Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

Experience of Breastfeeding, Does Not a Lactation Consultant Make...

Warning, graphic medical image of a damaged nipple follows.


I apply makeup and give myself a facial, but I'm not a beauty therapist.  I have feet and rub off the dead skin, but I'm not a chiropodist.  I eat food and plan my own meals, but I'm not a nutritionist.  I've planted up my garden, but I'm not a landscape gardener.  I've made tinctures, but I'm not a herbalist.  I can wash out and stick a plaster on an injury, but I'm not a nurse.

Using the last example - should someone ask me if I can recommend a good brand of band-aid, I'm happy to share my opinion.  Should they ask what my experience was of dealing with an injury, I'm happy to share tips I found helpful.  I would feel comfortable encouraging them that with the right help, the wound will heal just fine - yes mine was painful too (and here's how I coped with that), but long-term we got through and now there's just a tiny scar.

However should someone ask me why their wound isn't healing and what the best course of action would be - I would refer them to an appropriately qualified person to help.

Why?

Because I could (inadvertently and with the best intentions) give incorrect advice that could potentially make it worse.  I might not recognise the early signs of infection or be up to date with the latest best practice for wound healing.  I might recommend just leaving it to heal itself without doing anything more, using the affected area as normal and battling through the pain - because I did this and it worked out fine.

Because I don't know enough, I don't recognise what I don't know...

Breastfeeding is no different.

Lactation is a pretty sound science, it's not random luck based on old wives tales and myths (despite what half the books I've read over the years suggest).  Actions early on impact on outcome - how many times do we hear that effective, timely support is key?

Unless you have breastfed hundreds of babies, your experience of breastfeeding is likely microscopic compared to those who work daily supporting infant feeding.  Even then you breastfed your baby with your body and every dyad is unique; just like understanding my diet doesn't mean I'm in a position to extrapolate that to every other human being who eats food.

Yet should a mum post online that her nipples are cracked and bleeding and her baby appears constantly hungry, the stream of contradicting advice that follows must leave many reeling:

"Just feed, feed, feed, yes it hurts but it will pass"
"Use a nipple shield"
"Use a nipple shield for the first minute then take it off"
"Don't use a nipple shield it will mess with your supply"
"Express and feed back"
"Don't express it will mess up milk supply"
"Don't use a bottle it will mess up feeding technique"
"Use formula for a break"
"Don't use formula it will mess up your supply"
"It's normal for breastfed babies to feed constantly, co-sleep and wear a sling"
"It's not normal for any baby to want to feed constantly"
"Wake them up to feed"
"Never wake them unless they go more than 6 hours"
"Leave sore nipples to air dry"
"Use Lanolin for soreness"
"Use breastmilk for soreness"
"Use coconut/olive oil for soreness"
"Take a homeopathic remedy for soreness"
"Make nipples moist for effective healing"
"Don't make nipples moist as it may harbour thrush"
"Your pain probably is thrush"
"Ask your GP to treat you for thrush just in case"
"Don't use thrush medication, use coconut oil"

And on and on and on....

Given many mothers typically post their problem in multiple online forums, how helpful are the 3000 random suggestions really?

So let's quickly consider a potential worst case scenario.

Baby is attaching sub-optimally hindering milk transfer and causing damage.

Feed feed feed, if the baby is causing physical damage with their sucking style, can result in this:

And how long do you think a mum can realistically sustain feeding with that level of damage?

An intervention like introducing a nipple shield to a baby who already latches, may result in a whole host of unforseen consequences too - as well as not resolving the pain for many.  Some do get reduced pain, then remove the shield to find half their nipple damaged. Some get no further pain but the baby still doesn't get a good transfer, leaving them hungry.

Recommending a shield isn't something that should be done lightly, but as a tool a lactation consultant uses as one of many i.e. with specific cases, at a specific time, they can similarly save a breastfeeding relationship.

The other area of concern in the above scenario is the constantly feeding baby.  "Constant" needs defining as sometimes this is frequent but normal and it's the parents expectations that are unrealistic.  Baby may be feeding every 2-2 1/2 hours, when parents were expecting a 4 hour gap from the end of a feed.  However other times the baby is literally feeding all.the.time; one mum recently had an app that showed over 18 hours per 24.  This is not normal as an everyday feeding pattern, who could sustain that?

#freethenipple
Some babies, when feeding for such long periods, will get enough over 24 hours to grow and baby is declared "a snacker".  Others won't. So potentially we have a newborn baby not getting enough food.

