Rumination Disorder

Definition and Characteristic Features

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Rumination Disorder (also called Rumination Syndrome) is the DSM diagnostic term used in the case of a feeding disorder characterized by the repeated regurgitation or bringing back up of swallowed or partially digested food. Such food is then rechewed before being swallowed again, or in some cases spat out. The syndrome is most commonly seen in infants and the developmentally disabled. However, it does occur in children, adolescents, and adults with normal intelligence.

The term rumination is derived from the Latin word ruminare, meaning “to chew the cud.” The Greek equivalent is merycism, the act of regurgitating food from the stomach into the mouth, rechewing the food, and reswallowing it.

Rumination has been recognized for hundreds of years. It can be observed in developmentally normal infants who put their thumb or hand in the mouth, suck their tongue rhythmically, and arch their back to initiate regurgitation.

This behavior pattern is frequently observed in infants who receive inadequate emotional interaction and have learned to soothe and stimulate themselves through rumination. The onset of the syndrome generally occurs after 3 months of age; once the regurgitation occurs, the food may be swallowed or spit out.

Infants who ruminate are observed to strain to bring the food back into their mouths and appear to find the experience pleasurable. Infants who are experienced ruminators are able to bring up the food through tongue movements and may not spit out the food at all, but hold it in their mouths and reswallow it.

The disorder varies in severity and is sometimes associated with medical conditions, such as hiatal hernia, that result in esophageal reflux. In its most severe form, the disorder can be fatal. An awareness of the disorder is important, so that it is correctly diagnosed and that unnecessary surgical procedures and inappropriate treatment are avoided.

Epidemiology

Rumination is a rare disorder and not fully understood. It is believed to be due to coexistence of functional and psychiatric abnormalities. Recently it has been suggested that rumination syndrome is characterized by higher gastric sensitivity and decreased threshold for lower esophageal sphincter relaxation during gastric distension.

The syndrome seems to be more common among male infants, and emerges between 3 months and 1 year of age. It persists more frequently among children and adults who are mentally retarded. Adults with rumination usually maintain a normal weight. No reliable figures on predisposing factors or familial patterns are available.

Etiology

Rumination and gastroesophageal reflux Opens in new window often coexist, leading to a spectrum of variable contributions from organic and psychological factors for the emergence of the disorder.

In some cases, vomiting secondary to gastroesophageal reflux or an acute illness precedes a pattern of rumination that lasts for several months. It appears, for some infants, that the rumination behavior is self-soothing or produces a sense of relief, leading to a continuation of behaviors to bring it about. In those who are mentally retarded, the disorder may be attributed to self-stimulatory behavior.

Psychodynamic theories hypothesize various disturbances in the mother-child relationship as a contributing factor in the development of rumination disorder. The mothers of infants with the disorder have been characterized as immature, exposing the infant to increased levels of marital conflict, leading to understimulation and inadequate emotional attention to the baby.

These factors are hypothesized to result in insufficient emotional gratification and stimulation for the infant who seeks to self-stimulate. The rumination is interpreted as the infant’s attempt to recreate the feeding process and to provide gratification that the mother does not.

Overstimulation and tension have also been suggested as causes of rumination. A dysfunctional autonomic nervous system may be implicated. As sophisticated and accurate investigative techniques are refined, a substantial number of children classified as ruminators are shown to have gastroesophageal reflux or hiatal hernia.

Behaviorists attribute rumination to the positive reinforcement of pleasurable self-stimulation and to the attention the baby receives from others as a consequence of the disorder.

Diagnosis and Clinical Features

The diagnosis of rumination disorder is made mostly by observation, which may be difficult because rumination may cease as soon as the patient becomes aware of the observer.

Characteristic features are the onset immediately after or even during feeding and the absence of esophagitis. Partially digested food is brought up into the mouth without nausea, retching, disgust, or associated gastrointestinal disorder. This activity can be distinguished from vomiting by the clear, purposeful movements the infant makes to induce it. The food is then ejected from the mouth or reswallowed.

A characteristic position of straining and arching of the back, with the head held back, is observed. The infant makes sucking movements with the tongue and gives the impression of gaining considerable satisfaction from the activity. Usually, the infant is irritable and hungry between episodes of rumination.

