Innocent vomiting, commonly known as infant regurgitation [3] or “spitting-up,” consists of involuntary, effortless reflux of gastric content up to and out of the mouth that is not accompanied by nausea, retching, pain or food refusal; it occurs during and between feedings, several times per week or per hour. The vomitus contains no blood or bile and is not accompanied by weight lag, provided the infant is consistently fed to satiety. It affects about two-thirds of well babies during the early months of life and resolves by 12–18 months in most infants. Many parents are concerned that it may be a sign of organic disease. In my opinion, “Innocent Vomiting” is a better diagnostic term than “functional gastroesophageal reflux” because that later term implies the existence of abnormality rather than a variant of normal. Innocent Vomiting neither results from, nor causes organic complications. Calling it “reflux,” “medicalizes” the phenomenon and may predispose to burdensome diagnostic procedures or pharmacologic, positional and dietary regimens that contribute nothing to its resolution.

One can appreciate the concern of a couple who entered my consultation room with an alert, robust infant who “spat-up” several times an hour. Although the day was sunny, both parents wore raincoats to protect their clothes from their baby’s productions. They said they needed new carpeting. I suggested that they wait until next year.

Management consists of effectively reassuring the parents of the prevalence, safety and excellent prognosis of innocent vomiting. It is the only kind of frequent vomiting that is not associated with signs of disease, does not impair growth and is unresponsive to pharmacologic treatment or dietary manipulations [3].

Is innocent vomiting exacerbated by overfeeding? And should feedings be limited in such babies? Doing so would get in the way of satiety, which may result in insufficient intake as well as increased irritability. The amount of feeding infants want is determined by their metabolic needs plus replacement of amounts lost. Parents should be encouraged to feed until their baby turns away because it doesn’t want any more, regardless of how often or how much it “spits up.” The nutritional and developmental importance of feeding to satiety takes precedence over the cosmetic significance of innocent vomiting in any infant whose weight gain is progressing normally.

(Nervous vomiting is frequently accompanied by Failure-to-Thrive. The reader is referred to pages 157–159 in Chap. 7 for discussion of its clinical features and case vignette.)

Before describing the three categories of rumination, I’ll present my views on rumination in general.

Rumination has been defined as effortless, voluntary, regurgitation of recently ingested food into the mouth with subsequent re-mastication and re-swallowing and/or spitting out [4]. It is not accompanied by nausea, retching, or pain.

Rumination is a special kind of regurgitation—special in the sense of that it is a habit with the purpose of self-stimulation. It is akin to nail-biting, smoking or gum chewing—activities done for no purpose other than sensory self-stimulation. It is predisposed by boredom, excitement or anxiety. By contrast, the voluntary regurgitation of, for example, bulimarexic patients is done for the purpose of avoiding weight gain, not self-stimulation.

The literature contains widely divergent statements about rumination and its potential dangers. Rumination in adults has classically been described as a benign habit [5]. By contrast, almost half of a reported cohort of 38 alleged adult ruminators lost weight ranging from 6 to 150 pounds (average, 29 pounds). Serious hypokalemia and weight loss have been diagnosed as complications. Weight loss and abdominal pain were attributed to rumination in a series of 12 adolescents with effortless regurgitation [6–8].

Therefore, ruminators do not constitute a coherent population. Rumination can occur in patients of any age, from infancy to old age, and is “a broad spectrum of conditions ranging from short, benign and self-limited to severe and life threatening” [9].

The confusion about the nature of rumination results from applying that term to any and all patients who practice voluntary regurgitation of gastric contents, including patients with eating disorders who feel the need to expel any food in their stomachs or individuals who regurgitate for exhibitionistic purposes. This confusion could be cleared up if “lumping” all patients who voluntarily regurgitate as “ruminators” ceased, each patient in the various cohorts was known in more depth, and the significance of his/her regurgitation better understood.

I suggest that patients who regurgitate voluntarily be categorized as either true ruminators or individuals who practice voluntary regurgitation for purposes other than habitual self-stimulation.

