Rumination Disorder

Rumination disorder (or rumination syndrome) is a type of DSM-5 feeding disorder that is characterised by recurrent postprandial, effortless regurgitation. 

In this disorder, recently ingested food returns from the stomach to the oral cavity where it is re-chewed and then either spat out or re-swallowed. 

Because the food hasn’t yet been digested, sufferers report that it tastes normal and isn’t acidic like vomit. In addition to this, the rumination behaviour isn’t associated with a gag reflex or retching. 

Rumination typically happens during or after every meal, and people report that some foods (e.g., watery-based) are more easily dispelled than others. 

Symptoms of Rumination Disorder

There are numerous symptoms that are associated with rumination syndrome. Some of the more common symptoms include¹Halland, M., Pandolfino, J., & Barba, E. (2018). Diagnosis and treatment of rumination syndrome. Clinical Gastroenterology and Hepatology, 16(10), 1549-1555.

• Effortless regurgitation during or shortly after eating
• Abdominal pain or pressure relieved by regurgitation 
• Feeling of fullness 
• Bad breath
• Nausea
• Unintentional weight loss 
• Chest pain 

Causes of Rumination Syndrome

The cause of rumination syndrome is not entirely known.  

In infants, the disease has normally been attributed to over-stimulation and under-stimulation from parents and caregivers, causing the individual to seek self-gratification and self-stimulus due to the lack or abundance of external stimuli. 

The disorder has also commonly been attributed to a bout of illness, a period of stress in the individual’s recent past, and to changes in medication. 

In adults and adolescents, hypothesized causes generally fall into one of either category: habit-induced, and trauma-induced. 

Habit-induced individuals generally have a history of bulimia nervosa or of intentional regurgitation, which though initially self-induced, forms a subconscious habit that can continue to manifest itself outside the control of the affected individual. 

Trauma-induced individuals describe an emotional or physical injury, which preceded the onset of rumination, often by several months²Halland, M. (2019). Rumination syndrome: when to suspect and how to treat. Current Opinion in Gastroenterology, 35(4), 387-393.

Key Statistics 

Rumination syndrome is one of the rarest feeing disorder, and because of this obtaining data on the epidemiology of rumination disorder is extremely difficult.

From existing research, here is what we do know about this condition:

• The syndrome is most common in children and in individuals with intellectual disabilities 
• In infants, rumination syndrome typically occurs within the first 3-12 months of age
• The typical age of adolescent onset is 13 years, with males affected earlier than females.
• 12% of children with rumination syndrome report significant functional impairment 
• 75% of people with rumination syndrome have dental erosion 

How is Rumination Treated?

Effective treatments for rumination syndrome are not well-understood.

This is in part due to how rare this condition is and how little we know about it and its mechanisms of action.

Preliminary research has shown that certain medical and behavioural treatments may be effective for preventing, addressing, or stopping the regurgitation behaviour that is characteristic of rumination syndrome.

Let’s dive into some of these treatment approaches that show promise. 

Diaphragmatic Breathing

Diaphragmatic breathing has the most support to date by reports and studies that clearly indicated decreases in regurgitations³Murray, 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.

Diaphragmatic breathing operates as a competing response to habitual abdominal wall contraction by relaxing the abdominal wall. 

In this way, it can prevent the person from regurgitating the food that was eaten. 

Behavioural Interventions 

There is some evidence showing that various other behavioural strategies may help people with rumination syndrome ⁴Tack J, Blondeau K, Boecxstaens V, et al. Review article: The pathophysiology, differential diagnosis and management of rumination syndrome. Aliment Pharmacol Ther 2011;33:782–8..

Some behavioural strategies shown to be effectivein case series studies include:

• Alternate self-soothing strategies
• Cognitive strategies to facilitate riding out premonitory urges, 
• Behavioural experiments to test fears (e.g., about using diaphragmatic breathing in public)
• Behavioral exposures (e.g., systematic exposure to stimuli associated with regurgitations)
• Gum chewing 
• Aversion training

Baclofen

Baclofen is an antispasmodic medication that has shown to be effective in one randomized controlled trial for rumination syndrome. 

In this study, people who took baclofen experienced greater subjective improvement in rumination symptoms than people who took a placebo ⁵Pauwels A, Broers C, Van Houtte B, et al. A randomized double-blind, placebo-controlled, crossover study using baclofen in the treatment of rumination syndrome. Am J Gastroenterol 2018;113:97–104.

However, this was a small study and larger studies are needed to confirm the efficacy of Baclofen. 

Surgery

Surgery may be a last resort to treating rumination. 

In particular, Nissen Fundoplication has been shown in one case series of 5 people to help resolve regurgitation episodes ⁶Oelschlager BK, Chan MM, Eubanks TR, et al. Effective treatment of ruminations with Nissen fundoplication. J Gastrointest Surg 2002;6: 638–44.

Surgery has not been recommended as a treatment for rumination, as other safer options seem to be available. 

As you’re probably aware, rumination syndrome has been very difficult to study in part because of how rare the condition is.

The consequence of this is that we know very little about the aetiology, prevalence, and treatment of rumination syndrome. 

We do know that episodes of rumination are profoundly impairing to the individual affected, so we much more work is needed to better help those in need.