RELACTATION IN BIOLOGICAL BABIES WITH NIPPLE CONFUSION: A CASE REPORT

Mrs. L visited the Lactation Clinic of a Private Hospital in Depok on August 18, 2023, with her one-month-old child, named Baby S, weighing 3660 grams. The baby’s nutritional status is classified as good, with a weight gain of 27.7 grams per day from birth which is 2800 grams. Mrs. L mentioned that she had been giving her child 2 x 90 cc of formula milk for a week due to a decrease in her breast milk production.

Baby S is the second child of the Mrs. L and Mr. A, After birth, Baby girl S did not receive early breastfeeding Initiation and was taken directly to the baby’s room for the first 24 hours.  After this initial period, Baby S was brought to Mrs. L’s treatment room for rooming in.

On the first day at the hospital, Baby S was given formula milk by the nurse and later breastfed by Mrs. after rooming in, and Baby S was able to breastfeed directly. Mrs. L’s first child is now two years old and had a frenotomy performed in Palembang at the age of two months, but stopped breastfeeding at six months.

Mrs. L admitted that she regularly pumped breast milk with a frequency of nine to ten times per day, but she think her pumped breastmilk supply is still low, ranging at 80 to 120 cc. It has been two weeks since Mrs. L noticed that the baby sleeps continuously during the day, and wakes up more at night.

In the last two weeks, Mrs. L has been worried because the baby has had difficulty drinking from the milk bottle for several days. Additionally, when breastfeeding directly, the baby faces more frequent challenges. The baby has developed a preference for breastfeeding on the left breast and rarely feeds on the right breast.

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The baby also tends to take a long time to drink breast milk from the bottle and often falls asleep while breastfeeding. Prior to visiting the pediatrician, Mrs. L began to realize that Baby S has a tongue tie, similar to her first child.

After the examination by the lactation doctor, she identified ankyloglossia. Tongue tie anterior and upper lip tie grade 4. Mrs. L’s breast examination revealed symmetrical breasts, supple nipples, and abundant breast milk production.

The lactation doctor then requested Mrs. L to breastfeed directly. During observations of breastfeeding in the cradle hold position it was noted that the baby’s sucking reflex was less than optimal, and Baby S refused to suckle at the breast.

 The lactation doctor explained that tongue tie and lip tie were the causes of Baby.S difficulty in breastfeeding. The issue is becoming more serious as Baby S frequently uses the milk bottle, leading to nipple confusion. The lactation doctor suggested frenotomy for Baby.S.

As the baby continued to refuse breastfeeding, and Mr. A couldn’t accompany his wife, the frenotomy was postponed until the next appointment. The lactation doctor recommended 24 hours of skin-to-skin contact using a supplementer with a nasogastric tube and a syringe placed on Mrs. L’s breast while discontinuing the use of the milk bottle.

On 20 August 2023, Mrs. L returned to the private hospital’s lactation clinic with Mr.A to undergo the frenotomy procedure for the tongue tie with the lactation doctor. They also scheduled a consultation with the IBCLC (The International Board of Lactation Consultant) Pediatrician on August 25, 2023, to gather more information about the condition of Baby.S’s lip tie.

Following the tongue tie frenotomy performed at the lactation clinic, the baby immediately latched onto the mother’s breast, and the bleeding from the frenotomy scar resolved after breastfeeding. The doctor then demonstrated tongue exercises to be performed five times a day by the mother for the next three weeks, along with applying aloe vera plant gel under the tongue three times a day. Mothers were also instructed to provide regular tummy time for Baby S.

However, after returning home for two days, Mrs. L continues to offer milk bottle with expressed breast milk because she is concerned about the Baby S’s weight dropping and the potential recurrence of nipple confusion.

On August 25, 2023, Mrs. L returned to the hospital with Mr.A and reported that at home Baby.S was still being given a bottle containing 70 – 90 ml of breast milk eight to nine times a day. Additionally, Baby S was given formula milk once at home due to running out of the breast milk stock.

After meeting with the Pediatrician lactation consultant, inpatient lactation was recommended. Prior to this, Mrs. L and Mr. A were briefed on breastfeeding in Islam and the guidelines from the World Health Organization. The explanation reiterated the condition of ankyloglossia and emphasized the impact of bottle usage on the optimization of the breastfeeding process.

