Frenotomy and Supplementation in an Infant with Ankyloglossia and Undernutrition

Written by : Nayu Nur A.S. Dentist & Lactation Councelor, Malang

Infant N was a male baby born on December 23, 2025, via cesarean section (C-section) at a hospital in Depok. He was the first child of Mrs. F and Mr. I. The baby had a birth weight of 3140 grams and stayed in rooming-in care with the mother. Mrs. F works in the research field under a work-from-home (WFH) arrangement. At the time this case occurred, Mrs. F was on maternity leave until March 9, 2026.

On December 24, 2025, when the baby was 1 day old, the mother received a visit from a lactation doctor in the patient room. During anamnesis, the mother reported that the baby was actively breastfeeding, but she felt that her breast milk production was still low. Physical examination showed that the mother’s breasts were within normal limits, with protruding and elastic nipples, and colostrum had already been expressed. During breastfeeding observation, the baby appeared to have difficulty achieving a proper latch.

In the sidelying position on the left breast, the baby had difficulty latching and frequently detached. In the cradle position, the baby only latched onto the tip of the nipple. After trying the football hold position, the baby was able to achieve a deeper and more stable latch. The baby breastfed without causing pain to the mother and then released the breast as if satisfied. During this visit, the mother received education about the importance of breastfeeding from both breasts, the benefits of breastfeeding, and the risks associated with the use of formula milk, bottles, and pacifiers. In addition, she was informed about the possible presence of tongue-tie and lip-tie in the infant, as well as the plan for further evaluation.

On January 2, 2026, when the baby was 10 days old, Mrs. F visited the lactation clinic due to breastfeeding problems. The mother reported that the baby breastfed for long durations, often more than 30 minutes, and appeared never to be satisfied. During one feeding session, the mother frequently switched between breasts. She also felt that her breast milk appeared watery. The baby’s last defecation had occurred several days earlier and was blackish-green in color.

Examination showed that the mother’s breasts were within normal limits, with protruding and elastic nipples. Milk production was assessed as normal low milk supply. Examination of the infant’s oral cavity revealed an anterior tongue-tie and grade 3 lip-tie. At that time, the baby’s weight was 2610 grams, indicating a decrease of approximately 16.7% from birth weight. This condition indicated excessive weight loss.

Based on these findings, the infant was diagnosed with a breastfeeding problem caused by ankyloglossia. After providing education to the parents and obtaining consent for the procedure, a frenotomy was performed on both the tongue-tie and lip-tie. The procedure was carried out with minimal and controlled bleeding. After the procedure, the baby was immediately breastfed by the mother. The mother reported that the baby’s suction became deeper, the baby’s lips appeared more open, and swallowing sounds could be heard during feeding.

After the frenotomy, the mother was instructed to perform tongue and lip exercises for the baby five times a day. The incision site was treated with aloe vera gel. The mother was advised to continue direct breastfeeding from both breasts. The next follow-up visit was scheduled for January 6, 2026.

On January 6, 2026, when the baby was 14 days old, the patient returned for a follow-up visit at the pediatric clinic due to concerns regarding weight gain. The mother reported that breastfeeding had become more comfortable after the frenotomy and that the baby seemed to latch more easily. The mother also expressed a strong desire to breastfeed her baby until the age of two years.

Examination revealed a body weight of 2645 grams, which still represented a decrease of approximately 15.7% from birth weight and was below −2 SD. This condition suggested excessive weight loss with undernutrition approaching severe malnutrition. Oral examination still revealed residual tongue-tie tissue. The doctor then performed blunt dissection of the remaining frenulum tissue.

In addition, a Supplemental Nursing System (SNS) was introduced to assist supplementation while the baby breastfed directly at the breast. Supplementation was provided using plain formula milk delivered through the SNS. The baby also received additional therapy in the form of roborantia, and the mother received a lactagogue. The mother was advised to continue breastfeeding as frequently as the baby desired on both breasts.

On the same day, the mother also received further education at the lactation clinic regarding the use of the SNS and breastfeeding techniques. During observation of breastfeeding using the SNS, the baby was able to latch well onto the areola and consumed approximately 10 cc of formula before falling asleep. The next follow-up visit was scheduled for January 13, 2026.

