How Does An Upper Lip Tie Affect Breastfeeding?

Tongue tie division is a very effective procedure in the majority of babies with ankyloglossia. However, there are many reasons why an initial procedure to divide a tongue tie (a lingual frenotomy) can fail to improve breastfeeding symptoms.

• The procedure was not carried far enough under the tongue (the thin membrane of an obvious tongue tie was cut but the thicker portion behind it was left intact)
• The cut area under the tongue reattached (it healed too quickly) and the tongue's mobility mimics what it was prior to the procedure
• The tongue tie was not the only problem contributing to breastfeeding difficulties

It is this last point that I will address here. Most medical practitioners haven't even heard of an upper lip tie (ULT). While almost everyone has an upper lip frenulum, only those with restriction of function of the upper lip are defined as having a tie.

I previously touched on the importance of the upper lip flanging outward during a deep latch when I showed the various ultrasound studies that demonstrated proper breastfeeding motion. The normal breastfeeding motion is best achieved when the baby can widely open the mouth. This wide opening is best achieved when the baby is able to flange the upper lip outward, allowing the mucous membrane portion of the lip (rather than the dry outer portion) to contact the breast. This allows for a better seal, which is the first step in generating the negative pressure for breastfeeding. When a central ULT tethers the lip downward, that flanging motion is impeded. This results in a smaller mouth opening and forces the baby to adopt a more shallow position on the breast, leading to a multitude of problems.

The upper lip tie can affect the baby's ability to flange in several ways. The first is the most obvious - the shorter and tighter the frenulum is, the more uncomfortable it is for baby to flange that lip outward, even if mom flanges the lip out manually. I have repeatedly seen a baby with an ULT trying to nurse as mom attempts to flip the lip upward. Moments later, the baby will either pop off the breast completely or will very briefly relax the latch off the skin just enough to allow the upper lip to roll back in, which is a more comfortable position. The mom will often complain about repeatedly having to flip the lip upward in frustration. The second way that a tight ULT affects breastfeeding is just based on muscle flexibility. To widely open the mouth, a baby without an ULT pushes the upper lip up toward the nose. When an ULT is present and the lip is naturally rolled inward, the muscle around the lips (the orbicularis oris muscle) cannot be pushed up toward the nose. This puts an unnatural amount of tension on the muscle of the lip itself. Try this yourselves. First, open your mouths naturally as wide as you can. Compare that sensation to when you forcibly tuck in your upper lip followed by an attempt at widely opening your mouth. You will notice tension across the upper lip (and not on the ULT itself). A baby can't and won't open widely if the lip is tense.

It is important to know that there are no peer-reviewed studies showing the efficacy of dividing an ULT when breastfeeding is impacted. While there are qualitative objective measures that seek to grade the severity of breastfeeding dysfunction with respect to a tongue-tie, no such measures exist for an ULT. Many physicians and lactation consultants point to this and therefore argue that division of an ULT shouldn't be done. Of course, I disagree:

• As a physician, it is my duty to do what I can to help my patient (and their mothers). Like many other physicians, I practice the art and science of medicine by analyzing the available data and combining that with what is appropriate and safe. As a result, I often treat patients with medications or surgeries that have not been rigorously tested by a multicenter, double blinded randomized controlled trial. Like most other doctors, I use procedures and medications and tailor those to the specific patient's problems. Basically, I use my judgement. How can we generate data if we are asked not to investigate the procedure? Division of ULT is extremely safe. The anecdotal evidence in support of the procedure is quite overwhelming.
•  In a bulletin put out in 2004 by the American Academy of Pediatrics, Corrylos and colleagues write: "A baby who cannot flange his /her upper lip because of a tight upper labial frenulum may need to alter his/her nursing position or have it surgically released in order to permit effective nursing. A mother with a short nipple and inelastic breast tissue may have trouble even achieving latch-on with such a baby. It may be that a short or tight lower labial frenulum can cause similar problems by preventing the lower lip from flanging." This thought process isn't new, and its presence has been acknowledged by the AAP.
• In the best study of babies with tongue-tie, Dr. O'Callahan and colleagues (2013) found that 37% of babies with tongue tie also had a current ULT. Those ULTs were treated routinely as part of the study. While they were not specifically separated out and studied, it shows the importance of treating the baby to maximize breastfeeding outcomes. Many practitioners who routinely treat tongue-tied babies feel that this number likely underestimates the number of babies who would benefit from a lip tie revision. My experience has shown me the importance of addressing the ULT when it is present. Dr. O'Callahan's study confirms that importance. I feel that ignoring an ULT because of the lack of a dedicated study looking at ULT in breastfeeding is unethical. It increases the chances that babies need a second procedure, in addition to prolonging the breastfeeding problems that they are already having. A similar example exists when children with sleep apnea have large tonsils and adenoids. I don't think it's appropriate to just remove the tonsils because of the lack of good data saying that the adenoids should also be removed. We must treat the entire problem.

