Articles published on this blog are my opinion only, and may not necessarily reflect the views of any organisations with which I am associated. Please be aware that articles posted on this blog are not intended as a substitute for professional medical advice. If you have a medical problem relating to breastfeeding, please seek further advice from a Lactation Consultant (IBCLC) or trained Breastfeeding Counsellor.

Sunday, 27 March 2011

Introducing... the maxillary labial frenulum

Thoughts on breastfeeding with an upper labial tie

If your baby is struggling to latch properly and it's all a bit of a mystery, it might be worth checking for an upper labial tie.

Currently, there isn't much information about upper labial ties and breastfeeding, so I have done my best to piece together the research I have found in the hope that someone will find it useful. Some of the information I have included is from my own experience of feeding my own 4 children, all of whom have upper labial ties.

What is an upper labial tie?

Inside your mouth, there is a small fold of tissue which runs between your upper lip and gum (you can feel it with your tongue). This is called the maxillary labial frenulum (or frenum).  Most people have no significant frenulum attachment (1), but sometimes this frenulum attaches further down the gum, or runs between the front teeth and attaches behind them, causing restricted movement of the upper lip. It's similar to tongue tie, but involving the upper lip and gum instead. An upper labial tie can occur on its own or in conjunction with a tongue tie (2). It's also possible to have a lower labial tie (involving the bottom lip and gum).

The quickest and easiest way to find out whether a baby has an upper labial tie is to lift up his upper lip and have a look!

Most babies will have no significant frenulum attachment(1).
image reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

Some babies will have a maxillary frenulum which attaches into the gum above the front teeth. This is not normally a problem, as there should still be enough upper lip mobility in order to achieve a good latch.
images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

In some babies, the maxillary frenulum attaches just in front of the anterior papilla (that's the small bump of tissue on the upper gum just behind the area where the upper front teeth grow) (2). 
images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

Some babies (mine included) will have a maxillary frenulum which attaches into the papilla (the small bump of tissue just behind the area where the upper front teeth grow) and extends into the hard palate behind the front teeth (2).
images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC  

"It is very important to understand - the tightness of the frenulum can vary, and the degree of tightness can make a major difference as to any consequences."(3)

My children's dentist, Dr Chris Caldwell, has the following tip: if your baby has an upper labial tie, lift up his upper lip, stretching the frenulum. If the papilla blanches when you do this, the upper labial tie is likely to be a significant problem.

Healthcare professionals working with breastfeeding mothers and babies tell me upper labial ties are uncommon (is this simply because we aren't checking for them?). My children's dentist disagrees: they're fairly common, though they're not usually severe enough to cause major problems.

How might an upper labial tie affect breastfeeding?

Because an upper labial tie restricts movement of the upper lip, it may be difficult for the baby to latch effectively to the breast (3,4). Once latched onto the breast, the baby's upper lip may be tucked inwards, resulting in a shallow latch (5). The baby may be a 'clicky' feeder who takes in a lot of air during a feed. Breastfeeding may be painful for the mother. An older baby's upper teeth may dig into the breast during a feed, causing indentations or damage. Some babies will be able to breastfeed with an upper labial tie; others will have difficulty. The ability to breastfeed effectively depends on a range of other factors also affecting the mother (eg. breast anatomy, milk supply) and the baby (eg. oral anatomy), all of which may create further obstacles or make breastfeeding easier.

Ideas for improving the latch of a baby with an upper labial tie

If your baby has an upper labial tie and you are struggling with breastfeeding, seek help from a qualified breastfeeding specialist (such as a breastfeeding counsellor or lactation consultant).

The first step is to work on optimising the baby's latch in order to improve milk transfer: for some babies, this may be all that is needed to breastfeed successfully. In the hope that someone somewhere will find this information useful, I am sharing ways of overcoming an upper labial tie which worked for me and my babies:

A baby with an upper labial tie needs to be encouraged to accept the breast more deeply in his mouth. After much experimenting with more traditionally-taught breastfeeding holds (such as the cross-cradle hold), I initially found a variation of a technique called "exaggerated attachment" (adapted from 6) yielded some success:
  1. Cup your breast underneath with your hand (if you're using your right hand, your right hand cups your right breast).
  2. Use your thumb to tilt your nipple back so it points away from the baby's nose. This makes the breast under the nipple bulge forwards.
  3. When the baby gapes, his bottom lip and chin should come into contact with the breast first.
  4. Using your thumb, quickly roll your nipple forward into the roof of the baby's mouth.
  5. Then, as you take your thumb away, lift your thumb to catch the baby's upper lip and gently flick it outwards.
I've done my best to demonstrate this latching technique below (please excuse the change of holds part way through - it's hard to get good clear photos of a baby latching on!).

