The Role of Frenotomy, Supplementation Therapy, and Acupuncture in Malnutrition for Infants with Tongue Tie Reattached

By : Elisabeth Martha, MD

Baby FTS is the third child of Mrs. AN (43 years old) and Mr. FNS (46 years old) who was born at   38 weeks gestation by caesarean section for indication of transverse lie fetus and sterilization plan in a private hospital in Depok, West Java on August 15, 2022. Baby FTS cried immediately at birth with Apgar score 9/10, so that early breastfeeding initiation could be done for about 20 minutes in the operating room. Baby FTS was a full-term newborn, small for gestational age with birth weight 2360 grams and body length 46 cm. During hospitalization, mother and baby were treated together in the same room. The mother received lactation education during treatment and started learning to breastfeed the baby. When checked by the lactation doctor, breast milk had already been lactating.

On the third day after delivery, Mrs. AN was discharged from the hospital but Baby FTS developed hyperbilirubinemia / breastfeeding jaundice characterized by yellow skin color and increase of total bilirubin level to 18.9 mg/dL, so the baby had to undergo phototherapy in the hospital at perinatology room. During the phototherapy treatment, the mother regularly pumped her breast milk every 3 hours and produced milk about 50 ml per session. It was then delivered to the hospital to be given to her baby with glass feeding.

The next day, baby FTS’s bilirubin level decreased to 12.8 mg/dL, so the pediatrician discharged the baby at 4 days old with a body weight of 2175 grams; a decrease of 185 grams (7.8% from birth weight). The pediatrician also mentioned that baby FTS had posterior tounge-tie and lip-tie grade II – III (ankyloglossia) and suggested a frenotomy.

Mrs. AN had 2 children who were exclusively breastfed for 6 months and continued direct breastfeeding for almost 2 years, now 18 and 13 years old. She hoped to breastfeed her third child and had no idea that her baby had an anatomical tongue defect that could interfere with breastfeeding. Mrs. AN stayed at home to take care of the household and her husband worked as a government employee. She did not have a nanny or household assistant and took care of her baby at home by herself.

On August 27, 2022, the baby went to the pediatrician for immunization at the age of 12 days with a body weight of 2275 grams and had not reached their birth weight. Mother complained that during breastfeeding, the baby suckled for hours, often fussed, and felt that the baby was not full even though he had just breastfed. Her nipples were painful and sore when breastfeeding due to nipple fissure. The mother also felt that her nipples were large, making it difficult for the baby to get the whole areola into the baby’s mouth. Breast milk was plentiful, but breast emptying was not optimal. The pediatrician referred her to the lactation clinic and double frenotomy was performed by a lactation doctor referring to Carole Dobrich’s points 6/10 and 7/10. After the procedure, the baby suckled immediately and the mother was taught tongue exercises and lip exercises to be done every day at home 5 times per day, while applying aloe vera plant gel on the wound. Breastfeeding was continued to be done as often as the baby wants, day and night.

The mother was advised to go to lactation clinic one week later but did not come. Tongue and lip exercises were also not carried out routinely, so that at the next visit when the baby was about to be immunized at the pediatrician clinic; it was found that the former incision fused again to form a tounge tie. On September 28, the pediatrician again referred the baby to the lactation clinic with indications of growth faltering. At that time, baby FTS was 1 month and 14 days old and weighed 2710 grams, already exceeding birth weight with an increase of 435 grams from the last visit (13.6 grams/day). Based on the standard growth curve according to the World Health Organization (WHO), baby FTS’s weight showed slow weight gain with poor nutrition (weight/age  < -3 SD).

Based on physical examination of the mother, it was found that mother’s breasts were large and symmetrical, low milk supply only 2 points on the nipple. From the observation of the breastfeeding process with a cradle hold of the left breast, the baby was attached to the areola, but the mouth opening was still not wide enough, and the attachment was often loose. The lactation doctor performed a simple lingual frenotomy procedure again, and advised to routinely do tongue exercises 5 times a day and apply aloe vera gel on the wound so that the tongue cord does not fuse back        together. The mother received lactogogue therapy which was consumed 2 times a day and she was given a Supplemental Nursing System (SNS) device to be used with partially hydrolyzed protein formula milk. The formula milk was prescribed to be given with frequency 6 x 30 cc / day. As for the rest of the time, the mother was advised to breastfeed directly without SNS with a frequency as desired by the baby. Parents were advised to have the baby do tummy time frequently, and the mother was advised to get acupuncture therapy to accelerate the increase of breast milk production.

