Review for 10.1186/1471-230X-12-163 (2012)

Reviewer's report
Title:Rumination syndrome in children and adolescents: a school survey
assessing prevalence and symptomatology
Version: 3Date:20 September 2012
Reviewer: Guillaume Gourcerol
Reviewer's report:
Most of the points have been clarified. The author's answer includes many
references and citations, so will be my comments.
I still have a concern with the data interpretation, although it is difficult to blame
the authors who have used the best "available" tools to conduct their study.
First, the statement that rumination syndrome prevalence is "fairly high
percentage of adults and children" deserves cautiousness.
For instance, the Rome II version of rumination syndrome criteria, it was stated
"Rumination is a rare disorder characterized by the voluntary, habitual
regurgitation of stomach contents into the mouth for self-stimulation." (1). This
statement was further written in the Rome III version in adults ("The epidemiology
of rumination syndrome in the adult general population remains to be carefully
defined, but clinical impression suggests it is rare" (2)), but no mention of the
prevalence is made in the Rome III paediatric version (3). From these
statements, although we all agree good studies are lacking, it is understood that
rumination syndrome is still a pretty rare condition, despite the paper published
by Drossman et al (4) in 1993. In fact, in the report of Drossman et al, it is clearly
stated that "Since no medical evaluation was done to exclude structural
diagnoses, some may argue that our findings may overrepresent the true
frequency of the functional gastrointestinal disorders." (4). In this paper, the
authors were clearly aware that fitting items of an auto questionnaire was far
from being diagnosed with the disease. This may explain why in the third version
of the Rome criteria for paediatric rumination syndrome, a third criteria has been
added:
"3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process
that explains the subject’s symptoms" and was further detailed
"Gastroesophageal reflux, esophageal achalasia, gastroparesis, bulimia nervosa,
and obstructive anatomical disorders must be excluded by appropriate diagnostic
tests" . The authors finally " ... emphasize that when “absence of disease” is a
criterion, a diagnosis of functional disorder can only be made if diseases that
could account for the symptoms are absent or inactive" (3). In light of this, the
author's statement " Rumination syndrome is a clinical diagnosis ... Therefore it is
unlikely that we have picked up children with GERD" is in contradiction with the
Rome III criteria report (3).
Then my question comes back: how sure are you that these children have no
GER (or achalasia or whatever) instead of rumination that may fit in the same
items of the questionnaire? I understand that this information is difficult to be
picked up from a questionnaire based study. However, to my point of view, it is
one thing to discuss this limitation and not overstate the results of the study that
is somewhat well conducted, and another to omit to discuss this important
limitation and conclude firmly about the high (and as detailed above unexpected)
prevalence of the rumination syndrome. By contrast to the present paper, the
authors of the QPGS-RIII carefully remind the questionnaire users that "The
QPGS-RIII cannot substitute for the medical evaluation and clinical judgment
required for an accurate diagnosis". I fully agree with this prudent advice and
encourage the authors to do so.
In conclusion, and from my point of view, the authors monitored using this
questionnaire the prevalence of rumination-like symptoms but cannot conclude
on the prevalence of rumination syndrome as a disease or a condition, since
rumination syndrome, by contrast with IBS in adults, is not (only) a
symptom-based condition. Before being finally accepted, I would recommend
that this limitation appears more clearly and that the authors do not overstate
their results. This should include for instance changes in the title, results,
discussion and conclusion.
1. Rasquin-Weber et al, Gut 1999;45:II60–II68
2. Tack J et al, GASTROENTEROLOGY 2006;130:1466–1479
3. Rasquin A et al, GASTROENTEROLOGY 2006;130:1527–1537
4. Drossman et al, Digestive Diseases and Sciences, 1993;38: 1569-1580
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests