The Role of Frenotomy and Supplementation for NLMS (Normo Low Milk Supply) Mother and Her SWG (Slow Weight Gain) Baby with Good-to-Mildly Malnourished Nutritional Status, Tongue Tie and Lip Tie

Written by: Ernina Rahmatika Muis, MD

Baby F (male) is the first child of Mr F and Mrs D who was born via caesarian section with a birth weight of 3500 grams (g), at a full-term pregnancy on 4 September 2021. Mrs D gave birth at a private hospital in Jagakarsa, South Jakarta and had been counselled on the importance of breastfeeding. She wanted to exclusively breastfeed and continue to breastfeed her baby for up to 2 years.

At the first visit, on 10 October 2022, the mother came to the lactation clinic of Ali Sibroh Malisi Hospital complaining that her baby had been suckling for hours, was always fussy and seemed unfulfilled. She believed that the baby was always crying because she was not producing adequate breast milk, and so she purchased a breast milk supplement which she took daily. During the first week of breastfeeding, her nipples once got scratched and bled. The mother had pain while breastfeeding the baby, so the father gave the baby some formula milk since the baby cried as if he was starving all day. Subsequently, the mother fed the baby with a bottle of formula milk 5 to 6 times, 30 cc each, on a daily basis. Since then, the baby had frequent flatulence and developed multiple red rashes on his face and body. 

At age 5 days, the baby had a fever and was examined by a doctor in a hospital in Jagakarsa, South Jakarta. The mother was prescribed domperidone at 3×4 tabs for 2 weeks and then discontinued the medication without tapering off. The mother felt that she was producing more breast milk when taking domperidone. She had also been advised to use a syringe supplementation kit and nasogastric tube to supplement formula milk as the baby desired. From then on, the teat bottle had never been used. The mother said that she wanted the baby to be exclusively breastfed, and she wanted to breastfeed him for 2 years. The mother breastfed the baby using the right breast more often than the left. She once had a blister on her left nipple and was afraid of breastfeeding on her left breast. She said that currently she could only produce 10cc of breast milk, and she was worried that the amount of breast milk would be insufficient.

From the physical examination of the mother, it was found that the breasts were medium-sized, symmetrical but the milk production started to decrease (Normo – Low Milk Supply). The physical examination of the baby revealed a posterior tongue tie and thick lip tie at grade IV. During this visit, the baby was 1 month and 6 days old and his weight was 4100 g. The daily weight gain was 16.67 g. The baby’s nutritional status was good, but the daily weight growth was slow. Based on the breastfeeding observation, the baby’s suction reflex was not optimal, the suction was not adequate, and the mouth opening was not wide enough. The mother also felt pain in her nipple like being bitten.

Based on the history and physical examination, the lactation doctor explained that the cause of the baby’s slow weight gain was due to the baby’s suboptimal suction reflex. The suboptimal suction was due to the presence of tongue tie and lip tie as well as the frequent use of teat bottle for the baby. The lactation doctor then informed about the procedure of simple frenotomy to the parents. The parent was also encouraged to stop using a teat bottle since it could change the baby’s suction pattern. On this visit, the father and mother gave their consent for the doctor to carry out a simple frenotomy on the baby. The mother was also taught a tongue exercise by the lactation doctor. The mother was given lactagogue to be consumed 2×1 tablet a day. The mother also bought a book entitled “Anti Stres Menyusui”.

The second visit was held on 17 October 2022, the baby was 1 month and 13 days old during the visit. The baby’s bodyweight was 4115 grams (increased by 15 g/day from the first visit). The baby’s nutritional status was good (-2 SD: 3790 grams). The mother came for post frenotomy control, the tongue exercise was done regularly but the mother said that she could not put any pressure on the incision site. The mother had stopped giving the baby a teat bottle, syringe kit and nasogastric tube. The mother was still breastfeeding while sitting at night which made her tired when she woke up in the morning. She still pumped frequently because she was worried about the sufficiency of breastmilk. The lactation doctor then encouraged her to carry out some tongue exercises for the baby and apply pressure to the incision site. The mother was also encouraged to get an acupuncture treatment to accelerate breast milk production. The mother was taught the position of breastfeeding while sleeping, so that she would not get tired of breastfeeding at night. The mother was also advised to stop pumping and focus on breastfeeding directly to the baby. The mother was advised to continue consuming lactagogue.

