For the majority of the last century, rumination was mainly considered a condition affecting either neglected infants or mentally retarded individuals. During the past decade there has been increased awareness of otherwise healthy individuals who have frequent postprandial regurgitation. These patients are usually healthy until an intercurrent event triggers the initiation of rumination. Typically the symptoms last several months or years before a diagnosis of rumination syndrome is made (1). Possible explanations for the delay in diagnosis include lack of awareness of the condition, confusion with other disorders such as cyclic vomiting or gastroesophageal reflux, or discomfort with the psychosocial implications linked to the diagnosis and treatment of rumination syndrome.
To help medical providers make a timely and correct diagnosis of rumination syndrome, the Rome III criteria for this condition were recently revised. The current adolescent diagnostic criteria include repeated painless regurgitation and rechewing or expulsion of food that begins soon after ingestion of a meal, does not occur during sleep, and does not respond to standard treatment for gastroesophageal reflux. There must be no retching or evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the patient's symptoms. The symptoms must occur at least once per week for a minimum of 2 months before diagnosis (2). Antroduodenal manometry (3) and pH monitoring with multichannel intraluminal impedance (4,5) can be helpful in differentiating rumination from vomiting but such tests are not indispensable to make the diagnosis (6) (Fig. 1).
In the past, rumination syndrome was considered a benign condition (7). Several authors have described children and adults who were responsive to outpatient behavioral strategies, including relaxation techniques and diaphragmatic breathing (1,8). Although most patients with rumination syndrome have only modest weight loss, there have been also reports of children needing supplemental enteral or parenteral nutrition secondary to excessive regurgitation and caloric depletion (9). Nissen fundoplication was shown in 1 case series to be successful in treating adults with rumination syndrome (10); however, the surgery does not treat the underlying psychological dysfunction and may be associated with complications including gas bloat syndrome or vagus nerve damage. In the present article, we present a case series of adolescents with rumination syndrome severe enough to require hospitalization for intensive treatment. We describe the interdisciplinary inpatient protocol that we have found to be effective in both the short- and long-term treatment of this disorder.
PATIENTS AND METHODS
All of the patients were referred to our motility center consecutively from outside pediatric or adult gastroenterologists after the diagnosis of rumination syndrome was made or for manometric confirmation. Previous studies done at the outside institutions are listed in Table 1. The diagnosis of rumination syndrome was established clinically according to Rome III Criteria for Adolescent Rumination Syndrome (2), and all of the patients had psychiatric exclusion of a typical eating disorder before being referred to our motility center. All of the patients received an antroduodenal manometry before or at the time of the admission before therapy started. The patients took part in the same rumination rehabilitation protocol discussed below with some minor adjustments due to individual patient response to specific aspects of treatment. No patients withdrew or were excluded from the protocol or from the present report.
The psychology protocol was designed to address multiple factors that are likely to maintain the rumination behavior. Multiple authors have conceptualized rumination syndrome as a form of a habit disorder (11). Physiologically, rumination has been described as an automatic behavior (ie, abdominal wall contraction, esophageal sphincter opening) in response to either the anticipation or actual sensation of food or liquid entering the stomach (12,13). As such, the treatment strategy we used involves multiple aspects of traditional habit reversal protocols. Patients are trained to become more aware of the behavior. By using a daily log, patients track rumination “waves” (ie, regurgitation of food into the esophagus or mouth via abdominal wall contraction). In addition, the patients record any antecedent sensations to the rumination (eg, pain, nausea). The treatment protocol also focuses on increasing the aversiveness of the rumination. The patients are instructed to reswallow any food that is ruminated into the mouth. Full expulsion of food out of the mouth is not permitted. To increase compliance with reswallowing, all emesis basins and waste receptacles are removed from the patient's bedside. Patients are taught diaphragmatic breathing to address 2 components of rumination. First, because diaphragmatic breathing involves relaxation of the abdominal muscles, it is used as a competing response to contraction of the abdominal muscles (and thus, the act of rumination). Second, diaphragmatic breathing encourages reduction of autonomic arousal by eliciting the relaxation response. Given the role that autonomic dysregulation likely plays in functional gastrointestinal (GI) disorders (14), teaching patients to self-regulate autonomic activity may allow for a reduction in GI symptomatology.
