Frenotomy, Supplementation and Early Solid in Malnourished Infants.

Written by: dr.Dira Firzanti – Lactation Doctor, Bekasi, West Java, Indonesia

Baby RC is the third child of Mrs. S and Mr. I, a baby girl who was born normally at 37-38 weeks of gestation assisted by a midwife at the Beji Health Center, Depok, West Java on September 10, 2022. Baby RC is a term baby (NCB), appropriate for gestational age (AGA) with a birth weight of 3000 grams and a length of 48 cm. The baby was born with strong crying and got early initiation of breastfeeding for 20-30 minutes in the delivery room. She was immediately carried out when the mother was referred to hospital because the placenta had not descended. While Mother was being treated at the hospital, the baby was given formula in a bottle by Mr. I’s sister because the baby was separated from the mother. Mother was treated for 24 hours. After returning home the baby fed directly on the breast but the mother felt that the milk was coming out little by little. The mother felt pain in her left breast, but because the baby was her third child, Mrs. S felt no need to find out the cause and help. During pregnancy, the mother diligently checked her pregnancy at the health center midwife and received lactation education during pregnancy.

Mrs. S has 3 children. The first child was 6 years and 9 months, which was breastfed for 2 years and 4 months, the second son was breastfed for 2 years. The mother has a strong desire that her third child, Baby RC, would also get breastfed for 2 years. Mrs. S didn’t work and dad worked in a restaurant. Mrs. S did not have nannies or household assistants and took care of her baby and children at home by her selves.

Baby RC visited public health center for control after birth at the age of 1 day to be given the first immunization, and on the 5th day the mother brought baby RC for control because the baby looked yellow. When measurements were taken, the baby’s weight was 3000 grams and the midwife advised the baby to be breastfed more often and have it exposed to the sun light in the morning.

On September 30, 2022, Mrs. S brought baby RC for control to pediatrician at the Free Health Institute (LKC) Dompet Dhuafa to get immunized at the age of 18 days with a body weight of 3333 grams. Mrs. S complained that while breastfeeding the baby’s suction often came off, both breasts were swollen and sore, she had a fever for 4 days and her left nipple was bleeding. Mrs. S took 1 tablet of Paracetamol 3 times a day for 7 days and she pumped the sore breast. She also complained that the baby’s urine was little and the baby looked yellow. At the LKC Pediatrician Polyclinic, she met with an IBCLC Pediatrician. A double frenotomy was performed because from physical examination, the baby had a Tongue-tie Submucosa and Lip-tie grade 4. After the procedure, the baby immediately breastfed and the mother was taught tongue exercise and lip exercise to be done every day at home with frequency 5 times a day. She was also advised to breastfeed the baby as the baby desired, day and night. The mother was advised not to pump her breasts.

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Mrs. S came for control to see the same lactation consultant pediatrician at Puri Cinere Hospital (RSPC) on October 5, 2022, when the baby was 23 days old. At that visit, the baby’s weight was 3275 grams. Mrs. S informed that she felt better when the baby was sucking, and it was painless. The baby’s suction on the breast felt deep and strong. Mrs. S felt that she was producing a lot of milk, but within a few days the frequency of the baby suckling decreased. Mrs. S complained that the baby’s urine was little and more often fussy at night. On physical examination, the baby was not jaundiced, but because the baby’s weight decreased by 58 grams in 7 days, the pediatrician suggested additional supplementation using SNS (Supplemental Nursing System) containing formula milk with partially hydrolyzed protein as much as 5 x 60 cc/day . As for the rest  of the time, the baby was suggested to be breastfed directly without SNS with the frequency as much as the baby wants.

