to return to our department with their sons once the baby was born between the third and fourth weeks of life. All appointments took place at our Department between 9\u0026ndash;10 a.m. As the dyads came, children were prepared for the HRV recording by placing him/her on a crib and being undressed just enough to place the two electrodes. After the procedure, if the child became nervous, he/she was calmed down by the mother until the child reached a drowsy state and the recording could begin. The electrocardiogram recordings have been recorded for sufficient time to obtain at least five minutes artifact-free. After the recordings, the mothers filled out additional questionnaires about the possible presence of postnatal depression, the Edinburgh Postnatal Depression Scale (EPDS). A structured interview has also collected information about delivery and the perinatal period. Questionnaires were administered using a computer interface and secure REDCap link (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.projectredcap.org\u003c/span\u003e\u003cspan address=\"https://www.projectredcap.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAt first, correlations between prenatal attachment (PAI), empathy (EQ), postpartum depression (EPDS) scores, and HF component of the child\u0026rsquo;s HRV were run using Pearson r. False discovery rate correction for multiple comparisons has been made. Independent linear regressions were conducted to evaluate the predictive power of postpartum depression on the HF component of the child's HRV. Subsequently, the moderator effects of perinatal attachment and empathy were evaluated by adding them to the regressions and evaluating the interactions between perinatal attachment and postpartum depression in one model, empathy and postpartum depression in the other, on the HF. Cronbach\u0026rsquo;s alpha measure of reliability has been performed to evaluate consistency between items.\u003c/p\u003e \u003cp\u003eStatistics were determined using JASP (The JASP team 2018, version 0.19.2).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eAt the reliability analysis of questionnaires, Cronbach\u0026rsquo;s alpha for EQ was 0.86, for PAI 0.88, and for EPDQ 0.89. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e reports the scores obtained by the women in the questionnaires.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedian, 25- 75th percentiles, and number of clinical scores (where applicable) obtained by the mothers at questionnaires in the postpartum (EPDS) and in the prenatal period (EQ, PAI).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePRENATAL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePOSTPARTUM\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEmpathy (EQ)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePerinatal Attachment\u003c/p\u003e \u003cp\u003e(PAI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepression (EPDS)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25th percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75th percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN clinical scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9/24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLegend: EPDS: Edinburgh Postnatal Depression Scale; EQ: Empathy Quotient; PAI: Perinatal Attachment Inventory.\u003c/p\u003e \u003cp\u003eThe median HF percentage values in children were 8.200 Hz (3.425; 10.275), while the days of life at the recordings were 25 (20; 30 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations\u003c/h2\u003e \u003cp\u003eCorrelations between the measures of interest were run (see Fig.\u0026nbsp;1). The HF scores of the child\u0026rsquo;s HRV were significantly correlated only with the postpartum depression score obtained in the Edinburgh Postnatal Depression Scale (r\u0026thinsp;=\u0026thinsp;.539, p\u0026thinsp;=\u0026thinsp;.007, Fisher\u0026rsquo;s ES\u0026thinsp;=\u0026thinsp;.603). Postpartum depression was inversely correlated both with the Empathy Quotient (r=-.570, p\u0026thinsp;=\u0026thinsp;.004, Fisher\u0026rsquo;s ES=-.648) and Perinatal Attachment Inventory (r=-.463, p\u0026thinsp;=\u0026thinsp;.023, Fisher\u0026rsquo;s ES=-.501). The correlations remained significant after correction for the false discovery rate.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[INSERT FIGURE 1 HERE]\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of neonate\u0026rsquo;s HF component\u003c/h2\u003e \u003cp\u003eAt first, a linear regression was run to examine the contribution of postpartum depressive symptoms to the neonate's HF component. Postpartum depressive symptoms significantly predicted the neonate's HF component (b\u0026thinsp;=\u0026thinsp;.13, p\u0026thinsp;=\u0026thinsp;.045).\u003c/p\u003e \u003cp\u003eBy adding in the regressions EQ and PAI, a moderation effect emerges between the Empathy Quotient and Postpartum Depression (b\u0026thinsp;=\u0026thinsp;0.13, p\u0026thinsp;=\u0026thinsp;.03), while the principal effect of Postpartum Depression alone is no longer significant: higher levels of empathy predict lower symptoms of postpartum depression and stress, which in turn are associated with lower HF values (Fig.