The third visit was held on 25 October 2022, the baby was 1 month and 21 days old during the visit. The baby’s body weight was 4105 grams (decreased by 10 grams since the second visit). The baby’s nutritional status was good but close to moderately malnourished (-2 SD: 4030 grams). The mother said that the baby suckled for hours just like the beginning, thus the mother rarely carried out tongue exercises. The mother had never pumped breast milk anymore. She was worried about the baby’s lack of urination that week. At physical examination, the tongue cord was found to be reattached. The mother had a history of keloids since childhood. Lactation doctor performed re-incision or re-frenotomy of the tongue tie. The baby was also given supplementation with SNS (Supplemental Nursing System) containing formula milk with partially hydrolysed protein. After being titrated by the lactation doctor, it was observed that the baby consumed 60 cc per feed which meant 6 x 60 cc/day of SNS, while the rest of the time the baby fed directly to the mother’s breast without SNS with the frequency as the baby desired. The tongue exercise was continued 3x/day. Mother did not do acupuncture due to financial constraints. The mother continued to consume lactagogue.

During the fourth visit on 1 November 2022, the baby was 1 month and 28 days old. The baby’s body weight was 4360 grams (37 g/day since the third visit). The baby’s nutritional status was good (-2 SD: 4240 grams). The mother reported that the baby breastfeeds smoothly and comfortably. The mother routinely did the tongue exercise. She said the SNS was taken 5-6 x 60 cc/day. The lactation doctor suggested 1x/day tongue exercise, and the SNS was now reduced to 5-6 x 45 cc/day as the baby’s weight gain was good. The mother continued to consume lactagogue.

The fifth visit was held on 8 November 2022, at this time the baby was 2 months and 4 days old. The baby’s body weight at this time was 4565 grams (increased by 29 g/day since the fourth visit). The baby’s nutritional status was good (-2 SD: 4393 grams). The mother came for follow up, and said the baby suckled well, and the SNS was consumed 5 x 45 cc/day. Apparently at this time, the mother changed the milk to a sweet and savoury flavour. The lactation doctor advised to return to the formula with partially hydrolysed protein. While the tongue exercise was discontinued, the SNS usage was reduced to SNS 5-6 x 30 cc since the baby’s weight gain was good and considering that the mother’s milk production steadily increased. The mother continued to consume lactagogue.

The sixth visit was held on 29 November 2022, at this time the baby was 2 months and 27 days old. The baby’s body weight was 4970 grams (increased by 19 g/day since the fifth visit). The baby’s nutritional status was good but close to malnutrition (-2 SD: 4930 grams). The mother said that the baby suckled well and had just recovered from a cough and cold. The SNS was consumed 6 x 60 cc/day. The lactation doctor increased the SNS consumption to 6 x 45-60 cc/day. The mother continued to consume lactagogue.

The seventh visit was on 6 December 2022, at which time the baby was 3 months and 2 days old. The baby’s weight was 5030 grams (up 9 g/day since visit six). The baby’s nutritional status was poor (10 grams less than good nutrition, – 2 SD: 5040 grams). The SNS was consumed 6 x 60 cc/day. The lactation doctor informed the mother about the possibility of early complementary feeding when the baby reached 4 months of age. The SNS intake became 6 x 45-60 cc/day. The mother continued to consume lactagogue.

The eighth visit was held on 13 December 2022, at this time the baby was 3 months and 9 days old. The baby’s body weight was 5220 g (27 g/day increase since the seventh visit). The nutritional status was good (- 2 SD: 5180 grams). The SNS was consumed at 5-6 x 45-60cc/day. The lactation doctor suggested reducing the frequency of SNS use to 5 x 60 cc. The mother continued to take lactagogue.

The ninth visit was held on 20 December 2022, at this point the baby was 3 months and 16 days old. The baby’s body weight was currently 5445 g (increased by 34 g/day since the eighth visit). The baby’s nutritional status was good (-2 SD: 5330 grams). SNS was continued to be taken at 5 x 60cc/day. The lactation doctor counselled on 4-star complementary feeding. The mother received information on complementary feeding according to WHO standards. The early complementary feeding can be started when the baby turns 4 months old. She also bought the book “Anti Ribet MPASI”. The mother continued to consume lactagogue.

