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Pediatrics: Developmental and Behavioral > MEDICAL TOPICS
Eating Disorder: Rumination
Article Last Updated: Mar 28, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Cynthia R Ellis, MD, Director of Developmental Medicine, Associate Professor, Department of Pediatrics and Psychiatry, Munroe Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center
Cynthia R Ellis is a member of the following medical societies: Nebraska Medical Association
Coauthor(s):
Connie Jo Schnoes, PhD, Assistant Research Professor, Department of Special Education & Communication Disorders, University of Nebraska-Lincoln
Editors: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
eating disorder, rumination, ruminare, rechewing, regurgitation
Background
The word rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination is the voluntary or involuntary regurgitation and rechewing of partially digested food that is either reswallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.
In rumination, the regurgitant does not taste sour or bitter. The behavior must exist for at least 1 month, with evidence of normal functioning prior to onset. Rumination occurs within a few minutes postprandial and may last 1-2 hours. Though frequency may vary, rumination typically occurs daily and may persist for many months or years.
Pathophysiology
While the pathophysiology of rumination remains unclear, a proposed mechanism suggests that gastric distention with food is followed by abdominal compression and relaxation of the lower esophageal sphincter; these actions allow stomach contents to be regurgitated and rechewed and then swallowed or expelled.
Several mechanisms for the relaxation of the lower esophageal sphincter have been offered, including (1) learned voluntary relaxation, (2) simultaneous relaxation with increased intra-abdominal pressure, and (3) an adaptation of the belch reflex (eg, swallowing air produces gastric distention that activates a vagal reflex to relax the lower esophageal sphincter transiently during belching). Rumination may cause the following:
- Halitosis
- Malnutrition
- Weight loss
- Growth failure
- Electrolyte imbalance
- Dehydration
- Gastric disorders
- Upper respiratory distress
- Dental problems
- Aspiration
- Choking
- Pneumonia
- Death
Frequency
United States
No systematic studies have reported the prevalence of rumination; most of the information about this disorder is derived from small case series or single case reports. Rumination disorder has been reported in children and adults with mental retardation as well as in infants, children, and adults of normal intelligence. Among those with otherwise normal intelligence and development, rumination is most common in infants. The prevalence in adults of normal intellectual functioning is unknown because of the secretive nature of the condition and because physicians lack awareness of rumination among this population.
Rumination is more common in individuals with severe and profound mental retardation than in those with mild or moderate mental retardation. Prevalence rates of 6-10% have been reported among the institutionalized population of individuals with mental retardation.
International
Rumination has been reported and researched in other countries (eg, Italy, Netherlands); however, frequency of occurrences in other countries is unclear.
Mortality/Morbidity
Rumination is estimated to be the primary cause of death in 5-10% of individuals who ruminate. Mortality rates of 12-50% have been reported for institutionalized infants and older individuals.
Sex
Rumination occurs in both males and females. A male predominance has been reported by 1 case series, although this finding may not be definitive.
Age
Rumination onset in otherwise normally developing infants typically occurs during the first year of life; onset usually manifests at age 3-6 months. Rumination often remits spontaneously.
- For individuals with severe and profound mental retardation, onset of rumination may occur at any age; average age of onset is age 6 years.
- Rumination among adolescents and adults of normal intelligence is gaining increased recognition.
History
- Symptoms may include the following:
- Weight loss
- Halitosis
- Indigestion
- Chronically raw and chapped lips
- Vomitus may be noted on the individual's chin, neck, and upper garments.
- Regurgitation typically begins within minutes of a meal and may last for several hours. Regurgitation occurs almost every day following most meals.
- Regurgitation generally is described as effortless and rarely is associated with forceful abdominal contractions or retching.
