Upper Lip Tie – 4 Facts About Breastfeeding And Upper Lip Ties

Upper Lip Tie - 4 Facts About Breastfeeding And Upper Lip Ties

The topic of tongue and lip ties seems to come up often in many breastfeeding related Facebook discussions.

‘Ties’ is a collective term that refers to tongue tie, upper lip tie and maybe even buccal (cheek) ties.

The presence of the frenulum (band of connective tissue) underneath the upper lip is known as the labial (or maxillary) frenulum.

The presence of a labial frenulum is normal.

If the labial frenulum happened to affect function of the upper lip, it could be referred to as an upper lip tie.

It has been suggested that some breastfeeding problems (e.g. poor latch or ‘reflux’ signs and symptoms) may be contributed to by an upper lip tie.

However, to date there is insufficient evidence to either support or refuse these claims.

4 Facts About Breastfeeding And Upper Lip Ties

This article explores the evidence about breastfeeding and upper lip ties.

#1: Presence Of Labial Frenulum Is Normal

It has been suggested that where the labial frenulum inserts onto the upper gum is indicative of a class of an upper lip tie.

For example, the Kotlow classification scale notes that a class 3 maxillary lip tie is when the labial frenulum inserts ‘just in front of the anterior papilla’, and a class 4 maxillary lip tie is when the labial frenulum has an ‘attachment just into the hard palate or papilla area’.

However, what the Kotlow (and other scales) actually show is the range of normal labial frenulums.

A study of over 1,000 newborns who weren’t having any particular problems found:

  • 6.7% had ‘buccal’ insertions of the labial frenulum (class 1 or 2 ‘Kotlow’ attachment)
  • 76.7% had ‘crest of alveolar ridge’ insertions (class 3 ‘Kotlow’ attachment)
  • 16.7% inserted ‘palatally’ (class 4 ‘Kotlow’ attachment).

All these findings show the range of normal labial frenulums.

#2: Labial Frenulums Change

As a baby get older the labial frenulum changes. It tends to get smaller and thinner and rises up on the upper gum as the jaw grows.

While most babies have a class 3 or 4 ‘Kotlow’ attachment, only 21.2% of children with primary teeth, 10% with mixed (baby and permanent) teeth and 5.6% with permanent teeth (11-12 years of age) do.

#3: There Is No Diagnostic Criteria For Upper Lip Tie

Since the presence of a labial frenulum is normal, it’s not appropriate to call it an upper lip tie unless it’s clearly causing a functional problem.

So, with all the above in mind, when would a labial frenulum be called an upper lip tie in a baby? The truth is that this is anyone’s guess at the moment as we do not have any valid diagnostic criteria for it.

Evidence is significantly lacking with regards to when it may be helpful to release a baby’s labial frenulum.

This is because studies that have included releases of labial frenulums have not released ‘upper lip ties’ and tongue ties separately but rather have released them together.

Hence, it cannot be determined if results of such studies are due to the tongue tie release, the ‘upper lip tie’ release or both.

#4: Upper Lip Only Needs To Rest In A Neutral Position For Effective Breastfeeding

For effective breastfeeding, the upper lip does not have to flange out like the lower lip – it only needs to rest in a neutral position.

If the criteria used for diagnosing an upper lip tie were that the upper lip needed to flange out like the lower lip does when breastfeeding, then the vast majority of babies would have upper lip tie!

Finally, the high prevalence of the Kotlow class 3 and 4 amongst babies can lead to misdiagnosis during the first few years of age and result in unnecessary surgical correction.

As Nagavini indicates:

“Therefore, it is very important to distinguish between a wide normal frenulum and an abnormal one in young children, and knowledge about the frenulum types in children is highly essential among the clinicians to avoid unnecessary surgical intervention.”

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Renee Kam IBCLC CONTRIBUTOR

Renee Kam is mother to Jessica and Lara, an International Board Certified Lactation Consultant (IBCLC), a physiotherapist, author of 'The Newborn Baby Manual' and an Australian Breastfeeding Association Counsellor. In her spare time, Renee enjoys spending time with family and friends, horse riding, running and reading.


3 comments

  1. Having read this article, I see no evidence whatsoever to release a labial frenulum. Why fix what ain’t broke.
    Who knows in the long term whether there could be negative impacts from this.
    The wise mum should get several opinions and be sure the evidence is there before considering any “tongue tie release.”
    Well written Renee.

  2. My baby boy had both a post and anterior tongue tie. We had them cut as he was having difficulty latching to both nipple and bottle. After we had both his toes cut it did seem to help a little bit, but after 2weeks he stopped latching on all together. I only noticed the other week that his lip is also tied to the point you can not lift his lip to see his gums. I didn’t realise that this may have been a issue for him and also stopped him latching on properly. When I showed the HV she said they don’t do anything about lip ties and that I probably will never be able to see his gums with out causing him discomfort.

  3. My newborn wasn’t gaining weight while breastfeeding so on advice of a lactation consultant every time my daughter was hungry I attempted to breastfeed, then fed expressed breast milk in a bottle, then pumped milk for the next feed. She starting having excellent weight gains but I was exhausted. I really, really wanted to breast feed so between the ages of 1 and 4 months I saw a total of 3 lactation consultant, 3 paediatricians, a speech therapist, child health nurse, occupational therapist and physiotherapist.

    Each lactation consultant had me buy a new set of bottle teats (and 2 had me buy dummies) because each said the teats the other lactation consultants had me buy were wrong. I was told everything from I wasn’t positioning her right, wasn’t attaching her right, she has a small jaw, her reflux has given her an oral aversion…
    To remedy her oral aversion I was told to stop breastfeeding her for a week (only bottle feeds). My daughter’s motivation to attempt breastfeeding plummeted after that as she had developed a preference for the bottle.

    I looked up upper lip tie and together we had almost every symptoms, for example, she suffered with fussing and arching at the breast, crying before and after feeds, reflux and colic, and I suffered with nipple pain, squashed nipples, nipple thrush, engorgement and then low supply (until I started pumping and my supply normalised). When I asked I was told “her upper lip frenulum is normal”.
    By 4 months she would barely even attempt to breastfeed so I gave up and became an exclusive pumper until she was 8 months when I couldn’t cope anymore.

    At 11 months her top teeth came in and the lip tie became more obvious – she had a huge gap, with tissue joining her lip to her palate. At 11 months she still had reflux, snoring and trouble eating and drinking – coughing and gagging at every meal and spitting out any foods that required chewing.
    I finally found an oral surgeon who specialised in ties.
    In the waiting room I spoke with parents who had been through what my family had been through. One father said “I don’t understand why there is a cover-up about this problem” – it certainly felt that way to me.
    The surgeon also found my daughter had multiple tongue ties and was not surprised that her very obvious lip tie had been dismissed – I think he had heard my story many times from other parents.
    She had her lip and tongue tips released and we have a plan in place to have her reviewed regularly to prevent speech problems and check that her eating normalises.

    My advice to other mums having problems with breastfeeding – please look up the symptoms of lip and tongue tie and compare photos to your baby. I understand that lip and tongue ties may not cause breastfeeding problems in many babies, but if your baby does have a lip or tongue tie and does have breastfeeding problems or other symptoms (many other symptoms which can continue into adulthood) – see a specialist dental surgeon because your lactation consultant may dismiss your concerns and put the blame on you.

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