Induced Lactation for Biological Baby with Total Nipple Confusion

Written by dr. Ayu Yusriani Nasution

Case Report

Mrs. A went to the Lactation Clinic at a private hospital in Depok on 28 October 2022. She went to the doctor with her husband and her baby, named baby A, who was 2 months and 27 days old. The mother said she wanted to directly breastfeed her baby for up to 2 years so that she can maintain the bond with her baby and ensure the nutrition was given optimally. At that time, Mrs. A had never directly breastfed her baby. She expressed her breast milk and fed her baby the milk through bottle. Mrs.A used breastpumps every 3 hours and was able to express 200-240cc of milk each session. She only gave her baby breast milk.

Baby A is the second child of Mrs. A and Mr. S. Baby A was born at full term gestation through normal delivery assisted by a midwife with a birth weight of 2800 grams. Right after delivery, baby A was placed on Mrs.A’s body for less than 30 minutes. Baby A had not managed to find her mother’s nipple during that session. Since he was born, Baby A was never being breastfed directly; he was fed breast milk through bottle instead.

From the physical examination of baby A, it was found that there was a short tongue tie called ankyloglossia which was a grade 4 of medio-posterior tongue tie and upper lip tie. Based on the examination, it was also found that Mrs. A’s breast was symmetrical, enlarged and had protruding nipples.  The breast milk supply was observed a lot. During that visit, Mrs. A was asked to breastfeed directly, but baby A refused completely.

BANNER 728 x 90

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

After the inpatient administration process was completed, a breastfeeding counselor visited Mrs. A and baby A in the inpatient room. Mrs. A and her baby was asked to do a skin to skin contact for 24 hours except when they need to go to the toilet or do praying. Mrs. A also turned on a Murrotal (Quran recitation) to induce calming situation. A supplementary nursing systems (SNS) using syringe filled with expressed breast milk and a nasogastric tube was prepared. When baby A starts to feel sleepy, the SNS was placed on the mother’s chest and the breast was propped up with a roll of baby clothes. The breastfeeding attempt was immediately carried out with baby in cradle position. After being stimulated by the flow of breast milk, the baby showed an intention to attach to the mother’s breast. The moment when the intention was getting stronger and the baby was showing attempt to attach to the mother’s breast, a frenotomy was performed on baby A’s tongue tie . Immediately after the frenotomy was done, baby A was being breastfed by his mother. The baby was fussy so that further treatment using SNS was performed. The SNS was used to keep the flow of breastmilk aligned to the rhythm of the baby’s suction so that baby A maintained suction on the mother’s breast. After a few moments, the baby was fussy again. The amount of breastmilk consumed was 30cc of milk during that session before baby A detached from the breast and went fussy. The mother was asked to do skin to skin again, and then baby A fell asleep. The parent were taught how to do tongue excercise and asked them to do it 5 times a day. They were also prescribed an Aloclair gel to be applied 3times a day.

On the 2nd day of treatment (October 29, 2022,), baby A was 2 months and 28 days old with a body weight of 5395 grams. There was a decrease of 75 grams of body weight. The mother and the baby were still maintaining skin to skin contact. The baby started wanting to suckle directly at the mother’s breast without the help of SNS. On the second day, alip-tie frenotomy was performed. After the frenotomy was done, baby A was immediately breastfed by Mrs.A. The parents were taught a tongue and lip excercise and asked to do it 5 times a day. They were asked to continue applying Aloclair gel 3 times a day and to do tummy time for baby A.

On October 30, 2022, in the afternoon of the 3rd treatment day, baby A was observed that he was able to breastfeed well without fussing. The body weight had increased to 5600gr with good nutritional status for baby with age of 2 months and 29 days. Based on the good progress, Mrs. A and Mr. S were informed that they could go home and advised to continue breastfeeding directly. They were asked to go back for a check-up 4 days later.

On November 3, 2022 Mrs. A and baby A went to the clinic for control. Mrs. A said she felt very happy because baby A was able to breastfeed directly on her breast. On this visit, baby A was 3 months and 3 days old and his weight hadincreased by 46.6 gr per day. The weight increased from 5600 gr to 5750 gr and it was considered within category of a good nutritional status. The pediatrician explained that this was a good indication that the breastfeeding process went well. Mrs. A was more calm and confident to continue breastfeeding after this visit. The process of direct breastfeeding for this case was declared successful.

Graph 1. Baby A’s body weight during relactation hospitalization treatment and post-relactation hospitalization control

Table 1. Baby A’s weight during inpatient treatment of lactation induction and outpatient control
NO.DateBaby agePartBody Weight (Gr)Therapy
128/10/222 months 27 daysLactation Clinic5470Skin to skin 24 hoursPlay murotalMonitor BB and temperature/dayBy A:CTM 3 x 0.5 mg, NGT syringe filled with BREAST MILK Express all the baby wants, drink from a glass if it can’t attach to the mother’s breast,R / Frenotomy in stages when you want to attach to the mother’s breastMrs. A :milk if necessary,R / additional leave
228/10/222 months 27 daysHospitalization Day 15470Skin to skin 24 hoursPlay murotalMonitor BB and temperature/dayBy A:CTM 3×0.5mg,NGT syringe filled with breast milk Express as much as the baby wants,Tongue tie frenotomyTongue Excercise 5x a dayAloclair gel 3 times a day
329/10/222 months 27 daysHospitalization Day 25395Skin to skin 24 hoursLip Tie PhrenotomyTongue & Lip Excercise 5x a dayAloclair gel 3 times a dayDirect sucking 
430/10/222 months 28 daysHospitalization Day 35600Tongue & Lip Excercise 5x a dayAloclair gel 3 times a dayDirect breastfeedingTummy timeR / Go home
53/11/223 months 3 daysLactation Clinic5750Continue direct breastfeeding


