A Case of Frenotomy Procedure on an 8-Day-Old Baby with Ankyloglossia

Written by Dr. Krisna Dewi, Jakarta

SKA Baby is a female baby, the first child of the couple NY D and TN I. Ny D works as a civil servant and TN I is a general practitioner. The baby was born at a private hospital in the BSD area on September 21, 2023, through a cito cesarean section due to indications of preeclampsia, premature rupture of membranes (PROM), and intrauterine growth restriction (IUGR) at 38 weeks of gestation. Baby SKA was born weighing 2365 grams and measuring 48 cm in length. Immediately after birth, the baby cried and experienced skin-to-skin contact for a brief period of 5 minutes. After observing the baby for 6 hours, the mother and the baby were rooming in. The mother had visited a lactation counselor in the BSD area during pregnancy or antenatal care (ANC) for lactation.

A lactation counselor visited the mother three times during the postpartum hospitalization. From the beginning of the breastfeeding process, the mother felt that the latch was still not quite right because her nipples were always sore. The baby underwent examination by a pediatrician and a lactation counselor, who confirmed that the tongue and lip ties were not causing any problems. Consequently, the pediatrician recommended no further treatment. The mother really wanted to breastfeed her baby for 2 years, and her husband supported her. Feeling unable to find a solution to breastfeeding problems, the mother decided to consult a lactation pediatrician at a hospital in Depok based on a friend’s recommendation.

On September 29, 2023, when the baby was 8 days old, the mother met with a lactation pediatrician consultant. The mother complained that her nipples were always sore; her left nipple was shorter; and the baby had difficulty latching. She nursed for a long time, detached frequently, and made clicking noises. The baby weighed 2210 grams when measured. According to the World Health Organization’s (WHO) standard growth curve, the baby’s weight indicates a failure to thrive (FTT) condition, and nutritional status is approaching malnutrition, with a -2 standard deviation (SD) limit of 2613 grams and a -3 SD limit of 2187 grams. Over 8 days, the baby has lost 155 grams, or 19.3 grams per day (6.5%).

Following a brief counseling session on breastfeeding in accordance with religious commandments and WHO recommendations, Ny D’s desire to breastfeed for two years intensified, receiving support from her husband. During the physical examination, we discovered that the baby had a posterior tongue tie and a grade 3 lip tie, struggled with latching, particularly on the left breast, and appeared annoyed, refusing to nurse. We assessed the breast milk production as normal. The left nipple was shorter than the right one.

The doctor explained to the baby’s parents that they should perform a procedure on their baby to optimize breastfeeding and the baby’s weight gain. The doctor suggested performing a frenotomy on the tongue tie only first because the baby sometimes still refused or resented nursing. After obtaining consent, the doctor performed a frenotomy on the tongue tie, and the baby was immediately nursed on the mother’s breast. The mother felt that the baby latched more easily.

Next, the mother was referred to a lactation counselor to learn tongue exercises for the baby three times a day, apply aloe vera gel under the baby’s tongue, have skin-to-skin contact, and supplement with a nasogastric tube (NGT) and syringe. The counselor advised the mother to return for a follow-up on October 3, 2023.

At the first check-up on October 3, 2023, when the baby was 12 days old, the mother had already been using a Supplemental Nursing System (SNS) with expressed breast milk. The baby’s weight was measured, and the baby now weighs 2250 grams, showing an increase of 40 grams in 4 days with a daily weight gain of 10 grams. The baby’s nutritional status remains categorized as malnutrition, with a threshold below -3 standard deviations (-3SD) set at 2280 grams.

The doctor has suggested considering a procedure for the baby’s lip tie. After obtaining consent, the baby underwent a frenotomy for the lip tie, and the baby was immediately breastfed. The mother was referred to a lactation counselor to learn lip exercises. The doctor recommended upper lip exercises, continued breastfeeding on demand, supplementation with the Supplemental Nursing System (SNS) 5 times a day, with 2 sessions using expressed breast milk (ASIP) and 3 sessions using tasteless formula milk, roborantia, and a follow-up on October 10, 2023.

At the second check-up on October 10, 2023, when the baby was 19 days old, the baby’s weight was 2500 grams, showing an increase of 250 grams in 7 days and a daily weight gain of 35.7 grams. The weight gain has improved. The mother feels more comfortable breastfeeding, and there is no nipple pain. The nutritional status has improved to malnutrition, with a threshold below -2 standard deviations (-2 SD). The doctor suggested continuing breastfeeding on demand, continuing SNS 5 times with 30 cc, with 2 sessions using ASIP and 3 sessions using formula milk, roborantia, and a follow-up on October 24, 2023.

