case report management of ankyloglossia and breastfeeding

Case ReportManagement of Ankyloglossia and BreastfeedingDifficulties in the Newborn Breastfeeding SessionsMyofunctional Therapy and Frenotomy

Elvira Ferreacutes-Amat123 Tomasa Pastor-Vera4 Paula Rodriacuteguez-Alessi5

Eduard Ferreacutes-Amat1 Javier Mareque-Bueno16 and Eduard Ferreacutes-Padroacute1

1Service of Oral and Maxillofacial Surgery Hospital de Nens de Barcelona Barcelona Spain2Service of Pediatric Dentistry Hospital de Nens de Barcelona Barcelona Spain3Department of Oral and Maxillofacial Surgery Faculty of Dentistry Universitat Internacional de Catalunya Barcelona Spain4Service of Speech and Orofacial Myofunctional Therapy Hospital de Nens de Barcelona Barcelona Spain5Service of Pediatrics and Service of Human Lactation Hospital de Nens de Barcelona Barcelona Spain6Department of Oral and Maxillofacial Medicine and Oral Public Health Faculty of DentistryUniversitat Internacional de Catalunya Barcelona Spain

Correspondence should be addressed to Elvira Ferres-Amat elviraferreshospitaldenenscom

Received 21 June 2016 Accepted 8 August 2016

Academic Editor Isolina Riano Galan

Copyright copy 2016 Elvira Ferres-Amat et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

The problems of suction in newborns give rise to multiple consequences for both themother and the newbornThe objective of thispaper is to present a case of ankyloglossia (ldquotongue-tierdquo) and the suction problems that were treated by a multidisciplinary teamThe subject is a 17-day-old male patient with ankyloglossia and suction problems during breastfeeding (pain in the breastfeedingmother poor weight gain and long breastfeeds) The patient followed the circuit established in our centre between the servicesof Oral and Maxillofacial Surgery and Breastfeeding and Speech Therapy and Orofacial Rehabilitation (CELERE) The evolutionfollowing the breastfeeding sessions themyofunctional stimulation and the lingual frenotomywas very favourable thereby solvingthe suction problems that the newborn presented All our patients receive breastfeeding sessions and myofunctional therapy astreatment We know that a frenotomy is not always necessary and we believe that the stimulation of sucking before and after thesurgical intervention is important in order to improve the final result

1 Introduction

Newborns can have breastfeeding difficulties for many rea-sons for example their immaturity (preterm infants before37 weeks) and on other occasions it is caused by the prema-ture separation of mother and child due to the hospitalisationof either or because the baby has lost its sucking reflexIn other situations there is interference caused by teats orsoothers or even poor nursing posture when breastfeedingwhich makes sucking difficult [1ndash3]

The limitation in lingual mobility in newborns is anotherone of the reasons that can compromise sucking and latchingon to the breast during the breastfeed [2 4ndash7]

Around 3 of infants are born with a short lingualfrenulum which can lead to breastfeeding problems [6 89] The most important problems are those related to poorweight gain excessively long feeds and nipple pain of themother while breastfeeding [4 6]

The lingual frenulum is a fibromucous membrane thatjoins the base of the tongue with the floor of the mouth andwhen it is short and restricts movement we term this anky-loglossia or tongue-tie It consists of the remains of embry-onic tissue produced in the early stages of the developmentof the oral cavity An incorrect division of the genioglos-sus and hypoglossal muscles is considered [4 8 10ndash12]

Hindawi Publishing CorporationCase Reports in PediatricsVolume 2016 Article ID 3010594 5 pageshttpdxdoiorg10115520163010594

2 Case Reports in Pediatrics

It seems to have a genetic aetiology and is mainly found inmale infants [3 13ndash16]

Hence ankyloglossia is a limitation in lingual mobilitythereby impeding tongue protrusion as well as the liftingof the tip of the tongue due to the shortness andor thegenioglossus muscles [4 10ndash12]

The aim of this work is to present a case of ankyloglossiawith sucking problems treated by the Suction Pathology Unit(CELERE) This multidisciplinary unit is incorporated in theFoundation of Hospital de Nens de Barcelona (FHNB) and ismade up of the Service of Maternal Lactation the Service ofSpeechTherapy and Orofacial Myofunctional Rehabilitationand the Service of Oral and Maxillofacial Surgery whichis responsible for the study treatment and follow-up ofnewborn patients that have sucking problems It is a muchdebated topic on which there is still quite limited scientificevidence

