Rumination Syndrome

Rumination occurs when food that was swallowed but not yet digested is regurgitated. The food comes back up from the stomach, through the esophagus and into the mouth. Your child may not be able to tell that they are about to regurgitate. You may not be able to see or hear the regurgitation — it often does not look or sound like vomiting. Your child may either re-chew and re-swallow the undigested food or spit it out.

Individuals with rumination syndrome usually experience regurgitation at every meal, day after day. Some patients will regurgitate immediately after eating a bite of food while others eat a larger amount before regurgitation starts. Rumination is considered a reflex, not a purposeful behavior and can affect children as well as adults.

In the past, rumination syndrome was considered a rare disorder. We now recognize this disorder to be more common than initially thought. This may be due to healthcare providers being more aware of rumination syndrome and recognizing it more frequently. Rumination syndrome is also sometimes known as rumination disorder.

Rumination syndrome is a functional gastrointestinal (GI) disorder. Like other functional disorders, no organic disease or physical abnormality is present. However, the patient’s symptoms are very real and result from the way the brain and the digestive system interact.

In many cases, rumination symptoms begin with a “trigger” event such as a viral illness, a GI disease or changes in the patient’s life causing stress. The individual may develop increased sensitivity in the digestive tract. This can make having food or liquid in the stomach uncomfortable. As a result, the body has learned to contract the abdominal muscles, causing pressure resulting in food and/or fluids leaving the stomach (coming back up through the esophagus). Even after the “trigger” event has resolved, the regurgitation “reflex” remains in place, like a learned habit.

Rumination is different from vomiting. With rumination, there is repeated regurgitation of food. The food is undigested and often still tastes the same as when it was first eaten. Symptoms may be caused by a variation of the typical belching/burping reflex where instead of burping up gas, the reflex causes food to come back up. Some children may feel this and explain it as a feeling of food coming back up or burping up undigested food. Some patients may have pain with eating, while others will be pain-free. Others may experience nausea. Some patients may start to change how much they eat or what foods they eat in an attempt to avoid regurgitating.

• Complaints of stomach pain
• Complaints of indigestion
• Nausea
• Weight loss
• Bad breath

Due to the similarity with vomiting, rumination syndrome can be misdiagnosed as a vomiting disorder, possible delayed gastric emptying or gastroesophageal reflux disease.

Symptoms vary from each patient, and an accurate diagnosis is made through a detailed symptom history.

Your child’s gastroenterologist may ask:

• What does the regurgitated food look and taste like? Undigested food may still look and taste like it did before.
• How long after eating does regurgitation happen?
• Does regurgitation wake your child from sleep?
• Can you hear retching or see your child is about to regurgitate or vomit?
• Has your child taken medications to treat reflux? Do medications for reflux help?

The diagnosis of rumination syndrome is established by clinical description of signs and symptoms. To diagnose rumination, your provider does not usually require diagnostic testing. However, some blood tests and imaging may be required to rule out other causes of the symptom and evaluate for dehydration and malnutrition.

There are no medications available to treat rumination syndrome. Recent research suggests the best way to stop rumination syndrome is to relearn how to eat and digest food properly. In cases where weight gain and growth have been impacted due to your child’s symptoms, disease management is focused on nutritional rehabilitation. This includes dietary management with nutrition. and in some cases, supplemental enteral nutrition. The primary focus of treatment is behavioral therapy.

Behavioral therapy for rumination includes instruction in diaphragmatic breathing, use of behavioral strategies to “catch” and respond to sensations that come before regurgitation, and exposure therapy techniques. Behavioral treatment of rumination is similar to HRT (habit reversal training) and ERP (exposure and response prevention). At Children’s Hospital of Philadelphia, behavioral treatment of rumination is provided by clinical psychologists. The psychologist may observe your child eat a meal, help your child practice techniques to keep food down, and ask your child to practice these techniques regularly at home, with your coaching and support.

Experts aren't sure why rumination syndrome starts in the first place, so it’s unclear what can be done to prevent it. Diaphragmatic breathing training and other components of behavioral therapy can be effective at stopping rumination. The goal is to work with your child’s gastroenterologist and behavioral psychologist to end the pattern of rumination.

Rumination syndrome does not seem to do much physical damage. In rare instances, it can cause problems with the esophagus and sometimes weight loss. Disease management is necessary to avoid long-term complications of rumination. 

Some of the long-term complications may include:

• Increased risk of dehydration, malnutrition and weight loss
• Poor school attendance and involvement in activities
• Emotional issues such as anxiety, stress and depression

Continued use of diaphragmatic breathing when symptoms are present and follow-up as needed.

Our team can provide the tools for self-management strategies as well as guidance and consultation to local therapists. Therapists with expertise in behavioral and cognitive behavioral therapy, and especially those with experience providing HRT and ERP, can be especially helpful.

The Suzi and Scott Lustgarten Center for GI Motility team will provide education to families to understand their child’s diagnosis, assure that no other condition is present, and actively provide a treatment plan to improve symptoms. Our treatment approach includes treating the trigger symptoms, such as nausea or bloating that can contribute to the increased frequency of rumination, as well as identifying and managing secondary problems that may contribute to rumination such as anxiety, stress and worry.

We focus on behavioral treatment to undo the learned rumination "habit." This treatment includes increasing awareness of what the abdominal muscles are doing, learning to keep the body relaxed during mealtimes, and retraining the stomach to tolerate meals again.