Rumination Syndrome in Children and Adolescents: Diagnosis,
Treatment, and Prognosis
Heather J. Chial, MD; Michael Camilleri, MD; Donald E. Williams, PhD*; Kristi Litzinger, MS, LPP*; and
Jean Perrault, MD‡
ABSTRACT. Objectives. To characterize the clinical
features, results of diagnostic testing, and treatment out-
comes for children and adolescents with rumination syn-
drome.
Methods. Review of the medical records for all 147
patients ages 5 to 20 diagnosed with rumination syn-
drome at our institution between 1975 and 2000. Data are
presented as mean ⴞ the standard error of the mean.
Results. Sixty-eight percent were female. Age at di-
agnosis was 15.0 ⴞ 0.3 years. Symptom duration before
diagnosis was 2.2 ⴞ 0.3 years, 73% missed school/work,
and 46% had been hospitalized because of symptoms.
Before diagnosis, 16 (11%) underwent surgery for evalu-
ation or management of symptoms. Twenty-four (16%)
had psychiatric disorders; 3.4% had anorexia or bulimia
nervosa. All patients described postprandial regurgita-
tion after almost every meal (2.7 ⴞ 0.1 meals per day).
Weight loss was described by 42.2% (median: 7 kg). Ad-
ditional symptoms included: abdominal pain, 38%; con-
stipation, 21%; nausea, 17%; and diarrhea, 8%. Structural
studies were normal. Gastric emptying of solids at 4
hours was delayed in 26 of 56 patients. Esophageal pH
testing in 24 patients showed reflux/regurgitation in 54%.
Gastroduodenal manometry in 65 patients showed char-
acteristic rumination-waves in 40%. Outcome data (at
median follow-up 10 months) were available for 54 pa-
tients. Symptoms resolved in 16 (30%) and improved in
30 (56%).
Conclusions. Recognition of the clinical features of
rumination syndrome in children and adolescents is es-
sential; the diagnosis is often delayed and associated
with morbidity. Extensive diagnostic testing is un-
necessary. Early behavioral therapy is advocated, and
patient outcomes are generally favorable. Pediatrics 2003;
111:158 –162; rumination, regurgitation, pediatric, motil-
ity, reflux.
ABBREVIATION. CT, computed tomography.
From the Clinical Enteric Neuroscience Translational and Epidemiological
Research (C.E.N.T.E.R.) Program, *Department of Clinical Health Psychol-
ogy, Mayo Clinic Rochester, Rochester, Minnesota; and ‡McGill University
Health Center, Montreal Children’s Hospital, Division of Gastroenterology
and Nutrition, Montreal, Canada.
Received for publication Mar 26, 2002; accepted Jun 27, 2002.
Reprint requests to (M.C.) Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Charlton 7-154, Mayo
Clinic Rochester, 200 First St SW, Rochester, MN 55905. E-mail address:
camilleri.michael@mayo.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
158 PEDIATRICS Vol. 111 No. 1 January 2003
Downloaded from by guest on August 31, 2017
R
umination syndrome is characterized by the
effortless regurgitation into the mouth of re-
cently ingested food followed by rechewing
and reswallowing or expulsion.1,2 Individuals with
classic rumination syndrome typically do not expe-
rience heartburn, abdominal pain, or nausea when
the regurgitation occurs. The syndrome is most com-
monly seen in infants and the developmentally dis-
abled. However, rumination syndrome does occur in
children, adolescents, and adults with normal intel-
ligence.3,4
Individuals with rumination syndrome are often
misdiagnosed or undergo extensive, costly, and in-
vasive testing before diagnosis. Insufficient aware-
ness of the clinical features of rumination syndrome
contributes to the underdiagnosis of this important
medical condition. Rumination syndrome is fre-
quently confused with bulimia nervosa, gastro-
esophageal reflux disease, and upper gastrointestinal
motility disorders including gastroparesis and
chronic intestinal pseudo-obstruction. Complications
of rumination syndrome include weight loss, malnu-
trition, dental erosions, halitosis, electrolyte abnor-
malities, and significant functional disability.3
Rumination syndrome is a clinical diagnosis based
on symptoms and the absence of structural disease.3
Although the Rome II diagnostic groups include
childhood functional gastrointestinal disorders, only
“infant rumination syndrome” is described in detail
and pertains to infants with symptom onset before 8
months of age.5 Diagnostic criteria for children and
adolescents with rumination beginning after infancy
have not been defined.
