Sep 9 / Sarah Oakley

Lip tie

To understand how an upper lip tie may affect feeding, we need to look at how the baby attaches to the breast. Older breastfeeding literature talked about both the upper and lower lips flanging during breastfeeding to form ‘fish lips’. The idea that ‘fish lips’ are a good sign still litters the internet and popular literature on breastfeeding. However, ideas about the role of the upper lip have changed. In actual fact, only the lower lip should flange. Catherine Watson Genna IBCLC, in her latest 2017 edition of Supporting Sucking Skills in Breastfeeding Infants, says ‘lips are gently applied to the breast with the lower lip flanged completely outward and the upper lip neutral to slightly flanged (p 28). She goes on to quote an article by Kay Hoover IBCLC from 1996 on page 37. ‘The nasolabial crease should remain soft, and the upper lip should be neutral to slightly everted on the breast and should be relatively immobile during sucking.’ She says ‘an overly flanged upper lip is a sign of shallow attachment or overuse of the lip to compensate for tongue immobility’. A recent study using real time MRI to image swallowing supported Catherine’s view that during feeding the lip sits in a neutral or everted position and wouldn’t normally flange (Mills et al, 2020).

Babies who flange the top lip are doing so because they are compensating for a shallow latch due to poor positioning or a tongue tie. They are using the top lip to hang onto and compress the breast. Obviously if the top lip is tense, the baby will find it harder to employ the lip to compensate for the tongue tie. However, if the tongue-tie is divided the need to flange the lip will be eliminated and the presence of a lip tie will become irrelevant. Furthermore, tension in the upper lip is often related to tension coming from the tongue-tie, as the tongue-tie can cause tension is the lower jaw and under the chin. The tight lip often relaxes after tongue-tie division alone. Bodywork (cranial osteopathy, CST and chiropractic) can also help release lip tension. Currently there is no published research to support that lip ties are associated with feeding issues as a systematic review of the literature concluded (Nakhash et al, 2019).

A further review of the literature on lip tie and breastfeeding in 2021 by Gina Weissman (Dentist and IBCLC) and colleagues noted these key messages:

1. Many infants with upper lip tie undergo surgical procedures to release the maxillary frenulum to improve breastfeeding. However, it is not clear if this intervention is necessary or even useful.
2. Limited data exist that correlate breastfeeding and the maxillary frenulum/ULT. None are from randomized trials and each of the studies have significant limitations.
3. This critical review of the literature shows that there is currently no clear or strong evidence justifying maxillary frenulum release as a therapeutic procedure.

The Association of Tongue-tie Practitioners have a statement on lip tie on their website which summarises the UK situation www.tongue-tie.org.uk (See below).

Currently there is no published evidence supporting a link between breastfeeding issues and lip tie. NICE have not issued any guidance on this issue, and therefore, training is not available in the UK in lip tie division for practitioners. This situation may change in the future if new research and evidence influences best practice guidelines. Currently nurse/midwife tongue-tie practitioners working in the UK cannot offer lip tie division as the Nursing and Midwifery Council’s Code of Conduct states that nurses, midwives and health visitors must ‘deliver care based on the best available evidence or best practice’ and ensure any advice given is evidence based if suggesting healthcare products or services. The Code also requires that nurses and midwives recognise and work within the limits of their competence. On the rare occasions that lip ties are divided by surgeons in the NHS it is usually done in relation to concerns about dental issues, not breastfeeding. If you have concerns about lip ties we suggest you discuss this with your dentist.

The idea that upper lips ties are significant and need to be treated seems to originate largely from the United States where dentists perform many of the tongue-tie divisions and increasingly divide upper lip ties at the same time. Dentists initially appear to have developed an interest in upper lip tie because it was thought it could predispose babies to dental decay if they continue to breastfeed through the night once teeth come in. The tie may act as a pocket where milk can pool and cause decay. (E. Kernerman IBCLC, Live Tongue-tie Webinar, 3/4/14). However, we have no research to support the idea that lip tie is associated with dental decay in breastfed babies.

Not all dentists agree that treating lip ties in babies to prevent future dental problems is a good idea. The dental literature describes lip ties as normal anatomy. They form in the womb and are meant to be there and hold space for when the larger adult front teeth come in by creating a gap in the baby teeth. gaps in the baby teeth facilitate jaw expansion. They are a good thing! Associate Professor Angus Cameron from the Sydney Tongue-tie Clinic in Australia has this to say about lip tie division in babies on his website http://sydneytonguetie.com.au/#about :

Releasing an upper labial frenum can be a traumatic procedure as the lip is innervated and sensitive and the labial frenum is vascular so bleeds. Problems reported include the persistence of an anterior diastema (gap between the front teeth) that is difficult to close orthodontically and I have had professionals personally report to me seeing cases where the baby or adult teeth inside the gums were damaged during the procedure. In a recent study of 109 patients Richard Baxter, an American dentist, concluded that we should not be concerned about these potential risks as they did not occur in his sample and are unlikely if the procedure is done ‘properly’ (Baxter et al, 2022). But just as we have some medical and dental professionals taking scissors to babies mouths to divide tongue-tie with little or no training, there is no reason to think that every dentist or doctor doing this procedure has extensive training and skills in this. Especially when treating babies which for most will be outside their normal client group as most dentists don’t start treating people until around age 3. Richard’s study isn’t large enough to draw any conclusions about complication rates across practitioners, or in babies where teeth are still hidden within the gum. None of the patients in his study were babies. The youngest was 1.3 years and the oldest was 8.1 years and they all had teeth.

There are also suggestions that lip ties may cause speech issues. I have not seen any research to back this up or found any speech therapists who feel they are significant in terms of speech. The strongest indications for treating a lip tie seem to be to prevent dental decay, or gaps in the front teeth when adult teeth come through. Some dentists in the UK are starting to refer older children for treatment before orthodontic work. Because of the lack of evidence to support a link between lip tie and feeding difficulties the NHS does not offer lip tie division for feeding issues. However, some NHS Trusts will treat older children to prevent dental problems. If you have concerns about upper lip tie I would suggest talking to your dentist.

Here is a link to an article I originally wrote in 2016 and the updated in 2022 which provides more detail on this issue:

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