Rumination Disorder

Rumination Disorder

Definition

Rumination disorder is characterized by the repeated regurgita-tion and rechewing of food occurring for at least one month with prior normal functioning. As in the case of feeding disorder of in-fancy and early childhood, these behaviors cannot be the result of a medical condition affecting the gastrointestinal tract. Similarly, this diagnosis is not made in the presence of anorexia nervosa or bulimia nervosa.

Epidemiology and Etiology

Rumination disorder appears to be uncommon, occurring more often in boys than in girls and also in individuals with mental retardation.

Several authors have attributed rumination to an unsat-isfactory mother–infant relationship, (including neglect or lack of stimulation, and sometimes to stressful life situations of the parent. Others have considered rumination a learned behavior that is maintained by special attention by the caregivers to the child’s rumination and, consequently, the rumination has to be unlearned by counter conditioning. Rumination can be seen along a continuum: a patient may have gastrointestinal disease, such as hiatal hernia or reflux, and little psychiatric illness in the mother–infant relationship at one end of the spectrum; or the converse, a patient might have no reflux and severe psychi-atric illness in the mother–infant relationship at the other end of the spectrum. Reflux or a temporary illness associated with vomiting frequently precedes the rumination. At some point, the infant seems to learn to initiate vomiting and turn it into rumination to achieve self-regulation. It appears that in circum-stances in which the infant fails to elicit or loses either caring attention or tension-relieving responses from the caretaker, the infant resorts to rumination as a means of self-soothing and relief of tension.

Diagnosis

Most frequently, infants who ruminate come to the attention of professionals because of “frequent vomiting” and weight loss. Some infants ruminate primarily during the transition to sleep when left alone, and their ruminatory activity might not be read-ily observed. However, these infants are frequently found in a puddle of vomitus, which should raise suspicion of rumination. Other infants can be observed to posture with the back arched, to put the thumb or whole hand into the mouth, or to suck on the tongue rhythmically to initiate the regurgitation of food. Most of the regurgitated food is initially vomited, but gradually the infant appears to learn to hold more of the food in the mouth to rechew and reswallow. “Experienced” ruminators appear to be able to bring up food through repeated tongue movements. They learn to rechew and reswallow the food without losing any of it. Their rumination can be inferred only from the move-ments of their cheeks and foul oral odor because of the frequent regurgitation.

In addition to taking a thorough medical history, it is im-portant to explore the onset of vomiting and the social context under which the symptoms developed. An acute medical illness or a stressor in the parents’ life is frequently associated with the onset of vomiting.

When exploring the stressors in the mother–infant rela-tionship, one needs to be careful neither to alienate the mother nor to add additional stress to the relationship. It is best to ob-serve the infant in various situations with the mother, with other caretakers and alone in the crib during the transition to sleep. These observations will help in understanding the severity of the rumination, and whether it is situational or pervasive. In addition to assessing the rumination in the infant, the mother–infant rela-tionship and the mother’s life circumstances need to be evaluated because the mother’s ability to soothe and to stimulate her infant is critical for successful intervention.

Course and Natural History

The onset of rumination is frequently in the first year of life except in individuals with developmental delays, in whom the disorder may occur during later years. Rumination has also been reported to occur in adults with normal intelligence and in association with bulimia nervosa. In some infants and children, the disorder is believed to remit, however, electrolyte imbalance, weight loss, dehydration and death have been reported to result from rumina-tion, and rumination should always be taken seriously

Treatment

Diverse theories of etiology have resulted in various proposed methods of treatment. Besides surgical intervention to prevent reflux and the early use of mechanical restraints, treatment has been primarily behavioral or psychodynamic or a combination of both.

On the basis of the assumption that rumination is a learned habit reinforced by increased attention for regurgitation, un-learning by counter conditioning has been suggested. Some au-thors have used electric shock after other methods had failed. A number of alternative procedures of punishment, such as aversive taste stimuli (lemon juice or hot sauce), have been developed. There are difficulties in the use of aversive taste stimuli as pun-ishment. Frequently, the infants are out of reach of the caretak-ers when they ruminate; consequently, the use of lemon juice or hot sauce is inconsistent, and this delays learning. Some infants appear to become adapted to these aversive taste stimuli. These authors suggest scolding the infant by shouting “No”, placing the infant down, and leaving the room for 2 minutes immediately on initiation of rumination by the infant. If the infant is not ruminat-ing on the caretaker’s return, he or she is to be picked up, washed and played with as a reward.

There may be two behavioral causes of rumination: 1) re-ward learning through increased attention for regurgitation, and 2) social deprivation. Whereas punishment with time-out may be necessary for the first type, holding the child for 10 to 15 minutes before, during and after meals is the treatment of choice for the second type. A psychodynamic approach based on the assumption that rumination results from a disturbance in the mother–infant relationship has been advocated. Mothers of ruminating infants are frequently found to be overwhelmed by their personal lives, which make them unavailable or tense in their relationship with their infants. Psychotherapy for the mother and environmental changes that produce enhanced mothering have been proposed.

After an understanding of the mother’s situation has been gained, treatment is best individualized by use of a combination of psychodynamic and behavioral interventions to enhance the mother–infant relationship in general, and to address the symp-tom of rumination in particular.