SIMPLE FRENOTOMY AND SUPPLEMENTATION IN INFANTS WITH EXCESSIVE WEIGHT LOSS

CASE

Baby MA, male, 4 days old, was brought to Lactation Polyclinic at Private Hospital in Depok on 12th August 2022 by his parents. Baby MA is the first child of Mrs. F and Mr. M. The mother is a housewife, and the father works for a private company. Baby MA was born on August 8, 2022, assisted by a midwife with a gestational age of 40 weeks and a birth weight of 3100 grams. Baby MA was placed on top of Mrs. F’s body for about an hour after birth. Since the beginning, Baby. MA hadn’t been able to open his mouth wide enough to latch on Mrs. F’s nipples well. The midwife said that Baby MA had tongue and lip ties, and suggested them to see a pediatrician in Lactation Polyclinic.

Mother complained that Baby MA’s latching was frequently detached, took a long time for feeding, didn’t seem to swallow, easy to fall asleep, seems as if never full, appeared yellow, and had significant weight loss. Mrs. F’s nipples also hurt when she was breastfeeding. During the first visit, baby MA was 4 days old with weight of 2495 grams. The baby’s nutritional status was within category of undernourished status (<-2SD) with a drastic decrease of 151.25 gr/day from the baby’s birth weight, which was a decrease of 19.50% from the birth weight (Excessive Weight Loss).

During the physical examination by lactation doctor, it was found that the baby had posterior type tongue tie and lip tie grade 3, that the baby did not have a good suction reflex, and that the baby appeared yellow (Kramer 4-5). The mother’s breasts and the milk supply were observed to be normal. Based on observation of breastfeeding with the left cradle hold position, the baby tended to suckle on the nipple, unable to attach to the breast properly.

Mrs. F’s desire to breastfeed By. MA until two years old was growing stronger after learning about how important breastfeeding based on religious and WHO recommendations. This was also supported by Mr. M. The lactation doctor explained that tongue tie and lip tie were the causes of the baby’s difficulty in suckling at the mother’s breast, resulting in a decrease in weight and difficulty gaining weight. The doctor explained the simple frenotomy procedure to the baby’s parents, and they agreed to proceed with the procedure.

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The baby suckled at the mother’s breast immediately after a simple frenotomy was performed at the lactation clinic. The bleeding stopped immediately after breastfeeding. The mother noticed that the baby suckled less, stronger, and softer, and she no longer felt pain in the nipple. The lactation doctor showed how to do tongue and lip exercises and advice to do the exercise 5 times a day for the next 3 weeks. Parents were asked to have a tummy time routine for their baby and to apply aloe vera gel under the tongue and lips after a simple frenotomy action was performed. Control was scheduled in the next 4 days to the pediatrician who is pro-breastfeeding.

The second visit was on August 16, 2022, four days after the simple frenotomy performed.  During this visit to pediatrician, the baby was eight days old. The baby’s weight was 2190 grams which fell by 76.25 grams per day. The baby was in poor nutritional condition (<-3SD). The wound healed well after the frenotomy. The pediatrician recommended the parent to use SNS (Supplemental Nursing System) and showed SNS installation and sterilization procedures. The pediatrician prescribed a plain formula milk for SNS supplementation with a dosage of 6x30cc, vitamin for the baby, and lactogogue 2×1 for the mother. The doctor also advised to do skin to skin contact with the baby for 24 hours. They were asked to return to the pediatrician on August 23, 2022.

During the third visit on August 23, 2022, the baby was 15 days old. The baby weight was 2420 grams which gained 33 grams per day. The baby was still in malnourished category (<-3SD). Based on the examination, the post-frenotomy wound looked good, the baby did not appear yellow, the breastfeeding process was improving, and the mother’s milk supply was abundant. The pediatrician advised to increase the dose of SNS to 6x30cc and prescribed vitamin. They were scheduled for a control on September 1, 2022.

During the fourth visit, on September 1, 2022, the baby was 24 days old. The baby gained 16.1 grams per day, reaching 2565 grams. Nutritional status was still in malnourished category (<-3SD). The pediatrician recommended to increase the dose of SNS to 6x45cc and vitamin. They were scheduled for a control on September 15, 2022.

