Case Report: Relactation in a Preterm Newborn Baby with Slow Weight Gain, Tongue Tie, Lip Tie, and Partial Nipple Confusion

Written by dr. Inke Prasetyowati
Tangerang, Indonesia


Baby AS, female, was 27 days-old on her first visit to the lactation clinic. She was born on November 3rd, 2023, at a government hospital in East Jakarta. She is the second child and the only living child of Mr. A and Mrs. S. Baby AS was born through a caesarean delivery at 33 weeks of gestational age, following a preterm premature rupture of membranes. After the baby was born, she was not given the early initiation of breastfeeding. Soon after the delivery, she was admitted to the perinatology unit. Her birth weight was 2280 grams, appropriate to her gestational age. Baby AS was never directly breastfed and was initially formula-fed and given expressed breast milk later on, using a bottle teat. Mrs. S did not pump her breasts regularly while her baby was being bottle-fed because of the lack of lactation education at the hospital. After being discharged from the hospital, Mrs. S tried to directly breastfeed baby AS for three consecutive days, but the baby was unable to latch properly. The feeding only lasted for a few minutes because she often fell asleep in between feedings.The feeding also seemed endless because she was still hungry from time to time, and the mother felt her breasts were still full after breastfeeding. After three days, baby AS refused her mother’s breasts and chose bottle teat instead. Mrs. S started to pump her breasts after her baby refused to breastfeed.

Baby AS first visit to the lactation clinic was on November 30th, 2023, as recommended by their acquaintance. Mrs. S, who works as a spiritual teacher, came with her husband, Mr. A, who works as a tax consultant. Her main complaint was the baby refused to direct breastfeed, her prior experience of endless feeding, and the inability of baby AS to latch properly on the breasts. Because of this, Mrs. S had to pump her breasts regularly, but her expressed milk was not sufficient, her baby’s weight gain was slow, and she still had to give baby AS formula milk for preterm babies.

At the age of 27 days, baby AS weighed 2400 grams. The baby’s nutritional status was categorized as severely underweight (<-3 SD) according to her chronological age and underweight (<-2 SD) according to her corrected age, with a weight gain of 4.4 grams per day, indicating a slow weight gain (SWG). On a physical examination by the pediatrician and lactation consultant, it was found that baby AS had a medial tongue tie and a Kotlow class III lip tie. Her tongue movement was restricted; she was unable to maintain suction on the examiner’s finger and on the breasts, and her upper lip folded in during breastfeeding. Mrs. S’s breasts were symmetrical and normal-sized; her nipples are protruded and easily protractile. Her breast milk supply was normal.

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Based on history-taking and a physical examination, the lactation consultant explained that the cause of the baby’s slow weight gain was due to the baby’s poor suction reflex and inability to latch on the breasts. The poor suction reflex was due to the presence of tongue and lip ties as well as frequent bottle feeding. Using the Carole Dobrich Frenotomy Decision Tool for Breastfeeding Dyads, baby AS was scored 9/10, indicating a possible need for lingual frenotomy, and 8/10, indicating a possible need for labial frenotomy.

A simple lingual frenotomy was performed at the clinic on November 30th, 2024. Then parents were encouraged to breastfeed the baby for two years, to stop using bottle teat and to do the relactation program using the Praborini Relactation Method. Baby AS and Mrs. S were admitted for hospitalization at a private hospital in Depok soon after, to do the relactation program. During this relactation program, baby AS was put on her mother’s chest for 24 hours using a baby carrier. Baby AS was given oral sedation (CTM, or chlorpheniramine maleate) three times a day. Lactagogue was prescribed and given to Mrs. S twice daily. The supplemental nursing system (SNS) was used, and formula milk was prescribed at 6x30ml throughout the day. Direct breastfeeding without SNS was advised through the night. Tongue and lip exercise were performed three times daily. Aloe vera gel was applied three times daily to the incision area after every tongue exercise and lip exercise session. Baby massage was done once daily.

During the first 24 hours of the hospital stay, skin-to-skin was performed initially. Baby AS was fussy and cried frequently; oral sedation hadn’t been given, and the parents began to worry that the baby was hungry. A few hours later, oral sedation was given, baby AS appeared calmer, a labial frenotomy was performed by a lactation counselor on duty, and baby AS was nursed on her mother’s left breast immediately, using the SNS. Her latch was deep on the areola, and she sucked continuously, with frequent swallowing sounds. A single lingual frenotomy was performed initially, followed by the labial frenotomy on a different day because the baby had nipple confusion; this was done to prevent nursing strike.