The purpose of this study was to further charac-
terize the clinical features, results of diagnostic
testing, and treatment outcomes for children and
adolescents between the ages of 5 and 20 with rumi-
nation syndrome. We perceived that review of a
large cohort of patients in the 5- to 20-year age group
was necessary to develop future consensus criteria
for rumination syndrome in children and adoles-
cents.
METHODS
Patients
A computerized diagnostic index was used to identify children
and adolescents between the ages of 5 and 20 diagnosed with
rumination syndrome at Mayo Clinic Rochester during the 25-year
period between 1975 and 2000. One hundred forty-seven patients
were identified. Data extracted included demographics, clinical
features, past medical history, social history, evaluation, treat-
ment, and outcome. The study was approved by the Mayo Insti-
tutional Review Board, and authorization for the use of the med-
ical records for research purposes was confirmed before access
was provided to the medical records.
Statistical Analysis
Descriptive data are displayed as number of patients (percent),
or mean ⫾ the standard error or the mean (n ⫽ number of patients
with data available if less than the total number, 147). The Mann-
Whitney U test was used for comparisons of means between
groups. The ␹2 test was used for comparisons of proportions.
RESULTS
Demographics
Of the 147 patients identified, 68.0% were female,
and 97.2% were Caucasian. The majority (70.8%)
were from the midwestern United States (Minnesota,
Iowa, Wisconsin, Nebraska, North Dakota, Illinois,
Indiana, South Dakota, and Michigan). These demo-
graphics reflect the usual ethnic and geographic dis-
tribution of patients attending Mayo Clinic Roches-
ter.
Past Medical History
Forty-eight (32.7%) patients had prior diagnoses of
gastrointestinal illnesses; 49 (33.3%) had other med-
ical diagnoses; and 25 (17%) had concomitant psy-
chiatric disorders including depression (6.1%), anxi-
ety disorder (3.4%), attention-deficit/hyperactivity
disorder (3.4%), adjustment disorder (1.4%), obses-
sive compulsive disorder (0.7%), somatoform disor-
der (0.7%), and posttraumatic stress disorder (0.7%).
Anorexia nervosa and bulimia nervosa were docu-
mented in 2 (1.4%) and 3 (2.0%) patients, respec-
tively. A history of physical and/or sexual abuse was
documented in 4 (2.7%) patients. Developmental dis-
abilities were present in 7 patients including devel-
opmental delay in 5, autism in 1, and dyslexia in 1.
Past Surgical History
Before diagnosis of rumination syndrome, 16
(11%) patients had abdominal operations performed
elsewhere for evaluation or management of associ-
ated symptoms: 6 appendectomies; 5 cholecystecto-
mies; 3 laparotomies; 1 duodenal enterostomy; and 1
Fig 1. Distribution of age at diagnosis.
Downloaded from by guest on August 31, 2017
patient who underwent multiple operations includ-
ing pyloroplasty, partial colectomy with ileostomy,
and cholecystectomy. The clinical history of the latter
patient was reported elsewhere.2 None of the pa-
tients had symptomatic improvement postopera-
tively.
Social History and Family History
Eighty-five percent of patients lived at home with
their families, and 12% were college students who
lived on campus (n ⫽ 131); the remaining 3% were
married, living with a significant other, or living
with a foster family. Relatively uncommon was the
use of alcohol (13 patients), tobacco (14 patients), and
recreational drugs (4 patients).
Regarding school performance, 90% of the 39 pa-
tients with data available earned A and B grade point
averages. Using adjectival terms from the medical
records to categorize scholastic performance (n ⫽
73), 18.8% were excellent students, 58.9% were good
students, 2.7% were fair students, and 9.6% were
poor students. (Of note, data regarding school per-
formance were not available for the 7 patients with
developmental disabilities.)
Clinical Features of Rumination Syndrome
The age at diagnosis was 15.0 ⫾ 0.3 years as shown
in Fig 1. Symptom duration before diagnosis was
2.2 ⫾ 0.3 years (n ⫽ 126). Age at symptom onset was
12.9 ⫾ 0.4 years (n ⫽ 126). Males were younger at
symptom onset (11.0 ⫾ 0.8 vs 13.8 ⫾ 0.5; P ⫽ .003)
and at the time of diagnosis (13.2 ⫾ 0.7 vs 15.8 ⫾ 0.3
years; P ⫽ .001) than females.
