Breastfeeding Baby with Failure To Thrive, Posterior Tie Tongue, Upper Lip Tie Grade 3, and Cracked Nipple

Baby Z, female, was the first child of Mrs. N and Mr. C who was born on 12th December 2016 in a hospital in Banjarnegara. Mrs. N came to lactation clinic on 27th February 2017 with a complaint that the baby was thinner and feels no weight gain.

 

Weight at birth was 3300 grams and when the baby comes to lactation clinic (2 months and 15 days old) the weight was 3400 gram. The weight did not increase according to age, with only 1.3 grams per day. The baby was in a state of malnutrition according to the World Health Organization’s anthropometry standard (WHO), ie <-3 SD. During physical examination while in lactation clinic, there was a tongue membrane extending behind the tongue (posterior type) and upper lip membrane thickened grade 3, and the mother also suffered cracked nipples grade 4 on both sides and also with low milk supply.

 

Baby Z received nutrition from both breast milk and formula milk. Formula milk was given two times until the mother stopped the formula feeding due to her eagerness for direct breastfeeding. However, the baby sucked continuously with duration of more than one hour and if released the baby would cry without any sign of satiety. During sucking, the suction often loose, clicking sound could be heard, and there was often milk spilling out of the corner of the lips. During physical examination, some results were obtained such as: the vital signs were within normal limits, the weight of the baby only rose 100 grams for 2.5 months, ribs protruding, wrinkled and dry skin. There was a posterior tongue-tie and upper-lip-tie grade 3. Moreover, the baby was diagnosed with malnutrition with failure to thrive (FTT) and sucking difficulty due to tongue-tie and upper-lip-tie.

 

New insights were given to the parents about the condition of the baby and the therapy plan that would be given. Parents understood and approve all the therapy to be given. Simple frenotomy therapy was done on tongue-tie and upper-lip-tie in order to improve the breastfeeding attachment.

 

Supplementation was used using naso gastric tube (NGT) number 5F and 50 ml syringe (as shown below), which contains pasteurized donor milk or hypoallergenic milk formula. The supplementation was given when the donor milk was not sufficient. Supplementation was given six times a day with the volume of 60 ml. Supplementation was performed with the aim to accelerate the increase of baby weight and to increase mother’s milk production. Parents were taught to organize tongue and lip exercises five times a day to prevent post-frenotomy reattachment.  A routine control had to be performed for every 2 weeks at the Dompet Dhuafa Free Medical Service Lactation Clinic by a IBCLC certified pediatrician. Mother was given an ointment for blisters that contained 2% miconazole, 2% mupirosine, and betamethasone 0.1% and domperidone at doses of 20 mg for three times in a day to boost the milk production.

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Supplementation of baby Z

During the first control after frenotomy (3 months and 5 days old) weight of the baby rose to 4200 grams, with an increase of 57.1 grams per day. Baby’s weight was still in less nutritional condition according to WHO anthropometry standard, ie Z score between -2 SD and -3 SD. Supplementation was reduced to six times a day with the volume of 45 ml. Breastfeeding with football position was done by the mother in order to make the left breast to be more comfortable. The cracked on both nipples were improved from grade 4 to grade 3. However, the mother’s milk was still low, therefore the therapy for mothers still continues.

 

During the second control after frenotomy (3 months and 16 days old) weight of the baby rose to 4400 grams, with an increase of 14.3 grams per day. Infant weight gain was not optimal due to lack of donor milk supply and difficulty to obtain the hypoallergenic milk formula in the region where the family lived. The baby weight was still under the malnutrition conditions as according to WHO anthropometric standards, Z score between -2 SD and -3 SD. Supplementation was still given with six times a day and the volume of 45 ml. The blisters on both nipples improved from grade 3 to grade 2 and mother’s milk began to produce normal milk supply. Further therapy for the mother still continues.

 

During the third control after frenotomy (4 months and 2 days old) weight of the baby rose to 4900 grams, with an increase of 35.7 grams per day. Infant weight gain was in less nutritional condition according to WHO anthropometry standard, Z score between -2 SD and -3 SD. Supplementation was still given with six times a day and the volume of 45 ml. Cracked on both nipples were improved from grade 2 to grade 1 and mother’s milk started to produce a normal milk supply. The domperidone dose was reduced to 20 mg – 20 mg – 10 mg and the ointment for the blisters still continued.

 

During the fourth control after frenotomy (4 months and 18 days old) weight of the baby rose to 5285 grams, with an increase of 24.6 grams per day. Infant weight gain was in good nutritional condition according to WHO anthropometry standard, ie Z score right at -2 SD. Supplementation was still given with six times a day and the volume of 45 ml. The baby was also given complementary food in accordance with the guidance of Indonesian Pediatric Association (IDAI). The baby had suffered from fever for 3 days and laboratory tests were performed with Hb 7.6 gr / dl, Ht 23%, Tr 245,000, Leu 10.240, LED 19, X Ray chest with normal results, and Mantoux test with negative results. From the results of the examination, the baby was given iron supplements (Fe) of 2 × 1 ml, Vit C 2 × 25 mg daily, tuberculosis treatment INH 10 mg / kg BW for 6 months, and Vit B6. TB prophylaxis was given to infant Z despite the negative Mantoux Test and normal limits of X Ray chest. This was performed due of the malnutrition history of the baby, which often makes the Mantoux test results give false negative results and contact with tuberculosis patient was positive. The cracked on both nipples started to heal and breast milk production was normal. The ointment for nipple was stopped and doses of domperidone were reduced to 20 mg – 10 mg – 10 mg.

 

During the fifth control after frenotomy (5 months and 8 days old) weight of the baby rose to 6080 grams, with an increase of 39.7 grams per day. Infant weight gain was in good nutrition condition according to WHO anthropometry standard, ie Z score right at -1 SD. Supplementation was stopped due to sufficient nutrition condition and a steady breast milk supply. Complimentary feeding was still administered and the dose of domperidone was reduced to 10 mg for three times daily within two weeks period, then reduced again to 10 mg for two times daily within two weeks period. Finally, the dose was reduced to 10 mg for once a day within 5 days period before the treatment was discontinued.

 

During the sixth control after frenotomy (7 months 2 days old) weight of the baby rose to 7300 grams, with an increase of 48.8 grams per day. Infant weight gain was in good nutrition condition according to WHO anthropometry standard, ie Z score between -1 SD and Median. Direct breastfeeding was still performed together with a good complimentary feeding.

 

During the breasfeeding journey, the mother had performed a good determination and a strong desire to performed a direct breastfeeding for the baby, even though the mother suffered from abrasions on both nipples. Mother was still eager to breastfeed relentlessly in order for the baby to gain weight. This breastfeeding success story happened also due to sufficient support from the father, grandfather, grandmother, and the whole family towards the mother’s attitude in pursuing a continuous breastfeeding. The process of infant weight gain of baby Z can be seen in graph 1.

Graph 1. Weight gain and process of therapy

 

Reference:

International Standards for Tuberculosis Care: Diagnosis Treatment Public Health 2nd Edition 2009

Recommendation of Indonesian Pediatric Association: Recommendation of Evidence-Based Feeding Practice for Infants and Toddlers in Indonesia to Prevent Malnutrition. UKK Nutrition and Metabolic Disease 2015

Newton BC, Brent AJ, Anderson S, Whittaker E, Kampmann B. 2008. Paediatric Tuberculosis. Lancet Infect Dis august 8 (8): 498-510

Su Jin Jeong. 2011. Nutritional Approach to Failure To Thrive. Korean J Pediatric; 54 (7): 277-281

WHO Child Growth Standard for Girls

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