The Role of Frenotomy and Supplementation Therapy in Babies with Tongue Tie, Lip Tie, Malnutrition, and Congenital Heart Disease

By: Dr. Dhika Arifa, CIMI
Lactation Doctor – South Tangerang

Baby F was born on August 20, 2023, female, delivered via cesarean section from Mother E, aged 28 years. The delivery was at term (37 weeks) due to a previous cesarean section, fetal distress, and acute gastroenteritis (diarrhea). The baby was born crying immediately and was active, with no signs of cyanosis (bluish skin), and the umbilical cord was fresh. The APGAR score was 8/9. The measurement was as follows: birth weight 2895 grams, length 46 cm, head circumference 34 cm, chest circumference 32 cm, and abdominal circumference 29 cm. The mother did not attend any antenatal care (ANC) during the pregnancy.

The mother has a first child, a girl aged 1.5 years, who was breastfed exclusively for only 3 months. Baby F is the second child. The mother did not work and wishes to breastfeed for up to 2 years. The father was supportive and regularly accompanied her during breastfeeding-lactation consultations and hospital stays.

The baby was born at RSSIB (Mother and Baby Care Hospital) in area D and received visits from a lactation doctor. However, the baby was not placed in the same room as the mother due to infection. The mother felt she had little breast milk, had not yet removed the IV and catheter, and was unable to mobilize, so she could not learn to breastfeed the baby directly in the Perina room. With the support of the lactation doctor, the mother learned breastfeeding positions and latching techniques using a doll, and she was also taught how to hand express breast milk to be delivered to the Perina room. The mother went home earlier than the baby, who returned home two days later. The baby then returned for a check-up at 7 days old, with a weight drop to 2400 grams and signs of jaundice, leading to phototherapy in the hospital.

During the first visit to the lactation clinic, one month after the birth, on September 21, 2023, the baby was consulted by a pediatrician who is an international lactation consultant for inpatient care under the government insurance program BPJS (Social Insurance Organizer) due to dehydration. A nasogastric tube (NGT) was installed, and a syringe as a supplementer was attached to the mother’s breast with expressed breast milk (EBM). The mother was advised to pump regularly. The baby came to the lactation consultant upon referral from the community health center (Puskesmas). Initially, the baby drank from a bottle containing 30-60 cc of EBM each feeding but often spilled it. The mother was informed by a neighbor that the baby had a tongue tie and was advised to request a referral from the Puskesmas in area D to a private hospital supportive of breastfeeding for a frenotomy (the procedure to cut the tongue tie) by the pediatrician.

During the second visit on September 22, 2023, when the baby was 1 month and 2 days old, the baby was referred back to the lactation clinic for tongue and lip exercises, as well as the application of aloe vera gel on the incision site to promote healing. The baby was able to breastfeed directly without the supplementer (tube), and at night, the mother did not use the supplementer.

During the third visit on September 26, 2023, when the baby was 1 month and 6 days old, the baby was consulted by the pediatrician for re-installation of the Supplementary Nursing System (SNS) containing expressed breast milk (EBM) and to repeat the exercises. The baby had been exclusively breastfeeding (DBF) at home, no longer using the NGT syringe as a supplementer, but the weight had not increased. Breastfeeding was much better than before the procedure. The exercises were being done, but the mother often forgot, and aloe vera gel was applied three times a day. The condition of the mother’s breasts was symmetrical, with the areolas within normal limits, and both nipples were prominent and flexible, although there were abrasions on both breasts. There was a good amount of breast milk in both breasts. The breastfeeding position was the left cradle, with the SNS containing 30 cc of EBM attached. The baby was well latched on the left areola and was sucking continuously until the 30 cc of EBM was finished. Currently, the mother’s milk supply was normal, and the baby, post-frenotomy, was experiencing breastfeeding problems and failure to thrive, with malnutrition status (weight 2880 grams) below the -3 SD (standard deviation) threshold.

During the fourth visit on September 29, 2023, when the baby was 1 month and 9 days old, the baby’s weight was 2890 grams, and the SNS was still used. The therapy continued, but they started using unsweetened formula as a partial supplement in the SNS.

During the fifth visit on October 6, 2023, when the baby was 1 month and 16 days old, the baby’s weight had started to increase to 3005 grams. The SNS was still used, and the other therapies continued.

During the sixth visit on October 26, 2023, when the baby was 2 months and 6 days old, the mother and baby returned for a check-up. The baby’s weight had increased to 3280 grams, but the nutritional status remained under -3 SD, indicating continued malnutrition. The use of the SNS was still recommended. One week later, the mother and baby continued to have regular check-ups at the pediatric clinic, where the baby’s weight improved further to 3465 grams, but the nutritional status remained under -3 SD, still indicating malnutrition.

