Breastfeeding a baby with Failure to Thrive (FTT), sub-mucosal tongue tie and upper lip tie grade 4 (PART 2)

By: dr. Hazwani Fadhillah Nst, IBCLC

Baby AR is the first child of Mrs. RA and Mr. A who was born in one of the Hospital in Medan city on January 18, 2021. Baby AR was born through a cesarean delivery process at term with a birth weight of 2820gr. At the age of 29 days, the AR baby’s weight dropped to 2590gr and was categorized as Failure to Thrive and poor nutritional status with body weight below -3SD WHO growth curve. Then Mrs. RA and AR babies received optimal breastfeeding assistance so that at the age of 3 months 2 days AR babies have reached weight of 4570gr with good nutritional status. Learn more about Mrs. RA and AR infants from 29 days of age in PART 1.At the age of 3 months 2 days, with good nutritional status, baby AR continue to breastfeed directly to Mrs. RA. She was still using the SNS filled with formula milk at dose 60cc, 6 times a day. In the future, the goal of therapy was to increase maternal milk production so that mothers can breastfeed independently and the use of SNS and formula milk can be stopped.Eighth visit on May, 4th 2022, Baby AR weight was 4740gr, increasing about 12,1gr per day. At this time, her nutritional status decrease to undernutrition with -2SD 4766gr. Mrs. RA said the L size tube of the SNS was broken and she had to use the M size tube since then. It took longer for baby AR to nurse. Baby AR was a bit agitated and keep pulling the nipple when she nursed. Mrs RA have took acupuncture therapy 4 times and took lactogogue continuously. Mrs RA was advised to purchase another L size tube of the SNS and using both 2 M tube on one breast while she nurse.On May 25th 2022, Mrs RA and baby AR came for the ninth visit. Baby AR weight was 5160gr, increasing 20gr per day which is sufficient for her age and her nutritional status had increase (-2SD 5093gr). Mrs RA said that her baby has nurse peacefully since she put two M tube of the SNS on one breast while she nursed. She used SNS 7 times a day, with 60ml of formula each feeding. Baby AR sleep tight after feeding. Mrs RA had took acupuncture therapy for 6 times and she felt more confidence as she felt the breastmilk was increasing. Mrs RA was given option to start early solid feeding for her baby and took a preparation class for cooking the right complementary feeding. Mrs. RA continued take lactogogue and acupuncture therapy.Tenth visit on June, 29th 2021, baby AR was 5months 11days old. Mrs. RA has commenced early complimentary food 11 days ago. Baby AR current weight was 5550gr, increasing about 11,4gr/day compared to the previous visit, with good nutritional status (-2SD 5510gr). Mrs. AR continued breastfeed according to her baby’s cue and give nutrient-dense complementary foods twice a day. She also added 1 quail egg in every feeding session. She used SNS 5 times a day, two times as much as 30cc and three times as much as 60cc. Mrs. AR used SNS size M tube and only 1 tube was attached to 1 breast. She had completed acupuncture therapy 10 times and was still taking lactogogue.The eleventh visit on July 29, 2021, the baby AR weight was 6140gr with a weight gain of 19.6gr/day. Good nutritional status was -2SD 5810gr. Mother gives complimentary food 3 times main meals and once snack daily. Mothers continued to add quail eggs in every main feeding session. Mother still uses SNS 6 times, with 4 times as much as 30cc formula and 2 times as much as 60cc formula. She had been using an S size tube for the last 3 weeks because the M tube broke. Only 1 S tube was attached to the breast. The baby seemed calm when breastfeeding to the mother, sometimes felt asleep after breastfeeding, given the impression of being satisfied. Mother feels her breasts were soft after breastfeeding and felt that her breasts fill up quickly. Mother was still taking Galactogog twice a day.The next visit on August 31, 2021, Baby AR was 7 months 13days old and weighs 7020gr. Baby AR weight increased by 27.5gr/day and good nutritional status above -2SD 6886gr. Mother said that her baby enjoyed eating food she provided for her, baby AR ate the same menu as the parents everyday. Mrs. RA breastfeed according to the baby’s cue between meals and use SNS only 5 times a day. 4 times as much as 30cc formula and 1x as much as 60cc formula. She continued galactogogueThe thirteenth visit was on September 30, 2021. Currently the AR baby was 8 months 13 days old. Her weight was 7530gr with good nutritional status. Mother said that the last few days, AR baby had less appetite, she tried to vary the food menu and eating atmosphere. Mother uses SNS only 3 times a day, as much as 30cc formula and sometimes remain 10cc in the SNS. Mrs RA was advised to stop SNS but she was still not confident yet. She said sometimes in the middle of the night baby AR would cry if she breastfeeds without SNS. The baby cried very loud, she was worried about disturbing other family members, so the mother decided to continue to use SNS for breastfeeding at night. Mother continued to take galactogog twice a day.Last visit on November 11, 2021. Baby AR was 9 months 24 days old. Her current weight was 8170gr, increase about 15.6gr/day. The nutritional status was good with -2SD 6660gr. Mother said that she only uses SNS occasionally at night with a 30cc formula. Sometimes she breastfeed all day without SNS and the baby looked calm when breastfeeding to her. Baby AR have eaten 4 times a day of main meals and 1-2 times a day of snacks. Mrs. RA had felt confident breastfeeding her baby without SNS assistance and really enjoyed the process of eating with her baby. Mrs. RA were asked to reduce the consumption of lactogogue to 1tab a day for 2 weeks and then stop taking galactogogue.

