Relactation in Nipple-Confused Babies with Tongue Tie and Lip Tie

Written by : Dr. Patricia – Lactation Doctor, Karawang

Baby C, a boy, was born on September 11 2024. The first son of Mrs. C and Mr. S who had waited for a child for 5 years. Baby C was born via normal delivery, was born full term at 37 weeks and 5 days of gestation at the East Jakarta regional maternity clinic with a birth weight of 3420 grams and a body length of 49 cm. Immediately after birth, the mother and the baby undergo IMD (Early Initiation of Breastfeeding) for 1 hour. After that, the baby was put together with the mother. Her mother was taught to breastfeed and was very confident that she could do it.

At the age of 7 days, the mother took baby C for a check-up to a Pediatrician. The results of the examination showed that the baby’s weight (BB) was 3,150 grams (had not returned to birth weight with weight loss of 7.8%). The doctor asked her to continue breastfeeding and check again when the baby was 1 month old.

During the check-up at the age of 1 month, the baby’s weight was 3,770 grams (not an optimal weight gain). During the first month, baby C only breastfed directly from the mother without any other supplements. During the examination, his skin looked yellow up to his feet. Laboratory results showed a bilirubin level in the blood of 22 mg/dl and the doctor recommended phototherapy for 2×24 hours. While the baby is being treated in the hospital, the mother regularly expressed breast milk (ASI).

During the visit, the doctor told the mother that baby C’s weight gain did not reach the target (the doctor stated that the baby’s weight should increase by 250 grams per week). The doctor asked the mother to express breast milk and targeted the baby to drink 750 ml of expressed breast milk per day (drink 8 times 90 ml) through a bottle. However, at that time the result of the mother’s pumping was around 60-80 ml. Therefore, the doctor suggested that if the mother’s breast milk was not enough for the baby, it would be better to add 90 ml of formula milk per drink.

Since then, the mother felt down; she was very worried and afraid that her breast milk production would not be enough for her baby. This drove the mother to do everything she could to increase her breast milk production such as lactation massage, expressing breast milk every 2-3 hours, and trying to breastfeed directly at the same time. If the baby was still fussy, the mother would give her additional formula milk using a bottle. However, the mother became overwhelmed because she had to breastfeed, express, and feed the milk through a bottle at the same time. The mother became frustrated because the pumping results did not increase. 

After a few days, the mother felt that the baby’s sucking began to change, the baby had difficulty latching on, a lot of breast milk spilled from the side of the baby’s mouth, a clicking sound was heard and the baby seemed never satisfied breastfeeding. Occasionally, the mother felt pain while breastfeeding. The mother was advised by the doula to check the baby’s condition at the lactation clinic to see a Pediatrician (Sp.A) who is an international lactation consultant because she suspected a lip tie in the baby. 

On October 22, 2024, both parents met the pediatrician lactation consultant at the Depok Regional Hospital. At that time, baby C was 1 month 11 days old, weighed 4525 grams, gained 26.95 grams/day which means the baby experienced a slow weight gain. The nutritional status > -2 SD (Standard Deviation) which means the baby still had good nutrition. The results of the physical examination, Baby C was observed to have a posterior tongue tie and lip tie grade 3. When breastfeeding, Baby C seemed to have difficulty latching on, made a clicking sound, and was fussy. After the examination, the doctor provided education on the benefits of breastfeeding, breastfeeding instructions according to religious orders and WHO recommendations, the risk of using bottles and formula milk, an explanation of the results of the examination and an action plan. After hearing the doctor’s explanation, Mrs. C’s desire to breastfeed for 2 years grew stronger and received support from her husband. Baby C’s parents agreed to do a tongue-tie frenotomy procedure. After receiving the procedure, the baby immediately breastfed from the mother and was advised to undergo relactation hospitalization with the Praborini method and a lip-tie frenotomy plan in the treatment room.

