Frenotomy, Supplementation, and Early Complementary Feeding in Infants with Malnutrition

Written by dr. Anggita Dewati Putri


Baby RSD is the second child of Mrs. AW and Mr. D, born at 36-37 weeks of gestation by caesarean section with the indication of hypertension in pregnancy and a history of caesarean section in the first child. The operation was carried out at a private hospital in the city of D on March 12, 2022. The baby immediately cried with a birth weight of 2500 grams. The mother and baby were treated for 2 days before allowed to go home.

At the age of 5 days, the mother brought the baby to a pediatrician because the baby looked yellow. When the measurements were taken, the baby’s weight was 2330 grams (decreased by 6.8%), and the total bilirubin was 30.5. The baby were treated for phototherapy for 2 days.

Mrs. AW has 2 children. The first son was exclusively breastfed for 6 months. The breastfeeding was given for up to 2 years. Mrs. AW did not work and knew the benefits of direct breastfeeding so she wanted to breastfeed her second child for up to 2 years. Mrs. AW routinely take her baby to Posyandu (Integrated Healthcare Centre) and it was found that the baby didn’t gain weight optimally. So far, the baby only had direct breastfeeding. Mrs. AW complained her baby had poor latching, easily detached from the breast, and had endless duration of breastfeeding as if he was never full. Mrs. AW felt pain in the nipple area during breastfeeding. She also heard clicking sounds when the baby was fed. The mother was referred from Puskesmas (Primary Healthcare) to the Lactation Clinic at P Hospital in D City so that the breastfeeding process and the causes of poor weight gain could be evaluated.

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The first visit to the lactation clinic was on June 2, 2022 when the baby was 2 months and 22 days old. The baby weight was 3580 grams which means the weight gain was 17.4 grams/day. Based on the World Health Organization (WHO) standard growth chart, Baby R was categorized as failure to thrive and severely underweight considering the weight was below the limit of -3 SD (4240 grams). During a physical examination by a lactation doctor, it was found that the baby had an anterior tongue-tie and a grade 4 lip-tie. From the observation of the breastfeeding process with a cradle hold position on the left breast, the baby could not suck well and had difficulty attaching to the breast. Mrs. AW’s breasts were within normal limits and had good milk production.

The lactation doctor explained that tongue-tie and lip-tie were the reason why babies had difficulty in attaching on the mother’s breast properly; thus, it was difficult for the baby to gain weight. The doctor explained the simple frenotomy procedure to the baby’s parents and then they agreed to take the procedure.

After the procedure at the lactation clinic, the baby immediately suckled at the mother’s breast. Bleedingimmediately resolved shortly after feeding. Mother felt the baby sucked deeper and softer, and the mother did not feel the pain in the nipple as before. The mother was given an SNS (Supplemental Nursing System) device containing formula milk with partially hydrolyzed protein. The baby’s mouth was attached well to the areola and the amount of milk consumed from the supplementation device was 30 ml. Based on that, the mother were advised to use SNS with a dosage of 6×30 ml and do direct breastfeeding without SNS as often as the baby wants. The lactation doctor demonstrated tongue and lip exercises for the baby and advised the parent to do it 5 times a day for the next 3 weeks. Parents were asked to have frequent tummy time with the baby and apply aloe vera gel on the frenotomy wound under the tongue and lips. Then, they were scheduled to come back at the 5th day after the frenotomy to the IBCLC certified pediatrician.

The second visit to pediatrician clinic was on 7 June 2022 when the baby was 2 months and 27 days old. The baby’s weight increased to 3655 grams which was 15 grams / day.  The baby was still in severely underweight status. The frenotomy wound was in good condition. At home, the mother gave SNS 5×30 ml every day. Mother was asked to continue using SNS 5×45 ml, the pediatrician prescribed Piracetam 2x40mg and advised them to come back 2 weeks later.