On the second day of the hospital stay, baby AS weighs 2415 grams, with a weight gain of 15 grams per day. During observation by a lactation counselor on duty, Mrs. S and baby AS were co-sleeping; she appeared calm and slept well. On the latter visit, baby AS was nursing on her mother’s right breast using SNS. Oral motor exercise and baby massage were performed later on. Then the baby AS and Mrs. S were discharged and scheduled for a follow-up on December 5th, 2024.

Throughout the relactation process, baby AS gained weight significantly, about 27 to 35 grams per day. By the age of three months old, baby AS weighed 4145 grams. Her nutritional status was categorized as underweight (<-2 SD) according to her chronological age and normal weight (-1 SD and median) according to her corrected age, with a weight gain of 28.6 grams per day. But two weeks later, baby AS was not gaining weight adequately, approximately 8.5 grams per day, despite appropriate breastfeeding. Her nutritional status was categorized as underweight (<-2 SD) according to her chronological age and normal weight (between -2 SD and -1 SD) according to her corrected age. Therefore, baby AS was scheduled to start early complementary feeding at four months old, according to WHO recommendations.

On the next visit to the clinic, at the age of four months and five days, baby AS had already started feeding for five days with a full menu, three times a day, and continued to breastfeed directly using SNS. Baby AS weighed 4630 grams, with a weight gain of 21 grams per day. The baby’s nutritional status was categorized as undernourished (<-2 SD) according to chronological age and normal weight (between -2 SD and -1 SD) according to corrected age. Three weeks later, baby AS returned to the clinic. At the age of 4 months and 26 days, her weight reached 5470 grams, with a weight gain of 40 grams per day. Therefore, the pediatrician planned for baby AS to stop using SNS and only breastfeed on demand, and complementary feeding was continued with frequency, volume, and texture appropriate to age.

On the last visit to the clinic at the age of 6 months and 16 days, baby AS weighed 6780 grams. Her nutritional status was normal weight (-1 SD and median) according to corrected age, with a weight gain of 26.2 grams per day. She was still advised to breastfeed directly on demand, and complementary feeding was continued with frequency, volume, and texture appropriate to age.

Table 1. Baby AS’ growth and nutritional status during relactation process

DateChronological AgeBody Weight (grams)Body Weight Gain Or  Body Weight LossNutritional StatusAssessment & Plans
Nov 3rd 20230 day2280 < -2SD (underweight) according to chronological age 
Nov 30th 202327 days  2400↑ 4.4 gr / day< -3SD (severely underweight) according to chronological age <-2SD underweight) according to corrected ageSlow Weight Gain Partial Nipple ConfusionPost Lingual Frenotomy Plan : Praborini Relactation MethodSkin to Skin 24 hoursSNS (formula) 6 x 30 mlCTM 3 x 0,2 mgAloe vera gel 3x/dayTongue & lip exerciseBaby massage
Dec 5th 20231mo,2d (32 days)2420↑ 4 gr / day< -3SD (severely underweight) according to chronological age <-2SD (underweight) according to corrected agePost Labial FrenotomyRelactation succeed Plan : SNS 5-6 x 60 mlLactagogue 2 x 1Oral motor exerciseBaby massage Next follow up : Dec 15th 2024
Dec 15th 20231mo,12d (42 days)2730↑ 31 gr / day< -3SD (severely underweight) according to chronological age -2SD (normal weight) according to corrected agePlan : SNS 5 x 60 mlLactagogue  2 x 1 Next follow up : Dec 26th 2023
Dec 26th 20231mo,23d (53 days)3110↑ 35 gr / day< -3SD (severely underweight) according to chronological age -1SD (normal weight) according to corrected agePlan : SNS 5 x 60 ml Lactagogue 2 x 1 Next follow up : Jan 11th 2024
Jan 11th 20242mo,9d (69 days)3545↑ 27.1 gr / day< -3SD (severely underweight) according to chronological age median (normal weight) according to corrected agePlan : SNS 5 x 60 mlLactagogue 2 x 1 Next follow up : Feb 1st 2024  
Feb 1st  20243mo (90 days)4145↑ 28.6 gr / day< -2SD (underweight) according to chronological age -1SD & median (normal weight) according to corrected agePlan : SNS 6 x 45 mlCounsel to start early complementary feeding at 4 months old according to WHO recommendations Next follow up : Feb 15th 2024
Feb 15th 20243mo,14d (104 days)4265↑8.5 gr / day< -2SD (underweight) according to chronological age -2SD & -1SD (normal weight) according to corrected agePlan : SNS 5 x 45 mlFe 2 x 2 dropsVit D3 1 x 1 drop Next follow up : Mar 7th 2024
Mar 3rd 20244mo,5d (125 days)4630↑ 21 gr / day< -2SD (underweight) according to chronological age -2SD & -1SD (normal weight) according to corrected ageBaby already ate Plan : SNS 5 x 45 mlFe 2 x 2 dropsVit D3 1 x 1 drop Next follow up : Mar 28th 2024
Mar 28th 20244mo,26d (146 days)5470↑ 40 gr / day< -2SD (underweight) according to chronological age -1SD & median (normal weight) according to corrected agePlan : Stop SNSFe 2 x 2 dropsVit D3 1 x 1 dropContinue direct breastfeeding without SNS Next follow up : April 30th 2024
May 17th 20246 mo,16d (196 days)6780↑ 26.2 gr / day-1SD & median (normal weight) according to corrected agePlan : Continue DBF on demandContinue complementary feedingFe 2 x 2 dropsVit D3 1 x 1 drop Next follow up : June 26th 2024

