Written by dr Nisa Uswatun Karimah



Baby girl ‘S’ was born at term by a caesarean section under BPJS Kesehatan (national health insurance program) coverage from mother ‘F’ at one of the Mother & Baby Friendly Hospital in D city on 7th November 2020. The birth weight was 3230 grams. She was crying immediately and directly placed in the same room with mother F. From early on both mother and baby were highly supported to do the early breastfeeding. Mrs. F is an employee who works at the same hospital. As an employee of a well-known Mother Baby Friendly Hospital in D city, mother F had attended the lactation education for employees which held annually by the lactation team at the hospital. Therefore mother F really motivated to breastfeed for up to 2 years.


The next day after giving birth, the mother and baby were visited by a lactation-counseling doctor, in order to receive a breastfeeding counseling and direct practice in the inpatient room. Mother complained of sore in her breasts. After the examination, the baby was found to have a tongue-tie and a lip-tie, which interfered with the breastfeeding process. Both mother and father of baby S immediately decided for a tongue-tie and lip-tie frenotomy on the next day when the baby was 3 days old. When a frenotomy was held, the baby’s weight had dropped a lot, by 8% to 2970 gr. After the frenotomy was done, the counselor taught the parents about tongue and lip exercises. The tongue and lip exercise was recommended to be done 5 times a day for the next 3 weeks. In addition, the baby were advised to do the tummy time every day on the parents’ chest. The baby was also given jelly to be smeared under the tongue and upper lip in order to speed up the recovery. In the end, the baby was advised to be checked once a week after the frenotomy.


Because the mother felt the breastfeeding was smooth and she had nothing to complain about after 1 week, she did not attend the scheduled post-incision control. Unfortunately, the mother and the baby visited the doctor almost 2 months later because the baby’s weight increase was obstructed. They came on 29th December 2020 and it was found that at the age of 1 month 22 days, the baby’s weight was 3715 grams, with an increase of 9.7 grams/day since the incision. For such age, the nutritional status of the baby could be categorized as less than -2SD (standard deviation). The mother then consults with the doctor at the lactation clinic. From the anamnesis, it was found that tongue exercises were not carried out properly, which resulted in reattachment of tongue tie. This situation affected the baby’s difficulty in gaining weight since the reattachment impaired the breastfeeding process. The baby had her reattached tongue-tie incised (cut again) so that the baby could suckle properly again. However, because the baby was already experiencing growth problems, she was immediately supplemented with the Supplemental Nursing System (SNS) according to the prescribed dose.

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Already learned a lesson from previous experience, the mother (and the baby) always visited the doctor routinely as scheduled after the repeated incision. The baby’s weight increased well and the SNS dose could be decreased gradually until it was no longer needed. The SNS system could be stopped after the baby’s weight has met the desired weight gain according to the growth curve and reached a good nutritional status. The mother was also given additional paid leave to support the breastfeeding program for up to 2 years, which in accordance with the existing policies at the hospital for employees who want to breastfeed. Then the routine check was scheduled at the end of the following month, on 26th January 2021.


Unfortunately, before the next appointment scheduled, to be precise on 23rd January 2021, it turned out that the father was declared as being infected with COVID-19 based on positive swab-PCR results, after he had gone on a business trip out of town. The father had experienced symptoms such as fever and cough. After tracing the transmission of the disease, the mother and the baby were also declared as positive cases of COVID-19, but both of them were asymptomatic. Due to the symptomatic father, the family decided to do the isolation treatment at the hospital. The mother opted to be isolated in the same room and breastfeed the baby at her own will. The mother and the baby were supported by all health workers because all workers in the Mother Baby Friendly Hospital are pro-breastfeeding. The mother also took time to contact the lactation-counselling doctor (via WhatsApp) to ask for guidance on breastfeeding smoothly for up to 2 years, even though they were in a pandemic situation and contracted COVID-19 infection. The mother was motivated to breastfeed as usual, of course, with the awareness of performing transmission of infectious diseases prevention protocols, such as wearing masks, washing hands frequently, and using disinfectants.


After 7 days of treatment on 29th January 2021, the father was already asymptomatic, so the family were referred to do self-isolation at home. At home, the mother continued to breastfeed the baby as usual, with the awareness of maintaining COVID-19 transmission prevention protocols. After one week at home, to be precise, on the 5th of February 2021, the baby was declared negative for COVID-19 based on the swab-PCR test result, but both the mother and father still tested positive for COVID-19. The mother continued breastfeeding the baby as usual while performing COVID-19 transmission prevention protocols. A week later, on 12th February 2021, the father and the mother were tested again with negative COVID-19 results and the family was declared cured of COVID-19. After that, the baby was then scheduled for a follow-up check as soon as possible.


On 19th February 2021, at the age of 3 months and 14 days, the baby came back for a follow-up check after being declared negative for COVID-19, and after the examination, everything was all good. The weight gain was sufficient even without supplementation, and the mother’s breastmilk was still abundant. The mother was also in preparation to work again after she spent all of her additional paid leave. The mother and the father were taught about lactating management for working mothers.