One week later, on October 4, 2022, the baby was 1 month and 20 days old with a weight of 2985 grams, an increase of 275 grams (45grams/day) from the previous visit; but still with poor nutritional status (weight/age  < -3 SD). The baby was seen by lactation consultant pediatrician and advised to continue SNS with the same amount and advised mother to read the book “Anti Stress Menyusui” at home. Post frenotomy wound was observed good.

The next visit was on October 13, 2022 when the baby was 1 month and 29 days old. The baby gained 39.4 grams/day, a total of 355 grams from the previous visit. The baby’s nutritional status was still poor (weight/age < -3SD). The mother had just received the first acupuncture therapy and felt that the mother’s breasts were fuller faster, the mother was happy that the milk production was increasing. At home the mother was also taught acupressure techniques. SNS was also increased to 6 x 30-45 cc per day.

The mother, father and baby came for the next visit on October 27, 2022 when the baby was 2 months and 13 days old. When weighed, the baby weighed 3835 grams, an increase of 495 grams from the previous visit, about 35.3 grams/day. The baby’s nutritional status was still < – 3 SD in malnutrition. pediatrician suggested SNS to be continued 5-6x for 30 cc. Lactogogue consumption for mother was continued and the mother received the second acupuncture therapy. Mother said that she had felt an increase in breast milk production after the previous acupuncture.

At the sixth visit for control to the pediatrician clinic on November 17, 2022, the baby was 3 months and 4 days old and weighed 4575 grams. Weight gain was 35 grams/day, an increase of 740 grams from the previous visit one month ago. At this visit, the baby’s nutrition had improved and begun to enter malnutrition (weight/age < – 2 SD). The pediatrician recommended early solids food at 4 months of age with high protein and fat foods through the addition of coconut milk, oil, and eggs. SNS was slowly reduced to 5 x 30 cc, because the child’s nutritional status began to improve and the mother’s milk production increased. The mother received a third acupuncture therapy. The mother said that she really felt the benefits of acupuncture on the increase of breast milk production and relaxation of the mother. The patient was scheduled for a return control 2 weeks later on  December 1, 2022.

On December 1, 2022, the seventh control at the pediatrician clinic, the baby’s age was 3 months 18 days with a weight of 4990 grams, gaining 415 grams with a daily increase of 30 grams / day for the last 14 days. The baby’s nutritional status was in the undernourished category (weight/age < -2 SD). SNS dosage was maintained, and mother was educated on how to prepare complementary food according to WHO requirements for complementary food preparation at the age of 4 months. The mother was encouraged to read the book “Anti Ribet MPASI” at home.

On January 6, 2023, the mother came to bring the baby for the eighth control at pediatrician clinic. The baby was 4 months and 24 days old with a body weight of 6110 grams, gaining 1120 grams in the last 35 days with a daily weight gain of 32 grams. The increase was so good which the baby’s nutritional status achieved to good nutritional status (weight/age  > – 2 SD). Therefore, the pediatrician advised to stop SNS and stop giving brain vitamins. The baby was given iron supplements and vitamin D3 containing fluoride. Complementary feeding as recommended by WHO was continued with a gradual increase in portion and texture.

On January 6, 2023, the baby got the nineth control at pediatrician clinic with his mother and father on 5 months 8 days with body weight 6440 grams, gaining 33 grams and the daily weight gain within the last 14 day was 23,5 gram/day. The baby’s nutritional status was still in good nutritional status (weight/age > -2SD). Baby got immunization and advised to keep adequate complementary feeding as recommended by WHO and continued breastfeeding.

Table 1. Weight Growth and Nutritional Status of Baby FTS 

DISCUSSION

Breastfeeding involves good cooperation between mother and baby, and strong support from all family members, doctors, and all health professionals involved in newborn care for successful breastfeeding. Mothers need to be taught a good positioning and attachment from the start of breastfeeding, and any problems with breastfeeding should be checked and evaluated.

In the case of Baby FTS, the mother complained that the baby suckled for hours, often fussed and cried as if he was not full even though he had just breastfed and the mother had plenty of milk. In addition, the mother’s nipples were fissure and sore. After being examined by pediatrician, it was found that the baby had posterior tongue tie and lip-tie grade II-III (ankyloglossia), then referred to lactation clinic. The lactation doctor assessed Carole Dobrich score 6/10 and 7/10 indicating the need for tongue-tie and lip-tie frenotomy.

