Relactation in infants who have CTEV

Author :  L’Dea Risky Idopconscia Efilia, MD



Mrs. W came with baby Z and her husband to the Children’s clinic at X Hospital to meet dr. A SpA for relactation. Mrs. W wanted to try breastfeed baby Z, aged 4 months 25 days, who had experienced a total nipple confusion. Mothers and babies were referred to the lactation poly at X Hospital for inpatient lactation, taught supplementation with SNS (Supplemental Nursing System) devices and taught skin to skin.


History of Pregnancy and Childbirth

Baby Z is the first child, male with a birth weight of 3900 grams, the mother gave birth spontaneously assisted by a midwife. When the baby was born, the family was told that the baby had CTEV (Congenital Talipes Equinovarus) or often called Club foot. Mother and father were very sad but both were eager to find the best treatment for the baby, they finally brought the baby for a regular treatment to an Orthopedic Specialist (Sp. OT) at the Y Hospital.

BANNER 728 x 90

At the beginning of the baby’s birth, the baby could not maintain suction to the breast, so the mother gave expressed breast milk (ASIP) with a feeding bottle, then was then given additional formula milk on day 5. Mother breastfeed regularly but in the long run the mother’s milk production decreased that from the age of 4 months, the baby consumed only formula milk with a feeding bottle. When the mother checked with the SpOT doctor , the doctor had recommended relactation for the baby by looking for a lactation expert. The family and husband provided support for the mother to do the relactation.


Examination of mother and baby

A physical examination was performed on both mother and baby to identify relactation problems. The mother’s, breast was normal, the left nipple was inverted and the right nipple was short protruding. The nutritional status of the baby was good with a weight of 6780 grams at the age of 4 months 25 days, but a submucosal tongue tie and a grade III lip tie were found. From the physical examination, the baby’s feet use special shoes because the baby has CTEV and was being treated. Direct breastfeeding observation with or without breastfeeding aids (SNS), the baby still refused to suck at the mother’s breast. Father and mother had agreed to carried out the relactation process.

Mother and baby continue to carried out the relactation process using the Praborini Method. (1) During relactation, lactation visits were conducted daily by the lactation physician to assess the progress of relactation.


Hospitalization Relactation

On the first day of treatment, the baby’s weight was 6650 gram, the baby still did not want to suckle at the mother’s breast and was given formula milk in a cupfeeder by the nurse. During the morning visit, the SNS filled with formula milk with 60 ccs of partially hydrolyzed protein was attached, a nipple puller was attached to the mother’s breast. However at the beginning the baby still refused, then the mother blessing to the prophet and set Murottal Ar-Rahman, until the baby wanted to suck steadily and continuously. In the end the SNS ran out 20 ccs and then the baby cranky back. In the afternoon, it was observed that breastfeeding was paired with SNS and then pulled out of the areola of the mother’s breast with a nipple puller, the father helped to hold the baby’s feet, the mother prayed, the baby sucked steadily and continuously until the SNS used up 90 ccs.

On the second day of treatment, the baby’s weight was 6425 gram, the mother felt that the baby was about to suckle the mother’s breast. When observed, the baby immediately breastfed steadily and continuously until the SNS was exhausted, When it was observed that the attachment position was not optimal, the baby’s mouth was not wide open, the mouth went in only on the tip of the nipple and suckling was still uncomfortable, without the suction sensation in the breast it was still not stable. During the day the baby was given a frenotomy (incision of the frenulum tissue, Dorland)(2) On both tongue and lip straps were performed to help improve the baby’s attachment to the breast. Then, during the afternoon visit, my mother reported that my father was in the ER due to vomiting and abdominal pain. Mother seemed worried about her husband’s condition, then the lactation doctor gave encouragement to the mother while being taught TE&LE (tongue exercise & lip exercise) to train the mobility of the baby’s tongue and lips and reduce possible reattachment of the incised frenulum.