Biofeedback is used with our patients as a tool for learning effortless diaphragmatic breathing. This typically is achieved by using a respiratory strain gauge to monitor respiration, and a thermistor attached to the nondominant index finger to measure changes in body temperature (an index of sympathetic reduction). Surface electromyography sensors are used during mealtimes to allow the patient to become more aware of abdominal muscle contractions at the time of rumination.
On the basis of the diagnostic criteria for rumination syndrome as well as our own clinical experience, there appears to be a cognitive/attentional component to the behavior. In other words, during sleep or other distractions, there often is a significant reduction in rumination. Therefore, patients are provided with several distraction strategies to use during mealtime. Distraction strategies used include conversation, walking, playing video games, and reading aloud.
Throughout the day, the patients have 3 mealtime periods, initially lasting 2 hours each. Each period is divided into several trials (at first, four 30-minute trials). The patients begin with the smallest tolerable amount of food or liquid (often as small as a grain of rice). Initial food selections typically involve simple carbohydrates such as a small piece of cereal. Patients use both diaphragmatic breathing and the distraction strategies during the mealtime trials. At the start of the next trial, patients then ingest the next slightly larger predetermined amount of food or liquid. With this repeated exposure, patients eventually habituate to the stimuli (ie, food/liquid entering the stomach) and decrease the behavioral response to the stimuli (ie, abdominal tightening).
As the patient progresses, trial times are shortened, and the number of trials is increased within the 2-hour period (eg, five 25-minute trials, six 20-minute trials). As the patient's tolerance for the simple carbohydrates (eg, cereals, crackers) increases, variety and quantity of foods are also increased at each trial. Eventually, trials are eliminated and the patient is given 30 minutes to eat meals including items of their own selection. Mealtime goals transition from amount of food to caloric intake to ensure the patient is able to maintain weight without supplemental feeds.
The pediatric gastroenterology team serves as the managers of the patient's inpatient medical care. They coordinate care of the patient with the various services involved and prescribe any medication that may be beneficial for the patient's ongoing medical issues. Some of the drugs that are prescribed include acid suppressants, appetite stimulants, prokinetic agents, antiemetics, and antidepressants.
Throughout the patient's hospitalization the clinical nutritionist assists in the calculation of daily caloric intake and caloric goals, provides consultation regarding enteral feedings or nighttime supplementation, and assists with food selections based on the individual patient's needs and preferences.
The child life specialist serves as the coordinator of the patient's daily schedule and focuses interventions on the patient's general adjustment to hospitalization. The specialist also assists the patient in further development and refinement of the distraction strategies during feeding treatment.
The therapeutic recreation specialist works with the patient and promotes physical activity while he or she is in the hospital. Physical activity is used both as a distraction technique and as a means of maintaining physical well-being.
The goals of massage therapy are reinforcement of diaphragmatic breathing techniques, use of acupressure to assist with nausea (eg, acupoint CV 12, PC 6, LV 14), and promotion of general relaxation.
A “typical” case is summarized here to illustrate the protocol. The other patients' demographics, treatment, and outcomes are reported in Table 2 and Figure 2.
Before admission, this 14-year-old girl asked to begin eating sessions at home, initially focusing on eating 1 Cheerio every 30 minutes, and reswallowing it after every rumination. The patient was able to achieve this goal, and the small progress before admission allowed for a strong sense of self-efficacy as the patient began the inpatient protocol. A daily schedule was created including the three 2-hour eating sessions. During each trial, the patient was allowed to select from several strategies, including diaphragmatic breathing, distraction (eg, listening to music, working on a craft project, playing a card game), or walking with a parent inside the hospital. Reading aloud was chosen by her because reading aloud seemed to provide distraction and to encourage breathing similar to the diaphragmatic breathing technique. On day 3, the nasojejunal tube was removed, and the patient was transitioned to nighttime gastric feeds. Promethazine was used to reduce nausea and improve sleep. By day 4, vomiting had stopped, and for the next few days, the focus remained on increasing food amount and variety, while reducing the time for the eating trials. By day 10, the patient was selecting her own foods and eating 3 meals/day, with each meal being eaten slowly over 1 hour. Nasogastric feeds were discontinued on day 10, and the patient stated she experienced the sensation of hunger for the first time in months, an event that provided further motivation to engage in the treatment. The patient was discharged on day 11, with some rumination occurring sporadically, but she was able to eat all foods and drank enough to maintain weight and hydration without enteral feeds. For more than 1 year, she has tolerated oral feeds and has remained off all supplemental nutrition.
