Rumination Disorder

Rumination disorder is a condition characterized by unintentionally spitting up or regurgitating undigested or partially digested food from the stomach. It is believed to occur due to a habit or reflex that develops through a conditioned response to stimuli.

What Is Rumination Disorder ?

Rumination disorder, also known as rumination syndrome, is a rare and chronic condition that involves a person unintentionally regurgitating undigested food. Regurgitation occurs when ingested food rises to the oesophagus, throat, and mouth but is not involuntarily forced out of the mouth as it is when vomiting occurs. Rumination, also known as regurgitation in animals with compartmentalised stomachs such as cows and sheep, is a digestive function. However, it is thought to be a rare condition in humans.

Mind Help defines the condition as “a chronic psychological disorder characterized by unintentional and repeated regurgitation of partially digested or undigested food following consumption, then rechewing it. The process is then followed by either re-swallowing the food or spitting it out.” As it usually occurs within a period of 30 minutes after a meal, the food reportedly doesn’t taste as acidic as vomit.

Also known as merycism, it can often be confused with vomiting or digestive issues, but it doesn’t have any abdominal pain, heartburn, odor, nausea or retching. According to a 2019 study [mfn] Murray, H. B., Juarascio, A. S., Di Lorenzo, C., Drossman, D. A., & Thomas, J. J. (2019). Diagnosis and Treatment of Rumination Syndrome: A Critical Review. The American journal of gastroenterology, 114(4), 562–578. https://doi.org/10.14309/ajg.0000000000000060 [/mfn] , the disorder involves “repeated, effortless food regurgitation during or soon after eating, followed by rechewing, reswallowing or spitting out of the regurgitant.” This condition is a reflex response and not a conscious decision. Rumination syndrome is labelled as a “functional gastroduodenal disorder” as well as a “feeding and eating disorder.”

The exact prevalence and incidence of this condition are unknown. Due to lack of data, this condition is considered a rare occurrence. Studies [mfn] Rajindrajith, S., Devanarayana, N. M., & Crispus Perera, B. J. (2012). Rumination syndrome in children and adolescents: a school survey assessing prevalence and symptomatology. BMC gastroenterology, 12, 163. https://doi.org/10.1186/1471-230X-12-163 [/mfn] have found the prevalence rate was 5.1 percent in males and 5 percent in females. Surveys also showed a prevalence rate among infants to be 6 to 10 percent of the population.

Understanding Rumination Disorder

The syndrome may begin in childhood or adulthood. Rumination was reported [mfn] Bonifacci, P., Tobia, V., Marra, V., Desideri, L., Baiocco, R., & Ottaviani, C. (2020). Rumination and Emotional Profile in Children with Specific Learning Disorders and Their Parents. International journal of environmental research and public health, 17(2), 389. https://doi.org/10.3390/ijerph17020389 [/mfn] mainly in children with disabilities, especially mental retardation. But this condition has been largely unrecognized in adults, until recently, when physicians began to take a closer look at family history and other associated factors. However, it is a misconception that rumination only occurs in children with disabilities and cows.

Children with rumination disorder tend to rechew the regurgitated food and swallow it. Adults, on the other hand, spit it out. Individuals may begin to regurgitate within a minute of ingesting food. This condition is often found to adversely affect the normal functioning and social lives of individuals.

The Genetic and Rare Diseases Information Center (GARD [mfn] Rumination disorder. (2015). Genetic and Rare Diseases Information Center (GARD) – an NCATS Program | Providing information about rare or genetic diseases. https://rarediseases.info.nih.gov/diseases/7594/rumination-disorder [/mfn] defined this disorder as “the backward flow of recently eaten food from the stomach to the mouth.The food is then re-chewed before being swallowed or spat out.” Research [mfn] Chial, H. J., Camilleri, M., Williams, D. E., Litzinger, K., & Perrault, J. (2003). Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Pediatrics, 111(1), 158–162. https://doi.org/10.1542/peds.111.1.158 [/mfn] shows that this syndrome can cause significant impairment to a person’s life that includes medical complications and psychosocial disturbances.

For some people, regurgitation is minor and occurs over a long period of time after ingestion. After that, it is rechewed and swallowed. According to the American Academy of Pediatrics, symptoms can begin at any point in the ingestion of the meal to 120 minutes after consumption. However, it can range between 30 seconds to an hour after the completion of a meal. The regurgitated food does not taste bitter or sour because it did not have the time to mix with stomach acid and be digested. The primary cause of this condition is usually due to habitual abdominal wall contraction that makes the individual regurgitate after ingestion of food.

