Simple Frenotomy and Supplementation in Infants with Ankyloglossia and Failure to Thrive

Written by : dr. Indhi Vavirya Mestika

Case Report

Baby RA, a male, is the second child of Mrs. N and Mr. Y. He was born at a full-term pregnancy via cesarean section using BPJS Kesehatan (national health insurance program) with the indication of Hypertension and Diabetes Mellitus that was suffered by the mother. Baby RA was born in a private hospital in Depok City on May 25, 2022, with a birth weight of 2729 grams(g). The baby cried spontaneously and he was immediately admitted to the hospital and was supported for direct breastfeeding. Mrs. N’s first child was exclusively breastfed for 6 months and continued for up to 18 months.

The next day when Mrs. N was supposed to be discharged, baby RA was diagnosed with Respiratory Distress Syndrome (RDS) that was caused by Neonatal Pneumonia with Septicaemia. Thus, baby RA was not allowed to be discharged.

The mother was very sad but still determined to breastfeed. The mother continued to collect breast milk using breast pump and delivered it to the hospital every day. While at the hospital, the mother was also assisted by the other breast milk donor to meet the needs of the baby RA.

BANNER 728 x 90

The baby RA were treated for approximately 2 weeks, then on June 9, 2022 baby RA was allowed to go home with 2860 grams of body weight. He also got the polio vaccine before being discharged.

On June 15, 2022, a 21-day-old baby RA came to meet doctor in outpatient clinic, his weight dropped to 2800 grams, lower than he was discharged from the hospital. The baby did not get a direct breastfeeding, he receives expressed breast milk from a teat bottle every 2 hours with the amount of 60 ml each. Based on the examination, the doctor said that the baby had tongue-tie and lip-tie and scheduled to come back 1 week later.

On June 22, 2022, baby RA was 28-days old and his weight was 3020 grams. He gained 220 grams in 7 days. However, the baby had not been able to suckle well, so the mother continued giving him  breast milk (from donor) using bottle. The doctor said to keep trying to give direct breastfeeding instead of using bottle. The mother was willing to keep trying because she knew the great benefits of breastfeeding. The mother was asked to bring back the baby 1 month later for further observation.

On July 22, 2022, baby RA was 1 month-28 days old, 3560 grams, gained 540 grams in 1 month, where the minimum weight gain for babies aged 1-3 months is 750 grams. Mrs. N said that his sucking often came loose, made a clicking sound, and took more than 1 hour (endless feeding). The doctor said that she would refer the mother and the baby to the breastfeeding-consultant with a weight faltering, lip-tie, and tongue-tie.

Mrs. N came to the lactation clinic for the first visit on 27 July 2022 at a private hospital in Depok, the baby RA was 2 months 2 days old and weighed 3830 grams. Based on the World Health Organization (WHO) standard growth chart, the weight of baby RA showed a failure to thrive and malnutrition, with a limit of -3 SD of 4346 grams.

During a physical examination by a lactation consultant, she found that the baby had a posterior tongue-tie and also upper lip-tie grade 3. The mother’s breasts were in normal condition and the mother’s milk production had decreased. During the breastfeeding process examination, the baby tended to latch only on the mother’s nipple, made a clicking sound, the breast was easily detached, and the baby was unable to attach to the breast properly.

From the historical taking and physical examination, the lactation consultant explained why the baby had difficulty in gaining weight and attaching to the breast. The simple frenotomy procedure was explained to Mrs. N and Mr. Y, the baby’s parents. The baby’s parents also agreed to take that procedure.

After a simple frenotomy was performed by a lactation consultant, the baby was fed directly to the mother’s breast. Some improvements were noticed, mother says that he sucked stronger and softer, had deeper latch, sucked continuously and the swallowing sound was often heard. The lactation consultant also demonstrated how to exercise the tongue and lips 5 times a day for the next 3 weeks which was immediately practiced by the baby’s mother. This tongue-lip exercises was to maintain a good post frenotomy wound healing. Parents were also asked to have the baby frequent tummy time and apply aloe vera gel under the tongue and lips where the simple frenotomy conducted. They asked to come back to the doctor a week after .

The second visit was on August 2, 2022, a week after the simple frenotomy performed. The baby’s age was 2 months and 8 days and the baby’s weight had increased by 3960 grams (18.6 g/day). The baby was still in severe underweight nutritional status.

The doctor recommended to use a supplementation device (SNS) which contains 6 x 60 cc of milk formula with partially hydrolyzed protein. The baby was given piracetam 2 x 40mg and asked to come back to the Doctor on August 16, 2022.

At the third visit on August 19, 2022, the baby was 2 months 25 days and the weight increased by 4530 grams (33.5 gr/day).The baby’s the nutritional status categorized as underweight (<-2 SD). From the examination, it was observed that the mother’s milk was increasing. The doctor suggested to decrease the dose of SNS to 6 x 45 cc, Piracetam 2 x 45 mg and come back on September 2, 2022.

At the fourth visit on September 2, 2022. Mother felt that the baby RA was getting better at suckling, and she felt that the milk production increase. During this outpatient visit, the age of the baby RA was 3 months and 8 days-old and the weight was 4955 grams (30.4 grams/day). The nutritional status was still categorized as underweight, but the baby’s weight gain was getting better. The mother also said the baby RA fell asleep after breastfeeding, feeling full. The Doctor recommended to continue using the SNS at a dose of 6 x 40 cc and Ferritin serum drop 2 x 0.3 cc.

At the fifth visit on September 23, 2022, the baby’s weight was 5575 grams and increased by 30 grams/day. During the visit, the baby was 3 months and 29 days old and the baby RA was still in underweight nutritional status. However, it was only 20 grams less to get to a normal weight nutritional status according to the WHO standard growth chart. DSA recommended baby RA to be given complementary foods at the age of 4 months and continue to use SNS at a dose of 5 x 30 cc, then return for a check-up a month later.

