While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.
Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.
During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.
Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:
“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”
Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.” A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”
How might an upper lip-tie impact the developmental process of feeding?
The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:
Breastfeeding and Bottle Feeding
- Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
- Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
- In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
- Gassiness; fussiness; “colicky baby”
- Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
- Fatigue resulting in falling asleep at the breast
- Discomfort for both baby and mother, resulting in shorter feedings
- Need for more frequent feedings round the clock
- Poor coordination of suck, swallow, breathe patterns
- Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.
- Inability to clean the spoon with the top lip
- Inadequate caloric intake due to inefficiency and fatigue
- Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
- Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications
- Inability to manipulate food with top lip for biting, chewing and swallowing
- Possible development of picky, hesitant or selective eating because eating certain foods are challenging
- Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications
Oral Hygiene & Dental Issues
- Early dental decay on upper teeth where milk residue and food is often trapped
- Significant gap between front teeth
- Periodontal disease in adulthood
- Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.
After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.
For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.
In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.
Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.
Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating. She is the co-author of Parenting in the Kitchen: How to Raise Happy and Healthy Eaters in Our Chicken Nugget World (Aug. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food! Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs. She can be reached at Melanie@mymunchbug.com.