SIMPLE FRENOTOMY AND SUPPLEMENTATION IN INFANT WITH ANKYLOGLOSSIA AND SLOW WEIGHT GAIN

PRABORINI LACTATION TEAM

ON MARCH 23, 2023

Written by : dr. Mellati Zastia Putri

JAKARTA SELATAN

CASE REPORT

BANNER 728 x 90

Baby AA, a male, is the first child of Mrs. M and Mr. A. The mother is a midwife, and the father is a member of the Indonesian National Military Naval Force. Baby AA was born through a normal delivery at 39 weeks of gestation, assisted by a midwife on December 17, 2022 with a birth weight of 3000 gram. Immediately after the baby was born, he was given an early initiation of breastfeeding for approximately 30 minutes. During the initiation, the baby was able to find the nipples and began breastfeeding.

At the age of 3 days old, Baby AA was brought to a midwife for a check-up due to a yellowish appearance on the face, and the weight was measured to have decreased to 2800 grams (6,8% of birth weight). Mrs. M was concerned that her breast milk might not be sufficient, so she started pumping and providing expressed breast milk using a bottle until the yellowish on the baby’s face disappeared by the age of 1 week. After that, the mother stopped pumping and continued direct breastfeeding. During breastfeeding, she experienced pain and cracked nipples, and had endless duration of breastfeeding as if the baby was never full. When the baby was brought to a midwife at 1 month old, the baby’s weight was 3800 grams (gained 1000 grams). At 2 months old, Baby AA was brought to the midwife again, and the weight increased by 4100 grams (only gained 300 grams). The midwife suspected a tongue tie and referred the baby to a pediatric and lactation consultant.

The first visit was on February 21, 2023. Mrs. M came with her husband and Baby AA. She expressed concerns that the baby had endless duration of breastfeeding as if he was never full and the weight gain was not as expected. Additionally, the mother experienced pain and cracked nipple during breastfeeding. At that time, Baby AA was 2 months and 6 days old, and weighs 3925 grams. The baby’s nutritional status was categorized as underweight (<-2SD), nearly approach severely underweight (<-3SD), with a weight gain of 14.01 grams per day since birth, indicating a Slow Weight Gain (SWG).

Upon a physical examination by the lactation consultant doctor, it was found that the baby had a medial tongue tie and grade 4 lip tie, and the baby lacked of proper sucking reflex. The mother’s breasts were found to be in normal condition, and her breast milk supply was also normal. During the breastfeeding observation in the cradle hold position, the baby tended to latch onto the nipple and could not properly attach to the breast.

After being explained about the importance of breastfeeding according to religion and WHO recommendation, Mrs. M was more strongly motivated to breastfeed until 2 years of age. The intention to breastfeed for 2 years was also supported by the husband. The doctor explained that the tongue tie and lip tie were the cause of the breastfeeding difficulties, leading to slow weight gain. The doctor recommended a simple frenotomy procedure, which the parents agreed to.

The simple frenotomy was then performed by the doctor in the lactation consultant’s clinic. Following that, the baby was immediately breastfed. Bleeding ceased shortly after breastfeeding. The mother felt that the baby latched deeper, stronger, more gently, and did not feel pain on the nipple as before. The doctor demonstrated tongue and lip exercises to be performed by the parents 5 times a day for the next three weeks. The parents were advised to provide tummy time to their baby and apply aloe vera gel three times a day under the tongue and lip where the frenotomy was performed. The doctor recommended using a Supplemental Nursing System (SNS) for breastfeeding supplementation and provided instructions for its setup and sterilization. The SNS contained 6×60 cc of formula milk. The mother continues to do direct breastfeeding without SNS as often as the baby wants. Additionally, the doctor prescribed piracetam (2×40 mg) for the baby and a lactogogue (2×2) for the mother. A follow-up appointment was scheduled on February 23, 2023.

On the second visit, two days after the frenotomy, Baby AA was 2 months and 8 days old, with a weight gain of 100 grams per day, reaching 4125 grams. The baby’s nutritional status was still categorized as underweight (<-2SD). The post-frenotomy wound examination showed no remaining tissue. Breastfeeding attachment improved, and the mother’s breast milk supply increased. The doctor recommended continuing SNS supplementation (6×60 cc of formula milk), continuing tongue and lip exercises five times a day, lactogogue for the mother, and the piracetam for the baby. A follow-up appointment was scheduled on March 2, 2023.