The body mass index at the time of diagnosis was
21.5 ⫾ 0.4 kg/m2 (n ⫽ 119); no gender differences for
body mass index were detected (21.2 ⫾ 0.9 kg/m2 for
males vs. 21.7 ⫾ 0.4 kg/m2 for females; P ⫽ .3).
Although ‘vomiting’ was often the presenting
complaint, all but 1 of the 147 patients described
“effortless” postprandial regurgitation. Episodes of
regurgitation occurred after 2.7 ⫾ 0.1 meals per day
(n ⫽ 34). By the patients’ estimations, regurgitation
ARTICLES 159
commenced 21.1 ⫾ 5.7 minutes postprandially, me-
dian 10 minutes (n ⫽ 23), and persisted 72.3 ⫾ 9.4
minutes (n ⫽ 20). Reswallowing of regurgitated food
was described by 25 (17.0%) patients. On the other
hand, remastication of regurgitated food was docu-
mented in 4 (2.7%) patients. Nighttime episodes oc-
curred in only 3 (2.0%) patients.
In 15 (10.2%) patients, specific stressors were iden-
tified just before symptom onset including: 3 with
deaths in the immediate family; 3 starting school/
college; 2 accidents; 2 onset of sports season; 1 pa-
rental divorce; 1 geographical relocation; 1 change in
job for father; 1 change in church; and 1 going to
camp.
Associated Symptoms
Abdominal pain was an associated symptom in 56
(38.1%) patients. Other digestive tract symptoms in-
cluded: constipation in 31 (21.1%), nausea in 25
(17.0%), diarrhea in 12 (8.2%), bloating in 6 (4.1%),
and dental problems in 5 (3.4%).
Weight loss was reported in 62 (42.2%) patients;
the average weight loss in this group was 9.6 ⫾ 1.0
kg, (median: 7.1 kg; n ⫽ 56). Patients with weight loss
were older at symptom onset (14.5 ⫾ 0.6 years vs
11.6 ⫾ 0.6 years without weight loss; P ⫽ .0003) and
at the time of diagnosis (16.4 ⫾ 0.4 years vs 13.8 ⫾ 0.5
years without weight loss; P ⬍ .0001).
Medications Before Diagnosis
Before evaluation at Mayo Clinic Rochester, 78
(53.1%) patients were prescribed medications specif-
ically for symptoms associated with rumination; on
average, these patients received 1.8 ⫾ 0.1 types of
medications. Of note, no patients had significant
symptomatic improvement with medical therapy.
Sixty-six (45.0%) patients had been treated with acid-
blocking medications (histamine [H2] blockers
and/or proton pump inhibitors) and 56 (38.1%) with
prokinetic medications (cisapride, metoclopramide,
or erythromycin). Forty-three (29.3%) patients re-
ceived both acid-blocking and prokinetic medica-
tions. Twelve (8.2%) patients had been treated with
anti-emetic medications, 10 (6.8%) with antidepres-
sants, and 3 (2.0%) with narcotic pain medications.
Before evaluation at Mayo Clinic Rochester, 5
(3.4%) patients had required supplemental enteral
(via tube) or parenteral nutrition for management of
symptoms, dehydration, or nutritional support.
School/Work Absenteeism
Of the 44 patients with data available, 32 (72.7%)
had missed school or work because of symptoms. In
these 44 patients, rates of school/work absenteeism
were not significantly higher in patients with abdom-
inal pain; 83.3% of patients with abdominal pain had
missed school/work compared with 60.0% of pa-
tients without abdominal pain (P ⫽ .2).
Hospitalization
Of the 76 patients with data on hospitalizations
available in the medical record, 35 (46.1%) had been
hospitalized for evaluation of symptoms or treat-
ment of complications related to rumination. Patients
160 RUMINATION SYNDROME IN CHILDREN AND ADOLESCENTS
Downloaded from by guest on August 31, 2017
with prior hospitalizations were older at symptom
onset (15.0 ⫾ 0.8 vs 12.3 ⫾ 0.8 years; P ⫽ .02) and
older at the time of diagnosis (16.4 ⫾ 0.6 vs 14.6 ⫾ 0.6
years, P ⫽ .02) than patients who had not been
hospitalized. Of the 74 patients with historical data
available regarding weight loss and hospitalizations,
the prevalence of weight loss was significantly
higher in patients who had been hospitalized (58.8%
vs 30.0% in patients without prior hospitalizations;
P ⫽ .02).
