Rumination Syndrome: Symptoms, Causes, & Treatments

What Is Rumination Syndrome?

Rumination syndrome, also called rumination disorder, involves regularly regurgitating undigested food and then re-chewing, re-swallowing, or spitting it out following meals.¹ While this regurgitation after eating is most typically the result of an unintentional reflex, in some instances, it may be intentional. Rumination syndrome can lead to avoidance of certain foods and of eating in general due to embarrassment, especially around social eating.

While rare, misdiagnosis is common with rumination syndrome, and as a result, it may be under-recognized.^2,3 This is due in part to individuals experiencing rumination syndrome often describing their symptoms as vomiting; however, nausea and dry-heaving don’t typically precede rumination syndrome. Additionally, a historical lack of awareness by healthcare professionals may also result in misdiagnosis. Rumination syndrome can present in infants, children, teens, and adults. Rumination syndrome isn’t caused by an underlying health condition.

Is Rumination Syndrome an Eating Disorder?

While rumination syndrome isn’t specifically categorized as an eating disorder, it does share many characteristics with eating disorders, including resulting in weight loss and what can appear to be vomiting following meals. Research indicates that comorbid eating disorders have been diagnosed in up to 20% of individuals experiencing rumination syndrome.⁴ Rumination syndrome is particularly frequently confused with bulimia nervosa.

The symptoms associated with functional gastrointestinal disorders (FGIDs), such as rumination syndrome, may also be tied to eating disorders. One such example is the symptom of food restriction, which is present in rumination syndrome and some eating disorders. Additionally, some individuals with rumination syndrome do report concerns with their body shape or weight.

Rumination Syndrome Vs. Gastroparesis

In gastroparesis, the individual may feel nauseous or full after eating. Unlike rumination syndrome, nausea and dry-heaving do tend to occur with gastroparesis, and vomiting does take place in gastroparesis versus the regurgitation that happens in rumination syndrome.² Additionally, symptoms in gastroparesis tend to be less frequent and happen further from the time of meals than in rumination syndrome where symptoms happen essentially daily and closely following meals.² Gastroparesis tends to be caused by nerve dysfunction.

Rumination Syndrome Vs. Acid Reflux

Rumination syndrome and acid reflux, which causes a feeling of burning in your chest or throat, can co-occur in some cases, though they are separate diagnoses. One way to distinguish the two diagnoses is that treatments typical of reflux don’t help rumination get better. Additionally, in rumination syndrome, because the food is either undigested or only partially digested, it tends to taste normal and not acidic, while reflux tends to cause burning and a sour taste. Acid reflux tends to happen at night, while rumination syndrome takes place more frequently after meals throughout the day.

Rumination Disorder Symptoms

In rumination syndrome, regurgitation tends to take place about 10 or 15 minutes after eating but can happen for up to one to two hours following a meal.² In most cases, regurgitation takes place regardless of the type or size of the meal. A person experiencing rumination syndrome will exhibit certain behaviors which can lead to adverse physical effects, like avoiding eating or drinking.

Rumination syndrome symptoms can include:

• Weight loss
• Gastrointestinal issues
• Malnutrition
• Electrolyte disturbances
• Avoidance behavior related to social eating
• Dehydration

Outward Warning Signs of Rumination Syndrome

Warning signs of rumination disorder include:

• Regurgitating & re-chewing food often
• Bad breath
• Chapped lips
• Tooth decay
• In babies, there may be observable straining or arching of the back in addition to sucking noises

What Causes Rumination Syndrome?

While the exact causes of rumination syndrome are unknown, it is believed to stem from a variety of different factors. In some cases, rumination may provide a self-soothing or self-stimulating function. More research needs to be done to better understand the causes. A better understanding of the causes of rumination syndrome may contribute to the quicker diagnosis and treatment of the disorder.

Potential causes of rumination disorder include:

• Involuntary contractions: Mechanically, rumination seems to occur as a result of pressure in the abdomen accompanied by a voluntary, though unperceived and typically unintentional, reflex or contraction.² Some people may not learn the act of relaxing the muscles in the abdomen, resulting in the contraction of the diaphragm and regurgitation.
• As a response to an urge: Rumination syndrome can be a learned behavior. Individuals may develop rumination in response to an urge they experience, almost like a tic, and learning this behavior relieves the urge.
• As a result of an FGID: Rumination syndrome may also begin in response to other FGIDs, with regurgitation continuing after the resolution of the FGID due to an association formed with food or physical sensations that come with eating.
• Stress response: Rumination syndrome can also be learned in response to acute stress. The act of rumination may relieve uncomfortable emotional and physical feelings for the individual.
• Response to another condition: Individuals experiencing certain mental or developmental conditions are more susceptible to developing rumination syndrome.