The effect of ankyloglossia on breastfeeding has been a matter of controversy in the medical literature for 50 years. With the resurgence of breastfeeding, ankyloglossia has once again become an important clinical issue. About 90% of pediatricians and 70% of otolaryngologists believe that ankyloglossia rarely causes feeding difficulties; about 69% of lactation consultants believe that it frequently causes feeding difficulties; and an additional 30% believe it occasionally causes feeding difficulties.[1]

Ankyloglossia in infants is associated with a 25% to 60% incidence of difficulties with breastfeeding, such as failure to thrive, maternal nipple damage, maternal breast pain, poor milk supply, breast engorgement, and refusing the breast.[2] It may also prevent the baby from taking enough breast tissue into its mouth to form a teat and make it difficult to latch on breasts, and the mother may experience painful, bleeding nipples and frequent feeding with poor infant weight gain. The prevalence of persistent pain in these women is up to 80%; about 25% have intractable pain.[3] Studies have shown that, for every day of maternal pain during the initial three weeks of breastfeeding, there is a 10% to 26% risk of cessation of breastfeeding.[4] The ineffective latch caused by ankyloglossia could be one of the primary underlying causes of all of these problems.[2] Ankyloglossia in children can also lead to a range of problems, such as eating difficulties, speech impediments, poor oral hygiene, and dental problems.[3]

The most common treatment for infant ankyloglossia is a simple frenotomy. Frenotomy is accomplished by incising several millimeters into the lingual frenulum. This procedure is brief and usually bloodless and is described in detail in a recent position paper from the American Academy of Pediatrics on the effect of tongue-tie on breastfeeding.[5] Hemostasis, if needed, is achieved by breastfeeding, which also lengthens the tongue and acts as an analgesic and antiseptic.[6]

Relactation is the stimulation process for a woman who has given birth but did not initially breastfeed or has stopped breastfeeding for a few days to a few weeks to lactate.[7] Three important things that are required for relactation are a strong desire by the mother, stimulation of the nipple, and a strong support system.[8] Relactation achieved may be complete or partial. Complete relactation is defined as when an infant is growing well only through breastfeeding. Partial relactation is defined when an infant still requires artificial feed for adequate growth (in lactation failure) or more than 50% of artificial milk is replaced by breastfeeding (in low milk supply). If there was no milk secretion even after two weeks of continuous effort, then, this was regarded as relactation failure.[9]

Lactation failure is defined as the total absence of milk flow or secretion of only a few drops of milk following regular suckling for a period of at least 7 days. Low milk supply was defined when the mother complained of inadequate milk flow and an infant required artificial milk feeding.[10]

The younger the infant at the time of intervention, the better the relactation achievement will be. It was found that if the duration of artificial feeding was less, the possibility of complete relactation was greater.[8] Others have also reported that shorter the lactation gap, the better the relactation result.[11,12] For successful lactation, the breast should be emptied frequently, either by feeding the baby or by manual hand expression, and the infant should be fed frequently, which causes stimulation of breastfeeding reflexes.[13,14]

It was also found that in mothers who were still breastfeeding their infants, relactation can be achieved earlier (7 days vs. 17 days) as compared to mothers whose infants were on intravenous fluid, because these infants were sick and not able to suck vigorously. The present study shows that bottle-fed infants took longer to relactate (29 days vs. 21 days) as compared to infants fed with a cup. Bottle-fed babies may have severe nipple confusion because the feeding mechanism is different for bottle feeding and breastfeeding, which could be the reason for this finding.[8] Others also stated that for a complete relactation, it took an average of 15-20 days.[15]

Given the current evidence, it is safe to conclude that frenotomy should be viewed as a safe, effective, and practical approach to treat breastfeeding difficulties in infants with ankyloglossia after poor feeding and failure to thrive have been properly assessed.