After that, the baby was controlled regularly, and the baby’s weight increased well every month up until now. There was no breastfeeding problem, and the baby had also entered the complementary feeding period (Breastmilk Complementary Foods/MPASI), armed with a good 4-star MPASI counselling according to World Health Organization (WHO) guidelines. Currently, the baby is 6 months old with a weight of 6800 grams healthy, which is a good nutritional status. The mother is still motivated to do Direct Breastfeeding (DBF) and will continue breastfeeding for up to 2 years.





Frenotomy is a procedure used to correct congenital conditions where the frenulum of the tongue or the frenulum of the upper lip is too tight, causing restriction or limitation of movement which impairs the breastfeeding process. In other cases, these untreated conditions also cause problems such as gaping or spaced teeth, speaking difficulty, and digestive problems. When it occurs in the frenulum of the tongue, this condition is known as tongue-tie (the medical term is ankyloglossia).


The tongue is a complex organ consisting of 8 muscles involved in eating, breathing, speaking, sleeping, posture, and other essential functions. Ideal tongue function and muscle posture at rest also promote good growth, dental arch development, and the development of the facial and airways. 3


Ankyloglossia or tongue tie is a condition that the frenulum of the tongue that is short and tight, causing limited tongue movement. 4 According to the International Affiliation of Tongue Tie Professionals (IATP), tongue tie is tissue left over from the embryological process in the midline of the body between the bottom of the tongue and the floor of the mouth that impedes tongue movement.8 The prevalence of ankyloglossia is between 3.2% to 10.7%.2 Ankyloglossia is found to be more common in boys than in girls. Several studies have shown that tongue-tie is inherited in an autosomal dominant manner with incomplete penetration (which does not always occur).6,7 However, several studies, including by Han SH et al. (2012), that investigated the genetic inheritance of ankyloglossia by pedigree analysis, conclude that ankyloglossia is X-linked recessive, and mothers of female patients are carriers.8 The majority of ankyloglossia presents as a single problem. However, tongue-tie can also be associated with other events, such as X-linked cleft palate, Kindler syndrome, van der Woude syndrome, Opitz Syndrome3, Orofaciodigital syndrome, Beckwith-Wiedemann syndrome, Simpson-Golabi-Behmel syndrome9 and Pierre Robin Syndrome10.


Ankyloglossia occurs when proper apoptosis does not occur during embryological development.11 Tongue tissue develops around the fourth week of gestation. In this phase, an indentation is formed at the edge of the tongue tissue so that the tongue can move freely, except for the frenulum side of the tongue that reaches the tip of the tongue. As development progresses, cells in the frenulum undergo apoptosis and migrate to the medial side of the tongue. At this time, if there is a disturbance in cell control and migration does not occur completely or even does not take place at all, it will cause the ankyloglossia condition.12


Genetic factors, epigenetic, environmental, and physical injury during embryonic development can interfere with programmed cell death or apoptosis, causing malformations.7 Regarding genetic mutations, there are two genes reported to be associated with childhood ankyloglossia: 1) TBX22 gene mutation, which causes tongue-tie without the syndrome. 2) G-protein-coupled receptor (Lgr5) gene. The absence of the G-protein-coupled receptor (Lgr5) gene in mice causes a tongue-tie phenotype and causes death within 24 hours due to feeding difficulties, but further human studies are needed. 6,7


Epigenetic factors associated with ankyloglossia include the DNA methylation process. This process affects normal facial formation during embryo development. This process is very sensitive to stressors, such as viruses, chemicals, drugs, nutrients, and stress.11 An example of a nutrient that is required for DNA methylation is Folate.6 However, there have been no studies that have definitively proven the relationship between folate deficiency and the occurrence of ankyloglossia. Folate can be obtained from supplementation in the form of folic acid and from its natural form, namely 5-methyltetrahydrofolate. The latter form is easier to absorb and has better bioavailability. For the metabolism of folic acid into 5-methyltetrahydrofolate, the enzyme MTHFR (Methylenetetrahydrofolate Reductase) is required. In populations with MTHFR polymorphisms, there can be problems with folic acid metabolism, which is suspected of interfering with the DNA methylation process.6 Thus, the use of the natural form of 5-methyltetrahydrofolate is preferable to folic acid.13However, according to the Centers for Disease Control and Prevention (CDC), patients with MTHFR polymorphism can still use folic acid, but at a slower rate, so it is still recommended to use folic acid supplementation. 14


Symptoms caused by tongue-tie do not only appear in infants but also in mothers. Usually, the complaints that arise in mothers who are breastfeeding their children with tongue-tie are pain while breastfeeding, sore nipples, ineffective emptying of the breasts, and breast infections. Symptoms that may arise in babies include weight that doesn’t gain well, falling asleep while breastfeeding (because babies with tongue-tie will need extra energy to suckle compared to babies without tongue-ties, so they get tired easily), poor latch quality, reflux and colic symptoms, gumming or chewing the nipples, lip blisters, and short sleep time.2,15,16