On January 13, 2026, when the baby was 21 days old, the mother reported that the baby was breastfeeding more frequently and that breastfeeding felt more comfortable. However, she still experienced some difficulty breastfeeding from the left breast. The SNS was used approximately 6–7 times per day, with a volume of about 30–60 cc per feeding.

Examination showed that the baby weighed 3090 grams, indicating a weight gain of approximately 63 grams per day. Although the weight was still below −2 SD, the baby’s condition showed significant improvement. The doctor recommended continuing the use of the SNS, with the volume reduced to 45 cc, six times per day. The mother also received additional therapy in the form of lactation acupuncture and was advised to try the reclining breastfeeding position to improve comfort. The next follow-up visit was scheduled for January 22, 2026.

On January 22, 2026, when the baby was 1 month old, the mother reported that the baby was still using the SNS approximately 4–5 times per day, with a volume of about 50 cc. Examination showed that the baby weighed 3490 grams, with a weight gain of approximately 44 grams per day. The baby’s nutritional status had improved to the normal nutritional status category. The mother’s milk production was still assessed as normal low milk supply. The doctor advised continuing the use of the SNS and provided education regarding the possibility of early complementary feeding if necessary. The next follow-up visit was scheduled for February 5, 2026.

On February 5, 2026, when the baby was 1 month and 14 days old, the mother reported that the use of the SNS had begun to decrease. Previously, the baby consumed approximately 200–250 cc of supplementation per day, but over the previous two days, this amount had decreased to around 70 cc. Examination revealed a body weight of 3860 grams, indicating a weight gain of approximately 26.5 grams per day. The mother’s milk production had started to increase, and the baby’s nutritional status remained within the normal category. The doctor then recommended gradually discontinuing the SNS. The next follow-up visit was scheduled for February 19, 2026.

On February 20, 2026, when the baby was 1 month and 25 days old, the mother reported that the SNS had been discontinued for the past three days. Examination revealed a body weight of 4485 grams, with a weight gain of 41 grams per day. The mother’s milk production was considered abundant, and the baby was able to breastfeed directly without supplementation.

During this visit, the mother also received an extension of her maternity leave until May 9, 2026, to support breastfeeding success in accordance with Law Number 4 of 2024 on Maternal and Child Welfare in the First Thousand Days of Life. This law regulates maternity leave of up to six months under certain conditions to support maternal and infant health, as well as successful breastfeeding.

Discussion

Ankyloglossia is a congenital anomaly characterized by a short or tight lingual frenulum that restricts tongue mobility. This condition may lead to impaired oral function, particularly during breastfeeding in newborns.¹ The prevalence of ankyloglossia in neonates has been reported to range from 4% to 10% of the newborn population.²

In this case, the infant experienced breastfeeding difficulties from the early days of life, manifested by ineffective latch, prolonged feeding duration, and significant weight loss of up to 16.7%. These findings are consistent with commonly reported clinical manifestations of ankyloglossia in infants, including difficulty latching onto the breast, ineffective milk transfer, and inadequate breast milk intake.³

Weight loss in infants is an important indicator of breastfeeding problems. Infants with ankyloglossia who experience delayed treatment have a higher risk of losing more than 10% of their birth weight after birth.² This observation is consistent with the present case, in which the infant experienced excessive weight loss and breastfeeding difficulties due to limited tongue mobility.

Frenotomy is a simple procedure performed to release the lingual frenulum and improve tongue movement. In this case, following the frenotomy, the mother reported improvements in breastfeeding, with the infant appearing more comfortable and demonstrating deeper suction. These findings are consistent with several studies showing that frenotomy can improve breastfeeding outcomes, enhance the infant’s ability to latch onto the breast, and reduce maternal pain during breastfeeding.³

One study reported that approximately 91% of mothers experienced improvements in breastfeeding after frenotomy, accompanied by increased LATCH scores (a tool used to assess the effectiveness and quality of breastfeeding sessions) and reduced breastfeeding-related pain.⁴ These results support the clinical benefits of frenotomy in infants with ankyloglossia who experience breastfeeding difficulties.