2 Case Report

The case involves a 17-day-old newborn of masculine sexthat attends the Suction Pathology Unit (CELERE) who wasreferred by his pediatrician as a result of sucking problemsduring breastfeeding and ankyloglossia The diagnosis ofankyloglossia is carried out according to the Coryllos classifi-cation which defines four types of frenulum Type I fine andelastic frenulum where the tongue is anchored from the tipto the alveolar ridge and it is found to be heart-shaped TypeII fine and elastic frenulum where the tongue is anchoredfrom 2ndash4 millimetres of the tip to almost near the alveolarridge Type III thick fibrous and not elastic frenulum thetongue is anchored from themiddle of the tongue to the floorof themouth Type IV the frenulumcannot be seen butwhenpalpation is performed one can feel fibrous anchoring andorthick and shiny submucosa from the base of the tongue to thefloor of the mouth [8 17]

Besides the Coryllos classification functional clinicalcriteria were also taken into account poor weight gain (lessthan 100 grams per week) excessively long breastfeeds (morethan 60minutes) andmaternal pain (maternal breastfeedingshould not be a cause of pain for the mother)

The data has been gathered in three different momentsof the treatment at the beginning of it at two weeks of ouraction and at the end of the treatment and the degree ofankyloglossia maternal pain during breastfeeding weightprogress and the length of the feeds were evaluated 15 daysafter

The Visual Analogue Scale (VAS) was used in the evalua-tion of the pain [18]

The evolution of weight gain is assessed throughweighingthe child before each breastfeeding and stimulation sessionalways keeping in mind using the same scales (digital)

The time of the breastfeeds was measured by the motherherself and to this end the following time intervals wereestablished lt15 minutes 15ndash30 minutes 30ndash60 minutes andgt60 minutes the value chosen for the study and evaluatingthe evolution was the highest time interval

Figure 1 Lingual frenum with degree II ankyloglossia

The case involves a 42-year-old mother without previouspregnancies It was a natural birth from 39 weeksrsquo gestationand a cesarean delivery was performed due to the hyper-tension of the mother The weight of the child at birth was2900 grams and the 1-minute APGAR score was 7 and thesecond test performed 5 minutes later was 9 without peri-or postnatal complications The type of lactation chosen wasexclusive breastfeeding

The weight of the newborn on the first visit was 2970grams Maternal pain during breastfeeding was 10 (VAS)Poor weight gain was recorded less than 100 grams per weekThe breastfeeds were excessively long more than 60 minutesA thorough physical examination of the babywas undertakenwith special attention to muscle tone and the anatomy of theoral cavity and the maxillofacial region The newborn wasdiagnosed with ankyloglossia degree II (Coryllos classifica-tion) by visual inspection and palpation slight physiologicalretrognathia (normal condition of mandible developmentconsidering the age) poor latching and unproductive suck-ing (Figure 1)

The treatment began through undertaking breastfeedingsessions in order to correct nursing posture and improvelatching on to breast At the same time work with a specialistin orofacial rehabilitation was done involving the stimulationof sucking and rooting reflexes and the carrying out ofintraoral and extraoral exercises

The extraoral stimulation exercises are aimed at improv-ing the newbornrsquos rooting reflex which are exercises thatstimulate the masseter muscle (putting pressure with theindex fingers and thumb in a circular form in the area ofthe masseter muscles) stimulating the rooting reflex in theperioral region (with the thumbs and index fingers movingforward on the upper and inferior lip in an alternating wayand also making movements around the lips and on themwith the fingers) The intraoral exercises have the functionof stimulating the sucking reflex of the newborn The areasto be stimulated are the palate tongue the inner surface of

Case Reports in Pediatrics 3

Figure 2 Lingual frenotomy surgical technique

the cheeks and the sucking reflex itself (through rotationalmovements while the newborn sucks the index finger) [1920]

It was recommended to the family to carry out theexercises a minimum of 3 times a day repeating it 6 timeson each occasion This is always best recommended beforethe feeds as the baby has more appetite and is more likely tobe cooperative It is also suggested to maximise hygiene mea-sures before beginning stimulation andor use sterile glovesThemyofunctional therapy sessions will have a duration of 20minutes and they are carried out twice a week during a one-month period followed by the breastfeeding sessions [20 21]