The holistic management of Praborini Relactation Method for tongue- and lip-tied infants with slow weight gain or failure to thrive, which consists of frenotomy, supplementation using a supplemental nursing system, lactogogue usage, and acupuncture, has proven to improve infants’ nutritional status and the mother’s milk supply. Infants who undergo frenotomies could breastfeed without supplementation after treatment and gain weight.[16] Hospitalization with multimodal management is effective for treating nipple confusion.[17]

Relactation is possible for mothers with continuous, patient, and positive support from family members and trained health workers, along with proper counseling and positive reinforcement for building confidence in the mother. Therefore, the present study highlights the need for breastfeeding counseling and support for mothers, starting from antenatal, natal, and during the entire lactation period. It was found that most of the causes of lactation failure are preventable and correctable.[8]

In this case, a simple frenotomy was performed gradually because the baby had nipple confusion. This was done to prevent nursing strikes during breastfeeding. With relactation treatment, the baby’s nutritional status was increased to normal by direct breastfeeding and proper complementary feeding. The baby was also released from using SNS. This was successfully done due to proper counseling and holistic lactation management.


  1. Messner A, Lalakea M. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2):123-31.
  2. Segal LM, Stephenson R, Dawes M. Prevalence, diagnosis, and treatment of ankyloglossia. Can Fam Physician. 2007 Jun; 53(6): 1027-1033.
  3. Edmunds J, Miles S, Fulbrook P. Tongue-tie and Breastfeeding : a review of the literature. Breastfeeding Review, Vol. 19, No. 1. Mar 2011 : 19-26.
  4. Schwartz K, d’Arcy H, Gillespie B, Bobo J, Longeway M, Foxman B. Factors associated with weaning in the first 3 months postpartum. J Fam Pract. 2002;51(5):439-44.
  5. Coryllos E, Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby. 2004 Summer;:1-6.
  6. Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary to correct breastfeeding problems. J Hum Lact. 1990;6(3):117-21.
  7. Lawrence RA. 4th. St. Louis, MO: Mosby; 1994. Breastfeeding: a guide for the medical profession.
  8. Mehta A, Rathi AK, Kushwaha KP, Singh A. Relactation in lactation failure and low milk supply. Sudan J Paediatr. 2018; 18(1): 39-47.
  9. Bose CL, D’Evcole AJ, Lester AG, Hunter RS, Barrett JR. Relactation by mothers of sick and premature infant. Pediatrics. 1981;67:565-9.
  10. Rath BK, Ghai OP, Bhan MK, Arora NK, Dhar V, Thakkar D, et al. Metoclopramide in lactational failure. Ind Pediatr. 1983;20:341-4.
  11. Tomar RPS. Initiation of relactation: an Army Hospital based study of 381 cases. Int J Contemp Pediatr. 2016;3:635-8.
  12. Lakhkar BB. Breastfeeding in adopted babies. Ind Pediatr. 2000;37:1114-6.
  13. Mepham TB. National Childbirth Trust. Alexandra House, Oldham Terrace, Acton, London, UK: Suckling-induced stimulation of breastmilk. New Generation September 1991, 31/32.
  14. Wilde CJ, Prentice A, Peaker M. Breast-feeding: matching supply with demand inhuman lactation. Proc Nut Soc. 1995;54:401-6.
  15. De NC, Pandith B, Mishra SK, Pappu K, Chaudhuri SN. Initiating the process of relactation: an institute based study. Ind Pediatr. 2002;39:173-8.
  16. Praborini A, Setiani A, Munandar A, Wulandari RA. A Holistic Supplementation Regimen for Tongue-Tied Babies With Slow Weight Gain and Failure to Thrive. Clinical Lactation. May 2018 9(2):78-87.
  17. Praborini A, Purnamasari H, Munandar A, Wulandari RA. Hospitalization for Nipple Confusion A Method to Restore Healthy Breastfeeding. Clinical Lactation. May 2016 7(2):69-76.


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