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Rumination and Pica
Rumination Disorder
Rumination disorder is the repeated regurgitation of food, where the regurgitated food may be rechewed, reswallowed, or spit out, for a period of at least 1 mo following a period of normal functioning. Regurgitation is typically frequent and daily; it does not occur during sleep. It is not caused by an associated gastrointestinal illness or other medical conditions (e.g., gastroesophageal reflux, pyloric stenosis). It does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder. If the symptoms occur in the context of an intellectual developmental disorder or another neurodevelopmental disorder, the symptoms must be sufficiently severe to warrant additional clinical attention.
Weight loss and failure to make expected weight are common features in infants with rumination disorder. Infants may display a characteristic position of straining and arching the back with the head held back, making sucking movements with their tongue. In infants and older individuals with intellectual disability, the rumination behavior may appear to have a self-soothing or self-stimulating function. Malnutrition may occur in older children and adults, particularly when the regurgitation is associated with restricted food intake (which may be designed to avoid regurgitation in front of others). They may attempt to hide the regurgitation behavior or avoid eating among others.
Epidemiology
Originally thought of as a disorder predominantly seen in infants and those with intellectual disability, rumination disorder has also been recognized in healthy individuals across the life span and can be overlooked in adolescents. In otherwise healthy children, rumination disorder typically appears in the 1st year of life, generally between ages 3 and 12 mo. The disorder can have an episodic course or can occur continuously until treatment is initiated. In infants the disorder frequently remits spontaneously but can be protracted with problematic and even life-threatening malnutrition. Additional complications related to the secondary effects of malnutrition include growth delay and negative effects on development and learning potential.
Etiology and Differential Diagnosis
Risk factors for rumination disorder in infants and young children include a disturbed relationship with primary caregivers, lack of an appropriately stimulating environment, neglect, stressful life situations, learned behavior reinforced by pleasurable sensations, distraction from negative emotions, and inadvertent reinforcement (attention) from primary caregivers. Risk factors for rumination disorder in adolescents include similar early childhood factors along with female gender and comorbid anxiety and depression. The differential diagnosis includes congenital gastrointestinal system anomalies, pyloric stenosis, Sandifer syndrome, gastroparesis, hiatal hernia, increased intracranial pressure, diencephalic tumors, adrenal insufficiency, and inborn errors of metabolism. Older children and adults with anorexia nervosa or bulimia nervosa may also engage in regurgitation because of concerns about weight gain. The diagnosis of rumination disorder is appropriate only when the severity of the disturbance exceeds that routinely associated with a concurrent physical illness or mental disorder.
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