Frenotomy in Ankyloglossia and Bed-side Phototherapy in Hyperbilirubinemia Baby

Written by : dr. Nike Dewi Anggraini, Sp.A. Pediatrician in Bekasi

Baby YA, female, is the firstborn child of Mrs. I and Mr. G. The baby’s father is a private employee, while the baby’s mother is a housewife. The baby was born in a private hospital in Depok through a caesarean section by an obstetrician. Baby YA is a term baby, with gestational age 38 weeks, birth weight of 3,100 grams and birth length of 48 cm. When the baby was born, she immediately cried and moved actively. The early initiation of breastfeeding was not carried out after the baby was born. During the pregnancy process, mother routinely checked her pregnancy to the obstetrician and get supplements and iron supplements.

At the beginning of the birth process, the mother found that the baby had difficulty to suckle directly at the breast. Babies could only suckles for 3-5 minutes and then stop. When the baby suckled, sometimes the clicking sounds was heard. Mother’s breasts were not sore or got blister. On the second day, the mother’s breasts began to swell so the mother expressed the breastmilk. The mother gave expressed breastmilk using spoon and syringe because the baby was still having difficulty to breastfeed.

On May 9, 2023, when the baby was 4 days old, the mother had the baby checked at the IBCLC lactation consultant pediatrician at RSPD. The parents had expectation that they could breastfed up to 2 years so baby YA would get optimum growth and development. The parents also understood that breast milk is the best nutrition for baby. It was found that the weight was decreased to 2,885 grams, around 6.9% of birth weight (53 grams/day). During the physical examination, an anterior tongue tie and grade 4 lip tie were found. The doctor explained to parents to do a frenotomy for baby YA so the breastfeeding process would be improved and the baby’s weight could increase optimally. After signing the informed consent for the procedure, the doctor performed tongue tie frenotomy and the baby fed directly to the breast. The parents were taught to do tongue exercise 2 times a day and applied gel under the tongue. Mother was asked to breastfed as the baby wants (on demand) and used supplementation with NGT + syringe if needed. The mother was taught to do skin to skin with baby YA so that the baby could be breastfed faster and properly. The baby would also got home-visit by a lactation nurse.

On May 11th, 2023, the baby was 6 days old, the weight was 2850 grams, decreased by 35 grams from previous examination (17.5 grams/day). According to the mother, the baby has started to direct breastfeed even though sometimes still fussy. The mother was no longer expressed breastmilk routinely or gave milk with syringe. The baby had a lip tie frenotomy. Tongue and lip exercise was told to be done 3 times a day. The baby looked jaundiced all over the body, Kramer 5. The bilirubin test was carried out with a result of 29.9 mg/dl. The baby was decided for double blue light therapy co-hospitalization with the mother so the breastfeeding process could still be carried out.

BANNER 728 x 90

On the first day hospitalization, the baby could breastfeed smoothly and the mother was more confident. The mother was comfortable with cross cradle position on the left breast and  football position on the right breast. The baby was planned to be checked the bilirubin 2 times per day.

On the second day of hospitalization, the baby was breastfeeding smoothly and did not refuse. The mother was more comfortable to breastfed without NGT supplementation or syringe. The baby’s weight was 2,920 grams (increased by 70 grams). The results of bilirubin were 17.2 mg/dl in the morning and 16.0 mg/dl in the evening. Jaundice in the skin began to disappear (Kramer 3-4). The blood type was B Rhesus+ (same with mother).

On the third day of hospitalization, the baby was able to breastfeed better and the mother could breastfeed in a sleep position. The baby’s weight was 2850 grams (decreased by 70 grams). The jaundice has been much reduced (Kramer 1-2). The result of bilirubin was 8.6 mg / dl. The baby was allowed to be discharged.

The baby came to outpatient clinic 2 days after hospitalization and able to gain weight as targeted, around 28 grams/day. The baby was getting better at suckling with good position and attachment. The parents were told to stop the tongue and lip exercise. The baby continued to show good weight gain at 2 month old with a weight 5430 grams (increased by 51 grams/day) and at 2 month and 14 day old with a weight 5855 grams (increased by 35.4 grams/day).