On the third day of treatment, The baby’s weight was 6440 gram, the mother said that the father will perform appendicitis surgery at night, the mother was still enthusiastic to carry out the relactation, the husband also supports the mother, when the division of the baby appears early to suck, the breast often comes off, then stabilizes and continues, the SNS runs out 30 cc.

On the fourth day of treatment, the baby’s weight was 6360 grams, the father was in postoperative recovery. During the breastfeeding review, the mother was more enthusiastic, the baby sucked the breast with the help of stable and continuous SNS, there was no rejection, the paired SNS was exhausted, the mother also felt sucking on the breast deeper and the baby’s mouth is more open when feeding.

On the fifth day of treatment, the baby’s weight was 6390 gram, the mother said that the baby had fully fed directly with the help of the SNS, the baby was getting better at suckling, when it was observed that the baby sucked the breast with the help of the SNS, it was stable and the SNS was used up 90 ml continuously. The mother was also given lactation acupuncture at that time to increase her milk production.

On the sixth day of treatment, the baby’s weight was 6355 gram, the baby was breastfed more smoothly and there was no refusal, the mother felt pain in the left nipple with a pain scale of 7, the pain was also felt when the nipple was touched and the pain radiates to the areola. Raynaud’s phenomenon is a condition caused by reduced blood flow to certain parts of the body due to constriction of blood vessels (vasospasm). The parts of the body that are most often affected by this problem are the fingers and toes, but narrowing of the blood vessels can also occur in the breast. As a result of the narrowing of blood flow, the mother’s nipples can change color (can be white, then blue, finally red) accompanied by pain and an unbearable burning sensation in the nipples. Vasospasm is often triggered by cold temperatures, but other precipitating events have been reported, including emotional stress. (3)

Mother received the drug Nifedipine to treat Raynaud’s Breastfeeding. During the day visit, the mother received lactation acupuncture therapy again to increase the mother’s milk production. Mother and baby were allowed to go home with a post-hospitalized control advised a week later.

The mother’s enthusiasm for relactation was extraordinary and with the support of her husband completes the success of breastfeeding. By hearing the mother pray patiently and enthusiastically while nursing her baby mad her feel emotionally touched. In the End baby Z who has CTEV, can still do relactation. At that time, the husband, who needed an appendectomy, did not prevent the mother from continuing the struggle so that her baby could breastfeed again.

A week later, the post-hospitalized control mother went to the lactation polyclinic, to perform lactation acupuncture by the acupuncturist who is also the lactation team and was educated on the early complementary feeding plan on the advice of a pediatrician, and the baby’s weight during control became 6670 gr, increased by 315 gram in 7 days, the mother felt happy because she felt that the bonding with her baby was stronger and was comfortable when breastfeeding. In the next control, the baby’s weight also rose again to 6800 grams, an increase of 130 grams in 7 days. Mother said that the baby was eating more and more milk than before, the baby was getting smarter in arranging it. The SNS is still 8-10 x 90 ml, in the next control the baby is getting smarter at suckling and the SNS is reduced gradually, until finally it is only direct sucking accompanied by solid food. In the last control, the baby’s weight is 8230 grams.


Table 1.   Baby Z’s weight during inpatient relactation and control pos-relactation hospitalization
NO. Date Baby’s age Part Weight (Gr) Therapy
1 2/10/20 4 months 25 days Lactation Polyclinic 6780 ·      SNS 8-10x/day contains 90 ml
2 3/10/20 4 months 26 days Day 1 Hospitalization 6500 ·      SNS 8-10x/day contains 90 ml
3 4/10/20 4 months 27 days Day 2 Hospitalization 6425 ·      SNS 8-10x/day contains 90 ml

·      Frenotomy

4 5/10/20 4 months 28 days Day 3 hospitalization 6440 ·      SNS 8-10x/day contains 90 ml
5 6/10/20 4 months 29 days Day 4 Hospitalization 6360 ·      SNS 8-10x/day contains 90 ml
6 7/10/20 5 months Day 5 Hospitalization 6390 ·      SNS 8-10x/day contains 90 ml
7 8/10/20 5 months 1 day Day 6 Hodpitalization 6355 ·      SNS 8-10x/day contains 90 ml