Before further discussion of rumination, it is important to ask: What determines whether rumination or any other kind of regurgitation is benign or dangerous? Regurgitation becomes a serious threat to health when there are large, uncompensated losses of nutrients from the mouth that can result in hypokalemia or weight loss, even to the extent of inanition and death; [10] or erosive esophagitis causing scarring and blood loss anemia.

True rumination presents as three sub-syndromes: Infant Rumination Syndrome [ 11], rumination in neurologically damaged, socially impaired individuals, and classic Benign Rumination.

Infant Rumination Syndrome (IRS) begins as early as 2–3 months, the age at which infants begin to become able to stimulate themselves (stages 2–3 of Piaget’s Sensorimotor Period of Development) [12]. It occurs in an infant whose caregiver is emotionally disconnected and unable to sense her baby’s need for closeness and comfort during and between feedings. If there is inadequate reciprocal interaction between infant and mother, the infant learns to regurgitate gastric content into its mouth and does so habitually during hours it is awake and alone. This is presumably done for the sensory experience and the satisfaction of oral needs that would normally be supplied by its caregiver. Rumination ceases the moment the infant senses the presence of another person. (Therefore, observing and photographing a ruminating infant requires stealth [13].) Whether or not infant rumination ceases when the regurgitant becomes acidic and no longer tastes like food is not known. However, the danger of IRS is related to the infant’s inability to contain all that it brings up into its mouth; much is lost and eventually, death from inanition may occur.

The essential element in management is relief of the infants’ loneliness with caregiving that is sensitive, reciprocal, and need-gratifying. This has been called “holding therapy” during which a surrogate mother holds and comfortably interacts with the infant several hours a day. Catch-up weight gain commences and the frequency of rumination decreases within days of the start of ongoing holding therapy [14, 15] (see Fig. 7.​3, page 161, in the Chap. 7).

Rumination in neurologically damaged, socially impaired individuals is self-stimulation behavior practiced by some individuals whose ability to interact socially is severely limited and whose appearance and behavior make others disinclined to interact with them. In contrast to infant ruminators who cease to ruminate the moment they perceive the possible presence of another person, developmentally impaired ruminators may be oblivious to others in their environment. Their rumination may go on relentlessly for hours, regardless of how acidic the regurgitant may be. One patient repeatedly forced his hand down his throat to stimulate gagging in order to facilitate regurgitation. Severe peptic esophagitis may be signaled by hematemesis, drooling of bloody saliva and may cause serious anemia.

Management of the complication of erosive esophagitis includes gastric acid suppression, frequently administered sucralfate suspension, and supplemental iron.

Management of the disorder itself is essentially the same as that of IRS. If the patient’s central nervous system can support social interaction, the rumination may be cured by a devoted caregiver willing to interact with and nurture the patient long enough for the development of an emotional attachment. Rumination ceases when loneliness is recognized and relieved.

No developmentally impaired ruminator should be consigned to permanent tube feedings on the presumption that he or she is incapable of social interaction, without the benefit of a trial of emotional comfort analogous to “holding therapy.”

Benign Rumination is the classic, best known rumination syndrome. It is a learned, self-stimulatory, pleasurable habit practiced by neurologically normal adults [5] and children who typically suffer no serious complications or comorbidities, although benign ruminators may be anxiety-prone or have obsessional traits [7]. While most benign ruminators (including historically important individuals such as Samuel Johnson and Edward Brown-Sequard [11]) practice their habit in private, a few exhibitionistic ruminators exhibit their regurgitative skills for the entertainment of audiences [16].

Typically, the act of benign rumination begins minutes after the end of a meal. The ruminator may continue to enjoy savoring his recent meal for an hour or two until the regurgitant no longer tastes like food. Adults with benign rumination are attached to their habit. They tend not to discuss it or seek medical help for it, although they may present with chief complaints of halitosis or heartburn.