At the third check-up on October 24, 2023, when the baby was 1 month and 3 days old, the baby’s weight was 2955 grams, showing an increase of 455 grams in 14 days with a daily weight gain of 32.5 grams. The baby’s nutritional status is still malnourished, with a threshold below -2 SD. The doctor recommended continuing SNS five times with 30 cc, with two sessions using ASIP and three sessions using formula milk. The mother complained that the baby often had colic with formula milk, and the doctor suggested switching formula milk with DBM (donor breast milk), then a follow-up on November 7, 2023.

At the fourth check-up on November 7, 2023, when the baby was 1 month and 3 days old, the baby’s weight was 3420 grams, showing an increase of 465 grams in 14 days with a daily weight gain of 32.5 grams. The baby’s nutritional status is still malnourished, with a threshold below -2 SD. The doctor recommended continuing breastfeeding on demand, continuing SNS five times with 30 cc, three sessions using ASIP, and two sessions using formula milk. Roborantia is continuing, with a follow-up on November 21, 2023.

At the fifth check-up on November 21, 2023, when the baby was 2 months and 1 day old, the baby’s weight was 3825 grams, showing an increase of 405 grams in 14 days with a daily weight gain of 28.9 grams. The baby’s nutritional status is still malnourished, with a threshold below -2 SD. The doctor recommended continuing breastfeeding on demand, continuing SNS five times with 30 cc, three sessions using ASIP, and two sessions using formula milk. Roborantia is continuing, with a follow-up on December 5, 2023.

At the sixth check-up on December 14, 2023, when the baby was 2 months and 24 days old, the baby’s weight was 4410 grams, showing an increase of 585 grams in 23 days, with a daily weight gain of 25.4 grams. The baby’s nutritional status is now good, exceeding the threshold of -2 SD. The doctor recommended continuing breastfeeding on demand, continuing SNS with ASIP 3 times 30 cc per day, no longer using formula milk, and stopping roborantia. The next follow-up is on January 5, 2024.

At the seventh check-up on January 9, 2024, when the baby was 3 months and 20 days old, the baby’s weight was 5260 grams, showing an increase of 850 grams in 26 days, with a daily weight gain of 32.7 grams. The baby’s nutritional status is good, surpassing the threshold of -2 SD. The doctor recommended stopping SNS and only doing direct breastfeeding (DBF) and counseling for the mother’s preparation to return to work with a lactation counselor.

Date	Age	Body Weight	Weight Change	Nutritional Status	Action
September 29, 2023	8 days	birth weight: 2365 gr; body weight: 2210 gr	↘ 155 grams in 8 days   Decrease (19.3 grams per day)	<-2SD Malnutrition	Frenotomy for tongue tie Tongue exercise education (3x) and gel SNS (5x30cc)
October 3, 2023	12 days	body weight: 2250 g	↖  40 grams in 4 days (10 grams per day)	<-3SD Poor nutritional status	Lip exercise 3x a day and gel 3x SNS  5×30 Roborantia
October 10, 2013	19 days	body weight: 2500 g	↖ 250 grams in 7 days (35.7 grams per day)	The nutritional status has improved from poor nutrition to undernutrition (<-2SD)	SNS 5x 30cc Roborantia
October 24, 2023	1 month, 3 days	body weight: 2955 gr	↖  455 grams in 14 days (32.5 grams per day)	<-2 SD Malnutrition	SNS 5x 30cc (Expressed breast milk + formula) Recommended donor breast milk due to colic complaints Roborantia
November 7, 2023	1 month, 17 days	body weight: 3420 gr	↖ 465 grams in 14 days (33.2 grams per day)	<-2 SD Malnutrition	SNS (5x 30cc)   Roborantia
November 21, 2023	2 months 1 days	body weight 3825 gr	↖ 405 grams in 14 days (28.9 grams per day)	<-2 SD Malnutrition	SNS 5x 30cc   Roborantia
December 14, 2023	2 months 24 days	body weight 4410gr	↖ 585 grams in 21 days (25.4 grams per day)	-2SD Good nutritional status	Continue with SNS 3x30cc   Stop Roborantia
January 9, 2024	3 months 20 days	body weight 5260 gr	↖ 850 grams in 26 days (32.7 grams per day)	-2SD Good nutritional status	Stop SNS DBF only Preparation for mother returning to work

