The Role of Frenotomy and Supplementation Therapy in Malnutrition Baby with Ankyloglossia

Written by: dr. Michelle, CIMI, CBS

Baby KAS is the first child of Mr. RD (35years old) and Mrs. AIPL (35 years old) born in a private hospital in West Java on the 1^st of March 2023. She was born at 38 weeks gestation by section ceasarea with indication maternal asthma. As a term neonate, she was appropriate for gestational age birth, weighing 2400 grams.

At 5 days old, Baby KAS developed hyperbilirubinemia et causa breastfeeding jaundice characterized with yellow skin color. The increase of bilirubin serum to 18.9 mg/dL had caused Baby KAS to be hospitalized for phototherapy. Baby KAS body weight dropped by 340 grams to 2060 grams,  14.16% decrease from her birth weight. Baby KAS was hospitalized for a total of one day. When Baby KAS was 10 days old, her body weight was recorded at 2300 grams, a decrease of 100 grams (4.16%) from birth.

On 21^th March 2023, at the age of 20 days old Baby KAS with her parents came to the lactation outpatient clinic after receiving advice from Mrs. AILP’s sister. Baby KAS body weight is 2140 grams drop 260 grams from birth weight so it can be concluded Baby KAS develop failure to thrive (FTT) based on the World Health Organization (WHO) body weight Baby KAS shows malnutrition status (Weight/Age <-3SD). The mother complains with nipple soreness, nipple crack, baby nursing for hours, and difficulty with latching. In addition to direct breastfeeding, the mother sometimes gave breastmilk with cup feeder, never used bottle or  formula. Mrs. AIPL want to breastfeed her child for two (2) years according to recommendation from WHO and religion views.

Upon physical examination anterior tongue tie and lip tie grade 4 (ankyloglossia) was found. Mrs. AIPL breast was symmetrical, nipple crack -/+  grade 3 and normal breast milk supply. During breastfeeding observation in cradle hold left breast, baby tended to latch  onto the nipple, baby lips folding in dan mother feels painful.

Mr. RD and Mrs. AIPL agree with doctor recommendation to do a double frenotomy procedure and supplementation. After the procedure, Mrs. AIPL immediately breastfeed the baby and doesn’t fell pain while breastfeed. When breastfeeding lips appear to folded out, sucking continuously and latch deeper. The mother was taught tongue exercise and lip exercise to be done at home 5 times a day and apply aloe vera gel 3 times a day on the wound so the tongue tie would not fuse together. Mrs. AIPL was taught how to install and use Supplemental Nursing System (SNS). The SNS was filled with partially hydrolyze protein with dosage 6x50cc daily and the mother was advised to still breastfed without SNS as baby desired. Mrs. AIPL got lactogogue 2 times daily and nipple cream for nipple crack. It was recommended to do skin to skin between mother and baby.

One week later, on 28^th March 2023, baby age 27 days old with body weight 2395 grams increase 255 grams (36.4 grams/day) from last visit. Nutrition status was categorized as malnutrition (weight/age <-3 SD). Baby came to lactation consultant pediatrician and was advised to increase SNS to 6×50-60cc a day, and continued to breastfeed as the baby wanted, the baby given  and do BCG immunization. Post frenotomy wound was good, lip and tongue exercise frequency reduced to three (3) times daily and the aloe vera gel still needs to be applied three (3) times daily.

The next visit was on 6^th April 2023, the baby was 1 month and 6 days old. Body weight increased by 18.3 grams daily which in total 165 grams increase from the last visit. Nutritional status was still in malnutrition category (weight/age <-3SD). Baby got SNS 6x60cc daily and roborantia .

The next control was on 18^th April 2023, the baby was 1 month and 18 days old. The body weight increased by 380 grams (31.6 grams daily). Nutritional status was still in malnutrition category (weight/age <-3SD). Baby should continue SNS 6x60cc daily and roborantia. Tongue and lip exercise were stopped, post frenotomy wound was good. Pediatrician advised mother to read the book “Anti Stress Menyusui”. The mother was provided with a leave extension permit to be given to the school where she work.