\u0026nbsp;2), suggesting that the association between variables is more complex than a simple principal effect. Therefore, empathy is shown to moderate the effect of depression and stress on the child's HRV by reducing them. We did not find moderation effects for Perinatal Attachment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe first aim of our study was to investigate the effects of postpartum depressive symptoms on the offspring\u0026rsquo;s HF component (parasympathetic) of HRV, which, being a measure of stress responsiveness and regulation ability, possibly represents a key mechanism in the establishment of psychological vulnerability (Aim 1). We also wanted to explore the association of maternal empathy and perinatal attachment to the fetus whose mothers had postpartum depressive symptoms and their possible moderating effects on HRV (Aim2).\u003c/p\u003e \u003cp\u003eRegarding the first aim (Aim 1), we found that the development of depressive symptoms in postpartum is highly associated with an increase in the offspring\u0026rsquo;s HF component. The association between depressive symptoms and HRV suggests that the psychological state of the mother, probably acting on the interaction with the child, in some ways influences the early regulatory abilities of the baby, as reflected by the HF component of HRV, a well-known estimate of the parasympathetic branch of the ANS. By considering the effects on the offspring\u0026rsquo;s HRV of depression associated with pregnancy, we found a similar study in the literature, but evaluating the effect of prenatal depression on child\u0026rsquo;s autonomic measures [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In this research, the authors found that total HRV was significantly lower in children born by mothers reporting past major depressive disorder and life stressors. The effect of other maternal psychopathological symptoms during the prenatal period has also been investigated [\u003cspan additionalcitationids=\"CR48 CR49\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], mostly to explore the so-called \u0026ldquo;prenatal stress-immune programming\u0026rdquo; [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The women in our study have no previous diagnosis of depression or other psychopathology; therefore, to our knowledge, the present study is the first to evaluate the effect of postpartum depression on shaping the early regulatory ability of the child as reflected by the HRV.\u003c/p\u003e \u003cp\u003eInterestingly, the presence of maternal postnatal depressive symptoms in the present study is associated with higher HF power. Under conditions of fetal stress, a reduction of the parasympathetic (HF measure) branch of ANS is the most common result; however, increases have also been found. For example, perinatal asphyxia could determine bradycardia and consequent parasympathetic increase [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Similar effects have been reported in infants exposed to prenatal opiates and premature infants that developed apparent life-threatening events after discharge from the neonatal intensive care unit [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. This confirms previous observations that the ANS reacts in different and complex ways depending on the maturation level and the stressor typology [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. ANS is intricately connected to higher brain systems involved in emotion and cognition [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], and, at birth, it is still developing, particularly the parasympathetic branch (indexed by the HF component of HRV)[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. This renders it vulnerable to being shaped by perinatal factors [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], and early adversities could significantly limit the ANS's capacity to respond to challenges and external needs [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], with consequences on neurodevelopment [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, not all children exposed to maternal depression will be negatively affected [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], thus the association between maternal depression, maternal behavior, and child outcomes is probably complex and moderated by various factors [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Depression and its characteristics (e.g., severity, persistence) can be associated with personality traits and personal characteristics, such as empathy [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Therefore, we were interested in exploring if some maternal characteristics could moderate the development of psychopathological symptomatology and moderate the effects of depression on the child's HRV (Aim 2). We found that prenatal attachment, a construct that summarizes the crucial dimensions of maternal sensitivity, fantasy, interaction, affection, and differentiation of self from the fetus, negatively correlates with post-partum depressive symptoms, suggesting that the effects of a good prenatal attachment persist throughout the postnatal period. Previous works indicated prenatal maternal attachment as a key factor in promoting the development of maternal-child attachment [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], contributing to better mother-child bonding and supporting a more satisfactory interaction and self-efficacy in the mother, thus reducing the likelihood of developing depressive symptoms.