Diagnosis can be based on the following Rome II (‘symptoms-based”) criteria which include:

Criteria for Infants

For infants at least 3 months of repetitive behavior, with contractions of the abdominal muscles, diaphragm, and tongue culminating into regurgitation of gastric contents into the mouth that are expectorated or rechewed and reswallowed in addition to three or more of the following:

Onset between 3–8 months
No response to management of GERD, anticholinergic drugs, formula changes, or gavage or gastrostomy feeding

Unaccompanied by signs of nausea or distress
No incidence during sleep or when the infant is interacting with individuals in the environment

Initially, rumination may be difficult to distinguish from the regurgitation that frequently occurs in normal infants. In fully developed cases, however, the diagnosis is obvious. Food or milk is regurgitated without nausea, retching, or disgust and is subjected to what appears to be innumerable pleasurable sucking and chewing movements.

Criteria for Children and Adolescents

For children and adolescents, the following are the proposed criteria for diagnosis: at least 6 weeks of recurrent regurgitation of recently ingested food, in the preceding 12 months, which may not need to be consecutive, and:

Begins within 30 min of meal ingestion
Is associated with either reswallowing or expulsion of food
Stops within 90 min of onset or when regurgitant becomes acidic
Is not associated with mechanical obstruction
Does not respond to standard treatment for GER
Is not associated with nocturnal symptoms.

Pathology and Laboratory Examination

No specific laboratory examination is pathognomonic of rumination disorder. Clinicians must rule out physical causes of vomiting, such as pyloric stenosis and hiatal hernia, before making the diagnosis of rumination disorder.

Rumination disorder can be associated with failure to thrive and varying degrees of starvation. Thus, laboratory measures of endocrinological function (thyroid function tests, dexamethasone-suppression test), serum electrolytes, and a hematological workup help determine the severity of the effects of rumination disorder.

Differential Diagnosis

To make the diagnosis of rumination disorder, clinicians must rule out gastrointestinal congenital anomalies, infections, and other medical illnesses. Pyloric stenosis is usually associated with projectile vomiting and is generally evident before 3 months of age, when rumination has its onset.

Ruminaton has been associated with various mental retardation syndromes in which other stereotypic behaviors and eating disturbances, such as pica, are present. Rumination disorder can occur in patients with other eating disorders, such as bulima nervosa.

Course and Prognosis

Rumination disorder is believed to have a high rate of spontaneous remission. Indeed, many cases of rumination disorder may develop and remit without ever being diagnosed. Only limited data are available about the prognosis of rumination disorder in adults.

Treatment

The treatment of rumination disorder is often a combination of education and behavioral techniques. Sometimes, an evaluation of the mother-child relationship reveals deficits that can be influenced by offering guidance to the mother.

Behavioral interventions, such as squirting lemon juice into the infant’s mouth whenever rumination occurs, can be effective in diminishing the behavior. This practice appears to be the most rapidly effective treatment, with rumination reportedly eliminated in 3 to 5 days.

In the aversive-conditioning reports on rumination disorder, infants were doing well at 9- or 12-month follow-up, with no recurrence of the rumination and with weight gains, increased activity levels, and increased responsiveness to persons.

Rumination may be decreased by the technique of withdrawing attention from the child whenever this behavior occurs. The effectiveness of treatments is difficult to evaluate. Most reported are single-case studies; patients are not randomly assigned to controlled studies.

Treatments include improvement of the child’s psychological environment, increased tender loving care from the mother or caretakers, and psychotherapy for the mother or both parents. This is crucial to improve the bonding between the mother and the infant and also create a nurturing environment to the infant.

When anatomical abnormalities, such as hiatal hernia, are present, surgical repair may be necessary. If an infant is malnourished and continues to lose most nutrition through rumination, a jejuna tube may need to be inserted before other treatments can be utilized.

Medications are not a standard part of the treatment of rumination. Case reports, however, cite a variety of medications that have been tried, including metoclopramide (Reglan), cimetidine (Tagamet), and antipsychotics such as haloperidol (Haldol) and thioridazine (Mellaril) have been cited to be helpful according to anecdotal reports. One study showed that when infants were allowed to eat as much as they wanted, the rate of rumination decreased.

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