DiscussionMrs. RA continued to show enthusiasm and consistency to maintain breastfeeding baby AR. It took a long time to return the baby’s nutritional status to good nutrition and increase the mother’s milk production. In this case, the mother must be accompanied until the mother’s milk production increases and the mother can breastfeed independently without using SNS and formula milk. Sometimes on the way to SNS and formula milk weaning, mothers often felt insecure, worried that their breast milk will not meet the nutritional needs of their babies, so it is very important for health workers to continue to support and help increase mother’s confidence. Health workers can show objective things that show mother’s milk is increasing every day with indicators such as the supplementation dose that continues to decrease, the frequency of urination and defecation is sufficient and the baby’s weight gain is adequate according to age. The subjective signs that can confirm that the mother’s milk is getting more and more are the condition of the baby being calm when feeding to the mother without using SNS and the baby being able to fall asleep after. Do not forget to give praises to the mother for her efforts to maintain breastfeeding.In this case where the mother is still using supplementation with a fairly high dose of 6-7 times daily with 60cc of formula when the baby was 4 months old, therefore the option for early complementary feeding was conveyed to the mother as an effort to help reduce supplementation and formula dosage. This is in line with WHO recommendations. Since Mrs. RA commenced complementary feeding for baby AR, it can be seen that her weight gain was getting better and the use of supplementation was decreasing. Every day she uses SNS less and less and fills only 30 ml of formula, until finally she could stop using SNS. In addition to assist mothers in continuing their breastfeeding journey, it is also important for health workers to accompany mothers during the complementary feeding period. Sometimes mothers are faced with situations where the baby does not have an appetite and so on, mothers need to be given guidance and direction to make improvements and changes so that the complimentary feeding process can run smoothly again.In this case, we can conclude that the lack of breastmilk supply is not merely due to lack of milk but is triggered by a tongue tie that was not detected from the start. So that the frenotomy was delayed and performed at 36 days of age, when the mother was already in the lactogenesis stage 3 where milk production was highly dependent on the baby’s sucking. In babies with tongue tie, suction to the breast is not optimal, so that milk production decreases. With simple frenotomy, supplementation, galactogogue, acupuncture and complementary foods, babies can grow and develop optimally, and mothers can maintain breastfeeding for up to 2 years.

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