The sixth visit was on October 14, 2022, the baby’s age was 4 months and 20 days old. The baby’s weight was 6030 which was increased by 21.6 gr/day. Based on the WHO standard growth curve (weight > -2 SD), it means that the nutritional status of RA infants was good. The mother said that she never used SNS again because the baby was always full after feeding. The doctor recommended that complimentary breastfeeding food should be continued with WHO standards and the baby continued to breastfeed without SNS, and go to puskesmas (primary health care) for DPT-polio-HiB and hepatitis B vaccination.

Baby RA 1 month old
3020 gram =  <-2 SD, underweight 

Baby RA 2 months 8 days old
3960 grams = <-3 SD, severely underweight


Bayi RA 4 months 22 days old
6030 grams = -2SD, good nutritional status


 Baby RA Growth Chart                    

Discussion

Mrs. N had a strong desire to continue breastfeeding her child directly, and her husband was also supportive. This could be seen from how the mother immediately follow the directions from the previous doctor to go to the breastfeeding counselor to evaluate the breastfeeding process and how during the treatment period, the mother was always accompanied by her husband and the husband always seemed to encourage the mother.

In the case of baby RA, the weight did not increase according to the curve. At 2 months and 8 days old, baby RA’s weight was 3960 grams where the minimum weight of children his age was 4486 grams. This condition was categorized as failure to thrive (FTT), which was defined as an infant with body weight under the 3rd percentile or Z-score <-2, and FTT occurs when an infant continues to lose weight after 10 days and does not return to birth weight by the age 3 weeks or remains below the 10th percentile by the end of the first month.1Baby RA’s weight was below 3rd percentile. This was caused by the poor breastfeeding process due to the presence of tongue-tie and lip-tie or also known as ankyloglossia.

The symptoms caused by the tongue-tie were not only appear in the baby, but can also appear in the mother. The complaints that arise in mothers who are breastfeeding their children with a tongue tie are pain during breastfeeding, sore nipples, ineffective emptying of the breasts, and breast infections. Symptoms that may arise in babies are poor weight gain, falling asleep while breastfeeding (because babies with a tongue tie will need extra energy to suckle compared to babies without a tongue tie so they get tired easily), poor latching, reflux and other symptoms like colic, gumming or chewing of the nipples, lip blisters, and episodes of short sleep.2,3

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 a membrane. If the frenulum attached to the bone or upper gum, it limits the 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 the baby can suck well and the transfer of milk can be optimal. Flange-out lips also stimulate the oxytocin chain which causes an optimal milk secretion 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.4

Tongue-tie and lip-tie can lead to ineffective attachment, poor milk transfer, resulting in slow weight gain (SWG) or failure to thrive (FTT). The holistic management of tongue-tied babies with SWG or FTT consisting of frenotomy, supplementation, galactagogue, and acupuncture had shown a successful improvement in infant nutritional status and simultaneously the mother’s milk supply. 1

In this case, the baby was given a simple frenotomy which was a simple incision on the lingual frenulum using scissors. Based on research from Geddes et al, it showed that breastfed babies who had difficulty in breastfeeding, showed progress after frenotomy and tongue movements began to improve. An ultrasound examination was performed and showed that there was an increase in milk intake, milk transfer, attachment and improvement in nipples pain experienced by the mother.5 Babies were also given supplementation using a supplementary device, the mother’s milk supply can be maintained, and the baby’s weight gradually increases.

WHO only recommends giving a child complementary foods between 4 and 6 months if he or she (a) is not adequately gaining weight despite appropriate breastfeeding or (b) receives frequent breastfeeding but appears hunger soon after.6

Baby RA was recommended to do early complementary feeding at the age of 4 months according to WHO standards with the aim of reducing the dose of supplementation. Baby RA underwent early complementary feeding at the age of 4 months, the supplementation dose was gradually decreased and the baby’s weight gain increased well so he could get good nutritional status.

Conclusion

Tongue-tie or ankyloglossia can be one of the complications in babies who are breastfeeding directly to their mothers. Tongue-tie can be corrected with a simple frenotomy, a simple procedure that the baby can continue to breastfeed immediately after the procedure. In the case of baby with poor nutritional status, supplementation therapy needs to be added, that make the baby gets double intake, from the mother’s breast and supplementary device. It helps the baby grow well, allow direct breastfeeding and the mother’s milk supply was also well preserved. The successful treatment was also due to the mothers’ knowledge and beliefs that breastfeeding were the best options for mothers and babies. Moreover, they were also supported by families, especially husbands, facilities and health workers who are very supportive of breastfeeding.

“Breastfeeding is not easy, but the bond it creates is unbreakable”

References

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.      Geddes DT, et al. Frenulotomy for Breastfeeding Infants with Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Images by Ultrasound. 2008 July; American Academy of Pediatrics, vol 122: 188-194.

3.      Praborini A, Purnamasari H, Munandar A, Wulandari RA. Early Frenotomy Improves Breastfeeding Outcomes for Tongue-Tied Infant. United States Lactation Consultant 2015; 6(1): 9-15.

4.      Cole M. Tongue and Lip Tie: A Comprehensive Approach to Assessment and Care. Powerpoint presentation. 2017.

5.      lorenza, et al, Ankyloglossia, Exclusive Breastfeeding and Failure to Thrive, 2010, diunduh dari: https://pubmed.ncbi.nlm.nih.gov/20498175/

6.      World Health Organization. (2000). Complementary feeding family  foods for breastfed children. http://www.who.int/nutrition/publications/infantfeeding/WHO_NHD_00.1/ en/ 

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