Breastfeeding a baby with Failure to Thrive (FTT), sub-mucosal tongue tie and upper lip tie grade 4 (PART 1)

By : dr. Hazwani Fadhillah Nasution

Baby AR is the first child of Mrs. RA and Mr. A, who was born on 18th January 2021 in a mother and child hospital based in Medan. Mrs. RA came to the lactation clinic accompanied by her mother (baby RA’s grandmother). Mrs. RA delivered her baby through SC at term gestational age and weighed 2820 gr. At the hospital, baby AR was given formula milk via bottle due to the mother’s low milk supply. After being discharged from the hospital, at the age of 1-week-old, baby AR learned to breastfeed to Mrs. RA directly. Mrs. RA complained her baby had a poor latch on and easily fell off the breast. Moreover the baby also easily fell asleep on the breast and after the breastfeeding, the baby would still cry out of hunger. In respond to that, Mrs. RA added 30cc of formula milk via bottle.

At the first visit to the lactation clinic, on 16th February 2021, baby AR was 29-days-old. She was only weighed 2590 gr. She did not gain any weight, but loss 230 gr instead. Since at the age of 29-days-old the baby still had not gain to her birth weight, her nutritional status was categorized as Failure to Thrive (FTT) and malnutrition (weight below -3SD), which was based on the World Health Organization (WHO) anthropometry standard.

Physical examination found Mrs. RA breast was within the normal range but the milk supply had decreased. Two physical restrictions were found on the baby. By using kotlow maneuver these restrictions could be classified as sub-mucosal tongue-tie and also upper lip-tie grade 4. During the breastfeeding examination, it was obvious that baby AR body was so stiff with both hands flexed on the chest. During cross cradle position, she only latched onto the nipple, sucked continuously with few audible swallowing, and the breast easily fell off from the mouth. Mrs. RA also felt pain whenever she breastfed her baby, although there was no cracked on the nipple.

In regards to the previous observation, the objective condition of the baby and mother’s milk supply were explained. Further planned therapy including frenotomy, using supplementer, physiotherapy for baby AR and adjuvant therapy for Mrs. RA, were explained. Finally, Mrs. RA agreed to use supplementer at the mother’s breast first, took the baby AR to physiotherapist and eventually agreed to discuss about frenotomy with the family.

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On that day, the mother was assisted using supplementer device made of Nasogastric tube fr 5 and syringe 50cc, filled with 30cc formula. When the baby latched, she sucked and the mother pushed the formula in the syringe to further stimulate the baby to suck continuously. At home, mother would be using the supplementer 6 times a day with 30cc formula for each feeding. The mother was informed that the dosage of formula might be small at first but usually the dosage will be increased after baby AR nutritional status got better. Mrs. RA also received lactogog twice a day to stimulate her milk production.

Second visit at the lactation clinic, on 23rd February 2021, the baby’s weight rose to 2870 gr, with an increase 40 gr/day after using the supplementer. According to WHO anthropometry standard, her nutritional status has reach slightly above the -3SD thus categorized as underweight. However Mrs. RA still complained about the breastfeeding process. The baby did not suck well, so the mother always pushed the formula in the supplementer for the baby and she needed to feed her baby every 1 hour. She also still felt pain every time she breastfeed due to shallow latch. The baby has been in physiotherapy 3 times, the mother feels a lot of progress and the baby was not too stiff anymore. Mrs. RA continued taking lactogog twice a day.

During the second visit, Mrs. RA agreed to immediately perform frenotomy. After the action was carried out, the mother was attached to a supplementer containing 60cc formula and the baby was immediately breastfed. Some improvements were noticed, including a deeper latch, baby’s mouth opened wider, baby sucked continuously and the swallowing sound was often heard. The mother also did not feel pain and the formula in the supplementer was sucked by the baby without the help of the mother to push the supplementer syringe as seen before. The baby was fed up to 60cc of formula milk in the supplementer and soon the baby falls asleep. Then the mother was taught to do tongue-lip exercises to maintain a good post frenotomy wound healing. The baby was also given a gel to be smeared on the wound. Mrs. RA continued to take on lactogog twice a day. In the end, the mother was informed to change the formula milk she’s been using to a less sweet or bitter taste one, because it would be easier for the weaning process of the supplementer

During the third visit, a week after frenotomy performed, the mother said that her breastfeeding was more comfortable and feels the baby was easier to breastfeed. The latch was deeper, there was no pain and breast doesn’t come off easily. Baby AR aged 1 month and 15 days, her body weight was 3050 gr with an increase of 25.1 gr / day. Furthermore, the mother switched on to SNS system and used it 7 times a day filled with 60cc formula per breastfeeding. Mrs AR also still taking lactogog twice a day.

The fourth visit was on March 9, 2021. Mothers felt that baby AR was getting better at breastfeeding. SNS was used 7 times a day and filled with 60-90cc of milk formula. The baby felt asleep after breastfeeding with a satisfied impression. Mrs. RA also felt that her milk production had increased. Beside the consumption of lactogog twice a day, the mother was recommended to do an acupuncture therapy to accelerate the increase breastmilk production. At this visit, the baby AR was 1-month-and-22-days old weighed 3270 gr, which was an increase of 31.4 gr / day.

At the fifth visit, dated 23 March 2021, the baby AR weight was 3720 gr, which increased by 32.1 gr / day. The nutritional status of AR infants was in underweight (<-2SD). The mother used SNS 7 times a day containing 60-90 ml of formula milk. Mother had not done the acupuncture therapy, but still taking lactogog everyday.

The sixth visit was dated April 6, 2021, the weight of the baby AR had increased to 4210 gr, which increased by 35 gr / day. Mrs. RA regularly takes lactogog twice a day and seems to be more confident due to the increased breast milk production.

At the seventh visit on April 20, 2021, the baby AR weight was 4570 gr and increased by 25.7 gr / day. At this point, the baby was 3-months-and-2-days old and she had returned to a good nutritional status based on the standard WHO growth curve (body weight> – 2SD). The mother had done the acupuncture therapy 2 times, which affected the mother’s increased milk production significantly. The use of SNS was continued at a dose of 6x60cc per day. Lactogog and acupuncture therapy were continued until the use of SNS was no longer needed.


Throughout the therapy, Mrs. RA shows a positive motivation to continue breastfeeding on baby AR. Mrs. RA also received a full support from her husband and her closest family so that she felt helped to go through the whole series of therapy.

In helping mothers and babies to breastfeed successfully, the lactation team must be able to assess the situation as a whole. In this case, during initial visit it was observed that the mother had difficulties in breastfeeding her daughter, even though the supplemental nursing system device had increased the baby’s nutritional intake (as evidenced by a significant increase in body weight). However, this system did not necessarily improve the breastfeeding process in general. The mother still felt that the baby was not actively sucking and the formula milk in the supplementer could enter the baby’s body mostly because the mother pushed the supplementer. This was due to the presence of sub-mucosal tongue-tie and the upper lip-tie grade 4 in baby AR, which impaired the breastfeeding process. At the next visit after the frenotomy was performed, the mother felt a significant difference in the breastfeeding process. Baby AR sucked better and the pain that the mother felt was disappeared so that the breastfeeding process was more comfortable for both of them. In some cases tongue-tie did not only affect the tongue but the whole body as well. In Baby AR case, it was observed that her body become so stiff and it made her so difficult to be positioned to breastfeed comfortably. In regards to that physiotherapy was essential to be a part of the treatment for this baby. Gradually the nutritional status of the baby had increased towards a better nutritional status and the mother’s breast milk production had also increased until finally the use of SNS and lactogog in mothers could be stopped.


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