·      Lactation acupuncture

8 16/10/20 5 months 9 days Lactation  Polyclinic 6670 ·      SNS 8-10x/day contains 90 ml

·      Lactation Acupuncture

·      Plan to early complementary feeding (Education for complementary feeding)

9 23/10/20 5 months 16 days Lactation Polyclinic 6800 ·      SNS 8-10x/day contains 90 ml

·      Lactation Acupunture

·      Complementary feeding

10 6/11/20 6 months Children’s Polyclinic 7300 ·      SNS 4-5x/day contains 90 ml, gradually lowered

·      Complementary feeding

·      Vaccine DTaP-IPV-Hb-Hib

11 30/1/21 8 months 25 days Children’s Polyclinic 8100 ·      Complementary feeding

·      Vaccine PCV + Influenza

12 27/2/21 9 months 22 days Children’s Polyclinic 7920 ·      Complementary feeding
13 11/4/21 11 months 6 days Children’s Polyclinic 8230 ·      Complementary feeding                        


Graph 1. Baby Z’s weight during inpatient relactation treatment and control after relactation hospitalization   




Breastfeeding is one of the best investments to improve the health, socioeconomic development of individuals and nations. Exclusive breastfeeding is important for infants under 6 months and breastfeeding up to 24 months supports the first 1000 days of life. (4)

Breastfeeding is not just feeding the baby, when the mother hugs the baby she is breastfeeding, her eyes are fixed on the baby with shades of love and desire to be able to meet the baby’s needs, the mother’s attitude creates a sense of comfort and security for the baby. He feels understood, his needs met (hungry), affection, and loved. Through breast milk, both the baby and the mother learn to love and feel the pleasure of being loved. (5)

If the mother’s milk production decreases, the mother needs to increase it. If the mother has stopped breastfeeding, and the mother wants to start again, this is called relactation. (6) So relactation is an attempt to return the baby to suckle back to the breast after the baby had previously breastfed and then stopped and the mother who had previously breastfed stopped breastfeeding. (7) Situations where mothers want to do relactation include when :(6)- The baby is sick and has not breastfed for some time – The baby is fed artificial food, but now the mother wants to trybreastfeeding – Infants are sick or fail to thrive due to artificial feeding – Mother is sick and stops breastfeeding the baby – A mother adopts a baby, this is called lactation induction The length of time for relactation

The length of time it takes for a mother’s milk supply to increase varies greatly. It helps if the mother is highly motivated, and if the baby suckles frequently. But you don’t have to worry if it takes longer than expected. Relactation is easier if the baby is very young (less than 2 months) than if the baby is older (over 6 months). However, relactation is possible at any age. Relactation is also easier if the baby has just stopped breastfeeding, than if the baby has stopped breastfeeding for a longer period. However, relactation is possible at any time.(6)  According to Praborini et al, the length of relactation is between 24 hours to 5 days using the inpatient method. (1) Factors influencing the success of lactation :

1. Things related to babies

Success lies in the baby’s suction which is influenced by: (8)·

Baby’s desire to breastfeed. The success of relactation and induction of lactation will occur if the baby suckles immediately when brought to the breast. At first the baby needs help to be able to latch on properly to the breast. One relactation study found that 74% of infants refused to breastfeed immediately at the start of relactation due to difficulty latching on to the breast and requiring the assistance of a successful healthcare professional to resolve it. Rejection at the beginning of relactation does not mean the baby will always reject the mother, it takes the mother’s patience to deal with this.