Other Risk Factors for Developing Rumination Syndrome

Children and adults may be at risk of developing rumination syndrome if they have:

• Prior/current health conditions, including gastroenteritis or respiratory infection
• Diagnosed mental illnesses or comorbid psychological symptoms
• History of multiple or major surgeries
• Acute stress
• Eating disorder history

Rumination Syndrome & Autism

There may be a connection between autistic people and eating disorders, including rumination syndrome. Specific research on this relationship is scant, but some postulate this may happen due to underlying anxiety or health issues. It may also correlate with rigidity around food or hyper-sensitivity around certain textures, smells, or sensations that coincide with eating.

Who Can Develop Rumination Syndrome?

While rumination syndrome is generally associated with young children and babies, anyone can develop the condition, including teens and adults. Much of the research on rumination syndrome has focused on individuals with intellectual disabilities or other neurodevelopmental disorders; however, research is starting to identify prevalence in children, adolescents, and adults with neurotypical mental capabilities.

Rumination Syndrome in Children

While early studies seemed to show rumination syndrome primarily in children with intellectual disabilities or neurodevelopmental disorders such as autism, some recent studies have shown rumination syndrome significantly prevalent in children with neurotypical mental capabilities. Studies have found that 6-10% of infants with developmental delay experience rumination syndrome, while 5.1% of children with typical intelligence experience rumination syndrome.³

Infants and children who have experienced a lack of stimulation, neglect, stressful life situations, and/or problems in the relationship with their primary caregiver may be at greater risk of developing rumination syndrome.¹ Rumination syndrome in children can result in both medical complications, such as dental erosion and weight loss as well as social consequences, such as missing school. In some instances, rumination syndrome can result in death.

Rumination Syndrome in Adults

Adults with symptoms of depression, anxiety, and somatic symptom disorders seem more likely to experience rumination syndrome.⁴ Additionally, as with children, adults who have experienced acute stress or abuse, including physical, sexual, or psychological, are also more likely to develop rumination syndrome. Again, more research is needed to better understand what populations most develop rumination syndrome. Treatment of these comorbid psychiatric conditions may be important in addressing rumination syndrome.

Because of the need for more research, many adults experiencing rumination syndrome go through extensive, sometimes unnecessary, testing and even surgery before arriving at the appropriate diagnosis. Because adults are also often misdiagnosed, rumination syndrome may be more prevalent than it appears.

The Impact of Rumination Syndrome

Rumination syndrome is not inherently life-threatening, but it can cause various emotional and physical health problems that may worsen progressively over time. Severe rumination syndrome can disrupt ordinary life functioning and pose significant challenges around eating. When children have rumination disorder, the impact of such symptoms can affect everyone within the family.

Effects of rumination can include:⁵

• Severe abdominal pain
• Nausea
• Risk of dehydration
• Malnutrition
• Unintentional weight loss
• Anxiety
• Depression
• Social withdrawal

How Is Rumination Syndrome Diagnosed?

To diagnose rumination syndrome, healthcare professionals take a clinical history in addition to assessing for certain characteristics and behaviors, using a set of criteria for diagnosing an FGID (a disorder of gut-brain interaction).² It is recommended that people be assessed for rumination syndrome when they report regular reflux, vomiting, or regurgitation. Behavioral observation may also be used.

To be diagnosed with rumination syndrome, a person needs to meet the following criteria:

• Repeated regurgitation of food for at least one month; food may be re-chewed, swallowed, or spit out
• Regurgitation is not related to an underlying health condition
• Behavior does not occur specifically because of another eating disorder, including binge eating, bulimia, or anorexia purge subtype
• When rumination syndrome occurs alongside other developmental or medical conditions, the behaviors are severe enough to require attention

There is no specific test to diagnose rumination syndrome. However, doctors may use various tests to rule out any other medical issues. Tests used may include manometry, a tool that is often used in evaluating swallowing disorders. An upper endoscopy or gastric emptying test may also be used to assist in ruling out and diagnosing rumination syndrome.

Rumination Syndrome Treatments

A thorough explanation of the syndrome is an important first step in treatment. Diaphragmatic breathing training with or without biofeedback is then typically used for treating rumination syndrome.^2,6 People experiencing rumination syndrome are taught diaphragmatic breathing and encouraged to practice outside of meals in addition to using this skill in the 15 minutes following meals or until the sensation of impending rumination leaves. Diaphragmatic breathing is relatively easy to learn, and research supports its effectiveness in treating rumination syndrome.

Additional behavioral strategies that may be helpful include general relaxation, aversion training, and distraction, including through gum chewing. Cognitive behavioral therapy for rumination disorder (CBT-RD) may also be helpful for treatment. There is some evidence of the effectiveness of some prescribed medications, primarily baclofen, in the treatment of rumination syndrome; however, more research is needed in this area.^2,6,7

Can Rumination Syndrome Be Prevented?

Experts don’t exactly know why rumination disorder develops in some people. So, at this time, no data indicates that rumination disorder can be prevented. Instead, treatment focuses on reduction and management of symptoms. With the right care, you can treat your condition and still have a good quality of life.