Case report : Baby with Ankyloglossia, Failure to Thrive and Weak Suction Reflex

Written by : dr. Okky Nafiriana


Since the beginning of life, every child has the right to get a complete and good nutrition in order to optimize their growth and development. Breast milk has been given by God through a mother as a media to fulfill the nutritional needs of her baby. On the other hand, it is also a duty for fathers in maintaining a good emotional support for both mother and baby while making sure a supportive breastfeeding support system achieved at home.

Breast milk provide an ideal nutrition for babies, in which a good latch on to the breast will determine an optimal breast milk intake through appropriate suckling. Hence, the optimal breastfeeding condition will in return provide a sufficient weight gain for the baby.1 Ankyloglossia or Tongue-tie and Lip-tie are associated with 25% – 60% incidence of breastfeeding difficulty; such as sore nipples, swollen breasts, low milk supply and failure to thrive. Poor latching is one of the main causes of these breastfeeding problems.2 Ankyloglossia can interfere with the baby’s mouth suction to the breast which then will cause a poor latching so that the baby does not get an adequate amount of breast milk and thereby causes a slow weight gain or even failure to thrive.1


Case Report

BANNER 728 x 90

Mrs. U came on 13th of May 2020 to the hospital of lactation clinic in Depok (located in Java island in Indonesia) with his daughter, baby H, who was 1-month-old. She complaints that the baby’s suckle was slipping, the breast takes a long time to be emptied and always appears to be sleepy during a breastfeeding session. The baby was breastfed directly, not using a pacifier or lactation aid media. Baby H was born in hospital with normal delivery at 39 weeks of gestation and weighs 3020 grams. After giving birth, Baby H was placed on to the chest of Mrs. U only for 15 minutes because Mrs. U shivered, then Baby H was taken to a healthy baby room. Therefore baby H first breastfed was around 13 hours later when she underwent the first rooming in with Mrs. U. From the very beginning, Baby H could not open her mouth wide enough so that she could not devour all of Mrs. U’s nipple. Since Baby H reached the age of 1-week old, Mrs. U use a manual silicone pump to collect the dripping milk on the next breast when breastfeeding and sometimes pumping the breast in order to prepare for breastmilk stock as the preparation when she started working 2 months later in Kalimantan (a different island in Indonesia). When Baby H was 3-weeks old, her body weight was 2200 grams and for the first time Mrs. U went to a pediatrician at the hospital where Baby H born. At that time, the doctor saw and corrected the breastfeeding positioning of Mrs. U. The doctor then asked her to further control the baby at the hospital in within 2 weeks time, in order to appropriately measure the baby H’s weight gain goal of 400 grams. After that, Mrs. U initiated to consult with AIMI Depok and was advised to visit our lactation clinic.

At that moment, Baby H’s father, Mr. R was working in Kalimantan, so he could not accompanied Mrs. U. Mrs. U and Baby H then later came to the lactation clinic accompanied by Baby H’s grandmother and her older sister. Baby H is the second child of Mr. R and Mrs. U. Their first child was a 4-years old girl, with exclusive breastfed until the age of 7-months and later on formula milk was used due her history of a poor weight gain.

Based on the examination in our clinic, Baby H’s weight was 1860 grams with severe malnutrition compared to the minimum ideal body weight at her age of 3200 grams. On physical examination of Baby H, we found submucosal tongue tie and upper lip tie grade 3. During the breast examination of Mrs. U, a symmetrical breast shape, prominent nipples and low milk supply were obtained. When Baby H was breastfeeding, her lips were folded inward and only the tip of the nipple went inside the baby’s mouth (not the whole nipple), the suckling was slipping and the suction reflex was weak.

After we explained God’s command to breastfeed (according to Islamic guidance) and WHO guidelines about breastfeeding, Mrs. U’s desire to breastfeed Baby H up to 2 years getting stronger and this was supported by Mr. R who was contacted by telephone as well as Baby H’s grandmother. We also explained the nutritional status and physical examination results of Baby H, which was leading to Mrs. U’s approval for the doctor to perform double frenotomy on Baby H’s ankyloglossia and given the baby further supplementation therapy. After the frenotomy, Mrs. U gave breastfed with the aid of SNS (Supplemental Nursing System) containing formula milk. It was observed that Baby H breastfed with her lips folded out but the suction was still weak, so the leftover of formula milk in the SNS were still a lot as Baby H was fallen asleep. Mrs. U was taught to do tongue and lip exercises to Baby H 5 times a day for the next 3 weeks. Furthermore a breast supplement tablet that is routinely taken every day was given to Mrs. U.