Suckling directly to the mother breast is necessary for a baby as it fulfill their needs for emotional bonding, growth and development. A bond of affection is built between the baby and the mother as a manifestation of fulfilling the need for love. In addition, the nutrients contained in breast milk is needed for growth and development as a manifestation of fulfilling the need for care. 1

Breastfeeding is not just about feeding the baby. When the mother holds the baby when she is breastfeeding, her eyes are fixed on the baby showing affection and the desire to meet the baby’s needs. The mother’s affection creates a feeling of comfort and security in the baby. He feels understood, fulfilled his needs (hunger), and loved. Through breastfeeding, babies and mothers both learn to love and feel the pleasure of being loved. 2

In line with research conducted by Shafay et al in 2017, that there is a significant difference between mothers breastfeeding directly from the breast ( Direct Breast Feeding ) and mothers who only feed the baby with expressed breast milk with a pump ( Exclusive Pumping ) with the case of autism in children. The risk of children having autism disorders are higher in exclusive pumping mothers than mothers who do direct breastfeeding3

A research by Sherief Ghozy et al in 2019 stated that direct breastfeeding for 6 months can reduce the risk of autism in children by 54% and the risk is getting smaller if the child is breastfed for up to 2 years. 4

Induced lactation is a process to stimulate the process of breastfeeding in a mother without prior pregnancy, including for adoptive mothers so that they can directly breastfeed adopted babies with or without a history of previous breastfeeding. 1

At the first stage of the induced lactation process, hospitalization is carried out to oversee the skin to skin process between the mother and adopted baby. At this stage, mother and baby focus on forming an inner bond and building good breastfeeding. While maintaining a skin to skin position , including sleeping with the baby, the mother often offers the breast for the adopted baby to suckle. This is done at night. When the baby has started to suckle, the mother is assisted to position the baby so that he latch well to the breast. 2

Confidence and strong motivation are the main keys to the success of both relactation and lactation induction programs. A believe that the mother will be able to provide the best for the baby is necessary. Frequent breastfeeding activity andregular breast milk expression are the key to the success of stimulating milk production, both in relactation and induction of lactation. 1

Mrs. A came with a strong desire to be able to breastfeed baby A with the full support of her husband, Mr. S, so that the process and treatments went well. In this case, at the initial visit the mother told that she had never directly breastfed baby A. When she was about to offer breasts to baby A, baby A refused and even avoided Mrs.A’s breasts. Therefore, Mrs. A only fed expressed breast milk through a bottle since birth. This causes baby A to experience a total nipple confusion.

Based on examination, Mrs. A had no problems with her breasts or milk supply . However, baby A was found to have a grade 4 medio-posterior tongue tie and lip tie. The pediatrician who is also a lactation counselor recommends a frenotomy or cutting the tongue-tie and lip-tie gradually, after the baby starts wanting to suckle to the mother’s breast. Therefore, the Praborini Treatment Method was carried out by increasing skin to skin contact until the baby wants to attach to the mother’s breast.

At the end of treatment the baby can breastfeed directly without the help of a supplementary device. A frenotomy procedure has also been carried out to support the success of the direct breastfeeding process through good latching. The Praborini treatment method for inducing direct breastfeeding to biological babies with total nipple confusion was declared successful within 3 days of treatment and was proven by adequate weight gain for baby A.

This serves as an evidence that the research that has been conducted by Praborini et al regarding the treatment of the Praborini method for nipple confused babies can be applied properly and works effectively.

The research by Praborini et al in 2016 was based on 58 cases of nipple confusion, with 96.6% total nipple confusion.79.3% of these cases were due to the use of bottle and due to tongue tie . The length of treatment varied from 1 day (56.9%) to 5 days (3.4%). The success of the Praborini Treatment method reached 91.4%, which is 53 cases out of 58 cases. The younger the baby and the sooner it is detected, the higher the success rate. 5


  1. Jeanne-Roos Tikaolu. (2013). Breastfeeding Indonesian Book. Retrieved on 05 November 2022 from milk/relaktbreast milk-dan-induction-laktbreast milk.
  2. International Lactation Consultant Association. 2013. Core Curriculum for Lactation Consultant 3rd Edition. Jones & Bartlett Learning. p289. dalam Febriyanti, D. 2017. Artikel : Induksi Laktbreast milk Bayi Adopsi dari
  3. Shafay, T et al. 2017. Eping & Autism. DOI: 10.3390/nu14010045
  4. Ghozy, S et al. 2020. Association of breastfeeding status with risk of autism spectrum disorder: A systematic review, dose-response analysis and meta-analysis. DOI: 10.1016/j.ajp.2019.101916
  5. Praborini, A et al. 2016. Hospitalization for Nipple Confussion- A Method to Restore Healthy Breastfeeding.  DOI: 10.1891/2158-0782.7.2.69

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