  • Infant age. Praborini et al, in their research found that the younger the baby, the higher the success rate of relactation. (1)
  • The length of time lactation has stopped (interrupted feeding)

The delay in feeding a baby is from the last time the baby suckled, in general relactation is more likely to occur with shorter distances, for older children it takes more time. In the experience of breastfeeding during intervals, bottle-fed babies may develop a preference for a feeding bottle over the mother’s breast, so it is necessary to discontinue the use of bottles and pacifiers to overcome infant reluctance to breastfeed.

  • Special conditions in infants.

Evaluation of the baby’s condition that causes breastfeeding to stop early, especially in terms of anatomy (tongue strap/tongue tie, lip strap/lip tie, cleft lip/gum/palate), reflux disease and others.


2. Matters related to the mother, these factors are: (8)

  • Mother’s motivation. Mothers have a strong motivation because they know breastfeeding is very important in supporting the health of the baby. In Papua, mothers are motivated to engage in relactation when they know the dangers of using formula milk. The condition of the mother’s breasts.
  • The presence of infection or sores in the breast or the shape of the inverted nipple is the reason for the mother to stop breastfeeding. After the infection was resolved and the mother received lactation guidance, the mother’s motivation emerged to breastfeed her child again. Seema finds that with motivation, support and help to position the baby at the breast, most difficulties can be overcome (9).
  • Mother’s ability to interact with her baby. Ability to interact responsively with her child during relactation, the mother must be able to respond to the baby and breastfeed whenever the child shows interest and desire to breastfeed and make skin-to-skin contact with the baby. In order to fully respond, the mother must be freed from other tasks in order to focus on the baby.
  • Support from family, environment and health workers. It is important to get emotional support from husbands, family, friends, breastfeeding counselors and health workers .
  • Previous breastfeeding experience. Mothers who had previous breastfeeding experience did not significantly affect their relactation abilities. Seema reported that there was no difference in relatation success between mothers who had only one child compared to mothers who had more than one child.(9)

Skin-to-skin contact               

The importance of skin-to-skin contact, sleeping with the baby, and skin to skin as long as possible is reported to be useful for overcoming breastfeeding problems and possibly increasing milk production. Babies who have never breastfed or who refuse to breastfeed will gradually start to breastfeed if they have skin-to-skin contact with their mother. Some mothers find it helpful to do skin to skin with the help of a baby carrier such as a finger cloth. (8)


CTEV/ Club Foot

Club foot (CTEV) is a disease or congenital abnormality in the foot whose cause is not known with certainty. (10)               Club foot has four main characteristics, namely hindfoot equinus, hindfoot varus, midfoot cavus, and adduction forefoot. Club foot itself can be divided into two major groups, namely idiopathic (80% of cases) and syndromic (about 20%). (11)



The diagnosis of club foot which is often called Congenital talipes equinovarus (CTEV) can be made at 18-20 weeks of gestation using ultrasonography (USG). If the diagnosis has been made before the gestational age is below 20 weeks, amniocentesis is necessary to exclude the presence of severe genetic abnormalities. However, it is not accepted in the United States as a routine standard for decision-making because of the high false-positive rate for diagnosis of club foot via ultrasound during pregnancy and the possible risk of fetal loss due to amniocentesis. Therefore, the diagnosis of club foot is routinely carried out through history taking, physical examination and supporting examinations carried out after the baby is born. (12)



The safest and most appropriate method is periodic re-stretching of the tendons. The best time or golden period for wearing a cast in this method is the first 1-2 weeks after birth, which is done by an orthopedic specialist. The best treatment at this time is gradual non-operative management with the Ponsetti method introduced by Professor Ignacio Ponsetti from the University of Iowa, USA. (10)



During the therapy period, mother W showed a positive spirit to be able to return to breastfeeding baby Z, accompanied by her husband who also gave full support to mother and baby. In the inpatient room, the baby still wears special shoes which are therapy from the SpOT doctor while doing relactation. With baby Z aged 4 months 25 days, a baby who was already actively rolling over, on his stomach and already recognizing the surrounding environment that was easily distracted was a challenged in itself to carry out the relactation process but with the enthusiasm of the mother, father and support from medical personnel who help realize the relactation process succeed. The CTEV condition in baby Z was not an obstacle for the mother in carrying out the relactation process. The advice from Dr. SpOT for mothers to do relactation was very good, giving encouragement to mothers to return to breastfeeding their babies.