In the joint examination of the case it was decided toindicate the performing of a lingual frenotomy which themother accepted It was undertaken on the 21-day-old infantin the surgery area of the hospital

A grooved probe and 12-centimetre-long Metzenbaumdissecting scissors were used (Figure 2) Following surgeryfunctional stimulation was carried out and immediatelyfollowed by breastfeeding

The first check-up was performed 17 days after thefrenotomy (newborn was 5 weeks old) Maternal pain hadreduced to 5 (VAS scale) and theweight of the baby increased200 grams weekly reaching a weight of 3180 grams and thetime of the feeds reduced to 30 minutes

A second check-up was carried out on the newborn at 9weeks of ageThe pain of themother reduced to 0 (VAS scale)and the patientrsquos weight continued to increase by 200 gramsweekly The weight was 4600 kilograms and the time of thefeeds reduced to 15 minutes The patient was discharged

A graph has been prepared that summarises the mon-itoring of the patientrsquos progress by following the circuitestablished by the Suction Pathology Unit at our hospitalcentre (Table 1 and Figure 3)

3 Discussion

The World Health Organization (WHO) has recommendedthat mothers exclusively breastfeed for the first 6 monthsof the childrsquos life [22] The benefits of breastfeeding and thereasons of early weaning have been widely studied A short

Table 1 Table of the progress of the patient following the CELEREcircuit

Weight Pain Time2 weeks 2970 VAS 10 +601015840

3 weeks FRENOTOMY5 weeks 3180 VAS 5 301015840

9 weeks 4600 VAS 0 151015840

12 weeks 5414 VAS 0 151015840

lingual frenulum has been considered as one of the problemsof breastfeeding although it is still a much debated themeamong health professionals [1 3 23ndash26]

The exploration of the oral cavity must be systematic inthe examinations of newborns and infants focusing on thepresence of ankyloglossia without overlooking its detection[3 8]

Coryllos only used anatomical criteria whileHazelbackerincludes valid functional criteria Validation studies havebeen carried out in recent years with reproducible items thatare both anatomical and functional [6 7]

A lingual frenulum is a normal anatomical finding whoseinsertion point and Coryllos classification are not correlatedwith breastfeeding difficulties [27] We use the Coryllosclassification in combination with breastfeeding challenges

Currently there is a debate on how best to manage younginfants with tongue-tie who have breastfeeding problems [57 26 28]

Amir et al in 2006 affirmed that the classification ofHazelbacker is highly reliable in the recommendation of afrenotomy in newborns [6] Martinelli et al in 2015 demon-strated that after a lingual frenotomy babies with a shortlingual frenulum show changes that favour the appropriatestandards of breastfeeding and all the symptoms reported bythe mothers improved [2] Furthermore Power and Murphyin 2015 conclude that 50 of the breastfed babies withankyloglossia will not encounter any problems [5]


2970

3180

4600

5415

Wei

ght

0

5

10

Pain

15998400

30998400

45998400

60998400

Tim

e

2w

eeks

3w

eeks

5w

eeks

9w

eeks

12

wee

ks

Breastfeeding durationPain scale according to VASWeight gain

Figure 3Graph of the progress of the patient following theCELEREcircuit

In our protocol we stimulate sucking and rooting reflexesbefore frenotomy in cases of tongue-tie to improve the orofa-cial function and we agree with Martinelli et al who in theirhistological study said that the frenulum with ankyloglossiahad significant number of striated skeletal muscle fibers Thehigh amount of type I collagen fibers in deep areas mayjustify the restriction of the tongue movement Due to thisfact lingual frenectomy may be considered the appropriateprocedure to release the tongue in order to provide better oralfunctions [12]

The evolution of our patient after the breastfeedingsessions orofacial stimulation and the frenotomy was veryfavourable managing to address the sucking problems thatthe newborn baby presented It improved through elimi-nating the pain of the mother the times of the feeds werereduced and the newborn managed to reach the ideal weightfor his age

The age of the patients is a decisive factor to achieveoptimal results and it is vital to act as soon as possible and ina multidisciplinary way The collaboration and motivation ofthe family also play a decisive role in the resolution of unpro-ductive suctioning in newborns and it is essential to attendall the check-ups and programmed sessions and comply withthe guidelines set out for newborns and accomplish all thetasks assigned

