RUMINATION:
A
PSYCHOSOMATIC
SYNDROME
OF
INFANCY
By Julius B. Richmond, M.D., Evelyn Eddy, M.D., and Morris Green, M.D.
Department of Pediatrics, State University of New York Upstate Medical Center at Syracuse (J.R. and E.E.), and Department of Pediatrics, School of Medicine, Indiana University (M.G.)
(Accepted February 11, 1958; submitted January 25.)
ADDRESS: (J.B.R.) Syracuse Memorial Hospital, Syracuse 10, New York.
49
R
UMINATION may be defined as there-gurgitation of previously swallowed
food and the rechewing and reswalbowing
of the food. In ruminating animals this
process is, of course, physiologic. Because
of the withdrawal of the ruminating animal
from the herd and the air of introspection
and contemplation which seems to be
as-sociated with the process, rumination has
also come to mean deliberate meditation or
reflection.
When rumination occurs in infants-in
contrast to animals-it is not a physiologic process. Upon regurgitation, the infant
un-dertakes some rechewing and
reswallow-ing movements which are not complete.
The considerable food and fluid loss
result-ing is self-destructive inasmuch as
inani-tion, fluid and electrolyte disturbances, and
loss of life, may result if the process is
un-interrupted.
The pediatric literature of the early
decades of this century abounds in reports
on rumination. A comprehensive historic
review has been presented by Kanner.1 It is
of interest to note that with the exception
of a publication by Lounie2 the subject has
received little attention in the American
pediatric literature of the past decade. This
may be a reflection of the decline in
inci-dence of this disorder. It is the impression
of many pediatricians that rumination is
considerably less prevalent than it was in
the early decades of this century and that
this is a result of the over-all improvement
in infant care as a consequence of
improv-ing social and economic conditions.
The literature reflects the confusion
which has prevailed concerning this
syn-drome. Speculations concerning anatomic
and physiologic abnormalities are abundant.
Numerous feeding techniques and a barge variety of mechanical devices-particularly
“ruminator caps”-were designed in an effort
to prevent rumination. A thread runs through all the literature: that there
prob-ably are pyschologic factors related to the
development of the disorder. The emphasis
generally was on the “neuropathic traits” of
the infant. Very little attention was given
to parent-infant interaction. Our study has
therefore been concerned with such
observ-ations.
Because it so effectively describes the
syndrome, the following is quoted from an
article by Cameron3 published in 1925: “All
my cases have been in artificially fed
in-fants. After taking the meal quite in the
ordinary way, the baby, as a rule, lies quiet
for a time. Then begin certain purposive
movements, by which the abdominal
mus-des are thrown into a series of violent
con-tractions-the head is held back, the mouth
is opened, while the tongue projects a little
and is curved from side to side so as to
form a spoon-shaped concavity on its dorsal
surface. After a varying time of persistent
effort, sometimes punctuated by grunting or
whimpering sounds, expressive of irritation
at the failure to achieve the expected result,
with each contraction of the abdominal
muscles milk appears momentarily in the
pharynx at the back of the mouth. .. .
Final-ly a successful contraction ejects a great
quantity of milk forwards into the mouth. The infant lies with an expression of
su-preme satisfaction upon its face, sensing the
regurgitated milk and subjecting it to
innumerable sucking and chewing
move-ments. . . . It is very evident that
achieve-ment of his purpose produces a sense of
beatitude, while failure results in nervous
unrest and irritation. . . . The power to
ruminate successfully is not suddenly
ac-quired. In the earliest stages, before
dex-terity has been achieved, the act differs
relatively little from that of vomiting. . . . In
its earlier development, therefore,
rumina-tion is very apt to be mistaken for habitual
vomiting due to other causes, and it may
require careful observation to make the
dis-tinction evident. Nor are such babies easy
to observe. It is characteristic of the
rumi-nating child that it sins its sin only in secret.
To watch it openly is to put a stop to the
whole procedure. . . . Only when the child
is alone and in a drowsy, vacant state, while
nothing distracts attention or excites
curi-osity, does the act take place.”
OBSERVATIONS
Our study includes observations of four
infants and their mothers. There is
rela-lively limited data on the fathers. Although
the nature of the problems encountered in
these families placed significant limitations
on the observations which could be
oh-tamed, the information which is available
does provide some basis for furthering our
understanding of this disorder.