The success of breastfeeding is greatly influenced by the correct attachment. For all breastfeeding positions, the correct attachment of the mouth at the breast is seen from the areola (the dark circular part of the breast) mostly entering the baby’s mouth. The baby’s mouth is wide open, the baby’s upper and lower lips are folded out, and the baby’s chin will touch the breast. Anatomical tongue factors such as tongue tie and lip tie may inhibit the baby’s mouth from making the correct attachment.¹

Tongue tie, also known as ankyloglossia, is a thin membrane of embryological tissue remnants located in the midline between the lower surface of the tongue and the floor of the mouth that restricts normal tongue movement and affects oral function. The reported incidence of tongue-tie is around 4-10% incidence in the population, but the true figure may be even higher as many existing research studies did not count the posterior tounge tie type. It is quite possible that a person has this condition but is unaware of it. A tongue-tie can be the hidden reason for breastfeeding problems in infants, feeding problems in toddlers, speech problems in children, and even migraine headaches or neck pain in adults. ²

If there is a tongue tie, the baby’s tongue is pulled down so that the baby cannot lift his tongue to catch and press the breast to the palate, causing in many case that the baby will suckle loosely. Some babies retain the breast in their mouth with the help of the gums, so the mother can feel the breast like being bitten or cut. The mother can experience abrasions on the nipple or on the neck of the nipple which can develop into mastitis (inflammation of the breast) and abscess (collection of pus in the breast).³

The baby is also unable to empty the breast so that the mother feels that her breasts are still swollen or can even appear like lumps. Because of the difficulty in breastfeeding, the baby may be hungry even after a long time of breastfeeding, and may be very fussy.³

A lip tie is a cord or frenulum on the upper part of the lip that attaches to the upper jaw. This frenulum has no muscles and is just a membrane. When this frenulum attaches to the upper bone or gums, it can cause limited movement for the lips during feeding. The folded out lip position is needed in the suckling 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 breast milk can be optimal. The folded out lips also stimulate the oxytocin chain which causes optimal milk release from the mother’s breast.³

If there is a lip tie, the baby’s lips will fold inward during feeding, which also causes a pinched feeling and pain. When the baby is finished feeding, you may see different colored lips, half pink and half white or black, or water bubbles on the lips called blisters.³

Frenotomy (incision/cutting of the tongue tie and lip tie) is a procedure performed to cut the thin tissue connecting the tongue to the floor of the mouth or the upper gums of the mouth. The frenotomy is performed using the Pare method, where the tongue tie will be cut slightly and then pushed with the index finger until it touches the tongue muscle. After frenotomy, the baby can suckle directly to the mother. Tongue and lip exercises are very important so that tongue tie and lip tie do not fuse back together. The exercise is done every day for three weeks after the frenotomy to heal.³

In addition, after frenotomy, the baby also needs to be placed on the stomach (tummy time) so that the baby is more active in moving and stretching the stiff muscles to make the muscles more flexible, so that breastfeeding can be better. The baby’s movement also becomes better and brings the baby’s body axis (alignment) to the center or back to normal. Tummy time is performed up to five times a day when the baby is awake, for 5 – 15 minutes each time on the tummy, or more if the baby is happy.³

The nutritional impact of sub-optimal breastmilk transfer from mother to baby can result in stunted growth which can be indicated using WHO growth curve. Breastfeeding babies with poor attachment can cause slow weight gain or even failure to thrive. Weight growth is said to be slow (slow weight gain) if infants is less than 2 weeks experience a decrease of 10% or more from birth weight or infants aged 2 weeks to 3 months with a weight gain of less than 20 grams / day. Failure to thrive is defined as an infant weighing below the 3rd percentile or Z-score <-2, and occurs when the infant’s weight continues to decline after 10 days and does not return to birth weight by 3 weeks of age or remains below the 10th percentile at the end of the first month.⁴

In the case of baby F, the baby was born at full term with a low birth weight (LBW) below 2500 grams. At 2 weeks of age the baby had not returned to his birth weight. The baby was diagnosed with weight faltering with malnutrition status at the age of 1 month and 14 days where the baby’s weight was 2710 grams. The WHO weight/age curve standard – 3 SD for his age was 3320 grams. The holistic treatment of infants with malnutrition given in this case are the use of SNS (Supplementary Nursing System) supplementation with titrated doses, and acupuncture therapy for the mother and consumption of galactogogue to increase breast milk production.

