Intensive outpatient treatment of pediatric rumination syndrome in the era of telemedicine

Background: Rumination syndrome is a functional gastrointestinal disorder (FGID) that involves effortless postprandial regurgitation of food followed either by rechewing or expulsion, and can be challenging to both diagnose and treat effectively. Patients with more severe symptoms require intensive management. At our institution, we have had success treating children with severe rumination syndrome using a multidisciplinary intensive outpatient program (IOP) involving multiple treatment sessions daily. Due to the COVID-19 pandemic, we have needed to transition from in-person treatment to telemedicine. The objective of this study is to compare outcomes of patients with rumination syndrome who completed IOP treatment in person versus by telemedicine. Methods: We performed a retrospective review of patients diagnosed with rumination syndrome by Rome IV criteria and participated in IOP treatment from 2018-2020. IOP consists of intensive medical and behavioral treatment provided by a specialized multidisciplinary team. Until March 2020, this program involved 3 in-person treatment sessions with meals per day for up to a week. Similar treatment sessions were performed during telemedicine visits. We compared outcomes of patients who received IOP treatment in person versus by telemedicine. Families/patients were then asked to complete a survey outlining their child's current rumination symptom severity and review of the IOP. Results: We included 34 patients (79% F, median age 15 years, range 7-19 years) with rumination syndrome who completed IOP treatment. Patients had also been diagnosed with anxiety (17/34, 50%), depression (7/34, 21%), gastroesophageal reflux disease (6/34, 18%), constipation (6/34, 18%), functional abdominal pain (5/34, 15%), eating disorder (5/34, 15%), and superior mesenteric artery syndrome (4/34, 12%). At baseline, 9 patients (26%) required tube feeding or parenteral nutrition compared to 2 patients (6%) at follow up. Twenty-six patients (76%) were treated in person and 8 patients (24%) by telemedicine. There were no significant differences in sex, age, likelihood of anxiety or depression, and duration of IOP treatment between in person and telemedicine groups. The median duration of treatment for both groups was 4 days. Symptom severity at baseline and follow up are described in Table 1. For patients treated in person, 76% (19/25) had improvement in symptoms while 16% (4/25) had complete resolution of symptoms. For patients treated by telemedicine, 88% (7/8) had improvement in their symptoms. There were no significant differences between groups in likelihood of improvement. Of the 34 patients who completed the IOP, 23 (68%) completed both surveys. Overall, 78% (18/23) preferred in person therapy while 17% (4/23) did not have a preference. Of the telemedicine patients, 60% (3/5) would have preferred in-person IOP. All 18 of the in-person cohort preferred in-person management. When asked to elaborate, 4 families expressed similar answers including the need for “in-person interaction,” having a “hands-on approach,” and because the psychologist can give “body instructions.” Other reported strengths of in-person treatment included a majority of families believing this would lead to “a stronger connection with the provider” (90%, 19/21), “fewer distractions” (86%, 18/21), and noting “treatment would be more effective in person” (76%, 16/21). In-person challenges included transportation and parking (63%, 12/19) as well as concerns about time commitment (84%, 16/19). The primary strengths of online treatment were that it saves time (72%,13/18) and some parents felt their child was more comfortable at home (39%,7/18). One family described that it was “easier to integrate habits at home” after completing the process online. Online challenges included having more distractions (81%, 13/16) and some parents felt their child was more comfortable talking to someone in person (75%, 12/16). Conclusion: Although multidisciplinary intensive outpatient treatment for children and adolescents with severe rumination syndrome is effective and the likelihood of improvement appears similar when completed in person or by telemedicine, the majority of families prefer in-person therapy.