At the third visit on March 2, 2023, the baby was 2 months and 15 days old, with a weight gain of 43,5 grams per day, reaching 4430 grams. The baby’s nutritional status was still underweight (<-2SD). The mother reported that the breastfeeding process was improving, and her breast milk supply was plenty. The doctor recommended continuing SNS supplementation (6×60 cc), reducing tongue and lip exercises to three times a day, and increasing the piracetam dose to 2×45 mg for the baby. Another follow-up appointment was scheduled on March 23, 2023.

The fourth visit was on March 23, 2023, the baby was 3 months and 6 days old, with a weight gain of 40 grams per day, reaching 5270 grams. The baby’s nutritional status improved to normoweight (>-2SD). The doctor recommended reducing the SNS dosage to 6×30 cc due to the baby’s good weight gain and switching to a medium-sized white tube. Piracetam was discontinued, and tongue exercises were stopped. Another follow-up appointment was scheduled for April 6, 2023.

The fifth visit was on April 13, 2023, the baby was 3 months and 27 days old, with a weight gain of 27.6 grams per day, reaching 5850 grams. The baby’s nutritional status remained in the normoweight category (>-2SD). The goal of supplementation was achieved, so the doctor advised discontinuing the use of SNS and continuing breastfeeding on demand. Another follow-up appointment was scheduled on May 2, 2023.

The patient returned on May 12, 2023. At this time, the baby was 4 months and 26 days old, with a weight gain of 26 grams per day, reaching 6605 grams of weight. The baby’s nutritional status remained in the normoweight category (>-1SD). The doctor recommended continuing breastfeeding and postponing the complementary foods until the baby reached 6 months of age. Additionally, the doctor prescribed iron and vitamin D supplements. However, the mother was not able to provide this due to cost constraints.

At the final visit on July 4, 2023, Baby AA was 6 months and 19 days old, with a weight gain of 16.5 grams per day, reaching 7465 grams. The baby’s nutritional status remained in the normoweight category (>-1SD). At this time, Baby AA had started receiving complementary feeding at 6 months old while still breastfed directly from the breast as desired. The doctor recommended continuing breastfeeding until 2 years of age, along with appropriate complementary feeding, and regular monitoring of the baby’s growth and development every month.

Figure 1. Graph of Weight for Age (W/A) Baby AA (WHO)

Table 1. Weight Growth and Nutritional Status in Baby AA

DISCUSSION

Mrs. M understood the benefits of direct breastfeeding for herself and her child, which is why she is determined to give exclusive breastfeeding for 6 months, and continued to give breastfeeding until Baby AA turns 2 years old. Throughout the treatment, Mrs. M maintained a positive attitude and remained enthusiastic about continuing to breastfeed her baby. She received full support from her husband and family, which helped her successfully navigate the entire process.

In this case, during the initial visit, Mrs. M reported that the baby endlessly breastfed, causing pain and cracked nipple, and the baby had slow weight gain, resulting in underweight nutritional status, approaching severe underweight. Slow weight gain is defined as a weight loss of more than 10% of birth weight for babies under 2 weeks of age or a weight gain of less than 20 grams per day for babies aged 2 weeks to 3 months.1 This was attributed to Baby AA’s medial tongue tie and grade 4 lip tie, making breastfeeding ineffective and painful for the mother.

Optimal nutrition during the first two years of life is crucial, as it is associated with reduced long-term and short-term morbidity and mortality rates, decreased risk of chronic diseases, and overall better development. Undernutrition is estimated to be linked to 2.7 million child deaths each year, accounting for 45% of all child deaths. Therefore, feeding infants and children is essential for improving child survival and promoting healthy growth and development.4

The condition of Ankyloglossia, or tongue tie and lip tie in Baby AA, can disrupt the baby’s mouth attachment to the breast, leading to problems such as cracked nipples, swollen breasts, and reduced breast milk supply. This can result in slow weight gain or even failure to thrive.1 Untreated Ankyloglossia can lead to breastfeeding difficulties, eating problems, and speech disorders.2 Therefore, early frenotomy can yield better outcomes.

