BABIES WITH ANKYLOGLOSSIA AND EXCESSIVE WEIGHT LOSS IN EARLY BIRTH

Written by dr. Ayu Yusriani Nasution

Background

Every children have the right to get complete and good nutrition to optimize their growth and development since birth. God has provided breast milk since a mother was pregnant. With determination, knowledge, correct practice and family support, a mother will be successful in breastfeeding her baby.

Breastfeeding is the best way to fulfill the baby’s nutrition. To have an optimal breast feeding, a good position and attachment are needed so that the baby can suck well and get the milk according to his needs so that they can gain weight well. ¹ Ankyloglossia or Tongue Tie and Lip Tie are associated with a 25% – 60% incidence of breastfeeding difficulties; such as sore nipples, swollen breasts, little milk supply and failure to thrive. ² Ankyloglossia can interfere with the baby’s ability to suck to the breast which cause poor attachment so that the baby does not get adequate milk and causes slow weight gain and even failure to grow. ¹

Case Report

On August 26 2022, Mrs. D went to the Lactation Lactation clinic at a private hospital in Depok with her husband and her child, baby D, who was 7 days old. Mrs. D complained that when baby D was being breastfed, it was easily detached, took a long time (endless feeding)  and the baby tends to sleep a lot. In addition, Mrs. D’s nipples also hurt while breastfeeding. baby D was born by caesarean section assisted by an Obgyn doctor at 39 weeks of gestation and birth weight of 2605 grams. Immediately after baby D was born, he was placed on the chest of Mrs. D approximately for 1 hour. Since baby D was born, he couldn’t open his mouth wide so he couldn’t latch well. That condition also cause the nipples hurt and even bleed during breastfeeding.

When baby D was 1 week old, Mrs. D went to the Pediatrician and it was found that the baby’s weight was 2200 grams, a drastic decrease of 58 grams per day, which was 15.5% of the baby’s birth weight ( Excessive Weight Loss ).

From the physical examination of baby D, it was found that baby D had a tongue tie (ankyloglossia). It was a grade 4 anterior tongue tie and grade 4 upper lip tie. On examination of Mrs. D, it was observed that she had a symmetrical breast shape, cracked nipples and over milk supply. During breastfeeding, the baby’s lips were folded inward and only the tip of the nipple enters the baby’s mouth which makes the mouth easily detached.

To strengthen Mrs. D’s motivation, she was informed about the recommendation of direct breastfeeding based on religious and WHO perspective. Mrs. D was determined to breastfeed up to 2 years and this was supported by Mr. S. Mrs. A and Mr. S were firstly explained about the condition of baby D and the treatment plan that would be carried out. The treatment plans included a frenotomy action plan, use of supplementers, and other required additional therapy.

Mrs. D and Mr. S agreed on the frenotomy operation to treat the tongue tie and lip tie of baby D. After a frenotomy, Mrs. D breastfed baby D and it was observed that the lips were more folded out, and the baby could suck continuously. Mrs. D said that the suction felt stronger, deeper and comfortable. Mrs. D was also taught to do tongue and lip exercises to baby D. She was asked to do the exercise 5 times per day for the next 1 week. Alloclair gel was prescribed to be applied 3times per day. To treat the cracked nipples, a concoction ointment was given. Furthermore, Mrs. D was advised to return to the lactation clinic for control in the next week on September 1, 2022.

On September 1, 2022 Mrs.D and Baby D, 13 days old, went to the clinic for control. From the examination, it was found that the weight increase of baby D was not adequate which was 2 grams per day. Based on the standard growth curve according to the World Health Organization (WHO), baby D.’s was indicated as Failure to Thrive with severe malnutrition (Weight <-3SD). Mrs. D was recommended to use a supplementary device 5 times a day with 30 cc of formula milk (FM) for each session. In order to support this treatment, Mrs. D was taught how to use supplementary device. Furthermore, it was suggested that Mrs. D go to lactation clinic on the next week (September 8, 2022) for control.

