Sample FAQ: Lip-ties
What is a lip-tie?
There is a cord of tissue between the top lip and the upper gum. This is called the labial frenulum. It is normal and present in all babies. When the labial frenulum is blamed for causing breastfeeding problems, it can be called a lip-tie. Just as tongue-tie diagnoses have become extremely popular, so too have lip-ties. There is currently no reliable way to determine whether a labial frenulum is causing problems and no good evidence that surgery will solve breastfeeding problems. As a result, some highly-qualified experts do not support babies having lip-tie surgery for breastfeeding problems. Very rarely, a severe lip-tie can affect the movement of the upper lip and the bone of the upper gum.
A) Describing lip-ties
All babies have a labial frenulum, the cord of tissue between the top lip and upper gum (Ray 2019; Santa Maria 2017). It runs down the front of the gum to varying degrees, and provides stability for the upper lip.
One study (Santa Maria 2017) of 100 newborn babies found that the labial frenulum:
- Was rarely short or thin.
- Extended to the middle of the upper gum in 83 babies and to the lower edge of the upper gum in 11 babies.
As the baby grows, the upper gum becomes longer and the frenulum is then attached only to the top part of the gum and appears less prominent (Delli 2013).
Recently, excess tightness of the labial frenulum has been blamed for a variety of breastfeeding problems and has been called a lip-tie.
This is different from the lingual frenulum, which is the cord of tissue under the tongue that can cause tongue-ties.
B) Popularity of lip-tie diagnosis
Just as tongue-tie diagnoses have become extremely popular, many parents are concerned that their baby has a lip-tie, which is causing many or all of their breastfeeding problems.
Practitioners may cut a perceived lip-tie with lasers or scissors.
Lip-ties are often diagnosed along with posterior tongue-ties. Babies may then undergo two surgeries at once, resulting in two painful wounds. It would be more reasonable to see if the first surgery was effective before having a second costly and perhaps unnecessary procedure.
C) Lip-tie evidence
There is no classification system that reliably predicts which type of labial frenulum will cause breastfeeding difficulties. The most commonly-used rating tool is the Kotlow but it has been found to have significant problems (Kotlow 2013; Santa Maria 2017).
There are no reliable studies showing the effectiveness of cutting the labial frenulum (LeFort 2021; Nakhash 2019; Razdan 2020; Santa Maria 2017; Shah 2020).
Families may worry that a lip-tie is keeping the lip from curling outward (flanging) while breastfeeding. One MRI study (Mills 2020) has shown that the lip does not need to be curled out in order for babies to breastfeed successfully and only needs to be in a neutral position.
Some families worry that a lip-tie will cause increased spreading of the upper front teeth. Babies and toddlers have a space between their front teeth, which closes once the permanent teeth come in. One group of experts (Messner 2020) did not recommend babies have lip-tie surgery to prevent future excess spreading of the upper front teeth.
D) When to be concerned
Some mothers notice that their baby breastfeeds with the top lip folded or curled inwards into the mouth. The normal lip position is flat or curled outward on the areola and breast.
If you notice an inward curl, ensure that your baby is latching properly with a wide-open mouth. If you cannot uncurl the lip with your fingers or cannot lift the lip away from the gum, the baby should be checked by a qualified person such as a pediatric dentist or a physician-specialist.
In very rare cases, a severe lip-tie can affect the movement and shape of the upper lip and the bone of the upper gum (Heo 2018).
Delli K, Livas C, Sculean A, et al. Facts and myths regarding the maxillary midline frenum and its treatment: a systematic review of the literature. Quintessence Int. 2013 Feb;44(2):177-87
Heo W, Ahn HC. Upper lip tie wrapping into the hard palate and anterior premaxilla causing alveolar hypoplasia. Arch Craniofac Surg. 2018 Mar;19(1):48-50.
Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013 Nov;29(4):458-64
LeFort Y, Evans A, Livingstone V, et al. Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads. Breastfeed Med. 2021 Apr;16(4):278-281
Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020 Apr 14:194599820915457
Mills N, Lydon A-M, Davies-Payne D, et al. Imaging the breastfeeding swallow: Pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology. 2020;1–8
Nakhash R, Wasserteil N, Mimouni FB, et al. Upper Lip Tie and Breastfeeding: A Systematic Review. Breastfeed Med. 2019 Jan 25
Ray S, Golden WC, Walsh J. Anatomic Distribution of the Morphologic Variation of the Upper Lip Frenulum Among Healthy Newborns. JAMA Otolaryngol Head Neck Surg. 2019 Aug 22
Santa Maria C, Aby J, Trong MT, et al. The Superior Labial Frenulum in Newborns: What Is Normal? Global Pediatric Health. 2017;4:2333794X17718896
Shah S, Allen P, Walker R, et al. Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia. Laryngoscope. 2021 May;131(5):E1701-E1706
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