October 10, 2022 at the age of 1 month and 8 days, the mother brought the baby to the same lactation consultant pediatrician at Permata Depok Hospital (RSPD) because the position of the hospital was closer to where she lived. Mrs. S admitted that she forgot to do one of the lip exercises. The baby’s weight increased by 6,3 grams/day to 3370 grams. The nutritional status of the baby was undernourished (BB/U –2SD). On physical examination, there was reattachment of the upper lip. Therefore, a re-frenotomy lip-tie was performed. Mrs. S were advised to continue using SNS with the same amount. Mrs. S was referred to the lactation poly. The lactation doctor taught the left cross cradle position and recommended that the baby have frequent tummy time. Lip exercises were advised to be carried out 3x/day so that the lip cords didn’t reattached. Breastfeed was advised to be done as much as the baby wants and the use of SNS was continued 5 x 45 cc per day.

On October 28, 2022, the baby was 1 month and 16 days old, his weight increased by 280 grams, (35 grams/day) and the weight was 3650 grams, with poor nutritional status (BB/U –2SD). The baby was brought to the lactation consultant pediatrician poly and it was observed that the post frenotomy wound was a good, the mother had lots of milk, the baby was well attached, and it was advised to continue SNS 5 x 30-45 cc per day and use only 1 SNS tube. It was advised to continue breastfeeding the baby as much as the baby wants and to come back to lactation clinic in the next week.

On November 4, 2022 baby RC was 1 month and 23 days old. From the examination, it was found that the baby’s weight gain was 10 grams per day. It was increased by 70 grams in 7 days thus the weight at that visit was 3720 grams. Based on the standard growth curve according to the World Health Organization (WHO), baby RC showed slow weight gain with malnutrition (BB/U < -2SD). According to the mother, the milk from SNS sometimes didn’t run out in 60 cc, so the mother reduced it to 45 cc. Pediatrician lactation consultant advised to stop the tongue exercise, and continued the SNS 5 x 60cc per day. The mother was advised to come back in the next week.

On November 17, 2022 , Baby RC was 2 months and 6 days old with a body weight of 3765 grams there was an increase in weight of 3,5 grams/day. The nutritional status of the baby was still undernourished (BB/U < -2SD). Baby RC continued to breastfeed as long as the baby wants and uses SNS at a dose of 5 x 60cc per day. The mother was given Piracetam 2 x 40 mg per day.

The next visit was on December 1, 2022, the baby was 2 months and 20 days old. The baby’s weight was 3930 grams, an increase of 11,8 grams/day, a total of 165 grams of increase from the previous visit. The nutritional status of the baby was still undernourished (BB/U < -2SD). According to Mrs. S, baby RC plan to have a donor breast milk for his milk in the  SNS because she complained that her baby caught a cold more often when using formula milk. During examination of breast milk, the pediatrician lactation consultants suggested to increase the use of SNS to 6 x 60cc per day when using donor breast milk.

Mrs. S took baby RC to the emergency room of another hospital on the same day because baby RC had difficulty of breathing and was treated with a nebulizer.

On December 3, 2022 the baby had shortness of breath again and was nebulized at the clinic. The next day on December 4 2022, because there was no PICU room available, baby RC was referred to another hospital and treated for 1 day with a diagnosis of Bronchiolitis.

Baby RC came back to clinic for control on January 10, 2023 at 4 months old. The baby’s weight was 4085 grams, an increase of 17,8 grams/day. The nutritional status of the baby was in severe malnutrition (BB/U < -3SD). The mother was advised to start early complementary feeding, reduce the use of SNS to 4 x 60cc per day, Piracetam was still given the same amount. Being suggested to start early complementary feeding, Mrs. S was worried. However, after being explained and taught by the lactation doctor, she felt relieved and wasn’t worried anymore.

On January 31, 2023, baby RC was 4 months and 21 days old. His weight was 5150 grams; there was an increase in body weight of 50 grams/day, the nutritional status was classified as undernutrition (BB/U-2SD). Infant complementary foods were continued, Piracetam was given 2 x 50 mg per day and the SNS dose was reduced to 4 x 30 cc per day.