Mr. RD and Mrs. AIPL come to pediatrician with baby KAS on 4^th May 2023 when the baby was 2 month and 4 days old. The body weight increased  by 280 grams (17.5 grams daily) from the last visit. Nutritional status was still in malnutrition category (weight/age <-3SD). Baby KAS continued to use SNS 6x60cc daily, roborantia and paracetamol drops 4x10mg. BCG, Hib, Hepatitis B and Poli Oral immunization was also given in this visit.

On 19^th May 2023, Mr. RD and Mrs. AIPL came to pediatrician. Baby KAS body weight was measured 3755 grams, an increase of 535 grams (35.6 grams daily). The nutritional status improved from malnutrition to undernourished (weight/age <-2SD).  SNS was still continued 6x60cc daily and roborantia . Permission to extend leave was approved by the school until 14^th July 2023.

The 7^th control was on 2^nd June 2023 when the baby age was 3 month and 3 days old. The  body weight increased by 430 grams (30.7 grams daily). The nutritional status was still categorized as undernourished (weight/age <-2SD).  Baby KAS continued using SNS 6x60cc daily, roborantia, iron supplement and vitamin D3 containing fluoride. The next control was scheduled on 20^th June 2023.

They came for control on 14^th July 2023 when the baby was 4 month and 15 days old. The body weight was measured 5100 grams which increased by 21.8 grams daily. The nutritional status was still undernourished (weight/age <-2SD).  SNS was reduced to 3x30cc, and the baby was recommended to start early solid food. Roborantia, iron supplement and vitamin D3 containing fluoride were continued. They were referred to lactation clinic to learn about early start of baby solid food. The mother was educated about WHOs (World Health Organization) recommendation to start early solid food for baby at age 4 month if there is no adequate weight gain with only breastfeeding,  how to prepare solid food, four star food, baby portion, eat frequency, composition, texture and example of baby solid food. They were explained about high calory food like coconut milk, oil and butter. Mother advised to read “Antiribet MPASI”. 

The next visit was scheduled on 28^th July 2023. The body weight increased by 290 grams on this visit (20.7 grams daily). The nutritional status was improved to normoweight category (weight/age -2SD). Baby KAS got solid food as recommended by WHO with increase of portion and texture gradually. The SNS treatment was stop, roborantia, iron supplement and vitamin D3 containing fluoride.

Date	Age	Body weight	Weight change	Nutritional status	Action
1st  March 2023	1 day	2400 grams		Normo birth weight
21th  March 2023	20 days	2140 grams	260 grams (10,8% from birth weight)	FTT (failure to thrive), <-3SD (Malnutrition)	Double frenotomyEducation tongue and lip exercise 5 times daily Aloe vera gel 3 times daily SNS 6x50cc daily Mother: Lactogogue 2×2, SPS cream after breasfeeding
28th  March 2023	27 days	2395 grams	­255 grams, 36.4 grams daily	<-3SD (malnutrition)	Tongue and lip exercise 3 times daily Aloe vera gel 3 times dailySNS 6×50-60cc dailyroborantia Immunization  BCG
6th  April 2023	1 month 6 days	2560 grams	­165 grams, 18.3 grams daily	<-3SD (Malnutrition)	Tongue and lip exercise 3 times dailySNS 6x60cc dailyroborantia
18th  April 2023	1 month 18 days	2940 grams	­380 grams, 31.6 grams daily	<-3SD (malnutrition)	Stop tongue and lip exerciseSNS 6x60cc dailyroborantia Letter for extended leave for motherBook “Anti Stress Menyusui”
4th  May 2023	2 month 4 days	3220 grams	­280 grams, 17.5 grams daily	<-3SD (malnutrition)	SNS 6x60cc dailyroborantia Paracetamol drops 4x10mgImmunization BCG, Hib, Hep B, polio oral
19th  May 2023	2 month 19 days	3755 grams	­535 grams, 35.6 grams daily	<-2SD (undernourished)	SNS 6x60cc dailyroborantia Extended leave for mother approved until 14/7/23
2nd  June 2023	3 Month 3 days	4185 grams	­430 grams, 30.7 grams daily	<-2SD (undernourished)	SNS 6x60cc dailyroborantia Iron SupplementVitamin D3 containing  fluoride
14th  July 2023	4 month 15 days	5100 grams	­915 grams, 21.7 grams daily	<-2SD (undernourished)	SNS 6x30cc dailyroborantia Iron SupplementVitamin D3 containing  fluorideEarly solid foodEducation baby solid food WHOEducation solid food high calory
28th  July 2023	4 month 29 days	5390 grams	­290 grams, 20.7 grams daily	-2SD (normo weight category)	Stop SNSroborantia Iron SupplementVitamin D3 containing  fluoride