Evaluation of Symptoms Before Diagnosis of
Rumination Syndrome
Laboratory studies were performed in 93 (63.3%)
patients; results were normal with the exception of
hypokalemia in 1 patient who had been previously
diagnosed with Bartter’s syndrome.
Results from structural studies performed both at
Mayo Medical Center and elsewhere before consul-
tation at Mayo including upper gastrointestinal bar-
ium series (performed on 53.7%), esophagogas-
troduodenoscopy (53.7%), abdominal ultrasound
(31.3%), small bowel follow-through (29.3%), abdom-
inal computed tomography (CT) scan (18.3%), bar-
ium enema (4.9%), flexible sigmoidoscopy (4.1%),
video swallow evaluation (2.0%), and colonoscopy
(1.4%) were noncontributory. Brain imaging was done
in 30 (20.5%) patients; results were normal by CT scan
in 16, magnetic resonance imaging scan in 11, and CT
and magnetic resonance imaging scans in 3.
Scintigraphic gastric emptying at 4 hours was de-
layed in 26 of the 56 patients assessed. Orocecal
transit at 6 hours, a surrogate marker for small bowel
transit, was assessed in 28 patients and was delayed
in 13 patients. However, 7 of the 13 patients with
delayed orocecal transit also had delayed gastric
emptying at 4 hours. Scintigraphic colonic transit
was generally performed in patients with constipa-
tion or diarrhea. The method and normal values
have been described elsewhere.6 Colonic transit was
abnormally slow in 5, and accelerated in 1 of the 12
patients tested.
Esophageal pH testing was performed in 24 pa-
tients; results were normal in 45.8%, and showed
reflux/regurgitation in 54.2%. None of the patients
tested had significant nocturnal or supine reflux, and
the majority with reflux/regurgitation had numer-
ous, brief postprandial episodes. Regurgitation/
reflux occurred ⬎200 times after a single meal in 1
patient. Gastroduodenal manometry was performed
in 65 patients; 55.4% were normal, 40% had rumina-
tion-waves, and 4.6% had antral hypomotility. Re-
gurgitation/vomiting during the gastroduodenal
manometry assessment occurred only in patients
with rumination-waves on manometry. Esophageal
manometry testing performed using the station-pull-
through technique at the conclusion of the gastrodu-
odenal manometry assessment was normal in all but
2 patients, 1 of whom had evidence of a hypertensive
lower esophageal sphincter and the other a hypo-
tonic lower esophageal sphincter.
The average number of the above diagnostic tests
performed per patient was 3.3 ⫾ 0.2 (median: 3;
range: 0 – 8).
Treatment and Outcomes
Behavioral treatment was recommended for 127 of
the 147 patients, and was undertaken at Mayo Clinic
Rochester in 71 patients. Medical treatment was rec-
ommended for 25 of the 147 patients including: H2-
blocker in 9, proton pump inhibitor in 3, prokinetic
medications (cisapride, erythromycin, or metoclo-
pramide) in 11, tricyclic antidepressants in 3, hyoscy-
amine in 1, and anti-emetic medication in 1. None of
the patients were treated with supplemental enteral
(via tube) or parenteral nutrition.
Outcome data were available for 54 (36.7%) pa-
tients. The mean duration of follow-up was 10.2 ⫾
1.4 months. The baseline characteristics and clinical
features of rumination for these 54 patients were
similar to those of patients without outcome data
available. The only significant differences between
the 2 groups were a slightly older age at diagnosis
(15.8 ⫾ 0.5 vs 14.5 ⫾ 0.4 years; P ⫽ .02) and a higher
prevalence of surgeries before diagnosis of rumina-
tion syndrome (19.2% vs 5.6%; P ⫽ .02) for patients
with outcome data available. Therefore, the outcome
data are likely representative of the group as a
whole.