The data which has been obtained are
summarized in Table I. We may note that
although some gastrointestinal disturbances
might have been present earlier, the
young-est age of onset of rumination was 3%
months. All of the babies in this study were
males, although this has not been true of
all reported cases. The degree of
under-weight was rather considerable as estimated
from accepted standards. None of the
in-fants in this series was breast-fed.
The diagnoses which had been considered
prior to the recognition of the syndrome of
rumination are of interest. In the first
pa-tient, the constant loss of food and the
rela-tively low concentration of chloride in the
serum, associated with constant loss of
gas-tric juice, suggested the diagnosis of adrenal
insufficiency, for which this infant had been
treated without success for a number of
weeks. Other diagnoses considered were
pyboric stenosis, food allergies, duodenal
ulcer, esophageal abnormalities and severe
feeding problems of unspecified origin.
These mistaken diagnoses have particular
significance for the pediatrician since
physi-cal deterioration of the child and loss of life
may occur if the true nature of the problem
continues to be unrecognized. Thus,
al-though the syndrome is not common, it is
important for the pediatrician to keep it in
mind in differential diagnosis of
gastroin-testinal disorders of infants.
The nature of the underlying disorder in
this syndrome is suggested by the presence
of associated neurotic traits. In the first
pa-tient, autistic posturing was prominent; in
the second patient, there was excessive
genital and fecal play, body rocking, head
rolling and banging, and autistic play with
his hair. In the third patient, head rolling
was prominent, and in the fourth patient
there was excessive finger and thumb
suck-ing.
We were struck by the apparent
preoc-cupation of the infant with himself when
left alone or in the process of ruminating.
The act of rumination would not occur
when there was significant stimulation in the
immediate environment. Although these
in-fants were described as having somewhat
flattened affect, their response to stimulation
was prompt. Most significant perhaps was
the widely opened and searching
appear-ance of the eyes, which was designated by
some of the staff as “radar-like.”
The observations of the mothers revealed
considerable incapacity to relate adequately
to the baby. In one case we had relatively
little data concerning the mother beyond
that a diagnosis of psychopathic personality
had been made by a psychiatrist. The baby
was born out of wedlock, and the mother
had all but abandoned him. He was cared
for largely by a relatively ineffective foster
mother until the time we saw him.
Although there is considerable detail
Patient Age (mo) Re-On- fer-set ral Sex Weight (kg) - Ad-Birth mis-sion Ap-prox. % Un-derwt. #{149} ‘#{176}“ Diagnoses Associated Neurotic Traits Maternal Characteristics
R.C. 34 6 M S.2 5.1 31 Adrenal
in-sufficiency
Autistic
postur-ing
Striking immaturity.
Fear that baby would die. Severely compulsive; fearful
re-gurgitation would soil
furiii-ture or clothes.
1)id not voluntarily come to
vis-it baby ill hospital.
T.B. 8 20 M 2.5 8.18 25
Pyloric
sten-osis
Possible ad-renal
in-sufikiency
Genital and
fe-cal play Body rocking Head rolling and banging Autistic play with hair
Mother’s early care in an
insti-tution and multiple foster
homes.
An unwanted pregnancy;
reli-gious conflict.
Fear fetus would die.
Continued preoccupation about
death of child.
Conscious attempts at
compen-sation for the above; strong
tendency for projection of
problems onto organic
disor-ders.
I).E. 5 7 iI 3 .05 4.83 44 Severe
feed-ing problem
Head rolling
Psychiatric diagnosis of
psycho-pathic personality. No
addi-tional information available.
R.M. 4 10 M 2.6 . 6.0 31 Severe feed-ing prob-lem Food allergy Pylorospasm Celiac syn-drome Esophageal chalasia Duodenal ulcer Finger and thumb suck-ing
Extremely compulsive; fearful
regurgitation would soil
furni-ture.
Fear that baby would die of
can-cer (her father died of cancer 2
years previously with vomit-ing as a major symptom). Depressed.
Provided very little physical
con-tact with baby (stated he
pre-ferred to be left alone).
Fearful that baby would love
father more.
Marital discord over care of
baby.
