Rumination

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.[1]

Diagnostic criteria (DSM-5)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies rumination as a feeding and eating disorder.[2]

DSM-5 criteria for rumination are as follows:

• Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed or spit out.

• The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).

• The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder.

• If the behavior occurs within the context of another mental disorder (i.e., generalized anxiety disorder) or neurodevelopmental disorder (i.e., intellectual disability), it must be sufficiently severe to warrant independent clinical attention.

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:

• Halitosis

• Malnutrition

• Weight loss

• Growth failure

• Electrolyte imbalance

• Dehydration

• Gastric disorders

• Upper respiratory tract distress

• Dental problems, particularly dental caries[3]

• Aspiration

• Choking

• Pneumonia

• Death

Frequency

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 intellectual disability, 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 intellectual disability than in those with mild or moderate intellectual disability. Prevalence rates of 6%-10% have been reported among the institutionalized population of individuals with intellectual disability.

Demographics

Although rumination is rare in both males and females, it is reportedly more common among females.[4]

Rumination onset in otherwise normally developing infants typically occurs during the first year of life; onset usually manifests at age 3–6 months.[5] Rumination often remits spontaneously.

• In individuals with severe and profound intellectual disability, 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.

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.

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.

Infants with rumination display a characteristic position of straining and arching the back with the head held back, making sucking movements with their tongue. They may also exhibit irritability and hunger, as well as weight loss and failure to make expected weight gains. Malnutrition may occur.[2]

Physical findings in patients with rumination may include the following:

• Regurgitation

• Vomiting not visible to others

• Unexplained weight loss, growth failure

• Symptoms of malnutrition

• Antecedent behaviors including postural changes, putting hands into mouth, and gentle gagging motion of the neck region

• The patient 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

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

Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting. Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely. Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up.[6]

Perform hematology and chemistry tests to exclude anemia secondary to bleeding caused by esophageal or gastric ulceration and electrolyte imbalances due to the rumination and loss of essential electrolytes.

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

Other lab tests that may be useful include the following:

• Esophagogastroduodenoscopy, including cultures for Helicobacter pylori

• Scintigraphic studies of gastric emptying

• Radiological studies

Extensive and invasive GI testing rarely is indicated but may include the following:

• GI manometry[7]

• 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

Perform 24-hour esophageal pH monitoring to exclude GER.

Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome.[6]

See the list below:

• 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.

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.

Behavioral

Conduct a functional assessment to determine if rumination serves as self-stimulation or is socially motivated. Functional analysis can be used to compare the efficacy of various treatment strategies.[8] 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[9, 1]

• 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. One study recommends baclofen, at a dose of 10 mg 3 times daily, as a reasonable next step in refractory patients.[6]

Complications of rumination may include some or all of the following:

• 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

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.