Sometimes this condition can cause nutrition deficiencies. Studies have also found a direct link with depression. Since this condition is behavioral in origin, it is possible to unlearn it. This is the most effective method for managing the symptoms. The diagnosis of this condition can be a difficult and lengthy process. Once a diagnosis has been made, the doctor can help the patient with behavioral therapy to ease the symptoms of this condition. The treatment methods are quite effective in almost all cases.

Rumination Vs Reflux

The symptoms of rumination syndrome are different from acid reflux and gastroesophageal reflux disease or GERD [mfn] Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri medicine, 115(3), 214–218. [/mfn]. Here are some common differences:

In acid reflux, stomach acids are used to break down the food consumed. This acid food rises to the esophagus that causes a burning sensation in the chest and a sour taste in the mouth. This doesn’t happen in the case of rumination and regurgitated food rises to the esophagus in a painless manner.
In acid reflux, the food tastes sour or bitter, which isn’t the case for rumination.
Acid reflux occurs at night, particularly in adults. This happens because lying down makes it easier for the consumed food in the stomach to rise to the esophagus. Rumination occurs every time food is ingested.
The medications used to treat acid reflux and GERD doesn’t respond to the symptoms of rumination disorder.

Symptoms Of Rumination Disorder

A 2011 study [mfn] Talley N. J. (2011). Rumination syndrome. Gastroenterology & hepatology, 7(2), 117–118. [/mfn] defined rumination syndrome as “the regurgitation of undigested food from the stomach back up into the mouth.” The primary symptom of this disorder is the repeated and unintentional regurgitation of undigested food. It typically occurs between half an hour or two hours after eating. People suffering from this condition regurgitate almost every day and after every meal. Other symptoms associated with this condition are:

Bad breath or halitosis
Constipation
Nausea
Diarrhea
Bloating
Tooth decay
Weight loss
Stomach aches or indigestion
Dry mouth or lips

The symptoms of this disorder are the same in the case of an adult as well as children. However, adults are more likely to spit out undigested food. Children often tend to rechew and swallow it.

Causes Of Rumination Disorder

The exact cause of this condition is still unknown. However, some people may develop this syndrome due to emotional issues or undergoing any stressful events. It is believed to be an unconsciously learned disorder involving voluntary relaxation of the diaphragm. For instance, someone with this condition may unknowingly never have learned to relax their abdominal muscles.

Contracting the diaphragm muscles can cause regurgitation. One 2011 study explains “Rumination is commonly believed to be an unconscious learned disorder (ie, a behavioral issue) involving voluntary relaxation of the diaphragm.” Some probable causes for the development of this disorder may include the following:

1. Physical cause

It can be explained that when the food expands the stomach, it is followed by an increase in abdominal pressure and a relaxation of the lower esophageal sphincter. The following digestive sequence of events allows the stomach contents to be regurgitated.

2. Adverse Psychosocial Environment

The commonly notable environmental factor is the abnormal mother-infant relationship, where the infant seeks internal gratification in such cases or as a means to escape in an overprotective environment. Negligence of or an abnormal relationship between the mother and child that can cause the child to rely on self-comfort. In some children, the act of chewing is comforting.

Boredom, a lack of occupation, familial disharmony, and maternal psychopathology have all been linked to the onset of rumination.

3. Other probable causes

Apart from the ones mentioned above, some additional causes may include:

Physical illness
Severe stress
Trying to get attention from parents or caregivers
Sign of mental illness, such as depression or anxiety
Dilation of the lower end of the esophagus or the stomach
Overaction of the sphincter muscles in the upper portion of the alimentary canal
Cardiospasm
Pylorospasm
Gastric hyperacidity
Achlorhydria
Movements of the tongue
Insufficient mastication
Pathologic conditioned reflex
Aerophagia or air swallowing
Finger or hand sucking

Read More About Stress Here

Risk Factors Associated With Rumination Disorder

Rumination syndrome can occur in anyone, but it is most common in infants and children with intellectual disabilities. There are certain risk factors associated with this condition that include:

Suffering from an acute illness
Having a mental illness
Experiencing a psychiatric disturbance
Electrolyte imbalance
Dehydration
Choking
Pneumonia
Aspiration (when food gets in the airway)
Death
Undergoing a major surgery
Having a stressful experience

Diagnosis Of Rumination Disorder

The doctor will conduct a physical examination and evaluate the child’s symptoms and medical history. There is no test to detect this condition. The diagnosis is based on the signs and symptoms that are experienced by the patient. People with this condition also experience vomiting or acid sensation/taste in their mouths.

There are tests that may be used to rule out other underlying medical conditions. This may include blood tests and imaging studies that may help to rule out gastrointestinal disorders. The doctor may also look for other symptoms, such as dehydration or nutritional deficiencies. Other tests may include:

Gastric Emptying Test: This test measures the amount of time the patient takes for the food to move from the stomach to the small intestine.
Upper endoscopy: This test involves the doctor to examine the esophagus and stomach through an endoscope inserted down the throat.
X-rays: This helps the doctor with images of the inside of the esophagus and stomach.

