Breastfeeding Journey of Baby with Ankyloglossia, Failure to Thrive and COVID-19 Infection

Author: dr. Muthia Despi Utami


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 to fulfill the nutritional needs of the baby, providing compositional changes over time to suit the baby needs.

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

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Mrs M came on the 1st of July 2021 to the hospital of lactation clinic in Depok with her husband and daughter, named Baby H who was 17 days old. She complained that baby H’s suckle was slipping, the breast took a long time to be emptied and always appeared to be sleepy during a breastfeeding session. Baby H was born in hospital with normal delivery, helped by a midwife at 38 weeks of gestation and weighed 3450 grams. After birth, Baby H was placed on Mrs M’s chest in less than 10 minutes because Baby H was taken to a baby roomto be observed. From the very beginning, Baby H could not open her mouth wide enough so that she could not devour all of Mrs. M’s nipple, and the nipple looks flat after breastfed.

Since Baby H reached the age of 1-week old, Mrs M came to Paediatrician. Baby H body weight was 2850 grams and she lost her weight around 17.3% from birth weight. Mrs M suggested by Paediatrician to breastfeed every 2 hours and gave expressed breast milk 40 ml after breastfed. Hence Mrs M always pumped her breastmilk every day. However, every pumping session she only got 5cc on both breast and often felt a sore nipple.

At the first visit on the 1st July 2021, baby H was 17 days old with 2985 gram of weighs. She did not gain any weight, even she had experience a weight loss of 27.3 grams per days. Her nutritional status was categorized as Failure to Thrive (FTT) with good nutrition (weight -2SD), which was based on the World Health Organization (WHO) anthropometry standard.

Based on physical examination of Baby H, it shows that baby H had a restriction in both tongue and lips called as tongue-tie anterior and upper lip-tie grade 4. During the breast examination of Mrs M, a symmetrical breast shape, the breast is filling, prominent nipples and normal milk supply were obtained. When Baby H was breastfed, her lips were folded inward, only the tip of the nipple went inside the baby’s mouth (not the whole nipple) and the suckling was slipping.

After explained about breastfeeding according to Islamic guidance and WHO guidelines, Mrs M’s desire to breastfeed Baby H up to 2 years getting stronger and this was supported by Mr A, her husband. They also got explained about baby H condition and the treatment plan, including frenotomy, supplementary nursing system and additional therapy for Mrs M. After that, Mrs M and Mr A approved the doctor to perform double frenotomy on Baby H’s ankyloglossia.

After frenotomy, Mrs M had to breastfed Baby H and it was observed that the lips had folded out, the baby could suck continuously and have a strong sucking and comfort.  Mrs M have been taught about tongue and lip exercise for baby H, 5 times a day for 1 week and continue 3 times a day for the next 2 weeks. Mrs M was advised to stop pumping the breastmilk and only breastfed her baby on demand. But, Mrs M did not approve the supplementary therapy for baby H. Then, Mrs M was taught oxytocin massage and Mr A had to do the massage, which helps to overcome the smooth secretion of breastmilk. Mrs M was advised to come to the clinic next week on the 8th of July 2021.

On 9th July 2021, it was discovered that Mrs M and her family got COVID-19 infection and have to self-isolate at home. Baby H condition monitored by online consultation, so Mrs M suggested to kept breastfed her baby on demand, therefore she did not have to pump the breastmilk. On the 13th July 2021 during online consultations, Mrs M said that baby H breastfed more frequently, and the suckling was not slipping. Baby H only had flu like symptoms and the breath sounds heavy. Baby H weight had gained 26 grams/day which in total became 3300 grams.

On the next online consultation on the 23rd July of 2021, Mrs M said that baby H condition was good and had no symptoms. During the self-isolation at home, baby H only had mild symptoms in 2 days. Because the baby always breastfed to Mrs M’s breast, the baby heal faster than the other family. On that day, the weight of Baby H was gained to 3700 grams, increasing 40 grams/day. Mrs M and her family had to do swab test again tomorrow.

After diagnosed with negative COVID-19 from swab test, Mrs M came to the hospital with Mr A to check the baby H condition. In the examination on the 29th July 2021, baby H had a weight of 3860 grams, which gain 31.2 grams/day. Mrs M said that she will resign from her job to take care of baby H at home in order to breastfeed baby H exclusively up to 2 years.


Throughout the therapy, Mrs M showed a positive motivation to continue breastfeeding on baby H. Mrs M also received full support from her husband so that she felt helped to go through the whole series of therapy.

In this case, during initial visit it was observed that the mother had difficulties in breastfeeding baby H, the suckling was slipping and her weight did not increase significantly. This was due to the presence of anterior tongue-tie and the upper lip-tie grade 4 in baby H, which impaired the breastfeeding process. After the frenotomy was performed, the mother felt a significant difference in the breastfeeding process. Baby H sucked better, the lips can open widely and the pain that the mother felt was disappeared, so that the breastfeeding process was more comfortable for both of them.  At the next visit, the baby had significant increase in body weight and breastfeeding process got better.

When Mrs M and family got infected with COVID-19, baby H still breastfed to Mrs M, which was done in accordance to WHO and UNICEF recommendations. 3,4

Based on other research, currently there are no sufficient findings to conclude a vertical transmission of COVID-19 through breastfeeding. In infants, the risk of COVID-19 infection is low. The infection is typically mild or asymptomatic, while the consequences of not breastfeeding and separation between mother and child can be significant. Based on available evidence, WHO recommends on the initiation and continued breastfeeding of infants and young children, which also apply to mothers with suspected or confirmed COVID-19.3

At this case with breastfeeding, Mrs M can transferred the immune system for Baby H through breastmilk, which explained why baby H only got a mild symptoms for 2 days. In the end, Baby H got the first recovery among the other family. Mrs M felt there were no significant changes of breastmilk production when she got COVID-19 infection.

Even though the mother had symptoms of Coronavirus infection, like fever or cough, the mother still can breastfeed her baby. The benefits of breastfeeding are more dominant than the consequences. However mothers have to practice a good hygiene during feeding, such as wear a mask during feeding, wash hands with soap before and after touching the baby, wipe and disinfect surfaces regularly. 4,5 


  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. World Health Organization. Breastfeeding and COVID-19. Scientific brief 23 June 2020.
  4. Breastfeeding during COVID-19.
  5. Lubbe, W., Botha, E., Niela-Vilen, H., & Reimers, P. (2020). Breastfeeding during the COVID-19 pandemic – a literature review for clinical practice. International breastfeeding journal, 15(1), 82.




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