Although this technique helped my baby to stay on the breast, we still experienced slow weight gain, which improved after we learnt breast compressions.

Using a 'laid-back' or 'biological nurturing' position marked a major breastfeeding breakthrough for us. Catherine Watson Genna BS IBCLC suggests that "increasing head extension will allow the infant to grasp the breast sufficiently"(4) - I have noticed that this is naturally encouraged through self-attachment to the breast in a biological nurturing position. Biological nurturing, coupled with very frequent, on-demand feeds resulted in successful breastfeeding for us, despite an almost embarrassingly imperfect latch. And, as my baby grew bigger, his ability to latch vastly improved.

What if I'm considering having my baby's upper labial tie divided?

Because of the way the human face develops in the womb, an upper labial tie can occur on its own, or in conjunction with a posterior tongue tie. If your baby has an upper labial tie and you are debating whether it is the cause of any breastfeeding problems, it is worth getting someone to check for tongue tie. In some cases, dividing the tongue tie may resolve the feeding issues.

In the UK, it's not easy to find a practitioner who will divide a baby's upper labial tie. People who may be able to help you find a practitioner with the skills to divide a baby's upper labial tie include:
  • a Lactation Consultant (IBCLC)
  • the Infant Feeding Coordinator at your hospital
  • a paediatric dentist
  • a university dental school
It is worth considering that the procedure involved in dividing an upper labial tie is different to tongue tie division, and may require general anaesthetic. This really does depend on the skills of the practitioner carrying out the procedure: some will prefer to use a laser for the division; others may be more confident using a scalpel. Further information about the division of upper labial ties can be found here:

Dr. Lawrence A Kotlow DDS PC - articles
Dr. Brian Palmer DDS - Frenum Presentation
Dr. Brian Palmer DDS - Breastfeeding and Frenulums
please note: these are non-UK links

The decision to divide an upper labial tie is an individual one, based on evaluating the severity of the tie, whether it is impacting on breastfeeding, and whether it is possible to find a practitioner who will divide the tie.

What is the evidence suggesting that lip tie division is of any benefit to breastfeeding?

In addition to the websites above, I have found just one journal article suggesting that the division of an upper labial tie might benefit breastfeeding. It is a case report of one baby whose latching difficulties remained unresolved after a tongue tie division, but was able to breastfeed successfully after an upper labial tie division.

The rest of the evidence is anecdotal:
Spanjer, P (2000) What a difference a day makes, La Leche League
(2009) Lip tie clipping, Heidiopolis
(2009) Breastfeeding update... A nurse who knits (unsure whether lip tie clipping was helpful)
(2011) The trouble with frenulums and The last snip, Becoming Daizee (not yet clear whether lip tie division was successful)
(2011) Tongue Tie Q&A and Micah's First Perfect Latch, the mommypotamus

The lack of documented supporting evidence is likely a result of lack of funding to undertake research in this area, coupled with a lack of awareness that an upper labial tie can affect breastfeeding, and a lack of skills to divide an infant's labial tie. I wonder how many mothers have ended up bottle feeding as a result of an upper labial tie?

What could other impacts be of not having my baby's upper lip tie divided?

"There are no medical or dental benefits of having a tight [...] labial frenulum. There are many major medical and dental consequences that result from tight frenulums." (3) These consequences very much depend on the severity of the tie.

Apart from breastfeeding problems, an upper labial tie has been linked with:
  • having a gap between the two front teeth (2,4)
  • poor lip mobility, affecting smiling and speech (2)
  • increased dental decay on the upper front teeth (2)
Good dental hygiene is of particular importance for a baby with an upper labial tie. Although breastfeeding alone may not cause tooth decay, breastfeeding in conjunction with an abnormal maxillary frenulum attachment may be a contributing cause of tooth decay in a breastfeeding infant (7). This may be because the area around the upper labial tie is difficult to clean, so food particles remain trapped in the oral mucosa.

