Rumination Syndrome

What is rumination syndrome?

Rumination syndrome (also known as rumination disorder or merycism) is a feeding and eating disorder in which undigested food comes back up from a person’s stomach into his or her mouth (regurgitation). Once the food is back in the mouth, the person may chew it and swallow it again, or spit it out. This behavior usually occurs after every meal, and may appear effortless. Rumination may follow a sensation of burping/belching and typically does not involve nausea or retching. In rumination, the regurgitated food does not tend to taste sour or bitter because it has not had time to fully mix with stomach acid and be digested.

This act of regurgitation is a reflex action that can be a learned and intentional act or can be unintentional. People who have rumination syndrome are not regurgitating food because of a stomach illness or because they feel sick.

Who gets rumination syndrome?

Rumination syndrome has been long known to occur in babies and in people with developmental disabilities, but can occur in people of all ages. Children and adults with high levels of stress or anxiety may be at higher risk for rumination syndrome.

What are the signs and symptoms of rumination syndrome?

The signs and symptoms of rumination syndrome include:

• Regurgitating and re-chewing food on a regular basis.
• Digestive problems, such as indigestion and stomach aches.
• Dental problems, such as bad breath and tooth decay.
• Weight loss.
• Chapped lips.

Babies who have rumination syndrome may strain or arch their backs (which could also be a sign of gastroesophageal reflux) or make sucking noises with their mouths.

What causes rumination syndrome?

The exact causes of rumination syndrome are not known. Some people may develop this syndrome if they have emotional problems or if they are undergoing stressful events.

Mechanically, one explanation is that food expands the stomach, which is followed by an increase in abdominal pressure and a relaxation of the lower esophageal sphincter (the juncture where the esophagus [food tube from mouth] meets the stomach). The sequence of events allows stomach contents to be regurgitated.

How is rumination syndrome diagnosed?

Rumination syndrome can usually be diagnosed based on a medical history and physical exam. In many cases, the patient’s symptoms—specifically, the patient has been regurgitating, chewing and swallowing food for at least 3 months, but is not vomiting the food—are enough to make a diagnosis of rumination syndrome.

Officially, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a person must meet the following criteria to be diagnosed with rumination syndrome:

• Repeated regurgitation of food over a period of at leat 1 month. Regurgitated food may be re-chewed, re-swallowed or spit up.
• Repeated regurgitation is not due to a gastrointestinal or other medical condition (for example, gastroesophageal reflux, pyloric stenosis)
• The eating disorder must not occur only in the presence of anorexia nervosa, bulimia nervosa, binge eating disorder or avoidant/restrictive food intake disorder.
• If the eating disorder occurs together with another mental disorder (for example, intellectual disability), symptoms must be severe enough and be the main reason for seeking medical care.

Doctors may use tests to rule out other medical issues, such as blockages. These tests may include:

• Gastric emptying test. Measures how long it takes for food to move from the stomach to the small intestine.
• Upper endoscopy. The doctor examines the esophagus and stomach through an endoscope (a thin tube with a camera on the end) inserted down the throat.
• X-rays. Provides doctors with images of the inside of the esophagus and stomach.

How is rumination syndrome treated?

The main treatment for rumination syndrome is behavioral therapy to stop regurgitation. The behavioral therapy that is usually prescribed for rumination syndrome is diaphragmatic breathing.

The diaphragm is a large, dome-shaped muscle located at the base of the lungs. Diaphragmatic breathing is intended to help you relax the diaphragm and use it correctly while breathing to strengthen it.

To perform diaphragmatic breathing to help control regurgitation:

1. Lie on your back on a flat surface or in bed, with your knees bent and your head supported. You can use a pillow under your knees to support your legs. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe.
2. Breathe in slowly through your nose so that your stomach moves out against your hand. Keep the hand on your chest as still as possible. For children, we describe this as “breathing like an opera singer”, with the hand on the belly moving out with each slow breath, and moving in with exhalation.
3. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. Keep the hand on your upper chest as still as possible.

How often should I practice diaphragmatic breathing for rumination syndrome?

Practice this exercise for 5 to 10 minutes, three to four times a day. You can increase the effort of the exercise by placing a book on your abdomen. Individuals can also practice “belly breathing” after each bite or meal, as needed.

What complications are associated with rumination syndrome?

If it is not treated, rumination syndrome can damage the esophagus (the tube leading from the mouth to the stomach). Other complications may include:

• Embarrassment
• Poor nutrition
• Failure to grow
• Electrolyte imbalance
• Dehydration
• Aspiration (inhalation of food into the airway [trachea/lungs])
• Choking
• Pneumonia
• Death

Can rumination syndrome be prevented?

It may be possible to reduce your risk of rumination syndrome by learning more positive coping strategies for stressful situations.

What is the prognosis (outlook) for people with rumination syndrome?

Many people with rumination syndrome live otherwise healthy lives. Rumination syndrome usually does not affect a person’s daily routines.

When should I call the doctor about rumination syndrome?

Contact your doctor if you or your child have signs or symptoms of rumination syndrome, especially if you/or your child is regurgitating food on a regular basis.

What questions should I ask my doctor about rumination syndrome?

If you have rumination syndrome, you may want to ask your doctor:

• How serious is rumination syndrome?
• What causes this condition?
• What kind of treatment is right for me?