The third visit was on June 21, 2022 when the baby was 3 months and 11 days old. The baby’s weight increased to 4145 grams which was 35 grams/day. The baby’s nutritional status was still severely underweight. He had good post frenotomy wound. The pediatrician recommended that the SNS dose be increased to 5x60ml and the tongue exercise was stopped after 3 weeks. The patient was advised to come back again on July 5, 2022.

The mother and the baby came for the fourth visit on July 12, 2022 when the baby was 4 months and 2 days old. At that time, baby had cough with no fever. The baby’s weight increased to 4680 grams which was 25.4 grams per day. The baby’s weight gain was good but the baby was still in severely underweight status. Pediatrician prescribed cough powder and Piracetam 2x50mg. The baby was consulted to a lactation doctor to start early complementary feeding and the paper were advised to keep continuing the SNS with dosage of 5x60ml. The patient was scheduled for a follow-up on July 26, 2022.

The fifth visit was on 26 July 2022 and the baby was 4 months and 16 days old. The weight increased to 5030 grams which was 25 grams / day. Based on chronological age, the baby’s weight was still less than -3SD (severely underweight) and based on the corrected age (3 months 25 days), the baby’s nutritional status had started into the range of underweight (<-2SD). Pediatrician recommended that the infants should be provided with high-fat complementary meals with the addition of coconut milk and oil and should continue to use SNS 5x60ml.

The sixth visit was on August 12, 2022 and the baby was 5 months 0 days old. The weight increased to 5260 grams which was 16.4 grams / day. The mother said that the baby like to eat and SNS was given 3-4×60 ml/day. Based on the chronological age, the baby’s weight was less than -3SD (severely underweight), at the corrected age, the weight was less than -2SD (underweight). Pediatrician reduced the SNS dose to 3-4x30ml and prescribed iron and vitamin D3 supplements.

The seventh visit was on August 26, 2022 when the baby was 5 months 17 days old. The weight increased to 5485 grams which was 13.2 grams / day. Based on the chronological age, the baby’s weight was less than -3SD (severely underweight), at the corrected age, the weight was less than -2SD (underweight). The mother’s milk supply was plenty, and the children loved to eat; therefore, the use of SNS was stopped by the pediatrician and complementary food was resumed. The patient was advised to come back 3 weeks later. Iron and vitamin D3 supplements were prescribed, and piracetam was given with dosage of 2x55mg.

The eighth visit was on September 16, 2022, when the baby was 6 months and 8 days old. The baby ate well and was fed directly from the mother’s breast without using SNS. He had a good weight gain which was 5955 grams (22.4 grams / day). The nutritional status improved to <-2SD for both chronological and corrected age. Pediatrician prescribed piracetam 2x60mg, recommended to take vaccines in Puskesmas and advised to come back to Pediatrician on October 14, 2022.

The baby and mother came for the ninth visit on October 20, 2022 when the baby was 7 months and 10 days old. The baby’s weight was 6560 grams, which means there was an increase in weight of 16 grams / day. The baby was given 4-star complementary feeding and direct breastfeeding as much as the baby want. The nutritional status of infants at chronological age was <-2SD (underweight), and at the corrected age was -2SD (normoweight). The Pediatrician recommended to continue the diet and breastfeeding, prescribed iron, vitamin D3, and piracetam. The patient was scheduled to come back 1 month later.

Figure 1. Graph of Weight for Age (W/A) Baby RDS (WHO)

0 day old
2500 gram = -2SD (good nutrition)

2 months 22 days old
3580 gram = <-3SD (malnutrition)

5 months old
5260 gram = <-2SD (underweight) 

7 months 10 days old
6560 gram = -2SD (good nutrition)

Figure 2. Baby RDS Growth Photos


Mrs. AW understood the benefits of direct breastfeeding for herself and her children, so she had a strong determination to give exclusive breastfeeding up to 2 years of age. She had a full support from her husband and family so that she felt that she received a lot of help in going through the whole series of therapy.