This disorder has been often linked to other eating disorders, particularly bulimia nervosa. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM 5) laid down the diagnostic criteria [mfn] Murray, H. B., Juarascio, A. S., Di Lorenzo, C., Drossman, D. A., & Thomas, J. J. (2019). Diagnosis and Treatment of Rumination Syndrome: A Critical Review. The American journal of gastroenterology, 114(4), 562–578. https://doi.org/10.14309/ajg.0000000000000060 [/mfn] for rumination disorder:

Repeated regurgitation of food at least once a month. Regurgitated food may be rechewed, spit out, or swallowed.
Regurgitation isn’t caused by a medical condition such as gastrointestinal disorder.
Regurgitation is not always associated with another eating disorder, such as anorexia nervosa, binge eating disorder, or bulimia nervosa.
When it occurs along with other intellectual or developmental disorders, symptoms are severe enough to require medical assistance.

Read More About Eating Disorders Here

The doctor may also ask several questions that can include:

When did the symptoms first begin?
Do the symptoms occur with every meal?
How severe are the symptoms of this condition?
Is there anything that makes your child’s symptoms better?
Is there anything that seems to worsen the symptoms?

Treatment For Rumination Disorder

The treatment process for this condition is primarily focused on changing the child’s behavior. Some of the adopted techniques include:

Doing breathing exercises after eating
Changing the child’s posture during and right after eating
Encouraging more interaction between the child and the mother during feeding; giving your child more attention
Removing distractions during feeding
Creating a more relaxing and pleasurable feeding experience
Distracting the child when rumination begins
Aversive conditioning that involves something sour or bad tasting on the child’s tongue when they begin vomiting

Here some other treatment options available for this syndrome:

1. Behavior Therapy

People with rumination syndrome who do not have developmental disabilities are treated with habit reversal behaviour therapy (HRT). According to a recent 2020 study [mfn] Heinicke, M. R., Stiede, J. T., Miltenberger, R. G., & Woods, D. W. (2020). Reducing risky behavior with habit reversal: A review of behavioral strategies to reduce habitual hand-to-head behavior. Journal of applied behavior analysis, 53(3), 1225–1236. https://doi.org/10.1002/jaba.745 [/mfn] , “HRT has been effective in treating a host of repetitive behavior problems.” Research [mfn] Dutta, N., & Cavanna, A. E. (2013). The effectiveness of habit reversal therapy in the treatment of Tourette syndrome and other chronic tic disorders: a systematic review. Functional neurology, 28(1), 7–12. [/mfn] indicates that habit reversal therapy includes several aspects, such as “awareness training with self-monitoring, relaxation training and competing response training,” that can greatly help the patient overcome the symptoms.

In this therapy, the patient is taught to recognize when rumination occurs, to breathe in and breathe out using abdominal muscles (diaphragmatic breathing). Diaphragmatic breathing helps to prevent abdominal contractions and regurgitation. Studies [mfn] Becker, P. J. (2011). Rumination syndrome. ICAN: Infant, Child, & Adolescent Nutrition, 4(1), 38-43. https://doi.org/10.1177/1941406411431277 [/mfn] suggest that practicing this breathing technique is required to increase its effectiveness.

In order to perform diaphragmatic breathing you have to:

Lie on your back on a flat surface with your knees bent and a surface that’s supporting your head. You can use a pillow under your knees in order to support your legs. Place one hand on your upper chest and the other below the rib cage. It will allow you to feel your diaphragm as it moves when you breathe.
Next, breathe in slowly through your nose so your stomach moves out against your hand. Continue to keep your hands on your chest.
Tighten the stomach muscles, allowing them to fall inward as you exhale through your mouths.

Treatment for infants typically focuses on collaborating with parents or caregivers to change the infant’s environment and behavior.

2. Medications

In case frequent rumination is damaging the esophagus, proton pump inhibitors such as esomeprazole (Nexium) or omeprazole (Prilosec) may be prescribed by the doctor. These medications help to protect the lining of the esophagus until the frequency and severity of regurgitation with behavior therapy. Some people may benefit from treatment with medication that helps to relax the stomach after eating.

Prevention For Rumination Disorder

There’s no preventive measure for this disorder in babies and children. It is important to pay attention to your child’s eating habits. This may prove helpful in detecting the disorder early when the symptoms first start to appear.

Recovery From Rumination Disorder

Babies and children mostly recover from the condition with age and outgrow the symptoms and return to eating normally. This disorder can continue for months with children who are older. With treatment, it is possible to recover from this condition and live a healthy life.