In addition to frenotomy, supplementation using a Supplemental Nursing System (SNS) was provided to help meet the infant’s nutritional needs during the breastfeeding adaptation period. This approach proved effective in gradually improving the infant’s weight gain until an improved nutritional status was achieved at approximately one month of age.

Additional therapy was also considered to enhance breast milk production, namely lactation acupuncture. A case study has demonstrated that stimulation of specific acupuncture points can increase breast milk production in mothers with low milk supply.⁵ This improvement is reflected in increased breast milk volume following therapy, allowing the infant’s nutritional needs to be better met. The proposed mechanism involves stimulation of the hormonal system, particularly increased prolactin levels, which play a key role in lactogenesis, or breast milk production.

Beyond medical factors, breastfeeding success is also influenced by social and environmental factors, including family support, lactation education, and maternity leave policies. Maternity leave plays a crucial role in sustaining breastfeeding by allowing mothers time to adapt to breastfeeding, establish bonding with their infants, and recover physically after childbirth.⁶

Several studies have demonstrated a positive association between the duration of maternity leave and breastfeeding success. Mothers who receive maternity leave longer than three months are more likely to continue breastfeeding compared with those who return to work earlier. Furthermore, maternity leave of up to six months is associated with higher rates of exclusive breastfeeding for six months.⁶

In this case, breastfeeding success was also supported by care provided in a healthcare facility that implemented the Baby-Friendly Hospital Initiative (BFHI) principles. Early identification of breastfeeding difficulties related to ankyloglossia and timely management through frenotomy reflect responsive healthcare services addressing breastfeeding challenges.

Studies have shown that infants born in hospitals implementing the BFHI program are more likely to receive exclusive breastfeeding at ≤3 months and at 3–6 months of age compared with infants born in hospitals without BFHI implementation.⁷ This finding underscores the important role of healthcare system support, including lactation counseling and early intervention, in improving breastfeeding outcomes.

Conclusion

Ankyloglossia is a congenital condition that restricts tongue mobility, thereby impairing latch and the effectiveness of suction during breastfeeding. In this case, ankyloglossia led to breastfeeding difficulties that contributed to significant weight loss, resulting in the infant’s nutritional status declining to undernutrition, approaching severe malnutrition. The frenotomy performed in this case improved the infant’s ability to latch onto the breast, enabling more effective breastfeeding. This improvement was further supported by supplementation using a Supplemental Nursing System (SNS) to ensure adequate nutritional intake during the breastfeeding adaptation period. With improved feeding effectiveness and sufficient nutritional intake, the infant demonstrated appropriate weight gain, allowing nutritional status to return to the normal category. Over time, the infant was able to breastfeed directly and effectively without the need for additional supplementation. This case highlights the importance of early detection of breastfeeding problems and timely, appropriate management in supporting successful breastfeeding outcomes.

References 

1. Vancsa, C., Dima, V., & Vladareanu, S. (2021). Tongue-tie: Development, evolution and treatment. Romanian Medical Journal. 

2. Barberá-Pérez, P. M., Sierra-Colomina, M., Deyanova-Alyosheva, N., Plana Fernández, M., & Lalaguna-Mallada, P. (2021). Prevalence of ankyloglossia in newborns and impact of frenotomy in a baby-friendly hospital. Boletín Médico del Hospital Infantil de México, 78(5), 418–423. 

3. Webb, A. N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 77(5), 635–646. 

4. Muldoon, K., Gallagher, L., McGuinness, D., & Smith, V. (2017). Effect of frenotomy on breastfeeding variables in infants with ankyloglossia: A prospective before and after cohort study. 

5. Pierdant, G., Westphal, K., Lange, A., & Usichenko, T. I. (2022). Stimulation of lactation using acupuncture: A case study. Journal of Human Lactation, 38(3), 559–563. 

6. Navarro-Rosenblatt, D., & Garmendia, M. L. (2018). Maternity leave and its impact on breastfeeding: A review of the literature. Breastfeeding Medicine, 13(9), 589–597. 

7. Fan, Y. W., Fan, H. S. L., Shing, J. S. Y., Ip, H. L., Fong, D. Y. T., & Lok, K. Y. W. (2025). Impact of baby-friendly hospital initiatives on breastfeeding outcomes: Systematic review and meta-analysis. Women and Birth, 38, 101881.