RUMINATION DISORDER Lexy Moore

INTRODUCTION 16-year-old female diagnosed with rumination disorder.Rumination disorder was an interesting and new disease to study

OBJECTIVES Background information on rumination diseaseNutrition Implications Literature review dealing with rumination diseaseNutrition Care Process o Nutrition assessment o Nutrition diagnosis o Nutrition intervention o Nutrition monitoring and evaluation

Conclusion

INTRODUCTION OF RUMINATION DISORDERRepeatedly regurgitate food after eatingNo nausea or involuntary vomitingThe 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 regurgitationoOr an eating disorder

Regurgitation occurs several times a week, typically dailyRumination in adults of average intelligence has been associated with psychological distress such as depression and chronic anxiety

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/vomiting3.Cessation of regurgitation once gastric content is

acidified4.Does not occur during sleep5.Regurgitation food has a pleasant taste6.Symptoms do not respond to anti-GERD medications

(antacids, prokinetic agents, antiemetics)

PATHOPHYSIOLOGY

The pathophysiology is poorly understoodThe 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 deficienciesNo diagnostic tests for rumination disease

TREATMENT Behavioral techniques oRelaxationoBiofeedback oDiaphragmatic breathing

Psychiatric consultation may also be helpfulDrug therapy generally does not help with rumination disorderHealth risks related to vomiting and rumination include malnutrition, weight loss, dehydration, tooth decay, choking, and gastrointestinal bleeding If untreated, death from malnutrition may occurMay require enteral or parenteral nutrition support if patient is on clear liquids or nothing by mouth (NPO) status due to inadequate nutritional intake

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 breathingoConsumption 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- calorie tube-feeding formula

DIETARY REFERENCE INTAKESCalorie 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

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 psychologistsEducating patients and family members

PATIENT HISTORY16-year-old female diagnosed with rumination disorderAbout a year of vomiting occurring 1-2 times per day on averageFirst 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 disorderPatient has not been eating for the last 5 days due to vomitingPatient has associated abdominal spasms after vomitingShe feels all her anxiety is related to her vomiting

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

NUTRITION ASSESSMENTANTHROPOMETRICS 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 weighto75-90%ile for lengtho75-90%ile for BMI Z-score of 1.26 (no risk of malnutrition).

INTERPRETATION OF Z-SCORES Degree Z-score

Mild or at risk for malnutrition -1 to -1.9

Moderate -2 to -2.9

Severe < -3

BIOCHEMICAL Lab Test Normal Range Encounter Result

Sodium (mmol/L) 136.0-145.0 142

Potassium (mmol/L) 3.5-5 4.7

Chloride (mEq/L) 100-110 112

BUN (mg/dL) 8.0-26.0 6

Glucose (mg/dL) 65-99 114

Magnesium (mg/dL) 1.6-2.6 2.2

Phosphorus (mg/dL) 2.5-4.7 4.0

CURRENT MEDICATIONS Fluoxetine Vistaril Dextrose 5%/ NaCl 1000 mL + 20 mEq KCl Buspar Phenol oral spray Erythromycin Ethylsuccinate oral liquid Prilosec

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)

NUTRITION DIAGNOSIS Altered GI function related to vomiting as evidenced by the need for enteral nutrition feeding to meet estimated needs.

 

NUTRITION INTERVENTIONOnce NGT is placed start continuous enteral feeding of 1500 ml of Jevity 1.2 +980 ml of water run @103 ml/hrThis 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 kgRecommend 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

NUTRITION MONITORING AND EVALUATIONThe EGD biopsy results once again were normalThe patient’s tube feeding placement went well (some emesis with initiation)She is now tolerating Jevity 1.2 @50 ml/hrIncrease the rate of tube feeding as toleratedContinue to monitor tolerance to enteral nutrition and body weightIf any aspiration occurs with the NGT, a tube in the small bowel may be acceptable

NUTRITION MONITORING AND EVALUATION Monitor B vitamins, especially ThiaminFluid status should be monitored often: oElectrolytesoClinical observations (dehydration)oWeight fluctuationsoIntake and output recordsPotassium, magnesium and phosphate should be monitored for refeeding syndrome

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 healthMD discussed multidisciplinary behavioral modification therapy at a rumination clinic at Nationwide Children’s Patient will be a candidate for their inpatient programOffer best care with a multidisciplinary team that specializes in rumination disorder

NATIONWIDE CHILDREN’S

Multiple experts working to eliminate rumination behavior:GastroenterologyPediatric psychologyClinical nutritionChild lifeMassage therapyTherapeutic recreation

Daily Schedule includes: Times with each therapistSpecific times each day in which patients work on their eating skills Found that patients age 12and older seem to do the best in our programTreatment approach requires patients to have insight into their challenges, be able to work independently, and have the ability to work continuously throughout the day.

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    

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 bleedingBehavioral techniques like relaxation, biofeedback, using the diaphragm instead of the chest muscles to breathe for mild casesMore severe cases with weight loss may require continuous enteral nutrition support Multidisciplinary team Need for more case-controlled studies Thank you for everything!!!

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.

REFERENCES CONT. Nausea and Vomiting. Nutrition Care Manual. 2016. Available at https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=20079&ncm_heading=Nutrition%20Care&ncm_content_id=83027#BiochemicalandNutrientIssue. 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.