3. OBJECTIVES
Background information on rumination
disease
Nutrition Implications
Literature review dealing with rumination
disease
Nutrition Care Process
o Nutrition assessment
o Nutrition diagnosis
o Nutrition intervention
o Nutrition monitoring and evaluation
4. INTRODUCTION OF
RUMINATION DISORDER
Repeatedly regurgitate food after eating
No nausea or involuntary vomiting
The food may be spit out or reswallowed
Behavior must occur over a period of ≥ 1 month
oMust not be caused by a GI disorder that can lead to
regurgitation
oOr an eating disorder
Regurgitation occurs several times a week, typically
daily
Rumination in adults of average intelligence has been
5. ROME III DEFINITION OF RUMINATION
SYNDROME GREEN AD, ET AL.
Must Include:
1.Persistent/recurrent regurgitation of recently ingested
food into the mouth with subsequent reswallowing or
spitting out.
2.No preceding nausea/vomiting
3.Cessation of regurgitation once gastric content is
acidified
4.Does not occur during sleep
5.Regurgitation food has a pleasant taste
6. PATHOPHYSIOLOGY
The pathophysiology is poorly understood
The disorder is probably a learned,
maladaptive habit
oLearn to open the lower esophageal sphincter and
propel gastric contents into the esophagus and
throat by increasing gastric pressure through
rhythmic contraction and relaxation of the
diaphragm
May lose weight or develop nutritional
7. TREATMENT
Behavioral techniques
oRelaxation
oBiofeedback
oDiaphragmatic breathing
Psychiatric consultation may also be helpful
Drug therapy generally does not help with rumination disorder
Health risks related to vomiting and rumination include
malnutrition, weight loss, dehydration, tooth decay, choking,
and gastrointestinal bleeding
If untreated, death from malnutrition may occur
May require enteral or parenteral nutrition support if patient is
on clear liquids or nothing by mouth (NPO) status due to
8. NUTRITION RECOMMENDATIONS FOR
PROLONGED VOMITING AND
RUMINATION DISORDER
Dehydration, electrolyte, and acid-base imbalance
may occur
Mild cases where no weight loss is present:
oThe practice of reswallowing regurgitated food
oPractice of diaphragmatic breathing
oConsumption of very small, very frequent meals
oChewing gum after meals to increase the frequency of swallow
Significant weight loss, failure to thrive, and/or
malnutrition:
o24-hour continuous enteral nutrition support with a high-
9. DIETARY REFERENCE
INTAKES
Calorie Requirement:
o14-16 is 1760 kcal/day (33 kcal/kg/d)
Protein Requirement:
o46 g protein/day (0.85 g protein/kg/d)
Fluid Requirement:
Baseline fluid requirements for patients >20 kg is 1500 ml +
20 mL/kg for each kg above 20 kg
10. CHIAL, CAMILLERI, ET AL.
Methods: Review of the medical records for all 147
patients ages 5 to 20 dx with rumination disease
between 1975 and 2000
Results and Conclusions:
Early intervention with behavioral modification is advocated
Over 80% success in children and adolescents who have
received behavioral therapy (biofeedback, relaxation training,
instruction in diaphragmatic breathing, and/or cognitive
behavioral therapy)
Collaboration between gastroenterologists, pediatricians, and
psychologists
11. PATIENT HISTORY
16-year-old female
diagnosed with rumination
disorder
About a year of vomiting
occurring 1-2 times per day
on average
First EGD was normal and
they started her on proton
pump inhibitor (PPI)
Depression and anxiety
disorder
Patient has continued to
vomit 1 to 2 times a day since
diagnosis of rumination
disorder
Patient has not been eating
for the last 5 days due to
vomiting
Patient has associated
abdominal spasms after
vomiting
She feels all her anxiety is
related to her vomiting
12. ENTRY INTO NCP
Admitted to the hospital for vomiting and a 5
lb. weight loss over a 5-day period
The patient was scheduled for an EGD and
NGT placement
Referred to the RD for a tube feeding
recommendation
13. NUTRITION ASSESSMENT
ANTHROPOMETRICS
Admit weight was 73.6 kg (162 lbs.)
Height was 168 cm (66 in)
BMI of 26.1 kg/m2 (overweight category)
Growth Charts (CDC 2-20 girls):
o90-95%ile for weight
o75-90%ile for length
o75-90%ile for BMI
Z-score of 1.26 (no risk of malnutrition).
17. ESTIMATED NEEDS
Estimated Calorie Needs:
o1800 total calories/day (33 kcal/kg/d)
Estimated Protein Needs:
o>54 g protein/day (1.0 g protein/kg/d)
Estimated Total Fluid Needs:
o2180 ml/day
***Based on 54 kg (50th%ile weight for age)
18. NUTRITION DIAGNOSIS
Altered GI function related to vomiting as
evidenced by the need for enteral nutrition
feeding to meet estimated needs.