Discussion

Successful breastfeeding depends on a correct latch. Newborns should rest their chin on the breast below the nipple, with their lips everted and at least flanged outward. ¹ Anatomical factors might prevent a baby’s mouth from allowing optimal milk transfer; for example, an overly turned-out upper lip is a sign of a shallow latch and can favor excessive use of the lips to press milk out of the breast, and a tight superior labial frenulum can make it more difficult to maintain latching. ² Tongue tie is a well-recognized cause of breastfeeding difficulties that can prevent the baby from latching well, cause nipple pain and trauma, compromise feeding, inhibit weight gain, and, in some cases, reduce maternal milk supply. ³

If both tongue tie and lip tie are present and the baby has continuous difficulty latching, the best course of action is frenotomy (incision or clipping of the tongue tie and lip tie). The goal is to improve the breastfeeding process between the mother and the baby. ⁴

A simple surgical procedure known as frenotomy divides the frenulum either in the midline or at the underside of the tongue using sharp, blunt-ended scissors. During the procedure, the infant is swaddled in a blanket; generally, no anesthesia is administered and there is reportedly little bleeding or few complications following the procedure. ⁵ Prior to day 8, early frenotomy appears to have a greater impact on weight gain and lactation performance, resulting in more successful breastfeeding outcomes. ⁶

Babies undergoing early frenotomy not only nursed at the breast effectively and efficiently, improving both milk transfer and milk production, but also had sufficient breast milk volume from intrinsic stage II milk production to significantly increase weight in these babies. However, late frenotomy (after day 8), while improving the baby’s latch, only resulted in a small increase in weight. This is likely to be because the late release of tongue tie creates only low demand responses, leading to low milk transfer and insufficient milk production. Mothers experienced low milk supply, resulting in only small weight gains in these babies who were only breastfed.⁶

Conclusion

Breast milk is the best for babies. Human breast milk contains the most appropriate composition for humans, who grow slowly but have the most advanced brains among other mammalian species. ⁴ Breastfeeding is the best way to feed infants, but optimal milk transfer and weight gain depend on good latching. ⁷

Baby SKA has a posterior tongue tie and a grade 3 lip tie. The presence of tongue tie and lip tie in Baby SKA can disrupt the breastfeeding process, resulting in symptoms for the mother, such as nipple soreness, and for the baby, such as suboptimal weight gain, prolonged feeding, and difficulty latching, leading to breastfeeding frustration. In this case, the mother’s breast milk production is abundant, but the baby’s weight gain is still very poor, even failing to return to birth weight. This indicates poor breast milk transfer due to tongue tie and lip tie. At 8 days of age, Baby SKA underwent a frenotomy during the mother’s lactogenesis phase 2.

Milk synthesis occurs during lactogenesis stage II, even in the absence of infant suckling or milk expression. ⁶ With frenotomy performed during lactogenesis phase 2 (≤ day 8), the increase in the baby’s weight gain is significantly seen, the mother’s breast milk production is maintained, the baby’s latch improves, and optimal breast milk transfer is achieved. Additionally, the quality of the breastfeeding process for the mother improves, reducing complaints such as nipple soreness, prolonged feeding, and the baby’s refusal to feed, to the point where these complaints no longer exist. Now, the mother only breastfeeds the baby directly, without using SNS or breast milk booster medication. The mother feels a significant difference in the breastfeeding process before and after frenotomy. After frenotomy, the mother enjoys the breastfeeding process and is happy with her baby’s development.

References

1. Kotlow, L. (2011). Infant reflux and aerophagia associated with the maxillary lip tie (Maxillary Frenum). Clinicacal lactation,2-4,25-29.
2. Genna, C. W. (2013). Supporting sucking skills (2^nd ed.), MA: Jones and Bartlett.
3. Garbin, C. P., Sakalidis, V. S., Chadwick, L. M., Whan, E., Hartmann, P. E., & Geddes, D. T. (2013) Evidence of improved milk intake after frenotomy: A case report. Pediatrics, 132(5), e1413–e1417. http://dx.doi.org/10.1542/peds.2012-2651.
4. Praborini A., Wulandari RA. 2019. Anti-Stres Menyusui. Kawan pustaka.Jakarta.
5. Muldoon K. et al. (2017): Effect of frenotomy on breastfeeding variables in infants with ankyloglossia (tongue-tie): a prospective before and after cohort study. BMC Birth and ChildBirth doi: 1186/s12884-017-1561-8
6. Praborini A, et al. (2015): Early intervention improves the breastfeeding outcome for tongue-tied babies. Clinical Lactation, Vol. 6, Issue 1.