The next visit was on February 21, 2023 when baby RC was 5 months and 12 days old. His weight increased by 51 grams/day to 6230 grams. The nutritional status of the baby was still undernourished (BB/U -2SD) less than 30 grams to be considered in good nutrition status. The mother had lots of breast milk and the SNS was advised to stop. The mother was given iron supplementation, and advised to continue breastfeeding the baby as the baby desired and continue give him solids.

Baby RC came for the next visit on March 9, 2023 at the age of 6 months 28 days old. Baby RC had an increase of weight 27,5 grams/day and the weight at that visit was 6670 grams . Based on the standard growth curve according to the World Health Organization (WHO), baby RC was considered in good nutritional status (BB/U -1 SD). The mother was still advised to maintain adequate breastfeeding and complementary feeding to baby RC.

Table 1. Weight Growth and Nutritional status in baby RC

Figure 1. Graph of Weight Growth for Age (Weight/Age) of RC Baby (WHO)


What is a Frenotomy? This procedure dates back to the 18th century, when midwives opened the frenulum with a simple tool and was a common practice for midwives. Authors of medical books at the time also started recommending it for babies with breastfeeding difficulties. There are various perspectives and references to indicate whether frenotomy was necessary. However, it would be ideal if all physicians treating newborns to be skilled at performing this simple procedure. When indicated, a frenotomy in the newborn period can rapidly correct “poor latch” at the breast, and prolong a mother’s ability and desire to breastfeed.[1]

Tongue-tie and lip-tie can affect attachment and interfere with breastfeeding. Frenotomy plays a major role in the continuity of breastfeeding. Considering that: 

  1. Breast milk is the best nutrition for babies, and breast milk is irreplaceable
  2. Breastfeeding can help protect babies from several short-term and long-term illnesses and diseases. 
  3. Breast milk shares antibodies from mother to baby. 
  4. Mothers can breastfeed anytime and anywhere. 
  5. Breastfeeding can reduce a mother’s risk of developing breast and ovarian cancer, type 2 diabetes, and high blood pressure.[1]

Frenotomy is necessary and beneficial to be performed when breastfeeding problem occurred due to tongue-tie and lip-tie. 

Breast milk is considered as the best nutrition because it provides healthy nutrition. Compared to formula milk, the nutrients in breast milk are better absorbed and used by babies. This includes sugar (carbohydrates) and protein. Breast milk has the best nutrition for brain growth and the development of the baby’s nervous system. Studies on breastfed babies have found that they do better on intelligence tests as they get older. Breastfed babies’ eyes also work better. This is largely due to certain types of fat in breast milk. Breast milk can also prevent infection. Breast milk has many factors to fight disease. They help prevent mild to severe infections and hospitalizations.[2]


Mrs.S is fully aware of the importance of breastfeeding in child development and she has a strong desire to breastfeed her baby RC up to 2 years. The problems from the birth did not lessen Mrs.S’s determination to give direct breastfeeding for her baby. Even though family support had a big influence, Mrs. S’s determination to breastfeed was so strong that she could overcome the difficulties during therapy. The long process to give optimal breastfeeding for baby RC was not easy. Mrs. S’s breasts were swollen and the nipples were bleeding. Fast management of frenotomy in Ankyloglossia baby RC in the early months of birth plays a major role in the course of breastfeeding and its development.The success of improving nutritional status in baby RC was influenced by the mother’s strong desire to breastfeed her third child. The support and help from the family also influences the mother’s determination to breastfeed. Patience in breastfeeding despite illness and persistence for routine control at all times is a long struggle that really needs to be appreciated. Patience in using SNS and giving early complementary foods was the result of explanations and reinforcement from the lactation doctor. The explanations removed doubts and anxiety experienced by Mrs. S in starting something that is not commonly done by other mothers and babies in general. In summary, strong determination, family support, early education and informed consent for all planned treatments have a major influence on the success of the baby RC therapy course.



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