Due to Mrs. L’s strong desire to breastfeed for up to two years, she expressed her wish to be hospitalized. She intended to undergo relaxation using the Praborini method of treatment, followed by a lip tie frenotomy. Additionally, Mrs. L wanted to continue using the SNS (supplemental nursing system) with NGT (nasogastric tube) and syringe, along with other recommended therapies.

After the inpatient administration process was completed, Mrs. L and Baby S entered the treatment room. Throughout the day, a lactation doctor visited the room to care for Mrs. L and the baby S engaged in skin-to-skin contact for 24 hours, with exceptions only for going to the toilet, praying, and engaging in Murottal (chanting verses from the Quran). In the room, the baby began to suckle at the mother’s breast calmly.

During the treatment, the pediatrician also prescribed the drug Chlorpheniramine for Baby.S, and the Frenotomy of lip tie was  scheduled for the next day if the baby’s latch was optimal during breastfeeding.

Subsequently, the lactation doctor performed a lip tie frenotomy, after which Baby S immediately breastfed from Mrs. L. The parents were once again instructed on tongue and lip exercises to be done five times a day, along with the application of aloe vera plant gel three times a day. In the afternoon, the mother and baby were allowed to go home and were scheduled for a follow-up check at the peditrician clinic five days later.

On August 31, 2023, Mrs. L and Baby S came for a follow-up and reported that the breastfeeding process was progressing smoothly without the need for supplements. At one month and 14 days old, baby.S’s weight has increased by 24.5 grams daily, reaching 3880 grams with good nutritional status. However, Mrs. L expressed concern as the baby’s weight had decreased from the weight recorded at the time of treatment, which was 3890 grams.

The Pediatrician explained that the decrease was not very significant and was normal for babies undergoing the relactation process. Mrs. L felt calmer and more confident in continuing to breastfeed, deciding not to reintroduce the milk bottle with breast milk. The relactation or direct breastfeeding into Baby.S’s breast was declared successful.

weight during in-patient relactation treatment and post-relactation in-patient control
weight during in-patient relactation treatment and post-relactation in-patient control
NoDateBaby AgePartBody weight (grams)Therapy
1August 18, 2023One monthLactation Clinic3660 gramsSkin to skin 24 hours Turn murottal Stop dot Frenotomy plan
2August 20, 2023One month 2 daysLactation Clinic3740 gramsSkin to skin 24 hours Turn murottal Tongue frenotomy Aloe vera plant gel NGT + Syringe filled with 30 cc of expressed breast milk
3August 25, 2023One month, seven daysDay 1 of hospitalization3865 gramsSkin to skin 24 hours Turn murottal Aloe vera plant gel NGT + Syringe filled with expressed breast milk as desired by the baby CTM 3 x 0.3 mg Lactation massage Oral motor exercise
4August 26, 20231 month 8 days2nd day of hospitalization3890 gramsLip tie frenotomy Skin to skin 24 hours Turn murottal Aloe vera plant gel NGT (Nasogastric Tube) connected to a syringe, filled with expressed breast milk as per the baby’s preference. CTM 3 x 0.3 mg Lactation massage Oral motor exercise
5August 31, 2023One month, 13 daysPost-hospital control of relactation3880 gramsRelactation was successful Skin-to-skin continued in the evening
Table 1. Body weight baby S during inpatient relactation treatment and post-relactation inpatient control

DISCUSSION

Mrs. L is determined to continue breastfeeding her child directly, and her husband is equally supportive. This commitment is evident as the mother promptly undergoes in-patient relactation. Throughout the treatment period, the mother is consistently accompanied by her husband for check-ups, and it is noticeable that the husband consistently provides encouragement to the mother.

