Functional Rumination Syndrome

What is rumination syndrome?

Rumination occurs when food that was swallowed but not yet digested is regurgitated. The food comes back up from the stomach into the mouth through the oesophagus. 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 usually experience regurgitation at every meal, day after day.  Some kids 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 behaviour 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 we thought. This may be due to healthcare providers being more aware of rumination syndrome and recognizing it more frequently.

Causes of rumination syndrome

Rumination syndrome is a functional gastrointestinal 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 are interacting.

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 oesophagus). Even after the “trigger” event has resolved, the regurgitation “reflex” remains in place, like a learned habit. 

Symptoms of rumination syndrome

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 actual food to come back up. Some kids may have pain with eating while others will be pain-free. Some kids may have nausea. Some kids may start to change how much they eat or what foods they eat in an attempt to avoid regurgitating

Associated symptoms/complications

  • Complaints of stomach pain

  • Complaints of indigestion

  • Nausea

  • Weight loss

  • Bad breath

Diagnosing rumination syndrome

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.

Important questions to  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 that 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 is established by clinical description of signs and symptoms. To diagnose rumination, however, some blood tests, imaging or gastroscopy may be required to rule out other causes of the symptom and evaluate for dehydration and malnutrition.

Treatment for rumination syndrome

Treatment of Rumination syndrome is a combination of medical treatment and behavioural treatment.

Recent research suggests that 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, the 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 behavioural therapy.

Behavioural therapy for rumination includes instruction in diaphragmatic breathing, use of behavioural strategies to “catch” and respond to sensations that come before regurgitation, and exposure therapy techniques. 

Medicines used in Rumination syndrome-

Omeprazole- reduces acid production of the stomach. This medicine help to protect the oesophagus from the stomach acidity

Domperidone- This is a “prokinetic agent” which facilitates rapid movement of the stomach allow it to empty faster and reducing the gastric content volume.

The long-term outlook for rumination syndrome

Experts aren't sure why rumination syndrome starts in the first place, so it is unclear what can be done to prevent it. Diaphragmatic breathing training and other components of behavioural therapy can be effective at stopping rumination. The goal is to work with your gastroenterologist and behavioural 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 oesophagus and sometimes weight loss. Management is necessary to avoid long-term complications of rumination.