During treatment, Baby C was advised to have skin-to-skin contact for 2×24 hours, given 0.4 mg CTM powder to drink, if necessary. The mother should apply aloe vera gel to the incision wound, and have a Supplemental Nursing System (SNS) device installed containing the mother’s expressed breast milk (ASIP). During the first lactation doctor’s visit, it was observed that Baby C was able to suckle comfortably from both of the mother’s breasts with the aid of SNS.

During the second lactation doctor’s visit, the doctor examined and performed a lip tie frenotomy. After that, the baby was a little fussy while sucking. The mother installed SNS and the baby was seen starting to suckle deeply, latching and sucking well from the mother’s breast. 

On the second day of treatment, baby C breastfed better and when weighed, baby C’s weight increased by 80 grams, so that the baby and mother were allowed to go home. At home, the baby and mother were advised to continue skin-to-skin contact, apply aloe vera gel to the incision wound, do tongue exercises 3 times a day and install SNS if necessary.

On October 25, 2024, the mother came for post-relactation control. The baby C aged 1 month 14 days was declared to have successfully relactated because the examination results showed that baby C’s weight increased by 40 grams/day without using the SNS device. Baby C was observed to be able latch on to the mother’s breast well. Baby C and the mother were still advised to continue skin-to-skin contact and perform tongue exercises 3 times per day.

One week later, the second post-treatment check-up, on October 31, 2024, baby C’s weight was 4,860 grams, well-nourished, gaining 36 grams/day and the examination results showed no remaining tissue on the incision scar. The baby is getting better at breastfeeding and the mother feels comfortable when breastfeeding baby C. The mother was advised to continue doing tongue exercises regularly until exactly 3 weeks after the incision.

Graph 1. Weight Gain Graph

Figure 1. Weight growth curve of baby C in good nutritional status

Date	Age	Weight (gr)	Nutritional Status	Procedure
September 11 2024	Born	3420
October 22 2024	1 Month 11 Days	4525	-1SD – +1SD(Normal weight)	Tongue Tie frenotomySkin to skin contactSNS adjust to baby’s wishes and contain ASIPAloe vera gel 3x/dayTongue exercise
22 October 2024	1 Month 11 Days	4525	-1SD – +1SD(Normal weight)	Lip Tie frenotomyContinuing other procedures
Oktober 24 2024	1 Month 13 Days	4605	-1SD – +1SD(Normal weight)	Patient is dischargedContinuing other procedures
Oktober 25 2024	1 Month 14 Days	4645	-1SD – +1SD(Normal weight)	Breastfeeding on demand without supplements (SNS)Continuing other procedures
Oktober 31 2024	1 Month 20 Days	4860	-1SD – +1SD(Normal weight)	Breastfeeding on demand without supplements Skin to skin contact partialTongue exercise

Table 1. Weight Growth and Nutritional Status in Infant C

DISCUSSION

Successful breastfeeding depends on proper positioning and attachment. A good attachment allows for optimal milk transfer, a more comfortable breastfeeding experience and an increased supply of milk to the breasts. A baby who does not latch on and suckle properly will cause pain to the mother. In addition, it can make a mother appear as if she is not producing enough milk. In other words, she may appear to have an insufficient milk supply. Then, if this situation continues, her breasts may actually produce less milk. In other cases, it can result in poor baby weight gain or failure to breastfeed.^[1]

Tongue tie / Lip tie is one of the factors causing difficulty in breastfeeding which is characterized by pain in breastfeeding, feed for a long time, have a short break, then feed again, be unsettled and seem to be hungry all the time, make a “clicking” sound during breastfeeding, which can then have an impact on less optimal weight gain. If there is a tongue tie and lip tie, and the baby has difficulty attaching, the best action is frenotomy (incision/cutting of the tongue tie and lip tie) to make the breastfeeding process between mother and baby better. However, not all babies are immediately good at breastfeeding after frenotomy, especially if the baby has been introduced to other media such as bottle. The baby needs to learn how to breastfeed again. If the baby is not yet good at it, what needs to be done is 24-hour skin-to-skin contact, tongue exercises, and lip exercises routinely until the baby is good at breastfeeding. ^[2]

