Rumination

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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.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies rumination as a feeding and eating disorder. [1]

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 [2]

Aspiration

Choking

Pneumonia

Death

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 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.

International

Rumination has been reported and researched in countries outside the United States (eg, Italy, Netherlands); however, the frequency in other countries is unclear.

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.

Although rumination is rare in both males and females, it is reportedly more common among females. [3]

Rumination onset in otherwise normally developing infants typically occurs during the first year of life; onset usually manifests at age 3-6 months. [4] 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.

American Psychiatric Association. Rumination. Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). 2013. 332-333.

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. 2008 Jul. 14(5):435-9. [Medline].

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

Green AD, Alioto A, Mousa H, Di Lorenzo C. Severe pediatric rumination syndrome: successful interdisciplinary inpatient management. J Pediatr Gastroenterol Nutr. 2011 Apr. 52(4):414-8. [Medline].

Kessing BF, Govaert F, Masclee AA, Conchillo JM. Impedance measurements and high-resolution manometry help to better define rumination episodes. Scand J Gastroenterol. 2011 Nov. 46(11):1310-5. [Medline].

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. 2007 Winter. 40(4):743-7. [Medline].

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

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

Chial HJ, Camilleri M, Williams DE, et al. Rumination syndrome in children and adolescents: diagnosis, treatment, andprognosis. Pediatrics. 2003 Jan. 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, Williams WL. Overview of the treatment of rumination disorder for adults in a residential setting. J Behav Ther Exp Psychiatry. 1998 Mar. 29(1):31-40. [Medline].

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

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

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. 1998 Nov. 27(5):596-8. [Medline].

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.

Connie J Schnoes, MA, PhD Director, National Behavioral Health Dissemination, Supervising Practitioner, Boys Town Center for Behavioral Health, Father Flanagan’s Boys’ Home, Boys Town

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen 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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Angelo P Giardino, MD, MPH, PhD Professor and Section Head, Academic General Pediatrics, Baylor College of Medicine; Senior Vice President and Chief Quality Officer, Texas Children’s Hospital

Angelo P Giardino, MD, MPH, 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, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Nothing to disclose.

Rumination

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