Home Health Care Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

by Melanie Potock MA
written by

While many pediatric professionals are familiar with a tongue-tie, the elusive 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.
Spoon Feeding
  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications
Finger Feeding
  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. 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
  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. 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-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 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 mymunchbug.com/contact-us/ 

 

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19 comments

Melanie Potock March 10, 2015 - 6:04 pm

Thank you for the opportunity to raise awareness about Upper Lip-Ties. I’m looking forward to writing the next post on Ankyloglossia, commonly known as Tongue-Tie.

Pat March 10, 2015 - 10:01 pm

Great article-can’t wait to share. Yes, I have an infant with upper lip that was just released. She doesn’t want to suck, so,I need ideas on how to teach her. Very little suction when using applesauce on my gloved finger. Tongue won’t wrap around finger or follow finger along gum line. I believe she is tongue tied. She just found her tongue and can extend it outward.
She is having trouble latching on- has her 2 bottom teeth, like to chew the breast not suckle. Upper lip seems to be better but totally per Mom. Any ideas on teaching the tongue to suckle please let me know. I am open for suggestions, pat

Melanie Potock March 11, 2015 - 10:41 pm

Hi Pat, contact me via my website http://www.mymunchbug.com and I’ll try to reply as soon as I can. Thanks!

Alycia March 11, 2015 - 1:15 am

I am thrilled to see research in lip-ties being presented here on ASHA! I am an SLP but I do not have experience with infant/child feeding treatment. My experience with lip-ties has come since my son was born with a significant lip-tie and posterior tongue tie. It was a horrendous experience trying to, first of all find a doctor/specialist/lactation consultant that could identify the ties and then to find a way to keep him breastfeeding prior to his procedures. He had all the tradition symptoms listed above and minutes after his ties were released he could breastfeed beautifully and all my pain was gone. After my experience I have started to be interested in how ties affect feeding, tension in oral musculature, and possibly speech. We need more research and articles like this one in reputable sources available. Since my experience I have helped several close friends come to recognize that their children also had posterior ties and tongue ties. Another SLP colleague friend of mine that does infant feeding has had the unfortunate experience of having difficulty getting support of pediatric ENT’s in her area to recognize the negative impact of posterior tongue ties and lip ties. I am hopeful that as more information becomes available specialists will become better informed in how to recognize and effectively treat lip and tongue ties! Thank you!

Melanie Potock March 11, 2015 - 10:43 pm

Hi Alycia, I’m so glad that you found my article helpful, thank you. Your personal story is not uncommon – I’m sorry it took time to find the right answers – and I’m grateful for professionals who are helping to raise awareness, just like you.

Lydmarie March 11, 2015 - 1:46 am

Thanks for this article! I’m an SLP and mother of a 2 months baby. We’re having problem with breastfeeding and I had noticed the uper lip-tie since my baby was born. I din’t asociate it with our difficulties because I had this tie to until my pediatric dentist cut it, but it was just because the gap between my front teeth. I really want to know more about the steps that I could take and at what time its reccomended to cut or other intervention. Than you again and sorry for my spelling, English its not my first language…

Melanie Potock March 11, 2015 - 10:45 pm

Hi Lydmarie, thank you for sharing your story. The links in the article will guide you to the best resources on ULT and I”ll be writing more in regards to tongue tie in the near future!

Kate March 11, 2015 - 12:21 pm

Thanks for addressing this Melanie. My son was born with a tongue-tie and my daughter was born with a lip tie. Unfortunately, doctors, nurses, or lactation consultants were not very educated about ties and I was told that they would stretch over time. After severe, painful breastfeeding with both and weight loss with each of them, doctors finally listened to me. As a speech pathologist trying to educate these people on the problems caused by ties was difficult, I can see why so many nursing mothers just give up and go to bottle-feeding. I certainly agree that a lot more research and education should be done in this area!

Melanie Potock March 11, 2015 - 10:46 pm

Thank you Kate, for helping to raise awareness!

xanthippi March 11, 2015 - 3:16 pm

I have 3 daughters, all with an upper lip-tie. They breastfed without a problem, for 15, 13 and 25 months each. The older which is 8 years old though has a very wide distance between the front two teeth-there are 2 teeth missing from birth, we don’t know yet wether the adult teeth exist hidden. Is there a possibility this distance will become less if the frenulum is cut?

Melanie Potock March 11, 2015 - 10:47 pm

HI Xanthippi, That would be best addressed by a pediatric dental professional – as so many unique factors come into play. Thank you for asking – best wishes and thanks very much for commenenting.

Lydmarie March 12, 2015 - 12:35 am

Hi Xanthippi! In my personal experience my lip-tie was cut when I was five to six years and the distance from my two front teeth was reduced very significantly. Now my 2 months baby has the lip tie and I’m looking for an evaluation because we’re having problems with the breastfeeding fortunetly he can suck very well and is gaining weight but I feel pain in my breast almost all the time that I breastfeed him. I hope I can help with your question.

Upper Lip Tie and Feeding Challenges | Speech Therapist in Malaysia (STIM) March 12, 2015 - 4:16 am

[…] Source: ASHA […]

Kaylee Skelley March 12, 2015 - 7:35 pm

although I am not a speech therapist I am a mother of a child who had feeding issues. I asked several times if her lip tie could be the cause of her feeding difficulties which required a feeding tube. she had a NG tube from 3 months-9 months of age due to being failure to thrive at three months. she could not coordinate her suck breath swallow, reflux even though she never spit up and the Upper GI did not confirm it they still treated her for it, and she would get very tired and fall asleep while feeding and a bottle feeding of 2oz would take 2 hours. she also aspirated into her lungs when trying to eat. She eventually at 9 months got a g-tube placed. With a lot of feeding therapy she is now doing great and had her feeding tube removed a few months ago. However she still has the lip tie and we went to a dentist and she will be having it removed soon. It is so frustrating to me that we saw so many specialists GI, cardio, pulmonary, we went to 4 different feeding therapists and although they were amazing no one thought it could be her upper lip tie. Thank you for sharing this information as I think it will be very helpful for other families.

Melanie Potock March 16, 2015 - 9:57 am

Thank you Kaylee, for sharing your story. It’s once I’ve heard before, so I’m grateful for all of the professionals and parents who are sharing this information. Thank you!

Sarah Burton March 17, 2015 - 11:09 am

If a child has a lip tie (class 3), and is having difficulty taking a bottle, poor weight gain, who do you refer the family to? We have discussed the concerns with the pediatrician and she does not think it’s a problem so I wasn’t sure who to refer the family to for help.

sarah March 22, 2015 - 3:09 am

My son had a mild posterior tongue tie and tbe lactatio consultant we saw did not think ig caused the problem. I ended up exclusively expressing for almost a year as it wws near impossible to get him to latch on. At 11 months he fell on bis face and ripped his frenum. Since then he has gradually started to breastfeed and is now at 1.5 years sucessfully feeding! There should definitely be more awareness and your article has made things very clear to me. For example at 6 months i noticed the massive gap between his front teeth so but i was not aware of the impact it must have had on feeding.

Melanie Potock March 23, 2015 - 5:29 pm

Hi Sarah, Thank you for sharing your story and thank you for helping to raise awareness of ULTs – each one is different but is an important piece of the feeding puzzle for many kids.

Joan Harold March 23, 2015 - 7:02 pm

Hi. Great article. Well done. Im also an SLP and CST and wrote tge following. ..you might be interested :
http://stillspacetherapy.com/blog/

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