Rumination Syndrome: Symptoms, Causes, & Treatments

What is Rumination Syndrome?

In rumination syndrome, individuals regularly regurgitate undigested food and then re-chew, re-swallow, or spit it out following meals.¹ While this regurgitation 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 does tend 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 Syndrome Signs & 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.

Warning signs of rumination syndrome include:

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

Symptoms of rumination syndrome include:

• Weight loss
• Gastrointestinal issues
• Malnutrition
• Electrolyte disturbances
• Avoidance behavior of work or social eating
• Dehydration

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 individuals be assessed for rumination syndrome when they present reporting reflux, vomiting, or regurgitation. Behavioral observation may also be used.

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.

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

What Causes Rumination Syndrome?

While the exact causes of rumination syndrome are unknown, it is believed to stem from a variety of different factors. 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 individuals may not learn the act of relaxing the muscles in the abdomen, resulting in the contraction of the diaphragm and resulting regurgitation.

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. 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. 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.

Individuals experiencing certain mental or developmental conditions are more susceptible to developing rumination syndrome. In some cases, rumination may provide a self-soothing or self-stimulating function. More research does need 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.

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

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.

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.^2,5 Individuals 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 does support 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.^2,5,6

In My Experience

It’s important to talk to your doctor or trusted healthcare professional about symptoms related to rumination syndrome you may be experiencing and to follow their guidance. Because of feelings of embarrassment common in rumination syndrome as well as frequent misdiagnosis or the lengthy process of getting diagnosed, many individuals may experience rumination syndrome without help. Additionally, in my experience, rumination syndrome is often not considered to be very serious; however, the consequences on an individual’s mental and physical health, in addition to their social life, can be devastating.

Treatment is both possible and effective for rumination syndrome, and a healthcare professional may be able to provide treatment or help in addressing any barriers to treatment, including in addressing readiness for change. Reach out to someone you trust to start the conversation of seeking help.