Three days later on 16th of May 2020, Baby H and Mrs. U came back for hospitalization because there was no significant improvement from the way of Baby H’s breastfeeding. At that time, Baby H weight was 1870 grams, which was only increased 10 grams. Mrs. U said that at home, she regularly uses the SNS but often the formula milk was still a lot left because of Baby H sleeps a lot while breastfeeding and her suction were still weak.

When admitted to hospitalization, Mrs. U and Baby H did a skin-to-skin contact for 24 hours except when Mrs. U went to the toilet. Breastfeeding process was done with the aid of supplementation (SNS) with a minimum of formula milk content of 6 x 30 cc. Baby H was given Piracetam and immediately consulted to physical medicine and rehabilitation unit to be given Oral Motor Exercise therapy.

On the second day of hospitalization, Baby H’s weight increased by 50 grams to 1920 grams even though the suction reflex was still weak, nevertheless Mrs. U was very happy due to an improvement in the baby’s weight gain. On the third day, Baby H’s weight increased by 80 grams to 2000 grams. On that day, the expressed breast milk from a donor mother whom Mr. R’s relatives comes. Therefore from then on Baby H breastfed with the help of SNS contents of pasteurized donor breast milk as a replacement to formula milk. Oral motor exercise therapy was carried out routinely to Baby H every day. On the fourth day, Baby H’s weight increased by 20 grams and Mrs. U felt her baby’s suction was stronger. On the fifth and sixth day, Baby H was getting better at breastfeeding with the help of SNS and the suction was getting stronger. On the seventh day of hospitalization (22nd of May 2020), Baby H’s weight was 2065 grams and has been allowed to go home. Discharge instructions to Mrs. U was to continue breastfeeding on baby’s demand assisted by SNS with the donor’s breast milk for the contents and breast milk supplement tablets are continued. For Baby H, piracetam treatment continued and oral motor therapy was continued with homevisite every day.



Date Age Weight


Weight Gain


Nutritional Status Donor’s Breast Milk on SNS (cc/day) Therapy
26/5/2020 1 months 13 days 2105 23,5 < -3SD 200-300 · Minimum pasteurized donor’s breast milk on SNS: 300 cc/day

· Homevisite oral motor exercise every 2 days

5/6/2020 1 m 23 d 2365 26 < -3SD 280-300 · BCG vaccination

· Min. pasteurized donor’s breast milk: 360 cc/day

· Mrs. U given extra maternity leave letter for 2 months

16/6/2020 2 m 3 d 2740 34,1 < -3SD 165-395 · Min. pasteurized donor’s breast milk: 400 cc/day
30/6/2020 2 m 18 d 3250 36,4 < -3SD 375-435 · DPT – Polio – HIB – Hep. B vaccination

· Min. pasteurized donor’s breast milk: 400 cc/day

· Homevisite oral motor exercise stop

14/7/2020 3 m 1 d 3760 36,4 < -3SD 350-450 · Min. pasteurized donor’s breast milk: 400 cc/day
30/7/2020 3 m 17 d 4130 23,1 < -3SD 250-370 · DPT – Polio – HIB – Hep. B vaccination

· Min. pasteurized donor’s breast milk: 350 cc/day

13/8/2020 4 m 4665 38,2 < -2 SD 245-370 · Min. pasteurized donor’s breast milk: 350 cc/day
27/8/2020 4 m 13 d 4910 17,5 < -2 SD 220-385 · Baby H given early complementary feeding

· Breastfeeding on Baby H’s demand using SNS contain pasteurized donor’s breast milk

10/9/2020 4 m 26 d 5160 10 < -2 SD 60-135 · Breastfeeding on Baby H’s demand using SNS contain pasteurized donor’s breast milk

· Increase frequency of complementary feeding

24/9/2020 5 m 11 d 5655 35,4 Good 55-150 · DPT – Polio – HIB – Hep. B vaccination