19. NUTRITION INTERVENTION
Once NGT is placed start
continuous enteral feeding of
1500 ml of Jevity 1.2 +980 ml
of water run @103 ml/hr
This provides 1800
calories/day (33
calories/kg/d), 83 g protein
(1.5 g protein/kg/d) and 2180
ml free fluid/day based on 54
kg
Recommend starting at 25
ml/hr and advancing by 25 ml
every 4 hours to goal rate
Goals:
1. Tolerance to enteral
feeding, by time of next
nutrition intervention
2. Stable weight
20. NUTRITION MONITORING AND
EVALUATION
The EGD biopsy results once again were normal
The patient’s tube feeding placement went well
(some emesis with initiation)
She is now tolerating Jevity 1.2 @50 ml/hr
Increase the rate of tube feeding as tolerated
Continue to monitor tolerance to enteral nutrition
and body weight
If any aspiration occurs with the NGT, a tube in the
small bowel may be acceptable
21. NUTRITION MONITORING AND
EVALUATION
Monitor B vitamins, especially Thiamin
Fluid status should be monitored often:
oElectrolytes
oClinical observations (dehydration)
oWeight fluctuations
oIntake and output records
Potassium, magnesium and phosphate should be
monitored for refeeding syndrome
22. NUTRITION MONITORING AND
EVALUATION
Early recognition of the clinical features of
rumination and referral for behavioral treatment
to help reduce adverse consequences is vital to
the patient’s overall health
MD discussed multidisciplinary behavioral
modification therapy at a rumination clinic at
Nationwide Children’s
Patient will be a candidate for their inpatient
program
23. NATIONWIDE CHILDREN’S
Multiple experts working to
eliminate rumination behavior:
Gastroenterology
Pediatric psychology
Clinical nutrition
Child life
Massage therapy
Therapeutic recreation
Daily Schedule includes:
Times with each therapist
Specific times each day in which
patients work on their eating
skills
Found that patients age 12
and older seem to do the best in
our program
Treatment approach requires
patients to have insight into their
challenges, be able to work
independently, and have the
ability to work continuously
24. FUTURE DIRECTION
More variety of participants in studies
Overall case-controlled studies on participants
with rumination disorder
Rumination complicated by comorbid medical,
psychological, or psychiatric conditions may
require additional therapeutic interventions
Clinical features, extensive diagnostic testing
including gastroduodenal manometry and
esophageal pH testing is unnecessary
25. CONCLUSION
In rumination disorder, patients repeatedly regurgitate food after
eating, but they have no nausea or involuntary vomiting
The behavior must occur over a period of ≥ 1 month and must not
be caused by a GI disorder that can lead to regurgitation or an eating
disorder
Health risks related to vomiting and rumination include
malnutrition, weight loss, dehydration, tooth decay, choking, and
gastrointestinal bleeding
Behavioral techniques like relaxation, biofeedback, using the
diaphragm instead of the chest muscles to breathe for mild cases
More severe cases with weight loss may require continuous enteral
nutrition support
Multidisciplinary team
26. REFERENCES
Introduction to Eating Disorders. The Merck Manual Professional
Version. 2015. Available at
http://www.merckmanuals.com/professional/psychiatric-
disorders/eating-disorders/introduction-to-eating-disorders.
Accessed on February 23, 2016.
Developmental Disabilities. Nutrition Care Manual. 2015. Available at
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&
ncm_toc_id=255356&ncm_heading=Nutrition%20Care&ncm_content_
id=110329#DiseaseProcess. Accessed on February 23, 2016.
Rumination. The Merck Manual Professional Version. 2015. Available
at http://www.merckmanuals.com/professional/gastrointestinal-
disorders/symptoms-of-gi-disorders/rumination. Accessed on
February 23, 2016.
Land R, Mulloy A, Giesbers S et al. Behavioral interventions for
rumination and operant vomiting in individuals with intellectual
disabilities: A systematic review. Research in Developmental
Disabilities. 2011;32: 2193-2205.
27. REFERENCES CONT.
Nausea and Vomiting. Nutrition Care Manual. 2016. Available at
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_t
oc_id=20079&ncm_heading=Nutrition%20Care&ncm_content_id=83027#Bio
chemicalandNutrientIssue. Accessed on February 23, 2016.
Dietary Reference intakes: The essential guide to nutrition requirements
divided into smaller groupings. Based on NCHS/CDC 200 Growth charts.
Institute of Medicine. 2006.
Johnson, KB. Fluid and Electrolytes. The Harriet Lane Handbook. St. Louis. CV
Mosby 1993: 164-165.
Green AD, Alioto A, Mousa H, DiLorenzo C. Severe pediatric rumination
syndrome: successful interdisciplinary inpatient management. J Pediatr
Gastroenterol Nutr. 2011;52:414-418.