Fifty-two of the 54 patients with outcome data
available had received behavioral treatment consist-
ing of biofeedback, relaxation training, instruction in
diaphragmatic breathing, and/or cognitive behav-
ioral therapy. Of the 46 patients in this group who
underwent behavioral treatment at Mayo Clinic
Rochester, the number of treatment sessions with a
behavioral medicine professional was 2.7 ⫾ 0.5 (me-
dian: 1; range: 1–19). Overall, symptoms resolved in
16 (29.6%), and improved in 30 (55.5%); therefore, a
positive impact on symptoms was noted in 85.1%. In
12.9%, no improvement in symptoms was noted at
the time of follow-up. The 2 patients who did not
receive formal behavioral therapy consultation re-
ceived reassurance and an explanation of the nature
of their condition, and were noted to have improve-
ment of symptoms at follow-up. One patient who
also suffered from Bartter’s syndrome died during
the course of follow-up.
Patients with symptomatic improvement had sig-
nificantly higher body mass indices at the time of
diagnosis than those whose symptoms remained un-
changed (body mass index: 21.9 kg/m2 vs. 19.0 kg/
m2; n ⫽ 46; P ⫽ .02). No other baseline characteristics
or clinical features had a significant impact on out-
come.
DISCUSSION
In adults, the diagnosis of rumination syndrome is
usually based on eliciting classical symptoms in the
absence of structural disease.3 Unfortunately, our ex-
perience at a tertiary care center suggests that pedi-
atric and adolescent patients with rumination syn-
drome often undergo extensive, costly, and invasive
testing, and are frequently misdiagnosed as having
gastroesophageal reflux disease or gastroparesis. We
believe that insufficient awareness of the clinical fea-
tures of rumination syndrome in pediatric and ado-
lescent patients contributes to the difficulty in diag-
Downloaded from by guest on August 31, 2017
nosing this important medical condition. Formal
diagnostic criteria for rumination syndrome occur-
ring in children and adolescents with onset beyond
infancy have not been defined in the consensus cri-
teria.1
In the current study, gastric emptying was delayed
in 46% of patients assessed. However, there are a
number of caveats in the interpretation of scinti-
graphic gastric emptying tests in children and ado-
lescents with rumination syndrome. Delayed gastric
emptying may result from regurgitation and reswal-
lowing of food, which is then delivered intermit-
tently or later to the distal stomach for digestion and
mixing. Another caveat in the interpretation of the
scintigraphic gastric emptying test is the potential for
expulsion of the radiolabeled meal; when the major-
ity of the test meal is expelled, the study cannot be
completed. Although an assessment of gastric emp-
tying may help to exclude a significant stomach dys-
motility and a normal result may reassure the patient
and family, abnormal results should be interpreted
carefully in the setting of rumination.
In contrast to the relatively common observation of
delayed gastric emptying in the patient population
reported, antral hypomotility was extremely rare on
formal testing with manometry. Although gastrodu-
odenal manometry has been advocated as a diagnos-
tic test in the setting of rumination,7 only 40% of the
65 patients assessed in our study had characteristic
R-waves or simultaneous pressure spikes across all
sensors, suggesting an extraintestinal stimulus and
contraction of the abdominal musculature. In addi-
tion, gastroduodenal manometry is an invasive test
requiring significant technical and interpretive ex-
pertise, and is only available in tertiary care centers.
In general, we do not advocate esophageal pH
testing in patients with rumination, because quanti-
tatively abnormal ‘reflux’ is a consequence rather
than a cause of the symptoms. When prolonged pH
testing is performed for suspected gastroesophageal
reflux disease, rumination syndrome is characterized
by the predominance of postprandial regurgitation
of acid, rather than supine or nocturnal reflux, both
of which occur in classical gastroesophageal reflux
disease.8,9
Abnormal relaxation of the lower esophageal
sphincter, a common cause of classical gastroesoph-
ageal reflux disease in pediatric patients,10 is also
involved in the process of rumination. Thurmshirn et
al11 showed the mechanism of rumination involves
relaxation of the lower esophageal sphincter in re-
sponse to lower pressures in the fundus, and in-
creased gastric sensitivity. In healthy adults, there is
active contraction at the esophagogastric junction
and increased lower esophageal sphincter pressure
during periods of increased intraabdominal pres-
sure;12 tonic contraction of the crural diaphragm is
the proposed mechanism for this response. This
mechanism is altered in the setting of rumination
syndrome as transient lower esophageal sphincter
relaxations occur after abdominal straining events.13
In addition to postprandial regurgitation, many
patients in our study had other gastrointestinal
symptoms including abdominal pain (38.1%), consti-
ARTICLES 161
pation (21.1%), and nausea (17.0%). The presence of
additional gastrointestinal symptoms may induce
physicians to recommend more extensive diagnostic
testing. However, our study demonstrates that such
testing is not helpful in the presence of typical clin-
ical features of rumination.