51
TABLE I
SUMMARY OF CLINICAL MANIFESTATIONS
which it might be interesting to present, the
following problems seemed common to
each:
1. A striking inability to fulfill an adult
psychosexual role which reflects itself as
an incapacity to want, accept, and give to
the baby. In one case this was sufficiently
striking as to suggest the diagnosis of pre-psychotic behavior; in one mother, as al-ready indicated, the diagnosis of
psycho-pathic personality was made.
2. Marital conflict. This is undoubtedly in
part a reflection of the immaturity observed
husbands also had significant
psychopathol-ogy. There seemed to be very little evidence
of any mature love relationship in the
family. Ultimately, the conflict extended to
the management of the symptoms which the
baby manifested.
3. The fear that the baby would die. This
would also seem related to the inability of
these women to mother their infants and
probably is a reflection of death wishes
which these mothers may harbor.
There were other observations which
were not common to all of the mothers.
Marked compulsivity and fear that
regurgi-tation would soil furniture and clothes were
observed in two of the mothers; one mother
was considerably depressed and was fearful
that the baby would have greater love for
the father.
As an illustration of the case material, the
following brief summary of one case is
pre-sented.
History
CASE REPORT
T.B., a 20-month-old white male, was
ad-milled to the hospital for vomiting, electrolyte
imbalance and malnutrition.
He was the third and youngest of three
children of a 36-year-old mother and 37-year-old father. The siblings were 4 and 7 years of
age, respectively. The pregnancy was
un-wanted; religious background intensified the
mother’s conflict regarding these feelings. The
mother’s blood type was Rh negative; this
necessitated more than the usual number of
visits to the obstetrician. A rising Rh antibody
titer during the latter months of pregnancy
added to the earlier feeling that there would
be something wrong with the infant and that it
would die.
The patient weighed 2,460 gm at birth, after
a precipitous delivery. An exchange
transfu-sion was done, and apparently the infant im-proved rapidly and was discharged from the hospital at 6 days of age.
The patient was bottle-fed; the bottle was
never propped, though the mother stated she
had done so with the other children. He seemed
eager to feed, but fussed continually through
the feeding. No difficulty was encountered with
the addition of solid foods.
The mother reported that the patient refused
the bottle entirely at 8 months of age, and took little fluid for more than 1 week. He then began to accept cup feedings, and within a few days
began “vomiting.”
He sat at 9 months of age and walked at 1
year. At 20 months he spoke relatively little and communicated mainly by signs. He had been noted to roll the head and body, and to bang the head. The mother stated he did not respond to pain like other children and that he would obey only when vigorously spanked. He frequently played with feces and the mother stated that she had rubbed feces in his mouth in an attempt to make him as disgusted as she, since she was very disturbed by the habit.
Physical Findings and Course
The patient was thin, dehydrated, pale,
list-less, and ruminating. Physical examination was
otherwise not contributory. It soon became
ap-parent after admission to the hospital that the
patient was ruminating rather than vomiting. At
the time of admission, this occurred about 20
times a day. When alone the patient was oh-served to engage in a number of rhythmic bodily activities such as head rolling, head banging, and body rocking. He would also play with the genitalia and feces. Rumination could
be interrupted by diverting his attention. For
example, it was not possible to record rumina-lion on motion picture film because of his
inter-est in the activities going on about him.
Although the appearance was that of a small
lonely boy with flattened affect, he would smile
when given close attention by nursing staff and
would cry when left by the nurse. He ceased ruminating while in the hospital, as the nursing
staff provided stimulating tender and intimate
care, and he gained 1 ,800 gm in a period of 2 months.
Family and Social Background
Interviews with the mother revealed
con-tinued fear that the child would die and
in-sistence that there must be some organic cause
for the difficulty. Her continued rejection of him was evident from the statement that when she took him home from the hospital, he would not get very much of her time and attention, since he had already had a disproportionate amount at the expense of the other children.
During the interview, emotional instability was
fidgeting. She had considerable concern about
her own health; she gave no indication of
con-cern over the needs of her husband.
The maternal grandmother was 17 years old
when the mother was born. She was said to be
of limited intellect as a result of an attack of
meningitis as a child. The grandfather deserted
the grandmother 5 months after the mother
was born. She was then placed in an institution
for infants and spent her childhood in numerous
foster homes.