· Breastfeeding on Baby H’s demand using SNS contain pasteurized donor’s breast milk

· 1 month extra materniy leave letter for Mrs. U

8/10/2020 5 m 25 d 6050 28,2 Good 50-100 · Stop using SNS

· Complementary feeding and direct breastfeeding on demand or cup feeding when Mrs. U at work

· Baby H given D vitamin and Fe

Table 1. Baby H’s development when check up to dr. Asti Praborini, SpA, IBCLC


Picture 1. Baby H’s development serial photos


Picture 2. Mrs. U carrying Baby H and Baby H’s grandmother (left) with dr. Asti Praborini, SpA, IBCLC. Baby H was 5 months 11 days old, 5655 gram with good nutritional status.




Breastfeeding is the nature of every woman, which is stated in the holy book of all religions in Indonesia. In Islam, the command to breastfeed is found in 5 letters, i.e. Al Baqarah: 233, Al Ahqaf: 15, An Nisa: 9, Lukman: 14 and Al Qasas: 7, 12-13. In Catholic, breastfeeding has been supported for a long time by the Vatican from Pope Pius XII in 1941 to Pope Francis today. In Christian, it is stated in the Bible’s New Testament letters of Peter and Isaiah that breast milk is pure and necessary for growth and for obtaining salvation. In Hindu, the Vedas say that breastfeeding is for 3 oton. And in Buddha, it is said that mother’s love includes breastfeeding.3

Breastfeeding is also supported by the world and the Indonesian regulation. The World Health Organization (WHO) and UNICEF recommend exclusive breastfeeding for the first 6 months of a child’s life, and continued breastfeeding together with complementary feeding until the age of 2 years.4 In Indonesia itself, there are several regulations governing the exclusive breastfeeding, i.e. in UU no. 36 of 2009 articles 128-129, 200-201 and PP No. 33 of 2012 articles 21, 33.3

Ankyloglossia or tongue-tie and lip-tie is a condition that is caused by genetics (heredity). Tongue-tie straps the tongue tightly to the floor of the mouth causing limited movement of the tongue. The lip-tie straps the lips to the gums causing limited movement of the upper lip. Limited movements of the lips and tongue make it difficult for the baby to form a vacuum to suck and completely empty the breast. 5

The mechanism of a baby expressing milk is quite complex. The baby should first be able to form a seal to the breast with the lips folded out and the tongue catches the breast and presses the breast against the roof of the mouth. In a rhythmic motion, when the baby presses the breast against the roof of the mouth and then lowers his tongue down, it creates a bigger negative vacuum so that the breast milk will come out.5

If there is a tongue-tie, the baby’s tongue is pulled down so that the baby cannot lift his tongue to catch and press the breast against the roof of the mouth.5 Therefore often babies with tongue-tie will perform suckle slipping and breastfed will last for a long period of time because of the difficulty in optimally removing breastmilk, which is fit with the aforementioned case.

There are several problems that can be associated with ankyloglossia. Problems arise in the mother will include sore nipples, swollen breasts, blocked nipple pore, mastitis (inflammation of the breast), breast abscess (breast filled with pus) and decreased milk production. Problems exist in the baby are loose/slipping breastfeeding, prolonged / continuous breastfeeding, feeding with a ‘click’ sound, colic, bloating, constantly losing weight, insufficient weight gain and failure to thrive.5

In this case, there is a submucosal type of tongue-tie which can be diagnosed through palpation and grade 3 of lip-tie. The most common types of tongue-tie that affecting the slow growth of babies or failure to thrive are the posterior type and the hidden or invisible tongue tie (submucosal).7

Picture 3. Diagnostic criteria of tongue tie and lip tie according to dr. Kotlow6,7


Infants with optimal breast milk transfer are expected to have a good weight gain in accordance to the WHO’s graph. However, babies who are breastfed with poor latching on will result in a slow weight gain or even failure to thrive. Failure to thrive is a baby with a weight below the 3rd percentile or z-score <-2 SD, and occurs mainly when the baby continues to lose weight after 10 days and has not returned to their birth weight at 3 weeks or remains below the 10th percentile by the end of the first month.8 In infants younger than 8 weeks of age, problems with swallowin, sucking and difficulty during breastfeeding are few factors influencing the growth failure. Furthermore in the case of babies who are slow weight gain or fail to thrive, the supply of milk in the breasts usually has decreased, as a result of poor baby suction.5