During the tenth visit on 10 January 2023, the baby was 4 months and 6 days old. The baby’s body weight was 5720 grams (increased by 19.5 g/day since the ninth visit). The baby’s nutritional status was good (- 2 SD: 5680 grams). The mother said the baby had a history of cough and cold and fever for 1 week. The lactation doctor advised the SNS to be continued at 5 x 45-60 cc/day. The baby received iron supplement and Vitamin D. The baby started early solids. The mother continued to consume lactagogue.

The eleventh visit was held on 24 January 2023, at this time the baby was 4 months and 20 days old. The baby’s body weight was currently 6076 grams (increased by 26 g/day since the tenth visit). The baby’s nutritional status was good (- 2 SD: 5820 grams). The baby has started early solids, the baby was active and eager to eat. The mother put the baby in a swaddle when eating, as she felt that the baby ate inappropriately and kept trying to hold the spoon. The mother was afraid to give too many foods to the baby, therefore she limited the portion. The lactation doctor re-educated her about responsive feeding. The SNS was continued at 5×30 cc/day. The lactation doctor also performed baby massage. Up to this point, the mother was not willing to have acupuncture. The mother continued to consume lactagogue.

During the twelfth visit on 14 February 2023, the baby was 5 months and 10 days old. The baby’s body weight was currently 6475 g (increased by 18.5 g/day since the eleventh visit). The baby’s nutritional status was good (- 2 SD: 6100 grams). The mother said that SNS was taken at night for 1-2 x 30 cc, and the rest of the time, the baby was breastfed directly to the mother. The baby was active and eager to eat. The mother tried various recipes in the book “Anti Ribet MPASI”, and her baby liked it and ate very well. The baby had been given strained porridge, but not blended. The baby received routine vaccines at the midwife near the house. The lactation doctor advised mum to stop the SNS so that the baby can suckle directly at the breast and continue complementary feeding. The iron supplement and Vitamin D for the baby were continued. The lactation doctor added Vitamin D for the mother. The mother continued to consume lactagogue twice a day. The mother was given a flyer for a webinar entitled “Masak MPASI Yuk!” which was held on 19 March 2023.

During follow up by the lactation doctor, the baby was 5 months and 5 days old, and had been given 4-star complementary foods according to WHO standards. Heavy meals 3 times a day and snacks 1-2 times a day. The mother gave at least 1 chicken egg every day to the baby and did not miss the additional fat. The mother was confident in breastfeeding directly without SNS as the baby ate the complementary food well and the baby’s body weight increased well. There was no problem in breastfeeding and complementary feeding. The baby was healthy with good nutritional status. The mother was excited to continue breastfeeding until 2 years. The father also supported the mother to breastfeed.