Acupuncture is a long-established and evidenced-based form of Traditional Chinese Medicine (TCM), currently gaining popularity in industrialized countries since the 1970s. Acupuncture means inserting needles into specific parts of the body for medicinal purposes. According to the principles of acupuncture, diseases occur due to energy imbalances, and needles are inserted into specific parts of the body to correct these imbalances. Acupuncture points are located in specialized channels called meridians. In acupuncture, needle-based stimulation of several points along the skin of the body will improve blood circulation, increase energy, and remove blockages.⁵

Stimulation at specific acupuncture points will proceed to the target organs as needed to increase milk production and maintain smooth milk lactation. According to TCM, low milk supply is caused by deficiency of Qi and blood. It is caused by insufficient intake and bleeding. Insufficient intake and bleeding during childbirth result in spleen and stomach disorders which will result in Qi and blood deficiency which will result in insufficient breast milk. Having a lot of thoughts or anxiety will cause disruption of oxytocin hormone production. Therefore, the therapeutic principle is to strengthen the spleen – stomach, increase Qi and blood (Xue), and cleanse and strengthen the meridians around the breast.⁵

Acupressure is performed by applying constant pressure to increase blood circulation in the area, activate the parasympathetic system, and reduce neuromuscular excitability. Acupuncture and acupressure reduce anxiety and fatigue by reducing heart rate and lowering cortisol levels by regulating brain function and the circulatory system. Increased maternal anxiety and stress levels lead to decreased secretion of oxytocin and prolactin, which play an important role in milk secretion.⁵

WHO only recommends starting complementary feeding at 4-6 months of age, if: the baby’s weight gain is inadequate with breastfeeding alone or the baby is frequently breastfed but still shows hunger shortly after breastfeeding. In this case, baby FTS is advised to start complementary feeding at 4 months of age in accordance with WHO standards with the aim of reducing the supplementation dose and expected weight gain to achieve good nutritional status

CONCLUSIONS

In this case, the malnutrition did not result from Mrs. AN’s lack of breastmilk production or poor breastmilk quality, but from the tight frenulum on the baby’s tongue and lips that made it difficult for the baby to suck properly. Evidently, the baby’s two older siblings were breastfed until the age of 2 years without any problems.

Tongue and lip ties are one of the factors affecting babies to be able to suckle well at the mother’s breast. Breast suction was not optimal and breast milk consumption by the baby was inadequate to meet their energy needs, so that the baby’s weight gain does not meet the minimum standards (slow weight gain) and even causes malnutrition status in infants. Breast milk production also decreases due to poor breast emptying.

A frenotomy was first performed when the baby is 12 days old, then the tongue tie reattached and was cut again at 1 month and 14 days old. Tongue exercises and lip exercises are very important so that the tongue tie and lip tie do not fuse again.

Supplementation therapy was given so that the baby gets a double intake, breast milk from the mother’s breast and milk given from the supplementary device, hoped that the baby can grow well and the mother’s milk supply was also maintained. Lagtogogue consumption and acupuncture therapy play an important role in helping to increase milk production. In this case, early complementary feeding is recommended at the age of 4 months as recommended by WHO to achieve ideal weight gain with good nutritional status.

In this case, good nutrition was finally achieved, supplementation was stopped, the baby was only breastfeeding with adequate complementary foods. The support of the baby’s father, who always accompanied his wife and baby to the hospital, was crucial to the success of this case.

Because breast milk is irreplaceable. Breast milk has many benefits for both baby and mother. Benefits that cannot be replaced by any artificial baby food.

LITERATURE

1. Praborini A, Purnamasari H, Munandar A, Wulandari RA. Early Frenotomy Improves Breastfeeding Outcomes for Tongue-Tied Infants. United States Lactation Consultant 2015; 6(1): 9-15.
2. Baxter R, Musso M, Hughes L, Lahey L, Fabbie P, Lovvorn M, et all. Tongue Tied: How a Tiny String Under the Tongue Impacts Nursing, Feeding, Speech, and More. Pelham, AL: Alabama Tongue-Tie Center, 2018.
3. Praborini A, Wulandari RA. Anti-stress Breastfeeding. Jakarta: Kawan Pusaka, 2018. h.149-158.
4. 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
5. Hajian H, Soltani M, Mohammadkhani MS, Kermani MS, Dehghani N, Divdar Z. The Effect of Acupressure, Acupunture, and Massage Techniques on the Symptoms of Breast Engorgement and Increased Breast Milk Volume in Lactating Mothers: A Systematic Review. Int J Pediatr, Vol.9, N.2, Serial No.86, Feb. 2021
6. World Health Organization. (2000). Complementary feeding family foods for breastfed children