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If your young child is regularly vomiting undigested food, she could have rumination disorder, an eating disorder that may begin in infancy or early childhood. Typically, the child may burp or belch before throwing up. Unfortunately, this pattern of vomiting often becomes a habit that can lead to malnutrition if not treated.
The cause of rumination disorder isn’t known, says Michelle I. Lupkin, PhD, Clinical Director of the Eating Disorders program at Montefiore Medical Center in New York City. “It may happen once, and then it becomes a learned behavior and gets more common over time,” she explains. “Kids don’t make judgments. If it works for them, they go with it.”
The vomiting doesn’t just occur once; rumination disorder is always characterized by the repeated regurgitation of food over a period of time, explains Victor Fornari, MD, Director of Child and Adolescent Psychology, Zucker Hillside Hospital in Glen Oaks, New York and Cohen Children’s Medical Center in New Hyde Park, New York. “The food may be re-chewed, re-swallowed, and then spit out,” he says.
Rumination Disorder at Mealtimes
Rumination Disorder Most Noticeable at Mealtimes
One New Jersey mom of a third grader shared the story of her daughter developing rumination disorder as a reaction to an intense and irrational fear of vomit. “A stomach bug was going around at school and seeing her classmates vomit all around her was extremely distressing—traumatic, to her,” says the mom who asked not to be identified, adding that when her daughter eventually came down with the illness and started vomiting herself things got really spiraled out of control.
“In her young mind she figured that not eating very much would reduce—or eliminate—her chance of vomiting, so she’d take a few bites of food and spit the rest of it into her napkin which of course resulted in weight loss. She also developed school avoidance. When I took her to the pediatrician we were referred to a therapist.”
After a few sessions with the therapist, the 3rd grader learned cognitive behavior techniques and began to understand how throwing up and anxiety work. This understanding gave her a sense of control and made the whole ordeal less scary. Through therapy, the child learned to work through her problem by confronting the challenging situation and ultimately overcame her fear.
Diagnosing Rumination Disorder
The diagnosis of rumination disorder is made when there is repeated regurgitation for at least one month that is not attributable to another gastrointestinal issue. “The vomiting does not occur in the context of anorexia or bulimia,” Dr. Lupkin says.
Typically, she says, rumination disorder is diagnosed in infancy and early childhood. “It’s a rare disorder in general,” she says. “It is important to make sure that the regurgitation is not due to an underlying medical condition.”
While rumination disorder affects young children, it also can be present in adults. In particular, individuals who have intellectual disabilities, developmental disorders, and severe anxiety are most at risk, Dr. Fornari says. “A preoccupation with food and weight also serves as a risk factor,” he adds.
Stress can play a role, too, Dr. Fornari says. “And once the behavior develops, it becomes a habit that must be broken,” he says.
“It’s relatively rare, but we’re getting better at assessing it, so we’re seeing an uptick in the number of kids who are being diagnosed,” Dr. Lupkin explains.
If doctors suspect rumination disorder, a full medical workup will be done in order to rule out other medical problems, Dr. Fornari says. It’s important not to miss anything that could be significant, Dr. Lupkin says, although sometimes both rumination disorder and reflux disease can be present together. It’s easy to distinguish rumination disorder from other eating disorders as the food is undigested when the patient vomits, she says. (The name, rumination disorder, comes from the word “ruminate,” which is what cows do when they chew undigested food.)
Rumination disorder doesn’t involve any concerns about weight or one’s body shape, Dr. Lupkin says. “Often the regurgitation is either involuntary or with a lack of awareness of causes,” she explains. “In rumination disorder, patients are regurgitating previously eaten food. Often they may re-chew and swallow food that has been regurgitated.”
Bulimia nervosa, on the other hand, is more commonly diagnosed beginning in adolescence. “There are significant concerns about a patient’s weight or shape, and how a person feels about their body or weight significantly impacts their self-esteem,” Dr. Lupkin says. To meet the criteria for bulimia, patients must engage in a binge episode at least once a week, followed by a period of purging. “The purging is used as a way to try to lose weight and ‘get rid of’ food that may have been eaten in a binge episode,” Dr. Lupkin says.
As for a possible association between rumination disorder and mental health symptoms, “In children with rumination disorder, there can be distress over the disorder, which may be associated with the development of anxiety or depression,” Dr. Lupkin says. “It also becomes an issue in school-aged children as they may be ridiculed by their peers for these behaviors.”
Rumination Disorder Treatment
The good news is that rumination disorder is treatable, Dr. Lupkin says. It should always be treated, she says, because in addition to malnutrition issues, rumination disorder can have social implications.
Deep diaphragmatic breathing is very effective, Dr. Lupkin explains. The patient learns how to do this breathing, and then can practice it on her own. Even children can learn how to do this breathing technique, she says.
“With a young child, you may tell them to put their hands on their stomach or a piece of paper on their stomach,” she says. “Then they are taught how to do deep breathing that is through the diaphragm. They know they are doing it right when the piece of paper is moving up and down.”
Once they master the breathing technique, the symptoms of rumination disorder can stop pretty quickly, Dr. Lupkin says. “The breathing becomes a new learned behavior that can prevent the ability to regurgitate food,” she says. “And over time, just doing the breathing will prevent regurgitation.”
A parent may work with a psychologist or other therapist who specializes in behavioral techniques, Dr. Lupkin explains. “Parents can coach children to engage in diaphragmatic breathing when they notice the child regurgitating,” she says. “With younger children or those with more significant cognitive impairments, other behavioral and distraction techniques can be used to reduce the frequency of regurgitation.”
If anxiety is thought to be the cause of rumination disorder, behavioral therapy may be helpful, too, and when the patient is a young child, supervising her meals may be useful, Dr. Fornari says.
“If supervising meals is used as a treatment, behavioral plans are adapted to reinforce the extinction of the symptom,” he says.
This article was originally published October 30, 2018 and most recently updated September 4, 2019.
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