A study undertaken in 1999 found that although human breastmilk did not cause tooth decay, adding a small amount of sugar to breastmilk did cause tooth decay (8). Therefore it would be wise for children with an upper labial tie to avoid sugary foods which, in conjunction with breastmilk, might accelerate tooth decay.

There is some evidence suggesting a link between childhood tooth decay and low levels of vitamin D (9). Breastmilk is naturally low in vitamin D, so vitamin D supplementation may be a consideration for a breastfed baby with an upper labial tie.

An upper labial tie can cause dental issues later on, so even if you decide against having the procedure done in infancy, your child's dentist may suggest dividing the upper labial tie when your child is older. "Tight frenulums rarely go away by themselves (3)"; however, they can sometimes break: my eldest child accidentally tore hers on a badly-aimed dinner fork, and one of my sons fell and tore his in the skate park. My two youngest sons also have severe upper labial ties. Despite overcoming the obstacle of their upper labial ties without having them divided and breastfeeding them both successfully, I probably won't be able to help that momentary feeling of having been just a little bit short-changed if I'm told a division is necessary in future.

Last edited: 15/09/11

(1) Kotlow, L (2006) Diagnosis and Treatment of the Maxillary Frenum
(2) Ktolow, L (2010) Why can't my baby breastfeed: The effects of an abnormal maxillary frenum attachment
(3) Palmer, B (2003) Breastfeeding and Frenulums
(4) Watson Genna, C (2008) Supporting sucking skills in breastfeeding infants  Jones & Bartlett, p203
(5) West, D & Marasco, L (2009) The Breastfeeding Mother's Guide to Making More Milk  Mc Graw Hill, p91
(6) Abbett, M (1997) A Mother's Guide to Breastfeeding (6th ed), p9
(7) J Hum Lact August 2010 vol. 26 no. 3 304-308
(8) Pediatr Dent. March - April 1999 vol. 21 no. 2 86-90
(9) JCDA December 2008/January 2009 vol. 74 no. 10 863-864

Monday, 7 March 2011

Icecreamist extremist?

In February, radical Covent Garden ice-cream parlour, the Icecreamists, rapidly became famous for the creation of breastmilk ice-cream, sold for a staggering £14.99 a scoop (1) before it was seized by Westminster Council, who feared it may not be "fit for human consumption"(2).

Reactions to the breastmilk ice-cream have been interesting, to say the very least. Some have criticised the Icecreamists for using breastmilk as a 'cheap' publicity stunt; others have taken issue with the way in which the breastmilk ice-cream was publicised.

The publicity photos: why does breastmilk ice-cream need to be accompanied by Calpol, Bonjela and a bottle?

Whilst I cannot pretend to know what the Icecreamists were actually trying to achieve through a publicity photo such as this, the image does make an interesting and clever point, regardless of whether this stroke of genius was intentional or not.

Victoria Hiley, the donor who supplied the breastmilk for the ice-cream, described her experience as a "burlesque adventure"(3). And, in publicising their breastmilk ice-cream, the Icecreamists have indeed served us up a daringly burlesque image, beautifully censuring society's hypocrisy regarding human breastmilk.

Breastfeeding is an emotive, political issue: there are potentially serious risks involved in not breastfeeding, but the government provides shockingly little protection to mothers, infants and its healthcare system from aggressive advertising from the infant feeding industry. For babies, breastmilk is a matter of life and death: "Every day, more than 4,000 babies die because they're not breastfed. That's not conjecture, it's UNICEF fact." (4) Yet here, breastfeeding is trivialised, frivolously transformed into ice-cream, apparently in the name of pushing the boundaries of acceptability. And the Icecreamists push the boundaries further still: pharmaceutical medications and feeding bottles are treated in a coarsely trivial manner, presented as mere condiments on a tray. The overall effect borders on the grotesque, which upon reflection, is quite brilliant (even if it was just accidental).

My point is that everybody seems to have been so distracted with whether the idea of breastmilk ice-cream is attractive or repulsive that all but the most informed amongst us have rather dismissed its accompaniments.