Physical
- Regurgitation
- Vomiting not visible to others
- Unexplained weight loss, growth failure
- Symptoms of malnutrition
- Antecedent behaviors
- Postural changes
- Putting hands into mouth
- Gentle gagging motion of the neck region
- May appear to derive satisfaction and sensory pleasure from mouthing the vomit rather than considering vomitus in the mouth disgusting
- Tooth decay and erosion
- Aspiration that may cause recurrent bronchitis or pneumonia, reflex laryngospasm, bronchospasm, and/or asthma
- Premalignant changes of the esophageal epithelium (ie, Barrett epithelium) that may occur with chronic rumination
Causes
Although the etiology of rumination is unknown, multiple theories have been advanced to explain the disorder. These theories range from psychosocial factors to organic origins. Cultural, socioeconomic, organic, and psychodynamic factors have been implicated. The following causes have been postulated over the years:
- Adverse psychosocial environment
- The most commonly cited environmental factor is an abnormal mother-infant relationship in which the infant seeks internal gratification in an understimulating environment or as a means to escape an overstimulating environment.
- Onset and maintenance of rumination also has been associated with boredom, lack of occupation, chronic familial disharmony, and maternal psychopathology.
- Learning-based theories
- Learning-based theories propose that rumination behaviors increase following positive reinforcement, such as pleasurable sensations produced by the rumination (eg, self-stimulation) or increased attention from others after rumination.
- Rumination also may be maintained by negative reinforcement when an undesirable event (eg, anxiety) is removed.
- Organic factors: The role of medical/physical factors in rumination is unclear. Although an association between gastroesophageal reflux (GER) and the onset of rumination may exist, some researchers have proposed that various esophageal or gastric disorders may cause rumination.
- Psychiatric disorders: Rumination in adults of average intelligence has been associated with psychiatric disorders (eg, depression, anxiety).
- Heredity: Although occurrences in families have been reported, no genetic association has been established.
- Other proposed physical causes include the following:
- Dilatation of the lower end of the esophagus or of the stomach
- Overaction of the sphincter muscles in the upper portions of the alimentary canal
- Cardiospasm
- Pylorospasm
- Gastric hyperacidity
- Achlorhydria
- Movements of the tongue
- Insufficient mastication
- Pathologic conditioned reflex
- Aerophagy (ie, air swallowing)
- Finger or hand sucking
Adrenal Insufficiency
Diabetes Mellitus, Type 1
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Esophagitis
Gastroesophageal Reflux
Hypercalcemia
Peptic Ulcer Disease
Pyloric Stenosis, Hypertrophic
Sandifer Syndrome
Small-Bowel Obstruction
Other Problems to be Considered
Esophageal disorders (eg, esophageal stricture, achalasia, hiatal hernia)
Gastric disorders (eg, gastroparesis, gastric carcinoma, peptic ulcer disease)
Small bowel disorders (eg, pseudo-obstruction)
Metabolic or endocrine disorders (eg, Addison disease, adrenal insufficiency)
Pregnancy
CNS diseases (eg, tumors, organic lesions, infections such as basal meningitis)
Drugs that effect swallowing and esophageal functioning (eg, digitalis, some chemotherapeutic agents, benzodiazepines, neuroleptics)
Functional disorders (eg, functional dyspepsia, psychogenic vomiting, oral-motor dysfunction, anatomic defects, H-type tracheoesophageal fistula)
Food allergies
Lab Studies
- Hematology and chemistry tests to exclude anemia secondary to bleeding from esophageal or gastric ulceration and electrolyte imbalances secondary to the rumination and loss of essential electrolytes
Imaging Studies
- Barium swallow to demonstrate any of the following:
- Hiatal hernia
- Esophageal atresia or other malformations
- Stricture
- Achalasia
- Chalasia
- Upper GI series and small bowel follow-through examination to diagnose the following:
- Duodenal ulcer
- Other intestinal lesions
- Esophagogastroduodenoscopy, including cultures for Helicobacter pylori
- Scintigraphic studies of gastric emptying
- Radiological studies
Other Tests
- Extensive and invasive GI testing rarely is indicated but may include the following:
- GI manometry
- Upper GI motility
- Gastric emptying
- Lower esophageal sphincter pressure
- Trial of histamine 2 (H2) blockers, metoclopramide, or antacids to rule out underlying causes of rumination when more invasive medical investigation is not possible
Procedures
- Perform 24-hour esophageal pH monitoring to exclude GER.
Medical Care
- Correct caloric insufficiency/deprivation.