Frenotomy is an incision or cutting of the tongue-tie and / or lip-tie which is done when the baby has difficulty latching on continuously. The aim is to make the breastfeeding process between mother and baby better and to improve the baby’s suction to the breast. 5

However, frenotomy alone is not sufficient for the management of infants with slow weight gain and failure to thrive, supplementation should also be given. Supplementation provides an additional nutrition to breastfed babies other than breast milk from the mother’s breast. The additional nutrients include donor breast milk or formula milk. Supplementation using lactation aids can be in the form of a device that is worn around the neck such as the supplemental nursing system (SNS) or large injections. The two devices are connected to a tube that will be attached to the mother’s nipple so that the baby will drink from two sources, that is breastmilk from the mother’s breast and additional milk from the lactation aids. This lactation aid device aims to keep the baby getting optimal nutrition while stimulating the breast to produce more milk through the baby’s suction.5,9

The problem of sucking in newborns has many consequences for both mother and newborn. Multidisciplinary therapy is required for infants with ankyloglossia and sucking problems. Apart from frenotomy, at the same time it is also necessary to collaborate with the Physical Medicine and Rehabilitation team to stimulate the baby’s sucking reflex and rooting reflex through intraoral and extraoral exercises.10

The extraoral stimulation exercises are aimed at improving the newborn’s rooting reflex which are exercises that stimulate the masseter muscle and stimulating the rooting reflex in the perioral region. The intraoral exercises have the function of stimulating the sucking reflex of the newborn. The areas to be stimulated are the palate, tongue, the inner surface of the cheeks, and the sucking reflex itself (through rotational movements while the newborn sucks the index finger).10

WHO allows early complementary feeding to infants aged between 4-6 months only if; the baby’s body weight does not increase well even though he continues to breastfeed and / or often breastfeeds but the baby is still hungry.11 This is consistent with the aforementioned case, hence baby H were given early complementary feeding at the age of 4 months 16 days.



In infants with failure to thrive with severe malnutrition and a weak suction reflex, a multidisciplinary treatment is needed immediately, considering the cause was ankyloglossia. Multidisciplinary therapies, in this case, were frenotomy, supplementation and routine oral motor exercises that were very helpful in increasing the strength of the baby’s suction reflex, which then helped in reaching the ultimately goal of a good nutritional status. Supplementation, in this case using the SNS (Supplemental Nursing System) device filled with pasteurized donor breast milk, could increase the baby’s weight optimally without leaving the breast (still breastfeeding).







  1. Praborini A, et al. 2018. A Holistic Supplementation Regimen for Tongue-Tied Babies With Slow Weight Gain and Failure to Thrive. Clinical Lactation Vol 9 Issue 2, DOI: 10.1891/2158-0782.9.2.78.
  2. Segal LM, et al. 2007. Prevalence, diagnosis, and treatment of ankyloglossia. Can Fam Physician. 53(6): 1027–1033.
  3. Rulina Suradi, et al. Bahan Bacaan Manajemen Laktasi. Jakarta : Perinasia, 2019.
  4. World Health Organization. Breastfeeding.
  5. Asti Praborini, Ratih Ayu Wulandari. Anti Stres Menyusui . Jakarta : Kawan Pustaka, 2018.
  6. Kotlow,L. 1999. Ankyloglossia (tongue-tie a diagnostic and treatment quandary); Quintessence Internasional. 30(4) 259-262.
  7. Kotlow L. Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. Eur Arch Paediatr Dent. 12: 106-112.
  8. Powers, N. G. 2004. Low intake in the breastfeeding infant: Maternal and infant considerations. InBreastfeeding and human lactation (4th ed.,pp.325–363).
  9. The Academy of Breastfeeding Medicine Protocol Committee. (2009). ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, Revised 2009. Breastfeeding Medicine, 4(3).
  10. Ferres-amat E, et al. 2016. Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy. Case Rep Pediatr : 10.1155/2016/3010594.
  11. World Health Organization. 2000. Complementary feeding family foods for breastfed children. Retrieved from


Lorem ipsum dolor sit amet

Leave a Reply

Your email address will not be published.