My goal is to get everyone who is involved in improving breastfeeding outcomes to step back and use a practical approach while combining that with a knowledge of anatomy. Many of us know what the ideal latch looks like; the flanging upper lip is part of that ideal latch. If an anatomical problem limits the ability to form an ideal latch, and a simple procedure exists to completely change that ability, I maintain that it should be done. With time, we will generate more data. But I will not allow the lack of data to paralyze me in treating babies and moms who need help now.

How Tongue-Tie Affects Breastfeeding Mechanics

So far, we've discussed the myths propagated about abnormal breastfeeding, how to examine for tongue-tie and the various symptoms that arise from breastfeeding a tongue-tied baby for both mom and baby. This post will explain the mechanism by which the tongue-tie affects breastfeeding.

Before defining how breastfeeding actually occurs, it's important to clear up some misconceptions. How does a baby actually breastfeed? Here are some older theories for the mechanics of breastfeeding:

• The baby sucks on the nipple as if it were the end of a bottle 
• The baby uses the lips and tongue to strip the breast (e.g. milking the breast)
• The baby just drinks breast milk (believe me, I've heard this)

The most common misconception is the second of those mentioned. People think that the breast fills up with milk, and it is the baby's job to remove that milk by undulations of the tongue and upper lip in a milking movement. Ultrasound data show us that this isn't true. Occasionally, the first and third misconceptions do happen. When a baby is tongue- or lip-tied, they will cheat down to the end of the nipple and will nipple feed instead of breastfeed. And in some instances, when mom has an overactive letdown or oversupply, the baby has to exert very little effort and just drinks what is presented. This isn't a sustainable method of nursing.

The best data to date come from ultrasound studies. These studies show two important concepts:

1. They show the minimal involvement of the nipple in children without tongue-tie and conversely, a mechanism for the damage that occurs to the nipple in the tongue-tied child
2. They show that the mechanism of nursing depends on the baby generating negative pressure inside the mouth, which draws the milk out

Panel A shows a tongue-tied baby compressing the nipple tip. Panel B shows less compression following a frenotomy. From Geddes 2008.  (HSPJ = hard/soft palate junction)

What happens to the nipple while inside the baby's mouth?

The data from Geddes' study show two separate patterns of nipple positioning when a baby is tongue-tied. Interestingly, I have seen this in the babies in my office who cause two different patterns of nipple damage. The first pattern occurs when the nipple is in the appropriate position in the mouth, which is at the junction of the hard and soft palate (further back than most people think). These tongue-tied babies are able to get around the length of the nipple but tend to clamp down and bite at the base of the nipple. Clinically, this can result in creasing and blanching at the base of the nipple. The second pattern occurs when a baby uses the tongue to block or thrust the nipple forward in the mouth. These babies are unable to keep the nipple in the appropriate position, so the damage is more on the nipple itself rather than around it. This may also explain why some babies are unable to tolerate a bottle or a pacifier. Instead of moving freely, the tether of the tongue forces the tongue to move in a forward, rather than an upward, motion. Why a tongue-tied baby uses one tongue motion over the other is unknown.

What are the mechanics of breastfeeding?

Now that we understand that the baby does not physically "milk" the breast, let's look at what a baby does to draw milk out of the breast. Again, we will turn to the ultrasound studies. The most plausible explanation for how a baby nurses involves the generation of negative pressure (a vacuum of sorts) within the oral cavity using an up and down motion of the tongue. First, the baby must have the ability to form a seal around the breast. This involves the upper lip flanging outward and the tongue cupping and elevating the breast towards the palate. If the tongue cannot elevate, cupping can be quite weak and the baby can "fall" off the breast. As important is the ability for the midportion of the tongue to freely elevate and depress within the oral cavity. This is how the baby draws milk out of the breast - the baby will push their tongue up towards the palate and then quickly depress it, creating a vacuum.