Tabel.1 Baby F’s Body Weight Growth and Nutritional Status

No.	Date	Age	Body Weight	Nutritional Status	Action Performed
1.	04-09-22	Born	3500 g	Good
2.	10-10-22	1 month 6 days	4100 g Increased by16.7 g/day	– 2 SD: 3580 g Good	– Double Frenotomy– Tongue exercise 5 times per day- To stop teat bottle usage- Lactagogue 2×1 tab
3.	17-10-22	1 month 13 days	4115 gincreased by 15 g/day	– 2 SD: 3790 g Good	– Tongue exercise 3 times per day- To encourage acupuncture- Lactagogue 2×1 tab
4.	25-10-22	1 month 21 days	4105 gDecreased by 10 g	– 2 SD: 4030 g Good, but close to moderately malnutrition	– Re-incision Tongue tie– SNS 6x60cc/day- Tongue exercise 3 times per day- Lactagogue 2×1 tab- Acupuncture was not performed (due to financial issue)
5.	01-11-22	1 month 28 days	4360 gIncreased by 37 g/day	– 2 SD: 4240 g Good	– Tongue exercise once per day- SNS 5-6×45 cc/day- Lactagogue 2×1 tab
6.	08-11-22	2 months 4 days	4565 gIncreased by 29 g/day	– 2 SD: 4393 g Good	– To stop tongue exercise- SNS 5-6×30 cc/day- Lactagogue 2×1 tab
7.	29-11-22	2 month 27 days	4970 gIncreased by 19 g/day	– 2 SD: 4930 g Good, but close to moderately malnutrition	– SNS 6×45-60 cc/day- Lactagogue 2×1 tab
8.	06-12-22	3 month 2 days	5030 gIncreased by 9 g/day	– 2 SD: 5040 g Moderately malnutrition	– Sounding early complementary feeding- SNS 6×45-60 cc/day- Lactagogue 2×1 tab
9.	13-12-22	3 month 9 days	5220 gIncreased by 27 g/day	– 2 SD: 5180 g Good	– SNS 5-6×45-60 cc/day- Lactagogue 2×1 tab
10.	20-12-22	3 month 16 days	5445 gIncreased by 34 g/day	– 2 SD: 5330 g Good	– Counselling 4-star complementary feeding- SNS 5×60 cc/day- Lactagogue 2×1 tab
11.	10-01-23	4 month 6 days	5720 gIncreased by 19.5 g/day	– 2 SD: 5680 g Good	– Apply 4-star complementary feeding- SNS 5×45-60 cc/day- Lactagogue 2×1 tab- Iron and Vitamin D supplementary (for the baby)
12.	24-01-23	4 month 20 days	6076 gIncreased by 26 g/day	– 2 SD: 5820 g Good	– To improve complementary responsive feeding– SNS 5×30 cc/day- Lactagogue 2×1 tab
13.	14-02-23	5 month 10 days	6475 gIncreased by 18.5 g/day	– 2 SD: 6100 g Good	– To stop SNS- Continue supplementary feeding- Breast milk on demand with direct suckling- Lactagogue 2×1 tab- Vitamin D for the mother 1×5,000 IU

DISCUSSION

The breastfeeding process requires support from various parties, starting from the husband, closest family, health workers and the surrounding neighborhood. Mrs D and Mr F were aware and understood the importance of breastfeeding their babies. Mrs D wanted to breastfeed her baby for up to 2 years, and Mr F was supportive. However, Mrs D experienced some obstacles when breastfeeding her baby. The baby suckled ineffectively, resulting in slow weight gain.

A slow weight gain (SWG) has been defined as (a) an infant less than 2 weeks old who has lost 10% or more of their birth weight or (b) 2 weeks to 3 months old with a weight gain of less than 20 g/day. ¹ In this case, Baby F had a weight gain of 16.67 g/day (from birth to the first visit to our lactation clinic).

The mechanism by which a baby passes the breastmilk is quite complex. Firstly, the baby should be able to form a seal on the breast with the lips folded outwards and the tongue grasping the breast and pressing the breast to the palate. In a rhythmic motion, the baby will squeeze the breast to the palate and then drop the tongue down allowing for a greater negative vacuum, and then the breastmilk comes out. ²

Babies with tongue tie and lip tie cannot optimally empty the breast when suckling at the mother’s breast. This problem was also experienced by the baby By. F’s suckling ability, which was not optimal, resulting in slow weight gain. The reason why the suction was not optimal in Baby F is due to the presence of tongue tie and lip tie.

The tongue frenulum is a mucous membrane which connects the underside of the tongue to the base of the mouth. This tissue may vary in thickness and length. When the tongue frenulum is short, tight, or positioned too far forward, there will be limited tongue movement affecting oral function. This condition is known as Ankyloglossia or tongue tie. 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 consists of a membrane. If the frenulum is attached to the bone or upper gum, it can cause limited 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 that the baby can suck well and the transfer of the milk can be optimal. Flange-out lips also stimulate the oxytocin chain release, which causes the optimal release of breast milk from the mother’s breast. A baby’s lips that are not engorged when feeding to the breast can cause breastfeeding problems, such as pain and sore nipples. ⁴

Parents received a full explanation about tongue tie and frenotomy and gave written informed consent prior to the procedure. In preparation for frenotomy, the baby was swaddled to immobilize the arms and legs and laid supine on the examination table. An assistant helped

by holding the head still while the operator lifted the tongue with a finger to locate the frenulum.⁵