Discussion

            A successful breastfeeding journey does not only require teamwork between a mother and her baby but also the support from the spouse, family, and a well-trained medical team. The mother needs to have a knowledge on good baby positioning and placement even before the baby was born. Proper support and feedback throughout the breastfeeding journey will increase the success rate of breastfeeding. ¹

            In the case of baby KAS, there are problems that can be seen though the breastfeeding journey. The problem can be observed from 1) pain during breastfeeding, 2) long duration of breast feeding, 3) difficulty of latching and even cracked nipples. However, through a doctor’s examination, it was later found out that baby KAS had tongue tie anterior and li tie grade IV (ankyloglossia) with a Carole Dobrich score of 9/10 and 9/10 score. This indicate that a tongue tie and lip tie frenotomy procedure was required.

            The position and placement of a baby greatly influence the success rate of a breastfeeding journey. A good baby placement is indicated by the baby’s chin touching the mother’s breast with most of the areola inside of the baby’s mouth. The baby’s lips must also be folded outward and their mouth opening wide at a minimal of 130-160 degrees. When the baby is sucking, the mouth will act as a negative vacuum, emptying the milk within the breast. A vacuum like suction can be created during feeding when the baby’s lips is folded outward with their cheeks convex and their tongue able to pass through the lower gum. ² An anatomical factor like tongue tie and lip tie can inhibit the baby’s mouth to make a proper latching. ³

            Ankyloglossia or also known as tongue tie is a thin membrane of embryological tissue remnant located in the midline between the lower surface of the tongue and the floor of the mouth. This restricts the movement of the tongue and affect its function. Although incidence of tongue tie is reported at 3-10% of the population, there are still few physicians that examinate and report the cases. The presence of tongue tie is closely related to a success of breastfeeding process.⁴

            The presence of tongue tie prevents the baby’s tongue from passing through the lower gum. This causes the baby unable to create negative vacuum and therefore leads to a less optimal suction to empty the breast. Due to a less than optimal emptying, the mother can feel pain when breastfeeding, have crack nipples, breast infection (mastitis), and lower production of breastmilk. ²

            Lip tie is a thin membrane on the upper lip that attaches itself to the upper gum. The presence of lip tie makes the baby’s lip to fold inward when breastfeeding, causing pain to the mother’s nipple. After feeding, it can be seen that there are two tone of lips color, where the inside lip is paler than the outside.²

            Frenotomy is a procedure that can be done to release frenulum lingualis and labialis so that the tongue and lip can move freely. ⁴ Frenotomy procedure is performed using the Pare method, where the tongue tie is slightly cut and then pushed using the index finger until it touches the tongue muscle. This procedure can be done in an examination room. After the procedure, the baby will immediately do a direct breastfeeding to stop the bleeding. ^2,4 Tongue and lip exercise is very important to prevent tongue tie and lip tie to fussed back together.²

            Late frenotomy will impact the baby’s nutritional status due to suboptimal milk transfer from the mother to the baby, resulting in growth restriction. Difficulty to latch leads to delayed or slow weight gain and failure to thrive. Slow weight gain is defined as an infant aged less than 2 weeks who lose weight 10% or more of the birth weight or  who aged 2 weeks to 3 months with weight gain is less than 20g/day. Failure to thrive is defined as an infant with a body weight under the 3^rd percentile or Z-score <-2 and when an infant continues to lose weight after 10 days and does not return to their birth weight by the age of 3 weeks old or remains below the 10^th percentile on the end of first month. ⁵