\u003c/p\u003e \u003cp\u003eHowever, the perinatal attachment was not associated with the child's HRV, and it has no moderator effects on the association between depressive symptoms and HRV. On the contrary, empathy was not only associated negatively with depressive and stress symptoms, but it also moderates the effects of depression and stress on HRV, which means that the effect of depressive symptoms on HRV was different for different levels of empathy. In particular, women experiencing higher empathy have lower depressive symptoms and, consequently, children with lower HF power.\u003c/p\u003e \u003cp\u003eAs sensitive parenting requires an accurate and empathic response to signals from the child, empathy could be a crucial mechanism allowing sensitivity in the mother. It allows us to hypothesize that imagining and empathizing with the incoming child allows them to regulate emotions better. From a neurobiological perspective, we know that cerebral plasticity mechanisms occurring in the woman\u0026rsquo;s brain are circuits associated with empathic mechanisms [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. As confirmation, previous works found a correlation between empathy, depressive and remote maternal behavior in early postpartum women and that higher scores on an empathy test in the early postpartum period were associated with less remote and less depressive behavior [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis aspect opens important scenarios for the prevention of postnatal depressive symptoms, with cascading effects on the relationship with the child first and on the child's neurodevelopment later. If further research confirms the role of empathy in the development of depressive symptoms and in establishing the mother-child relationship, intervention programs enhancing empathy in the pregnant woman would perhaps make her better prepared to handle the intense demands of the early postpartum months.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the numerosity is low and does not allow for generalization of results. It also does not highlight possible subthreshold effects, as in the case of the role of perinatal attachment. In addition, it would be important to have long-term follow-up data to better understand the clinical value of the differences in HRV found. Finally, our women did not have a clinical diagnosis of postpartum depression but variable symptomatology that only allowed for correlational measures and not case-control group comparisons.\u003c/p\u003e \u003cp\u003eIn conclusion, we found that postnatal depression can influence the autonomic functioning of the offspring, suggesting that maternal psychopathology may interfere with the child's early regulatory mechanisms, with possible knock-on effects on the responses to stress, mother-child bond, and emotional regulation later in development. However, some maternal personal characteristics, such as perinatal attachment and empathy, can influence the development of depressive symptoms, suggesting the presence of moderators/modulating factors in the association of maternal depression and child autonomic changes. A better understanding of how maternal characteristics may affect the development of psychopathology in the child may open up interesting possibilities for early intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANS: autonomous nervous system\u003c/p\u003e\n\u003cp\u003eEPDS: Edinburgh Postnatal Depression Scale\u003c/p\u003e\n\u003cp\u003eEQ: empathy quotient\u003c/p\u003e\n\u003cp\u003eHF: high frequency\u003c/p\u003e\n\u003cp\u003eHRV: heart rate variability\u003c/p\u003e\n\u003cp\u003ePAI: Parental Attachment Inventory\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e. This study was performed in line with the principles of the Declaration of Helsinki. The Ethical Commitee of the Hospital (Comitato Etico per la Sperimentazione Clinica della Provincia di Padova, Prot.n 24139, February 2022) and of our Department (Comitato Etico della Ricerca Psicologica dell\u0026rsquo;Universit\u0026agrave; di Padova, Prot.n 193-c, January 2024) approved the study. Informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u003c/strong\u003e Data will be available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e This work is funded by the European Union \u0026ndash; NextGenerationEU and by the University of Padua under the 2021 STARS Grants@Unipd program (UTOPICO - In Utero and Postnatal Influences on Cerebral Organization - Exploring neurobiological mechanisms for advancing strategies fostering life-long wellbeing).