Please spend a moment to watch this brief video of an ultrasound showing the motion of the tongue in generating this negative pressure. Pay special attention to the fact that the nipple itself is not manipulated much in a baby that isn't tongue-tied. 

These data demonstrate that breastfeeding is less about the nipple and more about the depth of the latch and the mobility of the tongue. It explains how many babies with no visible tongue-tie can still have terrible latches. These posterior tongue ties are more hidden, but still cause significant restriction of movement (in that critical upward direction). It also explains why a baby's ability to stick the tongue forward is irrelevant in assessing whether tongue-tie exists.

The Geddes studies show us the importance of thinking about a baby's anatomy and how it will impact breastfeeding. I will make a similar argument when we discuss the importance of a tethered upper lip. If anatomy is preventing the latch from being initiated, a domino effect of compensatory movements begins. Prevention of that compensatory domino effect is critical in maintaining a long-term nursing relationship.

Reference: Geddes, et al. Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. Pediatrics. 122:1; e188-e194.

A Breastfeeding Mom's Symptoms Are as Important as the Baby's

My last post detailed how tongue-tie and lip-tie can have significant adverse effects on the baby trying to nurse. This post will detail how a poor latch from tongue-tie or lip-tie can harm mom.

While most moms would prefer to exclusively breastfeed, negative symptoms at the breast may prevent it from being possible.

I often hear from moms that they feel like they're being selfish for putting their children through a procedure, particularly if that child is not experiencing any significant negative effects from breastfeeding. The argument against this sentiment is quite easy: anything that jeopardizes a mom's ability to breastfeed obviously puts the baby in harm's way. I maintain that babies should nurse for as long as possible without having some external situation forcing them to wean. Sometimes, that means focusing on the mom's symptoms instead of the baby's if her symptoms are worse.

What are some of the consequences for mom when the baby has a poor latch from tongue-tie or lip-tie?

• Nipple damage - These are among the most obvious consequences of a baby's poor latch from tongue or lip restrictions. If the baby cannot flange out their lip appropriately, the lip will roll inwards, making the latch more shallow. Additionally, if the tongue is restricted, it cannot appropriately cup and lift the breast within the oral cavity, and the lower gumline is exposed. When the lower gum and the upper lip are what is being used to hold on to the breast, nipple damage can occur. Early signs include a change in the nipple shape following breastfeeding. Nipples can be creased or flattened, or can come out white (blanching) from compression and restriction of blood flow. If trauma is persistent or severe, mom can experience cracking, bruising or blistering. When it is most severe, mom can experience bleeding and scabbing. Even after the latch does improve with treatment, some moms have experienced long term nerve damage that may not improve with time.
• Pain - This is one of the most common symptoms a mom experiences. Unfortunately, it's one of the most commonly dismissed symptoms by healthcare providers. Too many are quick to propagate the myth that painful breastfeeding is normal. Painful breastfeeding is common, but that does not mean that it is normal. Is there a sensitivity at the beginning of breastfeeding? Sure, but that isn't what I am describing here. The often toe-curling pain that accompanies breastfeeding a tongue-tied baby can be severe enough that mom will begin to dread it. Even when the pain isn't as bad, but is still present, the persistence of the discomfort can most definitely lead to premature weaning.
• Poor or incomplete breast drainage - There are numerous reasons why a baby won't empty a breast. These include prematurely falling asleep at the breast, being unable to form an appropriate seal or being unable to use the tongue appropriately to draw enough negative intraoral pressure to nurse. Whatever the reason, stagnant milk can be indicative of future problems with lessening milk supply. Additionally, it can be a precursor to mastitis.
• Breast disease - Ultimately, if anything threatens the health of the breasts, milk supply becomes jeopardized. In the setting of a traumatic latch, mom's nipples can become infected from cracking. This can lead to breast abscesses. Surface trauma can lead to inoculation with thrush, which can be transferred to and from the baby. Superficial bacterial infections, blebs, or plugged ducts can also result. One of the more miserable results from a poor latch is mastitis, often recurrent. If a mom has recurrent episodes of mastitis, I always look for a restriction in the mouth as a primary potential cause. Mastitis can lead to hospitalization and a sudden drop in milk supply, so it must be taken seriously.