Breastfeeding is a fundamental activity, serving to meet basic human needs such as nurturing and care. Through breastfeeding, a mother addresses her child’s nurturing needs, providing essential stimulation for emotional development in interactions, particularly with the mother. This process fosters a strong affectionate bond between the baby and the mother, satisfying the need for care. Additionally, the nutrients present in breast milk contribute to the baby’s growth and development, further fulfilling the essential need for care.1

Breastfeeding transcends mere nourishment; when a mother cradles her breastfeeding baby, her gaze is unwavering, filled with affection and a profound desire to meet the infant’s needs. The mother’s demeanor fosters a sense of comfort and security in the baby, who feels understood, with their basic needs, including hunger, met, cherished, and surrounded by love. In the exchange of breast milk, both babies and mothers embark on a shared journey of learning to love and experiencing the profound joy of being loved.2

Previously, The fact that a child who regularly drinks from a milk bottle, it can lead to many problems, including autism.

Research conducted by Shafay et al. in 2017 also examined that there was a significant difference between mothers who breastfeed directly to the breast (Direct BreastFeeding) and mothers who only express breast milk with a pump (Exclusive Pumping) with the incidence of autism in children, where the risk of children with the disorder autism is higher in mothers who exclusively pump than in mothers who breastfeed directly.3

This was then confirmed by Sherief Ghozy et al. in 2019, who stated that breastfeeding directly to the breast for six months can reduce the risk of autism in children by 54%, and the risk becomes smaller if the child is breastfed for up to 2 years.4

During the physical examination, Mrs. L showed no issues with her breasts or breast milk supply. However, baby S was found to have challenges related to anterior tongue tie and grade 4 lip tie, leading to nipple confusion caused by bottle usage.

The Pedritician and lactation counselor recommended a frenotomy to facilitate the optimal attachment of Baby.S to Mrs.L’s breast. Consequently, the Praborini Treatment Method was employed to increase skin-to-skin contact until the baby exhibited a desire to latch onto the mother’s breast.

Children with tongue tie and lip tie may exhibit various symptoms during their growth and development. Common indications in babies include challenges with weight gain, tendency to fall asleep while breastfeeding (attributed to the extra effort needed for breastfeeding compared to infants without a tongue tie, leading to quicker fatigue), poor latch quality, reflux, and other signs such as colic, gumming or chewing on nipples, lip blisters, and short sleep episodes.5,6,7

Symptoms associated with tongue tie are not limited to babies; they can also manifest in mothers. Common complaints from breastfeeding mothers of children with tongue tie include pain during breastfeeding, sore nipples, ineffective breast emptying, and an increased risk of breast infections. 5,6,7

In addition to tongue tie, breastfeeding challenges can also stem from lip tie. Lip tie refers to a string or frenulum on the upper lip that attaches to the upper jaw.

. This membranous frenulum has no muscles. When it attaches to the bone or upper gums, it may restrict the movement of the lips during breastfeeding. A downward lip position is crucial in the breastfeeding process to enable the baby’s mouth to generate a vacuum or high negative pressure, facilitating effective sucking and optimal transfer of breast milk. Moreover, downward lips stimulate the oxytocin chain, promoting optimal milk release from the mother’s breasts. Failure of a baby’s lips to lower during breastfeeding can lead to issues such as pain and sore nipples.8

Tongue tie and lip tie can contribute to ineffective latching and poor breast milk transfer, potentially leading to slow weight gain (SWG) or failure to thrive (FTT) in babies. A holistic approach to therapy for infants with tongue tie, lip tie, SWG, or FTT includes a combination of interventions such as frenotomy, supplementation, lactagogue use, and acupuncture. This holistic approach has shown improvements in the baby’s nutritional status and an increase in the mother’s breast milk supply.9

In this case, a simple frenotomy was performed on Baby S, involving a straightforward incision in the lingual part of the frenulum using scissors. Research, such as that conducted by Geddes et al., indicates that infants facing breastfeeding difficulties demonstrate improvement after frenotomy, with enhanced tongue movement. Ultrasound examinations reveal increased breast milk intake, improved breast milk transfer, enhanced latching, and a reduction in nipple pain experienced by both the baby and the mother. Additionally, babies receive supplementation at the breast through a supplementary device to ensure the maintenance of the mother’s breast milk supply and gradual weight gain for the baby.11

Following the frenotomy procedure on the tongue tie and lip tie of Baby S, the baby’s mouth attachment to Mrs. L’s breast significantly improved, allowing for optimal breastfeeding. Effective breastfeeding is characterized by the baby’s mouth being wide open, the lips folded out, with most of the areola, especially the lower part, entering the baby’s mouth. The baby’s chin should adhere to the mother’s breast, the baby’s cheeks appearing rounded, no audible smacking sounds, and the mother should not experience pain during breastfeeding.3

