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Rumination disorder is a gastointestinal condition that causes effortless regurgitation of partially digested food after eating a meal. Sometimes the food is rechewed. Sometimes it is spat out.

Rumination disorder, also known as rumination syndrome or simply as rumination, is a condition named after the Latin word ruminare, meaning chewing the cud. Cows re-chew partially digested grasses that come back up from their four stomachs. People don't ever have four stomachs, but some people can "chew the cud" voluntarily or involuntarily after eating, usually without any effort, nausea, or retching, and without the sensation of bitter or sour taste in the food that comes back up.

What happens in rumination disorder?

Rumination can occur as part of the disease process in anorexia or bulimia, but the activity is not necessarily always intended to reduce weight gain or to avoid calories. People who ruminate learn how to relax the esophagus at the same time they put pressure on the core muscles of their abdomen. It's a kind of controlled belching that brings up food, not just air. 

What kinds of complications can result from rumination disorder?

  • One of the common complications of rumination is halitosis, really bad breath.
  • Repeated contact with stomach acid can erode the enamel of the teeth and cause cavities.
  • Long-term loss of digested nutrients can interfere with normal growth and development, leaving teenagers permanently stunted.
  • There may also be malnutrition.
  • When digested food is aspirated into the lungs, pneumonia may result.
  • And in extreme cases, rumination can result in death. From 12 to 50 percent of people in long-term nursing care who ruminate die from the complications of the condition.

Who develops rumination disorder?

Rumination sometimes occurs in babies who are otherwise healthy. It typically starts at the age of three to six months and resolves itself without medical intervention by the infant's first birthday. About six to 10 percent of people whose intellectual disabilities are so severe they have to be institutionalized develop rumination disorder. And rumination is being more and more frequently observed in teenagers and young adults of normal intelligence.

There are reports that about 0.7 to 0.8 of the population as a whole will develop rumination disorder at some point in life. This percentage jumps to seven to eight percent in people who have fibromyalgia. Rumination disorder also occurs in people diagnosed with adjustment disorder, attention deficit hyperactivity disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or constipation from a rectal evacuation disorder.

What are the symptoms of rumination disorder?

Nearly everyone who has rumination disorder has chapped lips. They have a recent history of losing weight, or, in the case of children, not gaining weight as expected. There may be vomit on the chin, around the mouth, and on the shirt or blouse. People who have rumination disorder regurgitate food from almost every meal almost every day.

The doctor has to rule out other conditions that have similar symptoms to make a diagnosis of rumination disorder. Some possibilities for differential diagnosis include achalasia, the inability to push food down through the esophagus to the stomach, bowel obstruction, adrenal insufficiency, brain tumors, food allergies, adverse reactions to the heart drug digitalis (Lanoxin), and pregnancy.

How is rumination disorder treated?

The doctor's first concern in treating rumination disorder is making sure air passages stay open. The doctor may prescribe a medication for reflex spasms of the larynx and bronchial passages. There may be treatment for asthma or pneumonia caused by food's "going down the wrong pipe." Then the doctor will make sure enough food is staying down to provide adequate calories and nutrients. In few cases, the problem can be corrected by a kind of surgery called gastroesophageal fundoplication, but this procedure is primarily for cases that are caused by problems with the anatomy of the digestive tract rather than behavioral issues.

What can families and friends do to help someone who has rumination disorder?

Most people who have rumination disorder have other life issues due to dementia or developmental delay. They often are already in full-time nursing care. Family and friends can help by doing things that keep anxiety levels low, since anxiety usually makes the condition worse.

Also helpful may be:

  • Providing large servings of tasty, thick food. Thick food is harder to regurgitate with the belching maneuver performed in rumination.
  • Small servings of other foods served over a long time, if it is obvious that rumination is intentional. (Don't do this at the same meal you serve thick foods.) Give the person living with rumination disorder less food than it necessary to be able to belch it up.
  • Encourage the person who has the rumination disorder to sip water between bites.
  • Avoid serving caffeine or alcohol.
  • Encourage thorough chewing. Depending on the intellectual level of the person you are helping, you might sing a song after each bite. For instance, "Chew, chew, chew, for it's the thing to do. Chew each bite. You know that's right. Chew, chew, chew." If there is one chew with each word, the food will be sufficiently macerated that it will be more difficult to regurgitate.
  • Try an extinction strategy. Don't give any special attention after an incident of rumination. Do not offer to replace favorite foods that have been regurgitated. Avoid any positive reinforcement of rumination.

  • Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol. 2006 Nov. 101(11):2449-52.
  • 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.
  • 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.
  • Photo courtesy of SteadyHealth

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