In the case of baby Z, when he was hospitalized for relactation, observations were made when the baby started sucking the breast, it was seen that the attachment was less than optimal when feeding, the mouth was not wide open resulting in suckling only on the tip of the nipple. This is because the baby has a submucosal tongue tie and a grade III liptie, so frenotomy is recommended. After frenotomy, the mother felt a significant difference that the baby sucked better, sucked deeper into the breast and opened the mouth wider when feeding. The mother also found Raynaud’s breastfeeding, the mother also received drug therapy for the treatment. And for the decreased production of mother’s milk, the team of lactation doctors also suggested that an acupuncturist perform lactation acupuncture to increase milk production. Indeed, the process is not instant, but after several times of lactation acupuncture from while in the inpatient room to post-hospital control, acupuncture helps increase the production of mother’s milk.

Treatment is carried out not only on the baby but also on the mother, so that breastfeeding difficulties and discomfort can be overcome. During the inpatient relactation process, the baby’s weight decreased due to the baby’s adaptation process in relactation, after the baby was better at breastfeeding.

With the baby’s weight gain gradually increasing and the mother’s milk supply also increasing, the use of SNS will be reduced slowly until it is stopped and breastfeeding is immediately accompanied by complementary feeding for baby Z.

The relactation process needs support from all parties, from mothers and babies, husbands, families and medical personnel who care for them. The main thing is the unwavering intention of the eager mother to return to breastfeeding her baby. Breastfeeding provides many benefits for mother and baby, including bonding between mother and baby, increasing antibodies in breastfed babies and other benefits for now and in the future.



  1. Asti Praborini et al. Hospitalization for Nipple Confusion a method to restore healthy breastfeeding, Clinical lactation official Journal of the United State Lactation Consultant Assosiation, 2016
  2. Newman Dorland, alih bahasa : Huriawati Hartanto, dkk. Kamus Kedokteran Dorland Ed 29, Jakarta : ECG, 2002
  3. Jane E. Anderson, Nancy Held and Kara Wright. Raynaud’s Phenomenon of the Nipple: A Treatable Cause of Painful Breastfeeding. American Academy of Pediatric. 2004.
  4. Kementrian Kesehatan RI. Berikan ASI untuk tumbuh kembang optimal. Jakarta: Kementrian Kesehatan RI. 2019
  5. Rulina Suradi et al. Bahan Bacaan Manajemen Laktasi. Jakarta : Perinasia, 2019.
  6. Sri Astuti S Suparmanto, M.Sc.(PH). Modul : Pelatihan konseling menyusui modul 40 jam (Standar WHO/Kemkes/Unicef). Jakarta : Perinasia. 2007.
  7. Asti Praborini, Ratih Ayu W. Anti Stress Menyusui ,Jakarta: Kawan Pustaka, 2018
  8. World Health Organization. Relactation ; Review of Experience and recommendation for practice. Geneva. 1998.
  9. Seema AK, Patwari L , Satyanarayana Relactation: An effective intervention to promote exclusive breastfeeding. J Trop Paediatr. 1997 ; 43 : 213-216
  10. Bagus Pramanta Sp.OT. Article: Kaki Pengkor atau Clubfoot (Congenital Talipes Equniovarus/ CTEV). Jakarta : Rumah Sakit ST. Carolus, 2018.
  11. Pavone, Vito et al. The etiology of idiopathic congenital talipes equinovarus: a systemic review. Journal Of Orthopaedic Surgery and Research (2018) 13 : 206.
  12. Anand, Ashish and Sala, DA. Clubfoot : Etiology and treatment. Indian J Orthop. 2008 Jan-Mar; 42(1) : 22-28. Available from :


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