The Upper Lip Frenulum and Breastfeeding Success

CQ #224 – May 24, 2021

by Anne Eglash MD, IBCLC, FABM

#LACTFACT

The presence of an upper lip frenulum is normal and has not been found to be associated with breastfeeding difficulties.

Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation with Ankyloglossia

Laryngoscope, 131: E1701-E706, 2021

How common are upper lip frenula and do they impact breastfeeding success?

The ‘upper lip tie’ has become a commonly discussed entity among lactating individuals. Many families share that they were told to have their infants’ upper lip frenulum clipped for various breastfeeding problems. Many professionals performing oral surgery procedures on tongue-ties will often cut or laser the upper lip frenulum. The question is whether the upper lip frenulum causes breastfeeding problems. Previous evidence has shown that the upper lip frenulum is a normal finding in all newborn infants.

The researchers for this week’s article evaluated the upper lip frenulum anatomy in healthy newborns, to determine if there is an association between the ‘grade’ of the frenulum (where it attaches to the upper gum) and breastfeeding success. Further, there is a belief that upper lip ‘ties’ correlate with tongue ties, and the researchers were interested to see if they could measure this relationship.

The study enrolled 100 healthy term newborns in Rochester NY, USA. Each newborn had their upper lip and tongue frenulum measured by 2 raters. Demographic information was collected, and the infant breastfeeding assessment tool (IBFAT) was used within the first week and at 2 weeks postpartum to evaluate maternal comfort with breastfeeding.

The researchers found that presence of the most prominent upper lip frenulum, which attaches all the way to the edge of the upper gum, was not associated with maternal pain during breastfeeding.

According to these authors, what do you think are accurate statements regarding the upper lip frenulum in this population?

Approximately 25% of the infants had a grade 3-4 upper lip frenulum that extended to the edge of the upper gum.
Approximately 50% of the infants had a grade 1 upper lip frenulum, meaning that the frenulum was barely noticeable and not considered a ‘tie’.
Infants who had more prominent upper lip frenula were more likely to have a tongue tie that extended to the tip of the tongue.

See the Answer

Correct Answer: A (not B nor C)

Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation with Ankyloglossia

Laryngoscope, 131: E1701-E706, 2021

Shah S, Allen P, Walker R, Rosen-Carole C, McKenna Benoit MK

Abstract

Objectives

There is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated.

Methods

A prospective cohort study of 100 healthy newborns was examined between day of life 3–7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter-rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated.

Results

Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip.

Conclusions

There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

This is the second study that graded the upper lip frenulum in 100 infants. Both studies confirmed that nearly everyone has an obvious, significant upper lip frenulum at birth! In this study, only 1 infant had a minimal grade 1 upper lip frenulum.
For this reason, I wish the authors did not title this article ‘Upper Lip Tie’. ‘Tie’ implies pathologic tethering.

One limitation of this study is that only 39.5% of mothers completed the 2-week follow-up survey on breastfeeding success/pain.

The authors suggested that perhaps it is not so much the length of the upper lip frenulum but the stretchiness and lip attachment site of the upper lip frenula that might determine impact on breastfeeding. I have to agree with this. My evaluation of infants includes sweeping my gloved finger beneath the upper lip to evaluate floppiness/flexibility. If the upper lip is tacked down, which is rare, then the upper lip cannot act as a relaxed seal/gasket on the breast, which is its main function.

There are certainly cases where the upper lip is relaxed on oral exam, but when at the breast, the upper lip tenses and curls due to other dynamics, such as having to hang-on for dear life.
Like nearly all problems in breastfeeding, starting with the basics of optimal positioning and latch is the best way to help dyads without doing harm.