Table 1. Weight Growth and Nutritional Status By. YA

NoDateAgeWeightWeight ChangeNutritional StatusTreatment
1.5/5/23Born3100 grams-1 SD 
2.5/9/234 days old2885 gramsâ 215 grams-1SDFrenotomy tongue tie, tongue and lip exercise 5 times/day, skin to skin
3.5/11/236 days old2850 gramsâ 35 grams-2 SDFrenotomy lip tie, bluelight therapy,tongue and lip exercise
4.5/14/239 days old2850 grams-2SDFinished bluelight therapy
5.5/16/2311 days old2990 gramsá 28 grams/day-2SDtongue and lip exercise 3 times/day
6.5/30/2325 days old3540 gramsá 39,2 grams/dayMedianStop tongue and lip exercise
7.7/6/232 months old5430 gramsá 51 grams/day+1 SDBreastfeeding on demand
8.7/18/232 months 14 days5855 gramsá 35,4 grams/day+1 SDBreastfeeding on demand  
Figure 1. Graph of Weight for Age By. YA
Figure 2. Bedside light therapy By. YA with mother

DISCUSSION

Breastfeeding is a process that requires support from various aspects. Mrs. I and Mr. G understand and aware the importance of giving breast milk to their baby. When their baby couldn’t breastfeed well, they immediately seek help by going directly to a pediatrician who is a pro-breastfeeding. The baby’s weight decreased quite excessively at the beginning of birth due to ineffective breastfeeding.

During the breastfeeding process, proper positioning and latching are needed so that the baby can breastfeed well. The process for a baby to express breast milk from the breast is quite complex. When sucking, the baby’s mouth forms like a negative pressure vacuum that enable the baby to suck and empty the breast milk. This condition can be met by lips that fold outward, tongue that can stick out past the lower gums, and the baby’s cheeks that are convex when breastfeeding.1

Baby with tongue tie and lip tie was not able to empty the breast optimally and had poor latching while breastfeeding. This is what happened in this case study. By. YA is unable to breastfeed optimally and thus the weight dropped quite excessively.

Ankyloglossia or what is often known as tongue tie is a short, tight or thick frenulum (string) of the tongue that interfere tongue movement. This is a congenital birth defect that can cause breastfeeding difficulty and speech articulation disorders. Along with the increased and widespread campaign of exclusive breastfeeding up to 6 months of age, tongue tie and its treatment are increasingly receiving special attention; although, there are still many pros and cons.2

In addition to tongue tie, there is also a condition called lip tie which can disrupt the breastfeeding process. In lip tie, there is a lip frenulum that attaches to the upper jaw so that lip movement is limited when breastfeeding. The position of the lips is necessary so that the baby’s mouth can form a vacuum or negative pressure so that the process of expressing breast milk is optimal.1

To overcome the problem of tongue tie and lip tie in this patient, frenotomy was performed. Frenotomy is the process of incision or cutting of the thin tissue (cord) connecting the tongue to the floor of the mouth or the upper gums to the lip which can interfere the breastfeeding process. After a frenotomy, baby YA was able to breastfeed better.

The patient also had high bilirubin level so the blue light therapy was carried out to reduce bilirubin level. Blue light therapy is carried out together with the mother (bedside phototherapy) so that the baby can still breastfeed directly while the light therapy is being carried out. This is considered more effective because the baby will feel more comfortable near the mother and can make a better breastfeeding process. When breastfeeding, the baby can be held by the mother and have direct breastfeeding while the blue light is directed to the baby’s body so that the blue light therapy can still be done simultaneously.

Blue light therapy with the mother was often done, especially in developing countries or areas where health facilities are limited. This method has several benefits, including reducing costs, reducing the possibility of infection, maintaining mother-baby bonding and direct breastfeeding, as well as giving parents peace of mind because they can be close to their baby.3,4 Of course, this treatment conducted with evaluation of doctor and the baby is assessed in stable clinical condition.

CONCLUSSION

The excessive weight lose at the beginning of baby life is caused by inability to breastfeed effectively. This is because tongue tie and lip tie affect the baby’s latching when breastfeeding. The baby’s father and mother are very cooperative and fully supportive with the success of direct breastfeeding. After the frenotomy was performed, it could be immediately observed that the latching was improved. The baby’s weight gain is increasingly getting better along the routine visit after hospitalization. The baby also had hyperbilirubinemia and underwent blue light therapy with the mother. The baby was not separated with the mother, had direct breastfeeding, and blue light therapy can still be done effectively. This can also give the mother peace of mind because she can be with her baby and makes the mother more motivated to breastfeed her baby.

REFERENCES

  1. Praborini A, Wulandari RA. Anti Stres Menyusui. Kawan Pustaka. Jakarta. 2019.
  2. Hill R. Implications of Ankyloglossia on Breastfeeding. MCN Am J Matern Child Nurs. 2019;44:73-9.
  3. Hillel Yafe Medical Center. New: “Light treatment” by the mother’s bedside. 2021 Aug 16 [diakses tanggal 10 Juli 2021]. Tersedia di : https://hy.health.gov.il/eng/?CategoryID=23&ArticleID=832.
  4. Fernandes JIS, Reis AT, Silva CV, Silva AP. Motherly challenges when facing neonatal phototherapy treatment: a descriptive study. Online Braz. J. Nurs.. 2016;15:188-195.

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