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e. EC conceived the research, coordinated the data collection, and wrote the first draft of the paper; BC supervised the data collection, interpreted the results, and critically reviewed the work; SP collected, analyzed, and interpreted the data and critically reviewed the work; FZ and PV collected and interpreted the data, and critically reviewed the work; DM and MD collaborated in analyzing the data and critically reviewed the work; AS interpreted the data, and critically reviewed the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eConroy S, Pariante CM, Marks MN, Davies HA, Farrelly S, Schacht R, et al. Maternal Psychopathology and Infant Development at 18 Months: The Impact of Maternal Personality Disorder and Depression. J Am Acad Child Adolesc Psychiatry. 2012;51:51\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eField T. Prenatal depression effects on early development: A review. 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Available from: https://pubmed.ncbi.nlm.nih.gov/24995584/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"prenatal, postnatal, depression, empathy, heart rate variability, attachment, mother-child bond","lastPublishedDoi":"10.21203/rs.3.rs-6302974/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6302974/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003ePerinatal maternal depression is a risk factor for the development of psychopathology in the offspring, probably by impacting its early physiological reactivity to stress and emotion regulation. The objective of this study is to evaluate the influence of postpartum depressive symptoms on the offspring\u0026rsquo;s physiological reactivity (heart rate variability -HRV) and the possible moderating effects of empathy and perinatal attachment.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e \u003cp\u003eWe recruited 24 mother-child dyads. The psychopathological profile and personal characteristics of pregnant women at 24\u0026ndash;28 gestational weeks were evaluated by administrating the Perinatal Attachment Inventory (PAI) and the Empathy Quotient (EQ) questionnaire. Three weeks after childbirth, women completed the Edinburgh Postnatal Depression Scale (EPDS), and the offspring underwent an HRV recording.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003ePostpartum depression was a good predictor of the offspring\u0026rsquo;s HRV activity (b\u0026thinsp;=\u0026thinsp;1.49, p\u0026thinsp;=\u0026thinsp;.045). Both perinatal attachment (r=-.463, p\u0026thinsp;=\u0026thinsp;.023, Fisher\u0026rsquo;s ES=-.501) and empathy (r=-.570, p\u0026thinsp;=\u0026thinsp;.004, Fisher\u0026rsquo;s ES=-.648) were negatively associated with postpartum depression. Finally, empathy showed a moderator effect on the association between postpartum depression and child\u0026rsquo;s HRV (b\u0026thinsp;=\u0026thinsp;0.13, p\u0026thinsp;=\u0026thinsp;.03). We found no moderator effects for Perinatal Attachment.\u003c/p\u003e\u003ch2\u003eConclusion.\u003c/h2\u003e \u003cp\u003eDespite the preliminary nature of our data, maternal depression showed predictive power on offspring's early regulatory mechanisms, with possible knock-on effects on emotional regulation and mother-child bond establishment. Interestingly, some maternal personality characteristics, such as empathy, can influence the development of depression symptoms, suggesting the presence of moderator factors modulating the association between maternal psychological status and child physiological reactivity.\u003c/p\u003e","manuscriptTitle":"Postpartum Depression and the Moderating Role of Empathy on Child Physiological Reactivity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 10:05:34","doi":"10.21203/rs.3.rs-6302974/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2025-05-29T17:43:54+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-04-08T09:42:25+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-30T09:24:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T04:31:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2025-03-25T06:50:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c6821b9-1fad-4b76-b483-f578d25f9511","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-21T16:11:05+00:00","versionOfRecord":{"articleIdentity":"rs-6302974","link":"https://doi.org/10.1186/s13052-025-02063-y","journal":{"identity":"italian-journal-of-pediatrics","isVorOnly":false,"title":"Italian Journal of Pediatrics"},"publishedOn":"2025-07-15 16:05:42","publishedOnDateReadable":"July 15th, 2025"},"versionCreatedAt":"2025-04-21 10:05:34","video":"","vorDoi":"10.1186/s13052-025-02063-y","vorDoiUrl":"https://doi.org/10.1186/s13052-025-02063-y","workflowStages":[]},"version":"v1","identity":"rs-6302974","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6302974","identity":"rs-6302974","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}