Treatment for rumination disorder depends on accurate diagnosis and finding the underlying cause of the disorder. It also encompasses managing symptoms and reducing complications that may arise as a result of regurgitating food, rechewing it and swallowing it again.

Accurate diagnosis should be made by excluding other causes for regurgitation, such as:

  • Esophageal disorders, like strictures or hernias
  • Gastric disorders, like ulcers
  • Small bowel disorders
  • Pregnancy
  • Endocrine (hormone) disorders
  • Brain disorders, such as tumors or infections
  • Drugs that affect swallowing
  • Food allergies

Rumination disorder treatment is primarily psychosocial or psychodynamic and consists of non-punishing behavioral strategies like:

  • Habit-reversal training
  • Diaphragmatic breathing
  • Eating thick food
  • Extending eating time with small bites
  • Specialized feeding techniques
  • Self-hypnosis
  • Relaxation techniques
  • Guided imagery
  • Biofeedback with abdominal relaxation

According to the Nationwide Children’s Hospital, the goals for treating rumination disorder are:

  • Education
  • Treating the trigger symptoms
  • Treating symptoms such as nausea or bloating
  • Undoing newly learned “habits”
  • Learning new behaviors for abdominal muscles
  • Retraining the stomach to hold food again
  • Teaching self-regulation
  • Identifying and addressing other problems like depression, anxiety and stress

Habit-Reversal Training and Behavioral Modification

According to a study posted in the Journal of Pediatric Gastroenterology & Nutrition, the three components of the simplified habit-reversal approach include:

  • Awareness training
  • The use of behavior that is incompatible (with regurgitation), such as diaphragmatic breathing
  • Social support from the family

In the study, the first habit-reversal training session consisted of the patient identifying the rumination with regurgitation and receiving instructions to record each time it occurred. Afterward, during the practice of diaphragmatic breathing, the patient was instructed to breathe slowly and to keep her chest from moving while making her abdomen rise and fall during breathing. The goal of this exercise was to make each inhale and exhale last for three seconds. At home, the client would practice diaphragmatic breathing after meals for three five-minute periods of inactivity with 10-minute breaks in between.

Diaphragmatic Breathing

Diaphragmatic breathing is a technique used to treat rumination disorder. By using diaphragmatic breathing exercises, the person uses a relaxation technique to inhale and exhale by expanding the abdomen instead of the chest. This type of breathing is incompatible with regurgitation of food, meaning a person can’t engage in rumination behaviors while practicing this breathing.

Diaphragmatic breathing in rumination syndrome can be practiced throughout mealtimes and for 10 minutes after the meal to allow the food to pass further down the stomach closer to the small intestine. The deep inhales and exhales move the abdomen and not the chest wall.

Relaxation Techniques

Currently, the most effective treatment strategies in rumination disorder consist of behavioral therapy focusing on breathing and relaxation techniques. Breathing techniques use habit reversal to create a competing behavior (or a distraction) to reduce the regurgitation episodes.

Relaxation techniques combined with diaphragmatic breathing and music help the patient relax, which reduces the likelihood that they will ruminate. Although complete reprogramming is necessary for sustained recovery, it’s best to start with snacks and small meals and advance the diet slowly to full meals. Education and realistic expectations during times of stress are additional tools a person can use to avoid setbacks.

Mild Aversive Training

Mild aversive training strategies are recommended only if the individual’s health is not at risk for deterioration. Mild aversive training includes:

  • Placing a sour or unpleasant taste on the tongue
  • Loud noises
  • Pinching
  • Withholding rewards

Stronger aversive strategies are usually used in refractory cases that are causing significant malnutrition, hospitalizations or electrolyte disturbances that might affect the heart. They include the following:

  • Electroshock therapy
  • Overcorrection
  • Withdrawal of positive reinforcement
  • Noxious tastes

Supportive Therapies

Rumination disorder strategies must include education for both the parents and child, rebonding of the parent and child, counseling, support groups, stress reduction and treating underlying psychopathologies like depression or anxiety.