4 Conclusions

Unproductive suction that some newborns have due to anky-loglossia and that occasionally causes pain for the motherduring breastfeeding and the excessively long breastfeedswhich determine the infantrsquos weight gain can be resolvedas a result of the action of a multidisciplinary team Acomplete oral examination (morphological and functional)must be undertaken which includes the tongue particularlywhen feeding problems exist It is important to rule out

abnormalities that can be the cause of sucking problems inbreastfeeding

It is recommended to firstly correct nursing posture dur-ing breastfeeding and stimulate sucking and rooting reflexesFrenotomy is necessary upon the diagnosis of ankyloglossiainterfering in the breastfeeding and when it is done suckingstimulation is recommended before and after the surgicalintervention

In this clinical case the multidisciplinary treatment hasbeen a decisive factor that has resulted in the satisfactoryevolution of our patient

Competing Interests

The authors declare that there is no conflict of interestsregarding the publications of this paper

References

[1] J Edmunds S C Miles and P Fulbrook ldquoTongue-tie andbreastfeeding a review of the literaturerdquo Breastfeeding Reviewvol 19 no 1 pp 19ndash26 2011

[2] R L D C Martinelli I Q Marchesan R J Gusmao H MHonorio and G Berretin-Felix ldquoThe effects of frenotomy onbreastfeedingrdquo Journal of Applied Oral Science vol 23 no 2 pp153ndash157 2015

[3] A Rowan-Legg ldquoAnkyloglossia and breastfeedingrdquo Paediatricsand Child Health vol 20 no 4 pp 209ndash213 2015

[4] A Brookes and D M Bowley ldquoTongue tie the evidence forfrenotomyrdquo Early Human Development vol 90 no 11 pp 765ndash768 2014

[5] R F Power and J F Murphy ldquoTongue-tie and frenotomy ininfants with breastfeeding difficulties achieving a balancerdquoArchives of Disease in Childhood vol 100 no 5 pp 489ndash4942015

[6] L H Amir J P James and S M Donath ldquoReliability ofthe hazelbaker assessment tool for lingual frenulum functionrdquoInternational Breastfeeding Journal vol 1 article 3 2006

[7] J Ingram D Johnson M Copeland C Churchill H Taylorand A Emond ldquoThe development of a tongue assessment toolto assist with tongue-tie identificationrdquo Archives of Disease inChildhood Fetal and Neonatal Edition vol 100 no 4 pp F344ndashF348 2015

[8] D Gonzalez Jimenez M Costa Romero I Riano Galan MT Gonzalez Martınez M C Rodrıguez Pando and C LobetePrieto ldquoPrevalence of ankyloglossia in newborns in Asturias(Spain)rdquo Anales de Pediatria vol 81 no 2 pp 115ndash119 2014

[9] A H Messner M L Lalakea A Janelle J Macmahon and EBair ldquoAnkyloglossia incidence and associated feeding difficul-tiesrdquo Archives of OtolaryngologymdashHead and Neck Surgery vol126 no 1 pp 36ndash39 2000

[10] E Ferres-Amat T Pastor-Vera E Ferres-Amat J Mareque-Bueno J Prats-Armengol and E Ferres-Padro ldquoMultidisci-plinary management of ankyloglossia in childhood Treatmentof 101 cases a protocolrdquoMedicina Oral Patologia Oral y CirugiaBucal vol 21 no 1 pp e39ndashe47 2016

[11] I Knox ldquoTongue tie and frenotomy in the breastfeedingnewbornrdquo NeoReviews vol 11 no 9 pp e513ndashe519 2010

[12] R LMartinelli I QMarchesan R J Gusmao A C Rodriguesand G Berretin-Felix ldquoHistological characteristics of altered


human lingual frenulumrdquo International Journal of Pediatricsand Child Health vol 2 pp 6ndash9 2014

[13] A Jamilian F H Fattahi and N G Kootanayi ldquoAnkyloglossiaand tonguemobilityrdquo European Archives of Paediatric Dentistryvol 15 no 1 pp 33ndash35 2014

[14] L A Kotlow ldquoAnkyloglossia (tongue-tie) a diagnostic andtreatment quandaryrdquo Quintessence International vol 30 no 4pp 259ndash262 1999