During the fifth visit, on September 15, 2022, the baby weighed 2865 grams and had grown by 21.4 grams per day. The nutritional status was still in malnourished category (<-3SD), but the baby’s weight gain was improving. The pediatrician taught the breastfeeding attachment procedure and baby massage again. The pediatrician also prescribed a new SNS tube size L with a dose of 5x60cc and vitamin. Baby MA was referred to a cardiologist, the mother was given lactogogue and booked for acupuncture session after lactation clinic. The father was taught to do oxytocin massage, and control was scheduled on September 27, 2022.  

The sixth visit was on September 27, 2022. The mother felt that Baby MA was getting better at breastfeeding and felt her milk supply was increased.  Based on echocardiography result and physical examination by cardiologist, Baby MA were found to be normal. At the time of this visit, the baby was 1 month and 20 days old, weighing 3360 grams and growing at a rate of 41.25 grams per day. Nutritional status was still in malnourished category (<-3SD). DSA recommended continuing to use SNS at a dose of 5x60cc, vitamin, and scheduled for a control on October 11, 2022.

During the seventh visit, on October 11, 2022, the baby was 2 months and 4 days. The baby gained 45.7 grams per day, reaching 4000 grams. The current nutritional status was within undernourished category (<-2SD). The pediatrician advised to continue using SNS at a dose of 5x60cc, vitamin, and scheduled for a control on October 23, 2022.

During the eighth visit on October 23, 2022, the baby was 2 months and 18 days old. The baby’s weight increased by 54 grams per day, reaching 4765 grams. Baby MA was in good nutritional condition (>-2SD). The pediatrician suggested that SNS be continued at a dose of 5x60cc and stop vitamin. They were scheduled for control on November 8, 2022.

During the ninth visit, on November 8, 2022, the baby was 3 months and 2 days old. The baby gained 47.1 grams per day, reaching 5425 grams. Baby MA was categorized in good nutritional condition (>-2SD). The pediatrician suggested reducing the SNS dose to 5x45cc with a red tube. They were scheduled for control on December 26, 2022. 

During the tenth visit, on December 26, 2022, the baby was 4 months and 20 days old. The baby gained 32.8 grams per day, reaching 7000 grams. Baby MA was categorized in good nutritional condition (>-1 SD). The mother said that the baby suckled well on the right breast and that the right breast felt fuller faster than the left breast. Baby MA was fussy when breastfeeding on the left breast, and that he was often spitting up after breastfeeding lately. The pediatrician suggested continuing SNS on the left breast with dose of 5x30cc and if the baby was fussy or if it is considered necessary, the mother could massage the baby. The mother was informed about early complementary feeding, and scheduled for control on December 31, 2022.

During the eleventh visit, on December 31, 2022, the baby was 4 months and 25 days old. The baby’s weight was 6980 grams which fell by 4 grams per day. Baby MA was still in good nutritional condition (>-1SD). After doing routine baby massage, the mother said that the baby appeared more relaxed and spitting up less. On January 10, 2023, DSA suggested direct breastfeeding without the use of SNS and early complementary feeding. They were scheduled for control on January 10, 2023.

During the twelfth visit, on January 10, 2023, the baby was 5 months and 5 days old. The baby gained 22.5 grams/day, reaching 7205 grams. According to the WHO standard growth curve, the nutritional status of Baby MA was indicated good (>-1SD). Because the baby was always full after breastfeeding, the mother said she never used SNS again. The pediatrician recommended that complementary feeding be continued in accordance with WHO standards, and the baby continued to breastfeed without the use of SNS. They were scheduled for control on February 10, 2023.

During the thirteenth visit, on February 14, 2023, the baby was 6 months and 10 days old. The baby gained 20.97 grams/day, reaching 7960 grams. Based on the WHO standard growth curve, the nutritional status of Baby MA was good. The mother said she never used SNS again because the baby was always full after feeding. The pediatrician suggested that complementary feeding be continued with WHO standards and the baby continued to breastfeed until the age of 2 years without using SNS. 

Figure 1. Chart of Infant Weight-for-Age (BB/U) Growth of Baby MA (WHO)

DISCUSSION 

Mrs. F understood the benefits of breastmilk and direct breastfeeding for herself and her child, and she was determined to breastfeed exclusively until Baby MA was two years old. Mrs. F showed a positive attitude throughout the therapy period and expressed a desire to continue breastfeeding Baby MA. Mrs. F received complete support from her husband and family, which assisted her in completing the entire course of therapy.