Weight loss was also commonly associated with
rumination, despite normal body mass indices at the
time of diagnosis. Considering the female predomi-
nance of the condition and the frequent occurrence of
weight loss, classical eating disorders such as an-
orexia nervosa and bulimia nervosa should be con-
sidered in the differential diagnosis. However, in our
study population, eating disorders had been diag-
nosed in only 3.4% of patients. Previous studies have
described a history of eating disorders (primarily
bulimia nervosa) in a larger proportion of adult pa-
tients with rumination syndrome.14 –16 Although
weight loss is a concerning symptom in children and
adolescents, we do not believe that weight loss is an
indication for more exhaustive diagnostic testing in
the presence of classical clinical features of rumina-
tion syndrome.
In general, rumination syndrome is a “benign”
condition.17 However, our study demonstrates sig-
nificant functional disability related to weight loss,
school and work absenteeism, hospitalization, and
extensive diagnostic testing in pediatric and adoles-
cent patients with rumination. Early recognition of
the clinical features of rumination and referral for
behavioral treatment help to reduce adverse conse-
quences in this patient population.
The current behavioral treatment for rumination
syndrome at our medical center consists of habit
reversal using diaphragmatic breathing as the com-
peting response.18 Habit reversal is an empirically
supported behavioral paradigm wherein a problem-
atic or target behavior can be eliminated by the con-
sistent use of an incompatible or competing behav-
ior. In this instance, one cannot perform the target
behavior and the competing response at the same
time. In the case of rumination, consistent cued prac-
tice of diaphragmatic breathing during rumination
effectively eliminates rumination, after proper train-
ing in both habit reversal and diaphragmatic breath-
ing. The vast majority of patients in our study had
significant symptomatic improvement, and many
had resolution of symptoms after behavioral treat-
ment. The median number of treatment sessions re-
quired was 1. Rumination complicated by comorbid
medical, psychological, or psychiatric conditions
may require additional therapeutic interventions.
CONCLUSION
There is a need for consensus clinical criteria for
the diagnosis of rumination syndrome in children
and adolescents. We would propose the criteria in
Table 1. With typical clinical features, extensive di-
agnostic testing including gastroduodenal manome-
try and esophageal pH testing is unnecessary. Early
intervention with behavioral modification is advo-
cated. Outcomes in children and adolescents who
have received behavioral therapy have been so fa-
162 RUMINATION SYNDROME IN CHILDREN AND ADOLESCENTS
Downloaded from by guest on August 31, 2017
TABLE 1. Proposed Criteria for Rumination Syndrome in
Children and Adolescents
At least 6 wk, which may not be consecutive, in the previous
12 mo of recurrent regurgitation of recently ingested food
which:
1. begins within 30 min of meal ingestion
2. is associated with either reswallowing or expulsion of food
3. stops within 90 min of onset or when regurgitant becomes
acidic
4. is not associated with mechanical obstruction
5. does not respond to standard treatment for
gastroesophageal reflux disease (ie, medical therapy or
lifestyle modification measures)
6. is not associated with nocturnal symptoms
vorable at our institution (⬎80% success) that a for-
mal, controlled clinical trial has not been pursued.
Collaboration between gastroenterologists, pediatri-
cians, and psychologists in addition to educating
patients and family members are key elements to a
successful outcome.
ACKNOWLEDGMENTS
This work was supported in part by grants R01-DK54681 and
K24-DK02638 (to Dr Camilleri) and by General Clinical Research
Center grant (#RR00585) from the National Institutes of Health.
We thank Cindy Stanislav for excellent secretarial assistance.
