eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder, Rumination

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
Coauthor(s): Connie J Schnoes, MA, PhD, Psychologist, Director of Training, Supervising Practitioner, Father Flanagan's Boys' Home, Boys Town
Contributor Information and Disclosures

Updated: Jun 4, 2009

Introduction

Background

The term rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination is characterized by 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. A diagnosis of rumination requires that the behavior must persist for at least 1 month, with evidence of normal functioning prior to onset.1 Rumination occurs within a few minutes postprandial and may last 1-2 hours. Although the frequency of rumination may vary, it 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 proposed, 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:

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 of rumination 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 countries outside the United States (eg, Italy, Netherlands); however, the frequency 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 in institutionalized infants and older individuals.

Sex

Although rumination is rare in both males and females, it is reportedly more common among females.11

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.

  • In individuals with severe and profound mental retardation, onset of rumination may occur at any age; the average age of onset is 6 years.
  • Rumination among adolescents and adults of normal intelligence is gaining increased recognition.

Clinical

History

  • Symptoms of rumination 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 is generally described as effortless and is rarely 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 has also 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 may also 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 of rumination 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

More on Eating Disorder, Rumination

Overview: Eating Disorder, Rumination
Differential Diagnoses & Workup: Eating Disorder, Rumination
Treatment & Medication: Eating Disorder, Rumination
Follow-up: Eating Disorder, Rumination
References
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References

  1. American Psychiatric Association. Rumination. Diagnostic and Statistical Manual of Mental Disorders (4th Ed.-TR). 2000;105-106.

  2. 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].

  3. Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol. Nov 2006;101(11):2449-52. [Medline].

  4. Ellis CR, Parr TS, Singh NN. Rumination Prevention and Treatment of Severe Behavior Problems: Models and Methods. Dev. 1997;237-52.

  5. Fredericks DW, Carr JE, Williams WL. Overview of the treatment of rumination disorder for adults in a residential setting. J Behav Ther Exp Psychiatry. Mar 1998;29(1):31-40. [Medline].

  6. Idaira Y, Nomura Y, Tamaki Y, Katsumura S, Kodama S, Kurata K, et al. Factors affecting the oral condition of patients with severe motor and intellectual disabilities. Oral Dis. Jul 2008;14(5):435-9. [Medline].

  7. Kuhn DE, Matson JL. Assessment of feeding and mealtime behavior problems in persons with mental retardation. Behav Modif. Sep 2004;28(5):638-48. [Medline].

  8. Lyons EA, Rue HC, Luiselli JK, DiGennaro FD. Brief functional analysis and supplemental feeding for postmeal rumination in children with developmental disabilities. J Appl Behav Anal. Winter 2007;40(4):743-7. [Medline].

  9. Malcolm A, Thumshirn MB, Camilleri M, Williams DE. Rumination syndrome. Mayo Clin Proc. Jul 1997;72(7):646-52. [Medline].

  10. Singh NN. Rumination. International Review of Research in Mental Retardation. 1981;10:139-82.

  11. Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, et al. Functional gastroduodenal disorders. Gastroenterology. Apr 2006;130(5):1466-79. [Medline].

  12. Wagaman JR, Williams DE, Camilleri M. Behavioral intervention for the treatment of rumination. J Pediatr Gastroenterol Nutr. Nov 1998;27(5):596-8. [Medline].

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Further Reading

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Keywords

eating disorder, rumination, rumination disorder, ruminare, rechewing, regurgitation

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Contributor Information and Disclosures

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, MD is a member of the following medical societies: Nebraska Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Connie J Schnoes, MA, PhD, Psychologist, Director of Training, Supervising Practitioner, Father Flanagan's Boys' Home, Boys Town
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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