On September 8, 2022, Mrs. D went to the clinic for control. Mrs. D said that at this time, the breastfeeding went more smoothly, and the latching was not easily detached. The baby’s weight had increased by 52.8 grams per day (the weight was  2580 grams) at the age of 20 days. Mrs. D was advised to continue using supplementary device 5 times a day with a dose of 30 cc containing formula milk. The frequency of lip and tongue exercises were reduced to 3 times per day. The Pediatrician also gave Piracetam 2x25mg for the next 1 month.. The next control was planned  on September 22, 2022.

At the next visit on September 22, 2022, Mrs. D told to the doctor that she felt her milk supply was not adequate. Baby D was 1 month and 4 days old, his weight had increased by 37.5 grams per day (from 2560 to 3105 gr). Based on the standard growth curve according to the World Health Organization (WHO), Baby D.’s weight shows improvement from severe malnutrition (Weight < -3SD) to malnutrition (Weight <-2SD). After being explained that the improvement was a good sign by the Pediatrician, Mrs. D was more calm and confident to continue direct breastfeeding.

On October 6 2022 Mrs. D went to control at the Lactation clinic. Mrs. D had no complaints on this visit. Baby D’s age was 1 month 12 days experience and he gained weight from 3105 to 3745 gr (45.7 grams per day). She was advised to keep using supplementary device and to go to clinic in the next 2 weeks.

On October 20, 2022 Mrs. D went to control to the lactation clinic. At that time, baby D was 2 months and 2 days old. From the examination of Mrs. D’s breasts, it was found to be symmetrical and the size indicated it had good supply of breast milk. The increase in weight of baby D was 43.2 grams per day (from 3745 to 4350 grams). Based on the standard growth curve according to the World Health Organization (WHO), baby D.’s weight indicated a good nutritional condition (BB -2SD). Therefore the treatment was declared succesful and the use of supplementary device was stopped.

On November 3, 2022, Mrs. D returned to control and the age of Baby D was 2 months and 16 days-old. Mrs.D seemed to be more confident in breastfeeding baby D. Baby D’s weight gain was also good which was 31.4 grams per day (from 4350 to 4790gr). Mrs. D was advised to continue direct breastfeeding on both left and right breasts. They were scheduled for control in the next month.

Baby Weight Chart D before and after treatment

Growth Table Baby D

Age	BB(gr)	Increase (g/day)	Nutritional status	Therapy
0 days	2605	–	Well nutrition	Breastfeeding Counseling
7 days	2200	-58	Severe  Malnutrition	Phrenotomy LT & TTLip and tongue exercises 5x a dayAlloclair gel 3 times a day
13 days	2210	2	Severe Malnutrition	SNS 5x30cc filled with FMLip and tongue exercises 5x a day
20 days	2580	52,8	Severe Malnutrition	SNS 5x30cc filled with FMLip and tongue exercises 3 times a day
1 month 4 days	3105	37.5	Malnutrition	SNS 5x30cc filled with FM
1 month 12 days	3745	45,7	Malnutrition	SNS 5x30cc filled with FM
2 months 2 days	4350	43,2	Well nutrition	Stop SNS, Supplementation was succesFMul
2 months 16 days	4790	31,4	Well nutrition	Continue breastfeeding

Discussion

Throughout the treatment period, Mrs. D showed a positive attitude to be able to breastfeed Baby D. Mrs. D’s determination were strengthened by the full support of her husband (Mr.S) and her closest family so that she felt helped in undergoing the whole series of therapy. The knowledge about breastfeeding recommendation from religious and WHO perspectives and the knowledge about breastfeeding benefits also help Mrs. D to be consistent in this treatment.

In this case, at the initial visit the mother felt that the baby’s sucking was easily detached and he was losing a lot of weight. Due to the anterior tongue tie and grade 4 lip tie in baby D, the breastfeeding process became ineffective and painful for the mother. After the frenotomy was performed, the mother felt a significant difference in the breastfeeding process. Baby D’s suction was getting better, the lips looked wider and there was no pain during breastfeeding. It made the breastfeeding process became morecomfortable for both of them. At the subsequent visits, Baby D’s weight gradually continued to have a significant increase from poor nutritional conditions to good nutritional condition. They also had better breastfeeding experience due to the mother determination and family support.

Source

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.