Mrs. F noticed that her baby’s mouth was frequently detached from the breast while breastfeeding, and that the duration of breastfeeding was long, as if the baby was never full. She also noticed that her baby appeared yellow. Jaundice (yellow) in newborns is also a sign of a lack of food intake (breast milk) in infants, as bilirubin from hemoglobin breakdown is not properly wasted with feces.1

In this case, the mother noticed that the baby was sucking loosely and that the weight loss was significant during the initial visit. In the case of Baby MA, this was due to posterior tongue tie and grade 3 lip tie, which rendered breastfeeding ineffective and painful for the mother. 

Ankyloglossia, which causes tongue and lip ties in Baby MA, was to blame for these issues. Ankyloglossia can interfere with the attachment of the baby’s mouth to the breast, resulting in problems such as nipple blisters, swollen breasts, and low milk supply, resulting in insufficient breast milk for the baby, slow weight gain, and even failure to grow.2 Untreated ankyloglossia will cause feeding disorders, swallowing (eating) disorders, and speech disorders.3 As a result, the sooner frenotomy was performed, the better the outcome.

Frenotomy is the act of making a simple incision on the tongue cord or upper lip cord using sterile scissors. Several studies have shown an improvement in the quality of breastfeeding in mothers and babies who were having difficulties breastfeeding. The baby’s breastfeeding attachment to the mother will improve, resulting in better milk transfer, more comfort for the mother while breastfeeding, and an increase in milk supply in the mother’s breast.3

Following frenotomy on tongue and lip ties improved the baby’s mouth attachment to the mother’s breast, allowing it to suckle optimally. Breastfeeding attachment is characterized by the baby’s mouth being wide open, his lips curved outward, and the baby being able to put more parts of the areola into his mouth. In the breastfeeding process, this outward lip position is required so that the baby’s mouth can create a vacuum or high negative pressure, allowing the baby to suck well and the milk transfer to be optimal. Baby MA was given formula milk through supplemental nursing system and continued to breastfeed on the mother’s breast, so that the mother’s supply of breast milk increased.

When By. MA was 4 months old, early complementary foods were given to help improve the baby’s nutritional status. Malnutrition in the first year of life had a significant impact on brain development and interfered with intellectual development, so it must be addressed appropriately.2 Complementary foods can be given starting from the age of 4-6 months, according to WHO recommendations. If the baby’s weight did not increase adequately despite good breastfeeding, complementary feeding could be given starting from 4 months of age.4 

According to WHO standards, Baby MA was recommended for early complementary feeding with the aim of reducing supplementation dosage and increasing infant weight. Baby MA was given complementary feeding starting from the age of 4 months and 20 days, the supplementation dose was gradually reduced, and the baby gained weight to achieve good nutritional status. When Baby MA was 5 months and 5 days old, he was stopped given milk from supplementation and was only breastfeed and eating solids. Baby MA achieved a good nutritional status. 

CONCLUSION  

Malnourished infants must be treated early and holistically because malnutrition in childhood has a significant impact on brain development and organ function later in life. Because Ankyloglossia makes it difficult for infants to receive optimal breast milk from their mothers, frenotomy is required to improve the suckling process. Supplementation is also required while continuing direct breastfeeding so that the baby receives a double intake from breast milk and formula milk from SNS so that the baby’s growth and milk supply are maintained. At 4 months-old, the dose of SNS was reduced, and the baby began to be given early complementary foods in accordance with WHO standards, while continuing direct breastfeeding. Therefore, the baby could receive optimal nutrition from breast milk and complementary foods and could achieve good nutritional status quickly. The whole process could be done well as supported by the mother believes that breastfeeding and direct breastfeeding are the best options for mother and baby. The support from family and health care system was also important for the success of the treatment. In this case, after frenotomy, supplementation, and complementary feeding, the baby was able to breastfeed directly without formula and continued breastfeed for up to 2 years.

REFERENCES

  1. https://www.idai.or.id/artikel/klinik/asi/air-susu-ibu-dan-ikterus
  2. 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.
  3. Forlenza, et al, Ankyloglossia, Exclusive Breastfeeding and Failure to Thrive, 2010. 
  4. World Health Organization. (2000). Complementary feeding family foods for breastfed children.

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