Patients who are motivated to get rid of habitual rumination have succeeded through the application of biofeedback training. Regurgitation is initiated by a brisk contraction of the abdominal muscles. Biofeedback training teaches the patient to avoid these muscular contractions with a result that regurgitation is prevented [17]. Comparison of the three types of rumination is presented in Table 3.2.

Oral defensive vomiting can occur in individuals of any age who are obliged to eat food they “cannot stomach” or food they might enjoy but for their feeling that eating it is an obligation that they are powerless to resist.

Nausea, with or without vomiting, that accompanies feelings of disgust or revulsion seldom, if ever, presents as a clinical problem because its cause and functional nature are generally well understood. However, the syndrome of Psychogenic Vomiting is a pattern described in 1968 by the British psychiatrist O.W. Hill [18]. He reported a series of 20 adolescents and adults who felt emotionally trapped in domestic relationships with individuals they hated, but felt powerless to leave. They were characteristically shy and avoided confrontation and arguments. Vomiting typically occurred at mealtimes during the stress of eating with someone who aroused strong negative emotions. Many of the patients had experienced loss of parents or other individuals to whom they were emotionally attached during their childhoods, traumas thought to have contributed to their inability to leave their current unhappy circumstances. Management consisted of psychotherapy and antiemetic medication, if needed.

Nausea is a chief complaint of adolescents who may seldom, if ever, vomit. Nausea may persist continuously or intermittently for weeks or months. They typically eat well, do not lose weight and have normal findings on physical examination, endoscopy, as well as tests for neurologic, infectious and metabolic diseases [26]. They are typically conscientious and anxiety-prone [25]. This clinical picture conforms to the diagnosis of Chronic Idiopathic Nausea (CIN) [27] which differs from another functional nausea syndrome, dyspeptic nausea, in that the latter tends to be associated with meals and its discomfort is more localized in the epigastrium.

The pathogenesis of CIN has not been established and it has no standard therapy. Patients are usually helped by the knowledge that their symptoms conform to a recognizable pattern and that their nausea neither results from, nor causes disease [27]. Measures to relieve anxiety and improve the quality of sleep should be considered. Symptoms may improve with a non-sedating antiemetic, e.g., ondansetron, during the day, and amitriptyline at bedtime.

Of the more than 100 conditions in the differential diagnosis of nausea and vomiting [27], the Postural Orthostatic Tachycardia Syndrome (POTS) [28, 29] is worthy of special attention because it is readily mistaken for functional nausea and its symptoms respond to appropriate treatment [30]. POTS typically presents in adolescents with orthostatic tachycardia, nausea, fatigue, exercise intolerance and other dysautonomic symptoms. The disorder involves a peripheral autonomic neuropathy with failure of the reflex vasomotor responses to gravity that normally prevent dependent pooling of venous blood. The symptoms steadily worsen for about 2 years and then slowly resolve by young adulthood in about 80 % of patients [30]. Symptomatic management, pending resolution of the neuropathy, includes increasing peripheral vascular resistance and intravascular volume. Diagnostic screening for POTS is accomplished by measuring heart rate and blood pressure with the patient supine, then sitting, then standing at intervals of 2, 5, and 10 min: a pulse rate increase of 30 beats per minute or more or a rate of 120 beats per minute after the first 10 min of standing is suggestive of POTS.

Panic attacks are associated with several anxiety disorders, including panic disorder, phobias, post-traumatic stress disorder, and generalized anxiety disorder [31]. Persistent anxiety or panic should be considered in any patient with recurrent nausea and vomiting.

A panic attack consists of the abrupt onset of a discreet period of overwhelming anxiety and aberrations of mental and autonomic function that peaks within 10 min and subsides spontaneously. The diagnostic criterion of panic attack is the experience of 4 or more of the 13 signs and symptoms listed in Table 3.3. As for symptom #7, “nausea and abdominal distress,” my experience and that of other gastroenterologists [32] is that nausea is often accompanied by vomiting and that “abdominal distress” is often described by patients as pain. Moreover, patients who are experiencing panic may not fully perceive their fear, palpations or tachypnea [32].