[15] A Kupietzky and E Botzer ldquoAnkyloglossia in the infant andyoung child clinical suggestions for diagnosis and manage-mentrdquo Pediatric Dentistry vol 27 no 1 pp 40ndash46 2005

[16] L M Segal R Stephenson M Dawes and P Feldman ldquoPreva-lence diagnosis and treatment of ankyloglossia methodologicreviewrdquoCanadian Family Physician vol 53 no 6 pp 1027ndash10332007

[17] CW Genna and E V Coryllos ldquoBreastfeeding and tongue-tierdquoJournal of Human Lactation vol 25 no 1 pp 111ndash112 2009

[18] M E Wewers and N K Lowe ldquoA critical review of visualanalogue scales in the measurement of clinical phenomenardquoResearch in Nursing amp Health vol 13 no 4 pp 227ndash236 1990

[19] A Bovey R Noble and M Noble ldquoOrofacial exercises forbabies with breastfeeding problemsrdquo Breastfeeding Review vol7 no 1 pp 23ndash28 1999

[20] M T C Sanches ldquoClinical management of oral disorders inbreastfeedingrdquo Jornal de Pediatria vol 80 no 5 pp S155ndashS1622004

[21] S D Colson J H Meek and J M Hawdon ldquoOptimal positionsfor the release of primitive neonatal reflexes stimulating breast-feedingrdquo Early Human Development vol 84 no 7 pp 441ndash4492008

[22] World Health Organization ldquoBreastfeedingrdquo httpwwwwhointtopicsbreastfeedingen

[23] J BerryMGriffiths andCWestcott ldquoAdouble-blind random-ized controlled trial of tongue-tie division and its immediateeffect on breastfeedingrdquo Breastfeeding Medicine vol 7 no 3 pp189ndash193 2012

[24] M Buryk D Bloom and T Shope ldquoEfficacy of neonatal releaseof ankyloglossia a randomized trialrdquo Pediatrics vol 128 no 2pp 280ndash288 2011

[25] A Cho G Kelsberg and S Safranek ldquoClinical inquiries Whenshould you treat tongue-tie in a newbornrdquo The Journal ofFamily Practice vol 59 no 12 pp 712andash712b 2010

[26] P Tsaousoglou N Topouzelis I Vouros and A SculeanldquoDiagnosis and treatment of ankyloglossia a narrative reviewand a report of three casesrdquo Quintessence International vol 47no 6 pp 523ndash534 2016

[27] A Haham R Marom L Mangel E Botzer and S DollbergldquoPrevalence of breastfeeding difficulties in newborns with alingual frenulum a prospective cohort seriesrdquo BreastfeedingMedicine vol 9 no 9 pp 438ndash441 2014

[28] L A Ricke N J Baker D J Madlon-Kay and T A DeForldquoNewborn tongue-tie prevalence and effect on breast-feedingrdquoJournal of the American Board of Family Medicine vol 18 no 1pp 1ndash7 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


It seems to have a genetic aetiology and is mainly found inmale infants [3 13ndash16]

Hence ankyloglossia is a limitation in lingual mobilitythereby impeding tongue protrusion as well as the liftingof the tip of the tongue due to the shortness andor thegenioglossus muscles [4 10ndash12]

The aim of this work is to present a case of ankyloglossiawith sucking problems treated by the Suction Pathology Unit(CELERE) This multidisciplinary unit is incorporated in theFoundation of Hospital de Nens de Barcelona (FHNB) and ismade up of the Service of Maternal Lactation the Service ofSpeechTherapy and Orofacial Myofunctional Rehabilitationand the Service of Oral and Maxillofacial Surgery whichis responsible for the study treatment and follow-up ofnewborn patients that have sucking problems It is a muchdebated topic on which there is still quite limited scientificevidence

2 Case Report

The case involves a 17-day-old newborn of masculine sexthat attends the Suction Pathology Unit (CELERE) who wasreferred by his pediatrician as a result of sucking problemsduring breastfeeding and ankyloglossia The diagnosis ofankyloglossia is carried out according to the Coryllos classifi-cation which defines four types of frenulum Type I fine andelastic frenulum where the tongue is anchored from the tipto the alveolar ridge and it is found to be heart-shaped TypeII fine and elastic frenulum where the tongue is anchoredfrom 2ndash4 millimetres of the tip to almost near the alveolarridge Type III thick fibrous and not elastic frenulum thetongue is anchored from themiddle of the tongue to the floorof themouth Type IV the frenulumcannot be seen butwhenpalpation is performed one can feel fibrous anchoring andorthick and shiny submucosa from the base of the tongue to thefloor of the mouth [8 17]