Baby S was supplemented using an NGT syringe while continuing to suckle at the mother’s breast, aiming to boost milk supply and facilitate a more optimal attachment to the baby. On the second day of treatment, Baby S demonstrated improved breastfeeding at the mother’s breast without the need for supplements. This was accompanied by an increasing amount of breast milk, leading to the cessation of supplements.10

By the end of the treatment, the baby could breastfeed directly without the need for supplementary equipment. The successful implementation of frenotomy further supported the direct breastfeeding process with a good attachment. The Praborini Treatment Method, designed for initiating direct breastfeeding in biological babies with nipple confusion, was partially declared successful within two days of treatment. This success was evidenced by the baby’s optimal attachment without the use of supplements.

This provides evidence that the research conducted by Praborini et al. on the Praborini treatment method for babies with nipple confusion can be effectively applied. Praborini et al.’s 2016 research was based on 58 cases of nipple confusion, where 96.6% experienced total nipple confusion, and 79.3% of these cases were attributed to bottle usage due to tongue tie. The duration of treatment varied, with 56.9% of cases resolved within 1 day and 3.4% taking up to 5 days. The success rate of the Praborini Treatment method was remarkably high at 91.4%, representing 53 cases out of the total 58. The success rate was observed to be higher when the baby was younger and the issue was detected earlier.11

CONCLUSION

The presence of Ankyloglossia in babies makes it difficult to get optimal breast milk from the mother, so a frenotomy is needed to improve the breastfeeding process. Additionally, supplementation is essential by continuing direct breastfeeding at the mother’s breast. This dual approach ensures that the baby receives both breast milk and supplements, promoting robust growth and sustaining adequate milk supply.

Self-confidence, robust motivation from the mother, and support from the family, particularly the husband, are pivotal factors for the success of the relactation program and lactation induction. These elements contribute to building trust that the mother can provide the best for the baby. Consistent breastfeeding, along with regular expression of breast milk while at work to facilitate optimal breast emptying, serves as a key strategy for successfully stimulating breast milk production in both relactation and lactation induction.

Bibliography :

  1. Jeanne-Roos Tikaolu. (2013). Indonesian Breastfeeding Book. Retrieved 05 November 2022 fromhttps://www.idai.or.id/article/klinik/asi/relaktasi-dan-induk-laktasi.
  2. International Lactation Consultant Association. 2013. Core Curriculum for Lactation Consultants 3rd Edition. Jones & Bartlett Learning. p289. in Febriyanti, D. 2017. Article: Induction of Lactation in Adopted Babies from https://www.praborinilactationteam.com
  3. Shafay, T et al. 2017. Eping & Autism. DOI:10.3390/nu14010045
  4. Ghozy, S et al. 2020. Association of breastfeeding status with risk of autism spectrum disorder: A systematic review, dose-response analysis, and meta-analysis. DOI:10.1016/j.ajp.2019.101916
  5. Geddes DT, et al. Frenulotomy for Breastfeeding Infants with Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Images by Ultrasound. 2008 July; American Academy of Pediatrics, vol 122: 188-194.
  6. https://www.drghaheri.com/blog/2014/2/20/a-babys-weight-gain-is-not-the-only-marker-of-successful-breastfeeding.
  7. 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.
  8. Cole M. Tongue and Lip Tie: A Comprehensive Approach to Assessment and Care. Powerpoint presentations. 2017.
  9. Forlenza, et al, Ankyloglossia, Exclusive Breastfeeding and Failure to Thrive, 2010, downloaded from:https://pubmed.ncbi.nlm.nih.gov/20498175/
  10. Suradi R, 2013. Correct Breastfeeding and Breastfeeding Position and Attachment.https://www.idai.or.id/article/klinik/asi/position-dan-perlekat-menyusui-dan-menyusu-yang-true
  11. Praborini, A. et al. 2016. Hospitalization for Nipple Confusion- A Method to Restore Healthy Breastfeeding. DOI: 10.1891/2158-0782.7.2.69

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