From the start, Mrs. AW complained her baby had a poor latch and easily fell off from the breast, and had endless duration of breastfeeding, as if he was never full. She complained that the baby had frequent breastfeeding but the weight gain was not optimal. Jaundice (yellow) in newborns was also a sign of a lack of food intake (breast milk) in infants so that the residual bilirubin from the breakdown of hemoglobin was not optimally disposed with feces.

The first visit to the lactation clinic was when the baby was 2 months and 22 days old and weighed 3580 grams. Based on the WHO standard growth curve, Baby RDS’s weight was indicated as a failure to thrive condition with malnutrition. Failure to thrive (FTT) is defined when an infant weighing below the 3rd percentile or Z-score <-2. Meanwhile, developing FTT is defined when the infant’s weight continues to decrease after 10 days and does not return to birth weight by 3 weeks of age or remains constantly below the 10th percentile at the end of the first month.2

These things were caused by the presence of Ankyloglossia, namely tongue-tie and lip-tie in baby RSD. Ankyloglossia interfere the attachment of the baby’s mouth to the breast, causing problems such as sore nipples, swollen breasts, little milk supply, so that the baby does not get adequate milk and causes slow weight gain and even failure to thrive, feeding disorders, swallowing (eating) disorders and speech disorders.3 Earlier a frenotomy is performed, the better is the outcome.

Frenotomy procedure is a simple incision on the tongue or upper lip frenulum using sterile scissors. Several studies have shown an increase in the quality of breastfeeding process in mothers and babies who have breastfeeding problems. The attachment of the baby to the mother will be better so the transfer of milk is more optimal. The mother feels more comfortable while breastfeeding, and the supply of milk increases.3

After frenotomy was performed on the tongue-tie and lip-tie of baby RDS, the attachment of the baby’s mouth to the mother’s breast became better and the baby could breastfed optimally. Effective sucking attachment is characterized by the baby’s mouth being wide open, the lips curved outward, the baby can put more parts of the areola into his mouth. Curved outward of lips 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 milk can be optimal. Baby RDS was given supplementation while continuing to breastfeed directly to the mother’s breast so that the supply of breast milk to the mother increases.

When the RDS baby entered 4 months old, early complementary foods was given with the aim of helping to improve the nutritional status of the baby. Malnutrition in the first year of life greatly affects brain development and interferes with intellectual development so it must be handled properly.2 In accordance with WHO recommendations that complementary foods can be given from the age of 4-6 months, it can be given at the age of 4 months if the baby’s weight does not increase adequately even though they are breastfeeding well.4 Baby RDS was recommended to be given early complementary foods according to WHO standards with the aim of reducing the supplementation dose and increasing the baby’s weight. Baby RDS babies was given early complementary foods at the age of 4 months, then the supplementation dose gradually decreased and the baby’s weight increased well. Furthermore, the baby achieved good nutritional status. The supplementation stopped at the age of 5 months 17 days. After that, the feeding was only from direct breastfeeding and complementary foods. He was in good nutritional status at that age.


Babies with severe malnutrition should be treated early and holistically because malnutrition in early life greatly affects brain development and organ function at later ages. The presence of Ankyloglossia in baby makes it difficult to get optimal breast milk from the mother. Therefore, frenotomy was needed to improve the breastfeeding process. Supplementation was also needed while doing direct breastfeeding so that the baby gets double intake from breast milk and the SNS. The aim are that the baby grows properly and the supply of mother breast milk is maintained. At the age of 4 months the dose of SNS was lowered and the baby was given early complementary feeding according to WHO standards and advised to continue doing direct breastfeeding. Therefore, the baby got optimal nutrition from breast milk and solid food so that he could immediately achieve good nutritional status. This can be done well if mothers believe that direct breastfeeding are the best for mother and baby, and have family and health facilities that support the breastfeeding process.


  2. 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.
  3. Forlenza, et al, Ankyloglossia, Exclusive Breastfeeding and Failure to Thrive, 2010. 
  4. World Health Organization. (2000). Complementary feeding family foods for breastfed children.

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