While the evidence for decision-making around tongue tie and breastfeeding is limited and controversial, the evidence around lip tie simply isn’t there.

That does not mean that the labial frenulum doesn’t need to be evaluated. In fact, assessment of the labial frenulum in addition to the lingual frenulum should always be a part of a feeding assessment by an IBCLC.

There have been many anecdotal reports of the revision of the upper labial frenulum improving breastfeeding outcomes. While anecdotal reports are easy to dismiss as not evidence-based, I know dozens of these “anecdotes” personally and they would tell you that revising the labial frenulum was critical to their breastfeeding success.

I also have found that upper lip ties cause a very specific, significant, and difficult to heal nipple trauma.

In the tongue tie blog, I emphasized the importance of not just evaluating appearance, but also evaluating function. We do not have a standardized and validated tool to evaluate lip tie to date, but there are a few recommended methods to identify if the lip’s movement is restricted.

What we do know is that the lips should be relaxed and generally still when an infant is breastfeeding. They should maintain a moderate seal so that no air leaks in or milk leaks out. (Watson Genna Sucking Skills)

When a baby is using his lips too much while breastfeeding, I as the lactation consultant need to ask myself:

  1. Does it matter (i.e. is it making breastfeeding uncomfortable or ineffective)? If the baby is using her lips but mom isn’t having any pain or nipple breakdown and the baby is transferring milk well, it doesn’t matter.
  2. Why is the baby using her lips? If it is impacting comfort or effectiveness, then we need to ask ourselves why baby is using her lips. I have found that baby’s use of the lips is for one of two reasons:
    • She needs to hold on because she can’t maintain seal with her tongue. If baby can’t hold onto the breast with her tongue due to limited function, she will often clamp with her gums and/or lips so she doesn’t fall off the breast. Chances are, this baby will be getting referred to the dentist for failing the HATLFF anyway.
    • The range of motion of her lip is limited. Kotlow rates lip tie based upon the insertion site of the frenulum. While that is important to note, I find that it is more important whether or not the frenulum can stretch without causing the baby discomfort or decreasing blood flow to the gums or lips.

Check out this guy right after coming off the breast:

This little guy shows us two signs that his lips are working too hard. One, he has lip callousing. This tells me that his lips are moving too much on the breast, causing friction and callousing of the lips. This may be because of a limitation in tongue movement or from restricted motion of the lip itself.

Number two, that sweet red rainbow above his lip means there was excess strain on his lip while it was flayed out on the breast. Sometimes we will even see two tone lips when a baby detaches from the breast, showing us that the blood flow was restricted by a taut labial frenulum.

When assessing the labial frenulum, I look for blanching in the frenulum itself or the gums. This may indicate that when the lip is at full extension (as it should be with a deep latch), there is limited blood flow and, therefore, discomfort for the baby. The baby will in turn curl his top lip under to make himself more comfortable. Unfortunately, this can be very uncomfortable for mom’s nipples.

The Disagreement over Lip Tie

In her most recent publication, Alison Hazelbaker PhD, IBCLC and author of the HATLFF made a strong argument that surprised me. I want to share this argument with you because it is arguments like this that should lead us to stop and think about what we are doing before we proceed.

Laurence Kotlow brought the lip tie into breastfeeding consciousness in 2013 in his article published in the Journal of Human Lactation.

Hazelbaker noted that Kotlow presents no evidence in this article that the maxillary lip tie causes breastfeeding problems and may even be classifying normal presentations of labial frenulums as abnormal.

“The bottom line is that we do not know what constitutes an abnormal infant maxillary frenulum, nor do we know what frena actually cause breastfeeding problems. Without diagnostic criteria, we are flying blind.” (atlas)

Hazelbaker also states in her book that even the authors of this book and she disagree on this issue!

“Dr. Kaplan and I have different views on the subject of maxillary lip-tie. I think it is rare, based on my clinical experience and expertise as a lactation consultant… Dr. Kaplan encounters what he considers to be maxillary lip tie more often than I do… Since we lack evidence to support revision for breastfeeding problems, you will have to use your best clinical judgment and allow health care ethics to guide you.”

When I first read this book, I was frustrated. I wanted Hazelbaker to give me the unequivocal answer of what to do about the “lip tie.” After a few weeks of pouting, I accepted what she was saying. We don’t know and we can’t act like we do.

So, where does that leave us with the lip tie? In my opinion, it is quite simple. It is not my role at the IBCLC to diagnose tongue or lip tie, right?  So, when I assess the function of the upper lip, if I find the range of motion to be limited, I refer. My trusted colleagues—experienced dentists, but also pediatric ENTs and some pediatricians—specialize in mouths. These providers, especially the dentists, see the impact of the labial frenulum throughout the lifespan. I fully trust that he or she will make diagnoses and recommendations that are in the best interest of the infant’s lifelong oral health.

Along with my referral to a dental or other provider, I also provide a few strategies that can really improve the comfort of a latch with a tight lip. I encourage the clients I work with to do use these specific strategies whether or not a lip tie revision is recommended by the revision provider.