In this case, after frenotomy was performed on baby C, the mother felt more comfortable, no longer felt pain when breastfeeding. However, introducing baby C to a bottle changed the baby’s sucking pattern. The technique of sucking to breast and sucking to bottle is very different. When the baby sucks to breast, the baby’s cheeks are convex, while when sucking to bottle, the baby’s cheeks will be concave. This change in sucking-technique is called nipple confusion. ^[3,4] Therefore, baby C is advised to undergo relactation (mother resumes breastfeeding and baby resumes breastfeeding after previously stopping). The baby is attached skin to skin on the mother’s chest and then carried with batik cloth and wearing pajamas. This is not easy, because it requires a struggle that involves emotions. Babies who are used to pacifiers may not be comfortable in this position and may continue to cry because they are addicted to pacifiers and separated from the comfort of bottles. Mothers need to be patient, have intentions and determination, entertain the baby by singing, walking here and there, or rocking with the baby. Make skin-to-skin contact with the baby for 24 hours until the baby is willing to breastfeed again. After relactation treatment, Mrs. C felt that baby C’s sucking was stronger, and weight gain increased. Family support, especially the father, is very important. In this case, the baby’s father is very supportive of the breastfeeding process for his wife and baby.

Figure 2. Skin to Skin Contact Process

CONCLUSION

Breast milk is the best food for babies. Human breast milk contains the most appropriate composition for humans who have the slowest growth rate but the most sophisticated brain among other mammals.^[1]

Breastfeeding is the best way to feed a baby, but optimal milk transfer and weight gain depend on good attachment. ^[1]

Breastfeeding with a bottle in the first few weeks can hinder the breastfeeding process because the technique of breastfeeding with a bottle is very different from the technique of breastfeeding on the mother’s breast. ^[2]

Tongue tie and lip tie are obstacles that prevent babies from being able to breastfeed directly from the mother’s breast and also make it difficult for mothers to breastfeed because of the pain during breastfeeding.^[3]

Supplemental therapy is given using a breastfeeding aid (SNS) so that the baby gets adequate nutrition, the baby continues to suck on the mother’s breast, thereby increasing breast milk production. ^[3]

Figure 3. Mrs. C Using the SNS Breastfeeding Aid

Research states that the shorter the interval between breastfeeding and relactation, the better the relactation results. To achieve successful breastfeeding, the breasts must be emptied frequently, either by direct breastfeeding or by manually expressing the breasts, and the baby must be breastfed continuously, to stimulate milk production in the breasts. ^[5]

In this case, the nutritional status is good but weight gain is slow in early age due to the presence of tongue and lip ties accompanied by partial nipple confusion. Frenotomy was performed in stages because the baby experienced partial nipple confusion and to prevent the baby from refusing to breastfeed (nursing strike). With relactation, the baby managed to gain adequate weight with DBF (direct breastfeeding) alone without using breastfeeding aids (SNS) or any additional milk and the breastfeeding process felt more comfortable for the mother and baby. This can be achieved because the patient was handled by a qualified team with holistic treatment.

BIBLIOGRAPHY

1. Direktorat Gizi Masyarakat Ditjen Kesehatan Masyarakat Kementerian Kesehatan Republik Indonesia. Pelatihan Konseling Menyusui. Jakarta. 2022.
2. Praborini A, Wulandari RA. Anti Stres Menyusui. Kawan Pustaka. Jakarta. 2019
3. Praborini A, et al. A Holistic Supplementation Regimen for Tongue-Tied Babies With Slow Weight Gain and Failure to Thrive. Clinical Lactation Vol 9 Issue 2. 2018. DOI: 10.1891/2158-0782.9.2.78.
4. Lawrence RA. 4^th . Breastfeeding: a guide for the medical profession. St. Louis, MO: Mosby; 1994.

Tomar RPS. Initiation of relactation: an Army Hospital based study of 381 cases. Int J Contemp Pediatr. 2016;3:635-8. https://doi.org/10.18203/2349-3291.ijcp20161054.