Rumination syndrome is an increasingly recognized chronic functional GI disorder in the pediatric population. Unfortunately, the diagnosis is often delayed for months to years after the initial presentation. In most cases, diagnostic criteria alone should be sufficient to reach a convincing diagnosis because the pattern of immediate regurgitation after ingestion of even a small amount of food is not consistent with most other diseases associated with vomiting. Definitive diagnosis can usually be confirmed with antroduodenal manometry displaying the typical r-wave pattern when the patient regurgitates shortly after a meal (1,9). All of the patients presented here had r-waves during antroduodenal manometry. Although not necessary, in our experience, the family and the patient have a better understanding of rumination syndrome and are more accepting of the diagnosis when manometry demonstrates the pressure changes associated with the abdominal muscle contraction. Other diagnostic techniques including combined esophageal manometry and multichannel intraluminal impedance can be used to confirm the diagnosis when antroduodenal manometry is not available (4,5).
Although the literature suggests that many patients with rumination syndrome benefit from treatment in an outpatient setting (8,11) using treatment strategies including diaphragmatic breathing and postprandial gum chewing (12,15,16), patients with the most severe presentations of rumination syndrome pose unique challenges. Many such patients often are not able to retain any food or liquid, and are at risk for dehydration and malnutrition and require enteral tube feedings or parenteral nutrition. For these cases with more complex medical needs, it may not be feasible to work with the patient solely on an outpatient basis. In our experience, inpatient management offers several advantages, including efficient use and titration of medications, the ability to gradually transition from supplemental feeds to oral feeds, close monitoring of nutritional and hydration status, focused and intensive work on the behavioral aspects of the rumination syndrome, and the ability to involve several disciplines on a daily basis. In this report, we have presented a series of patients with severe rumination syndrome who were successfully treated using such an interdisciplinary protocol on an inpatient basis. In addition to pediatric psychology and gastroenterology involvement, specialty services such as massage therapy, therapeutic recreation, child life, and clinical nutrition have played an integral role in treating these severe rumination cases. The use of progressive increases in the size of meals, starting with a tiny amount of food, constitutes a novel strategy in our protocol. Success in avoiding regurgitation of any type of ingested food was often interpreted by the patients as evidence that indeed they were able to make progress and instilled confidence in the value of the rehabilitation program. Although it would be difficult to implement the whole protocol in the outpatient setting, we believe that parts of the protocol could be used successfully on children with a milder form of the syndrome on an outpatient basis.
There are likely cost savings associated with an intensive inpatient treatment of rumination syndrome when compared with prolonged enteral or parenteral nutrition therapy. In 2000, the estimated yearly cost of home enteral nutrition ranged between $9,000 and $25,000 and the estimated yearly cost of parenteral nutrition between $86,000 and $140,000 (17,18). In contrast, our patients' hospital admissions ranged between $22,000 and $30,000. Third-party payer approval for inpatient treatment of what is perceived to be a behavioral or psychiatric problem can be challenging, but the potential for cost savings in long-term approval should be considered in making a decision.
Before hospital admission, many patients reported being told that the rumination was suggestive of a psychological disorder, thereby resulting in families and patients being defensive regarding the involvement of a psychologist in the treatment. As patients and families become increasingly comfortable with the interdisciplinary approach during their admission, issues such as anxiety, depression, and perfectionism are more easily identified, discussed, and addressed. Interestingly, all of the patients described in this article presented with many similar personality qualities. Each was an excellent student, empathic, personable, described as a “people pleaser,” and had a strong desire to do well and excel in our program. Although many of these personality features likely contributed to their success in the program, it may be important to further investigate the role that personality traits play in the development and maintenance of rumination.
Many of our patients were discharged still having some postprandial rumination waves; however, they were able to consume and retain enough energy to maintain their weight. After discharge, patients continued to make progress on their own using techniques they learned during the hospitalization, and rumination ultimately stopped. Some patients reported a brief return of rumination, typically around periods of stress. None of the patients needed to go back to supplemental nutrition within 1 year of graduating from the program. We have found that patients who were successfully treated and had graduated from the rehabilitation program had a strong desire to help other patients with severe rumination. Many have volunteered to talk to other inpatients with rumination and have helped build their confidence by sharing with them their success stories.
In summary, rumination syndrome has become a more frequent and accepted diagnosis in the last decade. Although many patients can be successfully treated on an outpatient basis, patients with more severe presentations can benefit from an interdisciplinary treatment in a hospital setting.
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