The father is a salesman who is away from
home 2 or 3 days a week. He was superficially
congenial and seemed interested in keeping
the family together. He indicated that he was
able to absorb the emotional swings manifested
by his wife, although her displays of wrath and
crying were quite frequent.
DISCUSSION
To borrow a biochemical model, we may
now consider the interaction between the
reagents (parental care) and the biologic
substrate (the baby). The dynamic
under-standing of babies with this disorder lies in
an evaluation of parental care and the
physiologic responsiveness of the infant.
The data presented offer an opportunity to
formulate some thoughts concerning the
pathogenesis of rumination.
The inability of these mothers to fulfill an
adult psychosexual role reflected itself in
marital inadequacy in our series. In
addi-tion, the need to satisfy their own
depen-dent needs was prominent and undoubtedly
contributed to the marital difficulties. In
the process of attempting to meet their own
needs, the women seemed quite incapable
of providing warm, comfortable, and
in-timate physical care for the infants. The
mother of the patient we presented in more
detail illustrated a not uncommon
back-ground for highly dependent women who
experience difficulty in mothering. The
in-stitutional background and care in multiple
foster homes would suggest that dependent
needs had not been adequately met since she experienced inadequate mothering
dur-ing early life. It has often been suggested
that the best preparation for motherhood is
to have had adequate mothering.
We can only speculate concerning the
preoccupation which three of the mothers
had concerning the potential death of the
infants. Once the rumination had become an
established pattern there was some realistic
basis for the fear. There was no question
that the fear preceded the development of
symptoms and was pervasive. Because of
the general immaturity of the women, one
may reasonably speculate that this
preoc-cupation with death was a manifestation of
unconscious death wishes. We would
fur-ther suggest that, in the conscious efforts to
deal with these wishes, the mothers tended
to be relatively distant from the babies.
They probably engaged in relatively little of the ordinary play which goes on between parents and baby after vision has developed to the point of recognition of the love
oh-ject.
We may now direct our attention to the
reactions of the infant to the “mothering”
provided by these women. Inasmuch as the
infant’s communication with the outside
world is largely through feeding and
fon-dling, we may speculate that lack of
com-fort and gratification which ordinarily comes
from without (outside) causes him to seek
and re-create such gratification from within.
Particularly during the period of growing
differentiation of psychobogic from
physi-obogic processes, it would seem that the lack
of stimulation and gratification from the
en-vironment would tend to enhance the
ex-ploration of substitution for these
experi-ences. Perhaps the best evidence for the
searching for gratffication from the
environ-ment is the alert, wide-eyed appearance of
the babies which we have previously
re-ferred to as “radar-like.”
In any psychosomatic syndrome, curiosity
concerning the choice of symptoms and the
timing of onset of symptoms is justified.
Although we have been interested in
con-stitutional differences in autonomic
func-tion in infants, we have no evidence that
this is a predisposing factor. We would
spec-ulate that other factors are of greater
con-sequence, as follows:
in-fants in that perhaps their greatest source
of gratification-even though
incomplete-has been through feeding. Substituton for
this process in the form of rumination
there-fore may be interpreted as an effort to
re-create the feeding process.
2. The infants seemed to have an unusual
capacity to explore substitute visceral
grati-fication as well as other forms of bodily
manipulation such as head rolling and
bang-ing, body rocking, hair pulling, and fecal
and genital play.
3. We would suggest that the onset of the
disorder follows the development of visual
maturation to the point of recognition of
love objects (parents). Lacking the
oppor-tunity for sufficient gratification in the form
of visual-and probably
auditory-stimuba-tion, the infant seeks substitution from
within.
It is important to emphasize that we are
not suggesting that specific maternal
psycho-pathology results in rumination in the
in-fant. Rather, we suggest that any factors
which deprive the infant of intimate,
stimu-lating relationships may predispose to the
disorder. In the early part of the century,
poor environmental circumstances probably
acounted for such deprivation most
com-monly. Currently, maternal
psychopathol-ogy which prevents the mother from
de-veloping a close and comfortable
relation-ship with the baby is probably a more
com-mon cause.
In the light of the severity of the
psycho-pathology of these mothers, one might
spec-ulate that the prognosis would be rather
dismal. Although our follow-up is not
suf-ficiently long to make any bong-term
predic-tions, the reversal of symptoms during
treat-ment has been striking. With an
interrup-tion of the mother-infant relationship by
hospitalization of the baby and the
provi-sion of a stimulating, warm environment
with a substitute mother figure, the infants
have dramatically ceased to ruminate.