During the seventh visit on November 9, 2023, the baby’s weight had increased to 3600 grams, but the nutritional status was still under -3 SD. The baby began receiving physiotherapy.

During the eighth visit on December 8, 2023, when the baby was 3 months and 20 days old, the baby’s weight was 3815 grams, but the nutritional status remained under -3 SD. The therapy continued.

During the ninth visit on December 21, 2023, when the baby was 4 months and 3 days old, the baby’s weight was 3750 grams due to a hospital discharge after an illness involving a cough and cold. The nutritional status remained under -3 SD, and the use of the SNS continued.

During the tenth visit on January 5, 2024, when the baby was 4 months and 18 days old, the baby’s weight was 3905 grams, with a nutritional status under -3 SD. The therapy continued. An echocardiogram was performed on the baby by a Pediatric Cardiology Professor, and an abnormality was detected in the form of an ASD (Atrial Septal Defect), which is a defect between the two atria of the heart characterized by a gap or hole measuring 4-5 mm.

During the eleventh visit on January 19, 2024, when the baby was 5 months and 2 days old, the baby’s weight was 3930 grams. The baby was currently experiencing diarrhea, and the use of the SNS was continued.

During the twelfth visit on February 2, 2024, when the baby was 5 months and 16 days old, the baby’s weight was 4465 grams, with a nutritional status under -3 SD indicating malnutrition. The use of the SNS was continued.

During the thirteenth visit on February 16, 2024, when the baby was 6 months old, the baby’s weight was 4690 grams. The baby continued to use the SNS and was given complementary foods (MPASI).

During the fourteenth visit on March 14, 2024, when the baby was 6 months and 27 days old, the baby’s weight was 5610 grams, with a nutritional status under -3 SD indicating malnutrition.

During the fifteenth visit on April 5, 2024, when the baby was 7 months and 19 days old, the baby’s weight was 5830 grams, with the use of the SNS and complementary foods (MPASI) continuing. The baby’s nutritional status had started to improve, now classified as undernutrition < -2 SD.

During the sixteenth visit on May 3, 2024, when the baby was 8 months and 17 days old, the baby’s weight was 6095 grams, with a nutritional status under -2 SD indicating undernutrition. The use of the SNS and complementary foods (MPASI) continued. The baby underwent a repeat echocardiogram, which detected a heart abnormality in the form of a small to moderate ASD (Atrial Septal Defect), characterized by a gap or hole between the two atria of the heart. The size of the gap had decreased to between 3.5 mm and 4.5 mm.

During the seventeenth visit on June 6, 2024, when the baby was 9 months and 21 days old, the baby was breastfeeding well and eating a lot. The weight was 6635 grams, still with a nutritional status indicating undernutrition (weight < -2 SD), but very close to the good nutritional threshold, which is -2 SD at 6640 grams. The baby had stopped using the SNS and was no longer on formula.

During the eighteenth visit on July 4, 2024, when the baby was 10 months and 19 days old, the weight was 6860 grams, with a good nutritional status (weight > -2 SD). The baby continued breastfeeding with full direct breastfeeding (DBF) and was eating complementary foods (MPASI) eagerly.

During the nineteenth visit on August 1, 2024, when the baby was 11 months and 17 days old, the weight was 7290 grams, showing continued improvement with a good nutritional status and an upward trend in the growth curve. A repeat echocardiogram was planned to assess the improvement of the heart defect.

During the twentieth visit on September 5, 2024, when the baby was 1 year and 17 days old, the weight was 7460 grams, showing further improvement with a good nutritional status and an upward trend in the growth curve. A repeat echocardiogram had been performed, showing that the ASD had closed and the heart was in normal condition. The next plan was to carry out routine vaccinations to support optimal growth.