Besides the Coryllos classification functional clinicalcriteria were also taken into account poor weight gain (lessthan 100 grams per week) excessively long breastfeeds (morethan 60minutes) andmaternal pain (maternal breastfeedingshould not be a cause of pain for the mother)

The data has been gathered in three different momentsof the treatment at the beginning of it at two weeks of ouraction and at the end of the treatment and the degree ofankyloglossia maternal pain during breastfeeding weightprogress and the length of the feeds were evaluated 15 daysafter

The Visual Analogue Scale (VAS) was used in the evalua-tion of the pain [18]

The evolution of weight gain is assessed throughweighingthe child before each breastfeeding and stimulation sessionalways keeping in mind using the same scales (digital)

The time of the breastfeeds was measured by the motherherself and to this end the following time intervals wereestablished lt15 minutes 15ndash30 minutes 30ndash60 minutes andgt60 minutes the value chosen for the study and evaluatingthe evolution was the highest time interval

Figure 1 Lingual frenum with degree II ankyloglossia

The case involves a 42-year-old mother without previouspregnancies It was a natural birth from 39 weeksrsquo gestationand a cesarean delivery was performed due to the hyper-tension of the mother The weight of the child at birth was2900 grams and the 1-minute APGAR score was 7 and thesecond test performed 5 minutes later was 9 without peri-or postnatal complications The type of lactation chosen wasexclusive breastfeeding

The weight of the newborn on the first visit was 2970grams Maternal pain during breastfeeding was 10 (VAS)Poor weight gain was recorded less than 100 grams per weekThe breastfeeds were excessively long more than 60 minutesA thorough physical examination of the babywas undertakenwith special attention to muscle tone and the anatomy of theoral cavity and the maxillofacial region The newborn wasdiagnosed with ankyloglossia degree II (Coryllos classifica-tion) by visual inspection and palpation slight physiologicalretrognathia (normal condition of mandible developmentconsidering the age) poor latching and unproductive suck-ing (Figure 1)

The treatment began through undertaking breastfeedingsessions in order to correct nursing posture and improvelatching on to breast At the same time work with a specialistin orofacial rehabilitation was done involving the stimulationof sucking and rooting reflexes and the carrying out ofintraoral and extraoral exercises

The extraoral stimulation exercises are aimed at improv-ing the newbornrsquos rooting reflex which are exercises thatstimulate the masseter muscle (putting pressure with theindex fingers and thumb in a circular form in the area ofthe masseter muscles) stimulating the rooting reflex in theperioral region (with the thumbs and index fingers movingforward on the upper and inferior lip in an alternating wayand also making movements around the lips and on themwith the fingers) The intraoral exercises have the functionof stimulating the sucking reflex of the newborn The areasto be stimulated are the palate tongue the inner surface of










3 Discussion





9 weeks 4600 VAS 0 151015840

12 weeks 5414 VAS 0 151015840








2970

3180

4600

5415

Wei

ght

0

5

10

Pain

15998400

30998400

45998400

60998400

Tim

e

2w

eeks

3w

eeks

5w

eeks

9w

eeks

12

wee

ks






4 Conclusions





Competing Interests


References




































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

























3 Discussion





9 weeks 4600 VAS 0 151015840

12 weeks 5414 VAS 0 151015840








2970

3180

4600

5415

Wei

ght

0

5

10

Pain

15998400

30998400

45998400

60998400

Tim

e

2w

eeks

3w

eeks

5w

eeks

9w

eeks

12

wee

ks






4 Conclusions





Competing Interests


References




































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















2970

3180

4600

5415

Wei

ght

0

5

10

Pain

15998400

30998400

45998400

60998400

Tim

e

2w

eeks

3w

eeks

5w

eeks

9w

eeks

12

wee

ks






4 Conclusions





Competing Interests


References




































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of







































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















case report management of ankyloglossia and breastfeeding

Documents