In the case of baby KAS, he was born at term, appropriate for gestational age. At 20 days old, her body weight has yet to return to her birth weight and have a nutritional status of malnutrition (Z-score <-3SD).  Baby KAS was diagnosed with failure to thrive (FTT) with body weight of 2140 grams and birth weight of 2400 grams. The minimum weight based on WHO growth chart for normo-weight is 2933 grams and minimum weight for undernourished is 2466 grams. Treatment for improving baby nutrition is done through holistic approach using Supplemental Nursing System (SNS) with titrated doses and continuing to breastfeed as much as the baby want.

SNS (Supplemental Nursing System) is a practice of giving the breastfed infant additional nutrition other than that obtained directly from breast. SNS may include expressed breast milk, breast milk donor, or breast milk substitutes formula. ⁵

When baby KAS was 4 months old, she was given early solid food to help improve her nutritional status. Undernutrition during first year of life may have long term effects on brain development and impair intellectual development and therefore must be addressed accordingly. ⁵ Early start of solid food according to WHO recommendation can start at 4-6 months of age if the baby weight gain is inadequate with breastfeeding alone or the baby is frequently breastfed but still shows hunger shortly afterwards. In this case, Baby KAS was advised to start early complimentary feeding at 4 months of age with the aim of reducing the supplementation and to increase body weight. 

Complementary food for baby KAS was given according to 4 star standard (animal protein, vegetable protein, fat, carbohydrates, and vegetable) and WHO’s guidance principles (1) Exclusive breastfeeding from birth to six months of age, and introduce complementary foods at six months of age (180 days) while continuing to breastfeed. (2) Continue frequent, on-demand breastfeeding until two years of age (3) Active-responsive feeding (4) Safe preparation and storage of complementary foods (5) Amount of complementary food needed (6) Food consistency (7) Meal frequency and energy density (8) Nutrient content of complementary foods (9) Use of vitamin-mineral supplement of fortified products for infant and mother (10) Feeding during and after illness. ⁶

Conclusion

            In this case, failure to thrive happened because of poor latching due to the presence of tongue tie and lip tie. Tongue tie and lip tie are one of the factors affecting babies to directly suckle from their mother’s breast and the mother’s capabilities to be able to directly breastfeed their babies due to pain.

            Suboptimal suction cause inadequate consumption of breastmilk, causing failure to thrive and malnutrition nutritional status in infant. Milk production decrease due to suboptimal breast emptying. Frenotomy procedure is performed to improve attachment to improve milk transfer and increase weight gain.

            Supplementation therapy is given so that the baby gets adequate intake and increase milk production due the baby continues to suckle at the mother’s breast. Early start of complementary food at 4 month of age is to stop supplementation and achieve ideal weight gain with good nutritional status. It was proven after getting complementary food for 2 weeks and reducing supplementary dose, nutritional status Baby KAS is within good nutrition (weight/ age -2SD) status. Support from spouse and family as well as place of work are  the factors that determine the success in this case.

Literature

1. Dieterich MC, Felice JP, O’Sullivan E, Rasmussen KM. Breastfeeding and Health Outcames for the Mother-Infant Dyad. Pediatr Clin North Am. 2013 Feb; 60 (1):31-48. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508512/
2. Praborini A, Wulandari RA. Anti Stres Menyusui. Jakarta: Kawan Pusaka, 2018.
3. Praborini A, Purnamasari H, Munandar A, Wulandari RA. Early Frenotomy Improves Breastfeeding Outcomes for Tongue-Tied Infant. United States Lactation Consultant 2015; 6(1): 9-15.
4. Knox I. Tongue Tie and Frenotomy in Breastfeeding Newborn. Neoreviews. 2010; 11(9), e513-e519. http://www.lunalactation.com/KnoxTT.pdf
5. 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.
6. Direktorat Gizi Masyarakat Ditjen Kesehatan Masyarakat Kementerian Kesehatan Republik Indonesia. Manajemen Makanan Pendamping ASI. 2016