Medications

Medications for rumination disorder can target multiple potential causal factors, including those to help the stomach accommodate the food, or empty, faster. The esophageal sphincter might be manipulated with medication. Medication for rumination disorder may include:

  • Levosulpiride: An antipsychotic drug that has gastrointestinal motion properties called levosulpiride was studied in conjunction with supportive counseling. The study showed that 38 percent of patients improved while 14 percent got worse.
  • Baclofen: A drug called Baclofen stops the sphincter from relaxing and has shown promise in some people with rumination disorder.
  • Buspirone: Buspirone is a drug that helps the stomach relax so that food can travel toward the small intestine. However, it has not been studied in rumination. Case reports suggest that it may prove useful and warrants further investigation.
  • Proton pump inhibitors: Proton pump inhibitors lower stomach acid production can help with some of the complications of regurgitation such as stomach and mouth pain and esophageal discomfort, as well as tooth decay from excess acid.

Treatment in Children vs. Adults

Treatment for rumination disorder in children is easier than with adults. For example, chewing gum in rumination is effective in children. Difficulty in the treatment for rumination disorder in adults is due to the long-standing nature of the condition. Some infants and children outgrow rumination disorder spontaneously. However, adults may be more motivated to correct the condition than children are, due to embarrassment. Additionally, adults can follow instructions more diligently than children can.

In the case of maternal neglect, an infant may use rumination as a way to stimulate him or herself. In cases of an over stimulating environment, the infant may use it as a way to self-soothe.

Rumination Disorder Prognosis and Outlook

In the case of rumination disorder, it is necessary to rule out underlying gastrointestinal diseases such as gastroesophageal reflux. Psychiatric evaluations can uncover other contributing factors, such as underlying depression or anxiety. Once the underlying cause of rumination is determined, rumination disorder prognosis is good.

Complications such as aspiration, bronchitis, pneumonia and asthma may be seen if there is a delay in diagnosing and treating the condition. Premalignant changes in the esophagus should be assessed in any long-standing cases of rumination disorder.

Other possible complications of untreated rumination disorder are:

  • Malnutrition
  • Weight loss
  • Dental problems
  • Choking
  • Social isolation
  • Bad breath
  • Death

While it may be rare, a person with rumination disorder may misuse drugs or alcohol. If you or someone you know struggles with drug or alcohol abuse and a co-occurring mental health condition like rumination disorder, help is available. The Recovery Village offers co-occurring disorder treatment programs to help heal substance abuse and mental health issues. Call today to learn more.

    

The Mayo Clinic. “Rumination syndrome:diagnosis-treatment.” Published in 2018. Accessed March 2, 2019.

Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. “Teaching diaphragmatic breathing for rumination syndrome.” American Journal of Gastroenterology, 2006. Accessed March 15 2019.

Nationwide Children’s Hospital. “Rumination Syndrome Inpatient Treatment Program.” (n.d.) Accessed March 15, 2019

Papadopoulos V, Mimidis K. “The rumination syndrome in adults: A review of the pathophysiology, diagnosis and treatment.” Journal of Postgraduate Medicine, July 2, 2007. Accessed March 15, 2019

Cleveland Clinic. “Diaphragmatic breathing.” Last reviewed September 5, 2017. Accessed March 15, 2019.

Milad M, McCallum R, “Rumination-Syndrome-An-Update-on-Diagnostic-and-Treatment-Strategies.” Practical Gastroenterology, September 2016. Accessed March 15, 2019.

Halland M, Pandolfino J,  Barba E. “Diagnosis and Treatment of Rumination Syndrome.” Clinical Gastroenterol Hepatol, June 12, 2018. Accessed March 15, 2019.

Lozano, R et al. “Effectiveness and safety of levosulpiride in the treatment of dysmotility-like functional dyspepsia.” Therapeutics and Clinical Risk Management, March 3, 2007. Accessed March 15, 2019.

Gupta, Ravi et al. “Adult rumination syndrome: Differentiation from psychogenic intractable vomiting.” Indian Journal of Psychiatry, September 2012. Accessed March 15, 2019.

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