It is critical that we look at breastfeeding as a tag-team effort if we are going to achieve long term success in babies who are otherwise anatomically unable to latch appropriately. If a baby is completely healthy and growing well but mom is persistently sick or too traumatized to frequently breastfeed, we have failed to treat the dyad in a supportive fashion. We must stop dismissing mom's symptoms and we must stop propagating a culture where it is somehow ok to ignore the needs of the mom.

Weight Gain is Not the Only Marker of Successful Breastfeeding

Where I practice in Portland, Oregon, I'm very fortunate to have a great network of ancillary services supporting breastfeeding moms, making it a great breastfeeding environment. On the more frustrating side, however, is that some insurance companies refuse to authorize releasing a tongue-tie or lip-tie for breastfeeding. Among the many reasons cited is: "Baby's weight gain has not suffered".

This post will detail many of the potential problems a baby can have when breastfeeding is not optimal, and will show you why weight gain is only part of the picture. The assumption here is that our common goal is to keep the baby on the breast as long as possible (there are numerous studies showing improved long-term health benefits when babies breastfeed compared to formula feed). There are cost advantages to breastfeeding as well. A 2009 cost analysis study in Pediatrics found that low breastfeeding rates cost the United States $13 billion. Additionally, a study by the USDA showed that $3.6 billion could be saved each year if 50% of children were breastfed for at least 6 months.Therefore, anything that lessens breastfeeding duration will cost the insurance company (and society) a greater financial burden.  

• Falling asleep while nursing - This is one of the most common symptoms that I encounter with tongue-tied babies. The most plausible explanation for why this occurs is that babies with tongue-tie have to exert much more effort to attempt to breastfeed than babies who can nurse normally. When it's combined with frequent nursing sessions (when they aren't fully satiated after the previous feedings), stamina becomes a problem. Why the insurance company should care: this symptom can lead to cessation of breastfeeding because of frustration or fatigue on mom's part.
• Poor quality latch - Obviously, if the baby's oral anatomy prevents them from performing the necessary movements to latch on to the breast, the latch can be visibly abnormal. Babies with tongue-tie or lip-tie aren't able to widely open their mouths. (Try this yourself - first, open your mouth as wide as you can and then close it. Next, roll your upper lip inwards against your gumline, hold it there, and then open your mouth again. You will feel significant tension that will limit your ability to open your mouth). Even if the baby starts out opening widely and gets on to the breast appropriately, it's not typically a sustainable motion so they slide down on to the end of the nipple, which affects their efficiency of nursing. Why the insurance company should care: an inappropriate latch is the root cause of many other breastfeeding problems, all of which threaten the success of long-term breastfeeding.
• Reflux and colic symptoms - I am not going to claim that all infantile reflux and colic is caused by tongue-tie and lip-tie. However, babies who have tongue-tie and lip-tie commonly take in significant amounts of air. With an inability to flange out the upper lip and an inability to appropriately cup the breast with the tongue comes a shallower, more bottle-like latch. This allows these babies to take in a significant amount of air. Sometimes, an audible clicking or gulping sound is heard. Parents can often feel or hear air in their child's stomach, and burping doesn't always work to get it out. This air can act as propellant, causing silent reflux, spitting up or even projectile vomiting. The baby can have significant abdominal discomfort as a result. Why the insurance company should care: infant reflux is often medicated. While generic Zantac is often a first-line medication, many go on to use more costly medications like Prevacid.
• Gumming or chewing the nipple - While some may describe this as a lazy latch, babies with tongue-tie or lip-tie are sometimes physically unable to avoid using their gums or to chew. If the upper lip doesn't flange out, the depth of the latch suffers. If the tongue cannot elevate and cup the breast while cushioning the lower gumline, what results is the baby using the lower gums and the outside of the upper lip to hold on to the nipple. Why the insurance company should care: this is one of the primary causes of nipple pain. Moms who experience pain are much more likely to wean prematurely, again causing long-term health problems (and subsequently, costs).