Table 1. Table Follow Up Baby F

Baby photo of Farhana	Date	Age	Weight	Weight change	Nutritional Status	Intervention	Description
	20 Augustus 2023	0 day	2895 gr		Good nutrition, weight above -2 standard deviations	–	BPJS/ Social Security Agency
	21 September 23	1 month 1 day	2810 gr	Lose weight 85gr	Malnutrition, weight below -2 standard deviations	Frenotomi,Supplement’s spuit NGT, hospitalization	dehidrasi, ankyloglossia BPJS
	22 September 2023	1 month 2 day	2875 gr	Gain weight 65gr	Malnutrition, weight below -2 standard deviations	Hospitalization	Can already breastfeed BPJS
	26 September 2023	1 month 6 day	2880 gr	Gained 5 gr in 6 days	Severe malnutrition, weight below -3 standard deviations	Using SNS filled with expressed breast milk	BPJS
	29 September 2023	1 month 9 day	2890 gr	Gained 10 gr in 3 days	Severe malnutrition, weight below -3 standard deviations	SNS 3×60 expressed breast milk SNS 2×60 formula milk	BPJS
	6 October 23	1 month 16 day	3005 gr	Weight gain 16.4 gr per day	Severe malnutrition, weight below -3 standard deviations	SNS expressed breast milk 3×60 SNS formula milk 1×60 Roborantia 2x30mg	BPJS
	19 October 23	1 month 29 day	3100 gr	Weight gain 7.3 gr per day	Severe malnutrition, weight below -3 standard deviations	expressed breast milk SNS 5x60cc	Cough and cold
	26 October 23	2 month 6 dayi	3280	Weight gain 25.7 gr per day	Severe malnutrition, weight below -3 standard deviations	SNS expressed breast milk 1x60cc  SNS milk formula 4x60cc	FOC (Free Of charge)
	2 November 23	2 month 14 day	3465	Weight gain of 26.4 gr per day	Severe malnutrition, weight below -3 standard deviations	Continued SNS Fisioterapi	There is muscle rigidity in the body and handsBPJS
	9 November 2023	2 month 21 day	3600gr	Weight gain of 19.8 gr per day	Severe malnutrition, weight below -3 standard deviations	Fisioterapi SNS expressed breast milk 1x60cc  SNS milk formula 4x60cc	FOC
	16 November 2023	2 month 28 day	3750gr	Weight gain of 21.4 grams per day	Severe malnutrition, weight below -3 standard deviations	Fisoterapi SNS expressed breast milk 1x60cc SNS milk formula 4x60cc	BPJS
	8 December 2023	3 month 20 day	3815gr	Weight gain of 3.6 grams per day	Severe malnutrition, weight below -3 standard deviations	Fisioterapi SNS expressed breast milk 2x60cc SNS milk formula 3x60cc	BPJS
	21 December 2023	4 month 3 day	3750gr	Weight gain of 5 grams per day	Severe malnutrition, weight below -3 standard deviations	Echocardiogram early complementary feeding Iron	BPJS
	5 Januari 2024	4 month 18 day	3905gr	Weight gain of 11 grams per day	Severe malnutrition, weight below -3 standard deviations	SNS expressed breast milk 3x60cc SNS milk formula 3x60cc complementary feeding	Moderate ASD 4-5 mm BPJS
	19 Januari 2024	5 month 2 day	3930gr		Severe malnutrition, weight below -3 standard deviations	SNS express breast milk 2x60cc SNS milk formula 3x60cc complementary feeding IronVitamin D	DiarrheaBPJS
	2 February 2024	5 month 16 day	4465gr	Weight gain of 38.2 grams per day	Severe malnutrition, weight below -3 standard deviations	SNS express breast milk 3x60cc MPASI zat besi vitamin D	BPJS
	16 February 2024	6 month	4690gr	Weight gain of 16.07 grams per day	Severe malnutrition, weight below -3 standard deviations	SNS express breast milk 3x60cc complementary feeding IronVitamin D	BPJS
	14 March 2024	6 month 27 day	5610gr	Weight gain of 34 grams per day	Severe malnutrition, weight below -3 standard deviations	SNS complementary feeding IronVitamin D	BPJS
	5 April 2024	7 month 19 day	5830gr	Weight gain of 23.75 grams per day	Moderate malnutrition, weight below -2 standard deviations	SNS ASIP/SF DBF complementary feeding IronVitamin D	BPJS
	3 May 2024	8 month 17 day	6095gr	Weight gain, weight below -2 standard deviations	Malnutrition, weight below -2 standard deviations	Stop SNSFull DBFcomplementary feeding IronVitamin D	Small to modereate ASD 3,5 mm-4,5 mm BPJS
	6 June 2024	9 month 21 day	6635gr	Weight gain of 18 grams per day	Moderate malnutrition, weight below -2 standard deviations	ASI complementary feeding  IronVitamin D	BPJS
	4 July 2024	10 month 19 day	6860gr	Weight gain of 7.5 grams per day	weight above -2 standard deviations	ASI complementary feeding IronVitamin D	BPJS
	1 Augustus 2024	11 month 17 day	7290gr	Weight gain of 15.3 grams per day	weight above -2 standard deviations	ASI complementary feeding IronVitamin D	Plan for follow-up echocardiogram BPJS
	5 September 2024	1 month 17 day	7460gr	Weight gain of 15.3 grams per day	weight above -2 standard deviations	ASI complementary feeding IronVitamin D	Echocardiogram results show that the ASD is closed and the heart is normal BPJS