REFERENCES
1. Clouse RE, Richter JE, Heading RC, Janssens J, Wilson JA. Functional
esophageal disorders. Gut. 1999;45(suppl 2):II31-II36
2. Malcolm A, Thumshirn MB, Camilleri M, Williams DE. Rumination
syndrome. Mayo Clin Proc. 1997;72:646 – 652
3. O’Brien MD, Bruce BK, Camilleri M. The rumination syndrome: clinical
features rather than manometric diagnosis. Gastroenterology. 1995;108:
1024 –1029
4. Soykan I, Chen J, Kendall BJ, McCallum RW. The rumination syndrome:
clinical and manometric profile, therapy, and long-term outcome. Dig
Dis Sci. 1997;42:1866 –1872
5. Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional
gastrointestinal disorders. Gut. 1999;45(suppl 2):II60-II68
6. Camilleri M, Zinsmeister AR. Towards a relatively inexpensive, nonin-
vasive, accurate test for colonic motility disorders. Gastroenterology.
1992;103:36 – 42
7. Amarnath RP, Abell TL, Malagelada JR. The rumination syndrome in
adults. A characteristic manometric pattern. Ann Intern Med. 1986;105:
513–518
8. Harvey RF, Gordon PC, Hadley N, et al. Effects of sleeping with the
bed-head raised and of ranitidine in patients with severe peptic oesoph-
agitis. Lancet. 1987;2:1200 –1203
9. Tytgat GN, Nio CY, Schotborgh RH. Reflux esophagitis. Scand J Gastro-
enterol Suppl. 1990;175:1–12
10. Cucchiara S, Bortolotti M, Minella R, Auricchio S. Fasting and postpran-
dial mechanisms of gastroesophageal reflux in children with gastro-
esophageal reflux disease. Dig Dis Sci. 1993;38:86 –92
11. Thumshirn M, Camilleri M, Hanson RB, Williams DE, Schei AJ, Kam-
mer PP. Gastric mechanosensory and lower esophageal sphincter func-
tion in rumination syndrome. Am J Physiol. 1998;275:G314 –G321
12. Mittal RK, Fisher M, McCallum RW, Rochester DF, Dent J, Sluss J.
Human lower esophageal sphincter pressure response to increased
intra- abdominal pressure. Am J Physiol. 1990;258:G624 –G630
13. Smout AJ, Breumelhof R. Voluntary induction of transient lower esoph-
ageal sphincter relaxations in an adult patient with the rumination
syndrome. Am J Gastroenterol. 1990;85:1621–1625
14. Larocca FE, Della-Fera MA. Rumination: its significance in adults with
bulimia nervosa. Psychosomatics. 1986;27:209 –212
15. Larocca FE. Rumination in patients with eating disorders. Am J Psychi-
atry. 1988;145:1610
16. Eckern M, Stevens W, Mitchell J. The relationship between rumination
and eating disorders. Int J Eat Disord. 1999;26:414 – 419
17. Levine DF, Wingate DL, Pfeffer JM, Butcher P. Habitual rumination: a
benign disorder. Br Med J (Clin Res Ed). 1983;287:255–256
18. Wagaman JR, Williams DE, Camilleri M. Behavioral intervention for the
treatment of rumination. J Pediatr Gastroenterol Nutr. 1998;27:596 –598
Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and
Prognosis
Heather J. Chial, Michael Camilleri, Donald E. Williams, Kristi Litzinger and Jean
Perrault
Pediatrics 2003;111;158
DOI: 10.1542/peds.111.1.158
Updated Information & including high resolution figures, can be found at:
Services /content/111/1/158.full.html
References This article cites 18 articles, 1 of which can be accessed free
at:
/content/111/1/158.full.html#ref-list-1
Citations This article has been cited by 7 HighWire-hosted articles:
/content/111/1/158.full.html#related-urls
Post-Publication One P3R has been posted to this article:
Peer Reviews (P3Rs) /cgi/eletters/111/1/158

Subspecialty Collections
Permissions & Licensing
Reprints
This article, along with others on similar topics, appears in
the following collection(s):
Gastroenterology
/cgi/collection/gastroenterology_sub
Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
/site/misc/Permissions.xhtml
Information about ordering reprints can be found online:
/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on August 31, 2017

Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and
Prognosis
Heather J. Chial, Michael Camilleri, Donald E. Williams, Kristi Litzinger and Jean
Perrault
Pediatrics 2003;111;158
DOI: 10.1542/peds.111.1.158

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/111/1/158.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on August 31, 2017