The bottle in the photo is manufactured by a company which is renowned for breaking the World Health Organisation (WHO) International Code of Marketing of Breast-milk substitutes and subsequent World Health Alliance (WHA) resolutions. Yes, feeding bottles and teats do in fact fall within the scope of the WHO Code (5). The WHO states that "Given the special vulnerability of infants and the risks involved in inappropriate feeding practices, usual marketing practices are therefore unsuitable for these products"(6). It explains that "feeding bottles [...] carry a high risk of contamination that can lead to life-threatening infections in young infants"(6). Furthermore, the inappropriate use of feeding bottles can adversely affect a mother's breastmilk supply, confuse the baby and lead to breast refusal(see 7), which can potentially jeopardise a breastfeeding relationship and expose the infant to the risks associated with not breastfeeding. Yet has any of the media coverage raised an issue with the feeding bottle?

A further accompaniment to the breastmilk ice-cream is Calpol. "Voted best health product by readers of Mother & Baby magazine four years running"(8), and with sales of "twelve million packets and bottles" each year (8), you may be forgiven for wondering what the issue with Calpol might be. However, Calpol contains "FIVE E-numbers, some of which have been banned in other parts of Europe and the US"(9). For further information about Calpol and its associated risks, read the Analytical Armadillo's article here. Yet, despite media coverage of the potentially harmful effects of Calpol in 2008/9, it managed to escape media attention when placed on a platter next to breastmilk ice-cream.

Also accompanying the breastmilk ice-cream is Bonjela. Commonly used on teething babies, Bonjela is another over-the-counter medicine which has received fairly recent media attention. Some forms of Bonjela are unsuitable for children under 16 because they contain a substance called choline salicylate, which carries a risk of Reye's Syndrome, a rare but potentially fatal disease of the brain and liver(10). Bonjela teething gel, which is aimed at children over 2 months old, does not contain choline salicylate, but it does contain Lidocaine hydrochloride and Cetalkonium chloride. I wonder how many people spotted that the breastmilk ice-cream is served with the unsuitable adult version? The media missed that too.

So, take the burlesque image of the breastmilk ice-cream, served with a bottle, Calpol and Bonjela. The overall concept is both attractive and repulsive: it is practically an invitation to choose the item you find most repulsive. The most informed amongst us would probably choose the feeding bottle, Calpol or Bonjela. Yet of course it is the least offensive, most normal item that causes international outcry: the breastmilk, which is "confiscated as a biohazard and described as "nausea inducing" by Lady Gaga"(3). By the way, Westminster Council, that was the wrong answer...

The breastmilk itself is nothing other than normal. This normal food contains myriad beneficial ingredients, including vitamins, fats, antibodies, minerals, stem cells, antiviral and antibacterial components, human growth factors and "about a hundred constituents that cannot be replicated in formula" (11). Breastmilk is not only completely safe and suitable - but actually specifically designed - for human consumption. Furthermore, the donor providing breastmilk for the ice-cream "had a blood test to rule out the few infections that are transmitted through breast milk" (3), which is exactly what happens when a human milk bank donor provides breast milk to be consumed by society's tiniest and most vulnerable human beings. In view of this, I rather feel that the attention the breastmilk ice-cream received was somewhat out of proportion.

And so to raising a satirical eyebrow to society's hypocrisy over human breast milk:

Breastmilk is hailed as "liquid gold". The slogan used to promote breastfeeding proclaims "breast is best," yet paradoxically it is revolting, icky, "nausea-inducing", a bio-hazard, "unfit for human consumption". At the same time, the bottle, the Calpol and the Bonjela all escaped media attention because they are accepted as normal in our society. The Icecreamists have now created an infant formula ice-cream. I'd like to believe it's because the world is still reeling from the brief phenomenon that was breastmilk ice-cream, but I can't help but note that this new ice-cream hasn't provoked quite the same reaction.

The Icecreamists tweet about their new 'formula' ice-cream, which has had disappointingly little impact in the wake of Baby Gaga.

Last updated: 08/03/2011

(1) Williams, Z (2011) Breastmilk ice-cream: the taste test in the Guardian 27/2/11
(3) Hiley, V (2011) Lady Gaga and my breast milk burlesque in the Guardian 7/3/11
(4) Baby Milk Action (2004) Your Questions Answered in
(7) Australian Breastfeeding Association (2005) Breast Refusal
(8) Crompton, S (2009) Is Calpol bad for children? in The Times 24/1/09
(9) Thomas, C (2010) Calpol - It's paracetamol Jim, but not as we know it! in Analytical Armadillo 11/10/10 
(10) Teething (2010) New Advice on Teething Products
(11) Thomas, C (2010) Ask the Armadillo - what's in breastmilk? in Analytical Armadillo