Dur-ing hospitalization of the baby, the mother
has some relief from the anxiety concerning
the physical care of the baby and, through
her relationship with the staff, develops a
greater feeling of confidence concerning her
ability to care for the infant. On returning
home these babies have not resumed
rumi-nating.
For really effective help, deeper and more
long-term therapy for the mothers would
seem indicated. This is an objective toward
which we are striving for both research and
therapeutic purposes. The immaturity of
these mothers may minimize the possibility
of engaging them more fully in formal
psy-chiatric treatment and investigation. We
should not minimize the effect of supportive
therapy in the pediatric setting, however,
since more intensive psychotherapy is often
not available. Particularly for mothers with
the degree of immaturity which these
women manifest, continuing contact with a
pediatrician with insight may provide just
enough ego support to permit the mother to
carry on with some degree of adequacy
and, perhaps, to permit growth to a more
adequate bevel.
SUMMARY
This study has been concerned with
ob-servations of four infants manifesting the
syndrome of rumination and the mothers of
these infants. The findings suggest that the
syndrome develops in response to a
dis-ordered relationship between parents and
baby. Some formulations concerning the
pathogenesis of rumination are presented.
It is hoped that further studies of this and
other syndromes reflecting disturbances in
the development of object relationships in
infants will provide a better understanding
of healthy as well as disordered growth in
early life.
REFERENCES
1. Kanner, L.: Historical notes on rumination
in man. M. Life., 43:27, 1936.
2. Lourie, R. S.: Experience with therapy of
psychosomatic problems in infants, in Psychopathology of Children, Hoch, P., and Zubin,
J.,
editors. New York, Crune, 1955, p. 254.ARTICLES
SUMMARIO IN INTERLINGUA
Rumination: Un Syndrome
Psycho-somatic Del Infantia
Rumination es un syndrome characterisate per regurgitation, remastication, e re-ingestion
de alimentos. Durante le prime quarto de iste
seculo, illo esseva describite extensemente, sed
in recente annos reportos de illo ha essite
in-frequente. Le litteratura del passato prestava relativemente pauc attention al interaction de
parente e infante. Ii es con iste aspecto del
disordine que be presente articulo es concernite.
Es presentate observationes de quatro
in-fantes ruminante e br matres. Le sequente
datos historic pare pertinente: Al tempore del
declaration del condition, le patientes habeva
etates de non minus que 3 menses e non plus
que 8 menses; be rumination durava 2 menses
in duo casos, 6 menses in un caso, e un anno
in un caso; omne le infantes esseva mascule, e
nulle habeva essite nutrite al pectore; omnes
habeva pesos sub-standard, con deficientias
amontante a inter 25 e 45 pro cento; e un habeva essite tractate sin successo pro
insulfici-entia adrenal.-Le diagnoses prendite in
con-sideration includeva stenosis pyloric, allergia
dietari, anormalitates esophagee, e sever
pro-blemas nutritional de causa indeterminate.
Le natura del disordine es suggerite per be
tractos neurotic del ruminatores e per br
pre-occupation con se mesme. Postura autistic,
movimentos cunante del corpore, movimentos
rolante del capite, manipulation excessive del
genitales e feces, e excessive suction digital
es-seva notate in vane combinationes. Tamen,
omne iste infantes esseva alerte e respondeva
frappantemente al ambiente stimulante del
hos-pita! per un abrupte cessation del rumination.
Le comprehension psychosomatic de babies
con iste disordine es a basar super un
evaluta-tion del attitude parental e del responsa physi-obogic del infante. Le infantes-private del
con-forto e del gratification que ordinarimente
obtenibile ab fontes externe (alimentation per
le parentes, caressas, ludos, etc.)-tendeva a
cercar e a recrear ille gratification per medio
de ressources intense (in be fonna del
rumina-tion como re-creation del experientia del
alimentation e de altere generes de
auto-stimu-lation.
Ii non es postulate que un specific psycho-pathobogia del matre resulta in le syndrome de
rumination in le infante. Non importa qual
factores que priva be infante de stimulante con-tactos de intimitate predispone a!