- Provide appropriate medical treatment for recurrent bronchitis or pneumonia.
- Reflex laryngospasm, bronchospasm, and asthma (associated with repeated pulmonary aspiration of gastric fluid) may require appropriate medical treatment.
Surgical Care
Gastroesophageal fundoplication has been used as an antireflux surgical intervention in cases with a clear physiological etiology and when the rumination has not responded to less invasive interventions.
Consultations
- Behavioral: Conduct a functional analysis to determine if rumination serves as self-stimulation or is socially motivated. Self-stimulation is often associated with reconsumption of ruminate; however, little or no reconsumption of ruminate is associated with socially motivated rumination. Rumination may begin as self-stimulation but becomes reinforced because of the attention it attracts.
- Nonaversive behavioral strategies include the following:
- Food satiation (eg, unlimited quantities of thick food)
- Small bites of normal amounts of food over an extended eating time, if self-stimulation is identified
- Reinforcement of incompatible behaviors
- Reinforcement of other behaviors
- Special feeding techniques
- Contingent exercise (eg, defined physical activity required upon ruminating)
- Habit reversal with relaxation
- Diaphragmatic breathing
- Self-hypnosis with relaxation
- Guided imagery
- Biofeedback with abdominal relaxation
- Complete chewing
- Relaxation while eating
- Weight reduction
- Stress management
- Throat clearing
- Sipping water between bites
- Decreasing caffeine and alcohol consumption
- Aversive behavioral strategies are recommended if the individual's health is jeopardized or if the individual's health status has had a rapid and dramatic change. Aversive strategies include the following:
- Electroshock therapy
- Overcorrection
- Withdrawal of positive reinforcement (ie, extinction)
- Contingent pinching (ie, individual is pinched upon ruminating)
- Noxious tastes
- Psychodynamic
- Provide noncontingent holding for individuals who are young and institutionalized.
- Address psychological distress, depression, and anxiety.
Very limited psychopharmacological research has been performed, and it consists primarily of uncontrolled case reports. Caution is recommended when considering use of medications to treat rumination.
Complications
- Malnutrition
- Weight loss
- Gastric disorders
- Upper respiratory distress
- Dental problems
- Aspiration
- Choking
- Pneumonia
- Social isolation and/or compromise at attempts at community integration because peers and caregivers find interaction with these individuals unpleasant
- Halitosis
- Death
Prognosis
- Little is known about the natural history and long-term outcome of individuals with rumination syndrome. The disorder remits spontaneously in infants more often than in older individuals. Rumination may persist for months to years.
Medical/Legal Pitfalls
- Failure to diagnose rumination
- Failure to identify physiological cause
Special Concerns
- Secretive behavior among individuals with rumination interferes with disclosure.
- Physicians lack awareness of prevalence of rumination among individuals of normal intelligence.
- American Psychiatric Association. Rumination. Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). 1994;96-8.
- Chial HJ, Camilleri M, Williams DE, et al. Rumination syndrome in children and adolescents: diagnosis, treatment, andprognosis. Pediatrics. Jan 2003;111(1):158-62. [Medline].
- Ellis CR, Parr TS, Singh NN. Rumination Prevention and Treatment of Severe Behavior Problems: Models and Methods. Dev. 1997;237-52.
- Fredericks DW, Carr JE, William WL. Overview of the Treatment of Rumination Disorder for Adults in a Residential Setting. Journal of Behavior Therapy and Experimental Psychiatry. 1998;29:31-40.
- Kuhn DE, Matson JL. Assessment of feeding and mealtime behavior problems in persons with mental retardation. Behavior Modification. 2004;28:638-48.
- Malcolm MB, Thumshirn MB, Camilleri M. Rumination Syndrome. Mayo Clinic Procedures. 1997;72:646-52.
- Singh NN. Rumination. International Review of Research in Mental Retardation. 1981;10:139-82.
- Wagaman JR, Williams DE, Camilleri M. Behavioral intervention for the treatment of rumination. J Pediatr Gastroenterol Nutr. Nov 1998;27(5):596-8. [Medline].
Eating Disorder: Rumination excerpt Article Last Updated: Mar 28, 2006
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