The frenulum was then snipped with blunt-ended sterile scissors, and sterile gauze was used to stop the bleeding. The tongue-tie was assessed as completely released if a neat diamond shape was visible with no palpable tissue remaining to restrict tongue movement. We favored not using general anesthesia to perform the procedure because this is likely to add delays in breastfeeding. Immediately after frenotomy, the mother was asked to breastfeed her baby for reevaluation of latch and improvement. The mother was taught how to perform tongue exercises to prevent reattachment. A follow-up visit was scheduled 3 days later to assess for complications and to evaluate the baby weight gain. A further review was scheduled 1 week later and continued every week after as necessary until the breastfeeding dyads’ course was considered as satisfactory. ⁶

Following the frenotomy performed for Baby F, the mother felt that the baby’s suction was stronger. However, it turned out the tongue exercise taught by the lactation doctor was not done optimally by the mother resulting in the tongue cord reattaching. In this case, the lactation doctor performed another frenotomy for Baby F. Prior to the frenotomy, baby F’s suboptimal suction on the breast would lead to a decrease in the mother’s milk supply. In this case, Mrs D’s breastmilk production had started to decrease and baby F’s weight was in good nutritional status but close to undernutrition. Hence, the baby required the SNS (Supplemental Nursing System) to ensure that the baby’s growth was well improved, and the milk supply was maintained as the baby continued to suck at the breast.

To assess the need for supplementation, the lactation doctor titrates the amount of the milk required with a supplementation device. Before breastfeeding, the lactation doctor fills the milk in a supplementation device and attaches it to the breast before feeding the baby. Once the baby is finished and full, the amount of supplementation that is required is calculated. For instance, if there is 90 cc of milk in the supplementation device, the baby feeds and 30 cc of milk is left, so the milk the baby drinks is 60 cc per feeding session. Based on the above, we recommend that the mother feeds with the supplementation device six times per day (e.g., 6×60 cc) from the morning until 9pm, and the rest of the time breastfeed without the supplementation device to prevent fatigue. ⁷

WHO only recommends complementary feeding at 4-6 months of age, if either: the infant’s weight gain is inadequate with breastfeeding alone or the infant is frequently breastfed but still shows hunger shortly after breastfeeding. In this case, Baby F was encouraged to start complementary feeding at 4 months of age according to WHO standards with the aim of discontinuing supplementation therapy and expected weight gain according to the WHO Weight Growth Chart. ⁸

CONCLUSIONS

Slow infant weight gain can be caused by suboptimal suction due to a limited tongue movement (tongue tie and lip tie). The baby’s suboptimal suction will cause the mother’s breast milk production to decrease. A frenotomy is appropriate as it can repair the tongue for optimal suckling and thus increase the mother’s breastmilk production. Supplementation is necessary to ensure that baby gets intake from breast milk and formula milk from SNS so that the baby’s growth improves well, and breast milk supply remains maintained. The early complementary feeding may be given in this case to stop formula feeding in supplementation therapy. In this case, with simple frenotomy, supplementation, maternal oral therapy, and early complementary feeding according to WHO standards, the baby can grow and develop optimally, and the mother can continue breastfeeding for up to 2 years. Supplementation can be completely discontinued, the baby could only suckle directly, getting some complementary foods, and achieving optimal growth and development. Strong support from husband, family and health professionals was the key to the successful outcome of this case.

BIBLIOGRAPHY

1. Walker, M. (2011a). Beyond the initial 48–72 hours: Infant challenges. In Breastfeeding management for the clinician: Using the evidence (2nd ed., pp. 347–427). Sudbury, MA: Jones and Bartlett.
2. Praborini A, Wulandari RA. Anti Stres Menyusui. Kawan Pustaka. Jakarta. 2019.
3.  Clay W, Hoover. The Breastfeeding Atlas Sixth Edition. United States of Amerika.  2013 : 144.
4. Cole M. Tongue and Lip Tie: A Comprehensive Approach to Assessment and Care. Powerpoint presentation. 2017.
5. Sunil Kumar, P., Raja Babu, p., Jagadish Reddy, G., & Uttam, A. (2011). Povidone iodine – Revisited. Indian Journal of Dental Advancements, 3 (3). 617-620.
6. Praborini A, Purnamasari H, Munandar A, Wulandari RA. Early Frenotomy Improves Breastfeeding Outcomes for Tongue-Tied Infant. United States Lactation Consultant Association. 2015; 6 (1): 9-15.
7. 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.
8. World Health Organization. (2000). Complementary feeding family foods for breastfed children.