In addition to tongue-tie, breastfeeding problems can also be caused by lip-tie. Lip-tie is a string or frenulum at the top of the lip that attaches to the upper jaw. This frenulum has no muscles and only consists of a membrane. If the frenulum is attached to the bone or upper gum, it can cause limited movement of the lips during breastfeeding.  Flange-out lip position is needed in the breastfeeding process so that the baby’s mouth can create a vacuum or high negative pressure so that the baby can suck well and the transfer of the milk can be optimal. Flange-out lips also stimulate the oxytocin chain, which causes the optimal release of breast milk from the mother’s breast. A baby’s lips that are not engorged when feeding to the breast can cause breastfeeding complaints, such as pain and sore nipples.11


In dealing with lactation patients, a holistic or comprehensive approach is needed. That is, a counsellor must be able to see the case of lactation as a series of interconnected events and as a process that involves the mother, the baby and the surrounding environment. Therefore, in solving the lactation problem, these three components must always be considered and monitored. For example, the case of tongue-tie and lip-tie does not just end with frenotomy. We also have to look at the baby’s weight (increase and nutritional status), mother’s milk production, mother’s profession, maternity leave, support from family and workplace, and evaluation of the post-frenotomy tongue and lips exercise. Routine and on-schedule post-frenotomy control is urgently needed to determine the next steps that need to be taken. In the case of tongue ties in older children, apart from asking about lactation history, we also need to explore problems around eating habit, speaking ability, and the quality of life of the children.


Coronavirus Disease (Covid-19) is a new disease that emerged in 2019 and is caused by infection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The outbreak of a new coronavirus named “SARS-CoV-2” caused a respiratory disease that originated in Wuhan, China. This disease has spread globally in the last 1.5 years and has been declared a pandemic. This disease can affect anyone, including breastfeeding mothers and babies. In several reported cases of women with COVID-19 and other coronavirus infections, up until now, there is no evidence that SARS-CoV-2 has been detected in breast milk. 17,18,19


The decision to breastfeed is the choice of the mother and the family. Considering the benefits of breastfeeding for the baby’s health and the current finding that breast milk is not a medium of transmission of SARS-CoV-2 viruses, mothers can opt to continue breastfeeding during the pandemic while implementing all necessary precautions. Both mothers who are contracted COVID-19 after giving birth and mothers who have contracted the virus while breastfeeding their babies will produce antibodies in breast milk, protecting their babies. Therefore continuing to breastfeed is one way to fight the virus and protect the baby. WHO states that mothers who contracted COVID-19 can still do Inisiasi Menyusui Dini/IMD (Early Breastfeeding Initiation), join mother-child inpatients, and breastfeed their babies while following supposed health protocols. 20,21,22


If the mother is in a good condition, for example, as an asymptomatic person or with mild symptoms, breastfeeding is a very reasonable option and should be followed by measures to reduce the risk of mother’s respiratory residue exposure to the baby’s respiratory system. This can be applied to breastfeeding mothers who are either self-isolating at home or isolated in health facilities. Mothers who show moderate symptoms can also still breastfeed their babies. However, this must be followed by necessary precautions, including wearing a mask when near infants (including while breastfeeding), washing hands before and after contact with infants (including breastfeeding), and cleaning and disinfecting contaminated surfaces. 18,20,21


On the condition when the mother has severe symptoms and requires hospitalization and still intends to continue breastfeeding, it is recommended for her to milk the breast milk to maintain production and give it to the child through a clean wide, mouth cup by someone healthy. For milking the breast milk with a breast pump, the mother should wash her hands before touching the pump or any part of the bottle and follow the recommendations for properly cleaning the pump after each session. If the mother’s health condition is unable to pump breast milk, the family are recommended to find a breast milk donor for the baby. The donor breast milk must be pasteurized before consuming by the baby. After the mother recovers, the mother can perform relactation (an attempt to be able to breastfeed again) accompanied by a doctor or a competent lactation counsellor. 18,21


In this case, the mother and the baby both tested positive for COVID-19. The mothers chose to continue breastfeeding while isolated together with the baby at the hospital where the mother works. The hospital is one of the Mother Baby Friendly Hospitals that strongly supports breastfeeding activities. The mother and the baby were taken care of by doctors and health workers who are also very supportive of breastfeeding activities. By continuing to breastfeed, the baby recovered faster than their parents, as evidenced by having negative swab-PCR test results earlier than her parents. Even though the mother was still declared positive for COVID-19, she continued to breastfeed her recovered baby, and the baby remained healthy. In the end, the mother and the father recovered from COVID-19 without interfering with the breastfeeding process at all. This could happen because the mother had sufficient knowledge and strong beliefs that breast milk and breastfeeding are still the best options for the mother and the baby in the current pandemic situation. Moreover, they were also supported by facilities and health workers who are very supportive of breastfeeding activities.




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  17. Centers for Disease Control and Prevention (CDC): Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation for COVID-19.
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  19. International Baby Food Action Network (IBFAN). 2020. Infant and Young Child Feeding in the Context of Covid-19.
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American Academy of Pediatrics Committee on Fetus and Newborn. 2020. Initial Guidance: Management of Infan

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