• Lip blisters - When an easy, classic breastfeeding latch isn't attainable because of anatomy, some very determined babies will do anything they can to hold on to the nipple. This includes using both lips, like a sucker fish. The most common manifestation of inappropriate reliance on the lips to hold on is a central upper lip blister. While common in the first few weeks of life because of the delicate upper lip skin, I feel that the persistence of blisters beyond the first few months of life is indicative of an upper lip tie. When examining children, it's important to analyze both lips for swelling. Any degree of swelling of the lower lip is cause for suspicion of underlying tongue-tie or lip-tie. Swelling along the sides of the upper lip (outside of the central blisters) is also cause for concern. Rarely, as pictured here, lip blistering can be extremely severe. Why the insurance company should care: trauma to the baby's lips can prevent the baby from continuing to breastfeed. It can be painful for the baby and can occur in the setting of severe trauma to the nipples.

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Upper lip blisters can be indicative of a baby's inability to flange outward.

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A severe case of upper and lower lip blistering. This severity is quite uncommon.

• Short sleep episodes - Certainly, there are a multitude of reasons for a baby to have frequent nocturnal awakenings. I'll be the first to tell you that there aren't data to support this claim. All I can say is that my experience has shown me that babies sleep better when they're satiated and when they aren't refluxing. When they're hungry, they wake up. When they're uncomfortable from acid going up, they wake up. When babies wake up frequently, moms sleep less. While sleep duration occasionally increases following a tongue or lip procedure, this should never be the sole reason why someone pursues revision. Why the insurance company should care: disrupted sleep cycles jeopardize the duration of breastfeeding. In some cases, poor sleep can exacerbate postpartum depression as well. Both can cost insurers money.
• Inability to hold a pacifier in - I'm not going to address the pro's and con's of pacifier use. It is quite common for a baby with a tongue-tie or lip-tie to have an inability to hold in a pacifier, regardless of pacifier shape. This often improves with revision. This has little to do with insurance companies.

This child was treated at 6 months of age. Prior to the treatment, the child had been dropping percentiles in weight. Despite having reattachment that needed a secondary procedure 3 months later, this child nearly immediately began to gain weight. This change in weight post-procedure is common for children who can't gain weight because of a tongue-tie or lip-tie.

• Poor weight gain - This symptom is the most concerning to parents and the baby's doctor. It's the symptom that convinces doctors to act, either by treating the baby or referring them to a specialist. It is also the symptom that insurance companies seem to focus on. This can manifest as losing significant amount of weight immediately after birth (many cite 10% of weight loss as a concerning amount). It can also take the form of a prolonged time period until the baby returns to birth weight. Why an insurance company should care: Weight loss often undermines a mother's attempt at exclusively feeding their children breast milk. Reliance on formula to bolster a baby's weight increases the chances that the mother will stop nursing and/or pumping altogether, resulting in long-term costs to the insurance company.

Finally, I think we must analyze the various reasons how a baby can gain weight when they have a tongue-tie and/or lip-tie. Early on, a mom's supply can be strong enough where it allows the baby to drink rather than nurse. This is especially true at letdown or in situations where mom has oversupply. When their caloric demands are lower, this drinking is sufficient to maintain growth. The insurance company may deny treatment if presented with a request during this period of life. But as the baby grows and caloric demands increase, weight gain can definitely fall off later. Secondly, supplementation with either pumped milk, donor milk or formula can be needed to keep the baby's weight up. An insurance company will look at the raw numbers but doesn't focus on how that weight was sustained. I will contend that babies who are exclusively breastfed have a better chance at long-term breastfeeding than babies dependent on pumped milk. Finally, a determined mother can power through all of the negative consequences of poor breastfeeding quality in an effort to keep her child healthy. That does not mean that the relationship is a healthy one. Looking at weight alone does not give the insurance company the whole picture.

As I will show you in future posts, there are distinct advantages to breastfeeding when compared to bottle feeding. I think it's overly simplistic to think of breastfeeding as just nourishment for the baby. Ignoring the symptoms that can complicate getting a baby to latch appropriately and feed normally can have detrimental long-term effects. We need to broaden our understanding of breastfeeding problems so that we may address what we can to improve the success of the dyad.