31.9b Rumination Disorder
1207
Pathology and Laboratory
Examination
No single laboratory test confirms or rules out a diagnosis of
pica, but several laboratory tests are useful because pica has
sometimes been associated with abnormal levels of lead. Levels
of iron and zinc in serum should be determined and corrected if
low. In rare cases when this is the etiology, pica may disappear
when oral iron and zinc are administered. Hemoglobin level
should be determined to rule out anemia.
Differential Diagnosis
The differential diagnosis of pica includes avoidance of food,
anorexia, or rarely iron and zinc deficiencies. Pica may occur
in conjunction with failure to thrive, and be comorbid with
schizophrenia, autism spectrum disorder and Kleine-Levin
syndrome. In psychosocial dwarfism, a dramatic but reversible
endocrinological and behavioral form of failure to thrive, chil-
dren often show bizarre behaviors, including ingesting toilet
water, garbage, and other nonnutritive substances. Lead intoxi-
cation may be associated with pica. In children who exhibit
pica that warrants clinical intervention, along with a known
medical disorder, both disorders should be coded according to
DSM-5.
In certain regions of the world and among certain cultures,
such as the Australian aborigines, rates of pica in pregnant
women are reportedly high. According to DSM-5, however, if
such practices are culturally accepted, the diagnostic criteria for
pica are not met.
Course and Prognosis
The prognosis for pica is usually good, and typically in chil-
dren with normal intellectual function, pica generally remits
spontaneously within several months. In childhood, pica usu-
ally resolves with increasing age; in pregnant women, pica is
usually limited to the term of the pregnancy. In some adults
with pica, particularly those who also have autism spectrum
disorder and intellectual disability, pica can continue for years.
Follow-up data on these populations are too limited to permit
conclusions.
Treatment
The first step in determining appropriate treatment of pica is to
investigate the specific situation whenever possible. When pica
occurs in the context of child neglect or maltreatment, clearly
those circumstances must be immediately corrected. Expo-
sure to toxic substances, such as lead, must also be eliminated.
No definitive treatment exists for pica per se; most treatment
is aimed at education and behavior modification. Treatments
emphasize psychosocial, environmental, behavioral, and family
guidance approaches. An effort should be made to ameliorate
any significant psychosocial stressors. When lead is present in
the surroundings, it must be eliminated or rendered inaccessible
or the child must be moved to new surroundings.
When pica persists in the absence of any toxic manifesta-
tions, behavioral techniques have been utilized. Positive rein-
forcement, modeling, behavioral shaping, and overcorrection
treatment have been used. Increasing parental attention, stimu-
lation, and emotional nurturance may yield positive results. A
study found that pica occurred most frequently in impoverished
environments, and in some patients, correcting an iron or zinc
deficiency has eliminated pica. Medical complications (e.g.,
lead poisoning) that develop secondarily to the pica must also
be treated.
31.9b Rumination Disorder
Rumination is an effortless and painless regurgitation of par-
tially digested food into the mouth soon after a meal, which is
either swallowed or spit out. Rumination can be observed in
developmentally normal infants who put their thumb or hand
in the mouth, suck their tongue rhythmically, and arch their
back to initiate regurgitation. This behavior pattern may be
observed in infants who receive inadequate emotional interac-
tion and have learned to soothe and may stimulate themselves
through rumination. However, rumination syndromes can be
found to occur in children and adolescents, and rumination is
considered to a functional gastrointestinal disorder. The patho-
physiology of rumination is not well understood; however, it
often involves a rise in intragastric pressure, generated by
either voluntary or unintentional contraction of the abdomi-
nal wall muscles causing movement of gastric contents back
up into the esophagus. The onset of the disorder can occur
in infancy, childhood, or adolescence. In infants, it typically
occurs between 3 months and 12 months of age, and once the
regurgitation occurs, the food may be swallowed or spit out.
Infants who ruminate are characteristically observed to strain
with their backs arched and head back to bring the food back
into their mouths and appear to find the experience pleasur-
able. Infants who are “experienced” ruminators are able to
bring up the food through tongue movements and may not spit
out the food at all, but hold it in their mouths and re-swallow
it. The disorder is less common in older children, adolescents,
and adults. It varies in severity and is sometimes associated
with medical conditions, such as hiatal hernia, that result in
esophageal reflux. In its most severe form, the disorder can
cause malnutrition and be fatal.
The diagnosis of rumination disorder can be made even if an
infant has attained a normal weight for his or her age. Failure
to thrive, therefore, is not a necessary criterion of this disorder,
but it is sometimes a sequela. According to DSM-5, the disorder
must be present for at least 1 month after a period of normal
functioning, and not better accounted for by gastrointestinal ill-
ness, or psychiatric or medical conditions.
paper, her mother was coached to engage her in a play activity
rather than screaming at her and grabbing her mouth. Chantal and
her mother continued in therapy for a year, during which their
relationship gradually became more interactive and warm, while
Chantal’s chewing behaviors decreased, and even her thumb
sucking abated.