Frenotomy is a simple procedure that involves making an incision on the lingual frenulum or upper lip tie using sterile scissors. Several studies have shown improved breastfeeding quality in babies with tongue tie and lip tie who underwent frenotomy.2 The baby’s attachment to the mother’s breast will be improved, leading to a more optimal transfer of breast milk, the mother feels more comfortable while nursing, and increasing her breast milk supply.2 Following frenotomy, it is recommended to implement a combination therapy for infants with nutritional issues and mothers experiencing low breast milk supply. This therapy includes supplementation with lactation aid, domperidone, and acupuncture.1 Supplementation involves providing additional nutrition to the baby besides what is obtained directly from breastfeeding. Supplementation may consist of expressed breast milk, donor breast milk, or breast milk substitutes (formula milk). The administration of supplementation is gradually reduced and eventually discontinued as breast milk supply improves.1

Following frenotomy for tongue tie and lip tie in Baby AA, the baby’s mouth attachment to the mother’s breast improved, enabling optimal breastfeeding. Effective breastfeeding attachment is characterized by the baby’s wide-open mouth, the lips folding outward, most of the areola (particularly the lower part) inside the baby’s mouth, the baby’s chin adhering to the mother’s breast, the baby’s cheeks rounding, absence of clicking sounds, and no pain for the mother during breastfeeding.3 Baby AA was provided with supplementation using a Supplementary Nursing System (SNS), while still breastfeeding from the mother’s breast, with the aim of increasing breast milk supply and improving the baby’s nutritional status. By the fourth visit, the baby’s nutritional status improved from underweight (<-2SD) to normoweight (>-2SD). The baby was able to breastfeed effectively with increased breast milk supply, leading to reduction in the supplementation dosage.

The next visit, when Baby AA was 3 months and 27 days old, the baby’s weight gain was satisfactory, and the nutritional status remained in the good nutrition category. The goal of supplementation was achieved, with increased breast milk supply and improved nutritional status. As a result, the doctor discontinued supplementation and advised Mrs. M to continue direct breastfeeding and delay introducing complementary foods until the baby reached 6 months of age. According to WHO recommendations, complementary feeding can be introduced to babies aged 4-6 months, if the baby is not adequately gaining weight despite appropriate breastfeeding or receives frequent breastfeeding but appears hunger soon after.5

WHO and IDAI recommend that complementary foods be prepared using locally available and varied ingredients to meet the baby’s macro and micronutrient needs, while also ensuring the cleanliness and safety of the ingredients used. Complementary foods should be prepared using simple utensils like pots, pestles, sieves, and graters. It should be given at the right time, in the right amount and frequency, adjusting the texture according to the baby’s age, and provided responsively in a pleasant environment and avoiding distractions.5,6 In this case, the baby’s weight gain improved through appropriate complementary foods provided by the mother starting at 6 months of age, while continuing to breastfeed directly as desired by the baby.

CONCLUSION

Babies with undernutrition and slow weight gain must receive early intervention, as nutritional deficiencies, especially in the first two years of life, significantly impact a child’s growth and development. Ankyloglossia in infants complicates optimal breastfeeding from the mother, which requires a frenotomy procedure to improve the breastfeeding process. Additionally, supplementation is required while continuing direct breastfeeding from the mother’s breast, allowing the baby to receive a dual intake from both breast milk and a Supplemental Nursing System (SNS). This approach enhances the baby’s growth and maintains the breast milk supply. As the baby’s nutritional status improves to good nutrition, along with an increased supply of breast milk, the SNS dosage is gradually reduced until the baby can breastfeed directly without it. This can be successfully achieved when the mother is confident that breastfeeding and breast milk are the best choices for both her and the baby, with the support of family and healthcare facilities. In this case, after frenotomy and supplementation, the baby can breastfeed directly effectively. The baby’s nutritional status improves from underweight to normoweight, and it is hoped that the mother can comfortably breastfeed the baby until the age of 2 years, along with appropriate complementary feeding starting at 6 months of age.

REFERENCES

  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. Forlenza, et al, Ankyloglossia, Exclusive Breastfeeding and Failure to Thrive, 2010.
  3. Suradi R, 2013. Posisi dan Pelekatan Menyusui dan Menyusu yang Benar. https://www.idai.or.id/artikel/klinik/asi/posisi-dan-perlekatan-menyusui-dan-menyusu-yang-benar
  4. World Health Organization. 2016. Infant and young child feeding. Retrieved from http://www.wpro.who.int/nutrition_wpr/publications/infantchildfeeding.pdf
  5. World Health Organization. 2000. Complementary feeding family foods for breastfed children. Retrieved from https://www.who.int/publications/i/item/complementary-feeding-family-foods-for-breastfed-children
  6. IDAI. 2015. Rekomendasi Dokter Anak Indonesia, Rekomendasi Praktik Pemberian Makan Berbasis Bukti pada Bayi dan Batita di Indonesia Untuk Mencegah Malnutrisi.

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