Advice to ignore the problem and continue blindly on is surely negligent if you aren't 100% sure baby is getting enough milk.. Otherwise all you may actually be doing is setting the parents up for a lethargic baby later and even admittance to hospital a few days later due to Hypernatremia - a fast track route to breastfeeding cessation for many, not to mention potential long term health consequences for baby.

What's more, even if we don't have absolute worst case but other ongoing problems - mothers tell me blind
reassurance doesn't help.  Instead their gut instinct is something isn't right, and so they either stop breastfeeding thinking if that's "normal" I can't do it, or they continue to breastfeed but feel uneasy there's still an underlying issue, even if they can't quite put their finger on what it is.

When you give advice, rather than information and support,  you're taking responsibility for the outcome if things go wrong.  When you tell a mum to ignore advice given to her by a midwife or health visitor - you better be absolutely sure you absolutely have a handle on things, or you could be making a difficult situation ten times worse.

A prime example of this was a mum I saw last year.  A gorgeous baby arrived for a consultation with mum in a panic.  She had just taken baby to the GP due to a referral for growth concerns at nearly 8 weeks of age, only to discover baby was below birth-weight.  The GP arranged for them to go straight to hospital and mum told him she had a session booked with a lactation consultant; she asked if she could attend before the hospital or was it critical she attend immediately.  He agreed since it was feeding related, the baby had gained some small amounts of weight, and appeared healthy in all other respects, he was happy for her to see me and then go straight to paediatrics.

As we unpicked the previous 8 weeks, I discovered concerns had first been raised about baby's weight gain weeks before.  The health visitor had suggested expressing and giving back, and topping up with formula if necessary until baby was full.

However mum's online support groups disagreed.  Some babies are just meant to be petite, the charts aren't even based on breastfed babies (they are), my baby was very slow gaining and he was just fine, it's normal for it to take some babies much longer to gain weight (it isn't), a gain is a gain no-matter how small and fine as long as baby hasn't lost, any health professional recommending formula isn't supportive of breastfeeding, ignore the health visitor and just feed, feed feed, express what you can and just give that back".

And so that's what mum had done.

Initially the 10-40 mls expressed was a good supplement, however by 8 weeks and with no improvement in breastfeeding effectiveness, these supplements were by now barely touching the sides.

For those who haven't seen an 8 week baby not back at birthweight (which should be regained by day 10, or day 14ish if loss was larger than typical, but baby is now gaining well), let me give you a rough picture.

Length and head growth continue in babies until they're severely malnourished.  This can confuse some that actually baby is getting enough to grow, and they're clearly just meant to be long and thin.

If lack of gain continues, their head starts to look excessively big on their body - resembling a premature baby.  Their limbs become thinner and the skin hangs loosely, sometimes looking "baggy" in places.  Their bottom disappears, and their eyes appear large and often sunken.  You pick them up in a babygrow and instead of baby squidge, you just feel bones.

So back to the above mum.  A feed assessment highlighted baby was only actively transferring milk for the first few minutes of a feed, after that there was lots of sucking (burning calories) and lots of snoozing (attempting to conserve them), but little swallowing.  In this situation our best chance of keeping baby out of hospital is to feed the baby, and then set a plan of supplements to be given - so the consultant can see a guaranteed intake of food.

First we try expression.  But after 8 weeks of poor transfer, and no doubt the stress of the current situation, that's not successful enough to give more than a few mls.  We then discuss donor milk, and mum makes a few calls to try and see if we can get any in the next half hour or so.  No go.  The only option in this situation is to give formula.  Am I also therefore someone to be ignored too?

Sure there are risks to formula, but do you know what else there are risks to?  Not getting enough food to function.  Babies are well programmed to survive and will usually try and alert their caregiver they're not getting enough food, with constant crying/showing feeding cues.  If intake doesn't increase, their mouth and lips can become dry, their cry can sound hoarse (like the pterodactyl screech on Jurassic park) - most lactation consultants instantly recognise this cry.  They can start shutting down to conserve energy and preserve their vital systems, becoming lethargic and more difficult to rouse to feed, sleeping longer periods.

Jaundice might follow, compounding the sleepiness.  As my colleague pointed out, this is how babies can be pulled from the wreckage of earthquakes and suchlike, days later still alive - they "shut down" for self preservation purposes.

It's absolutely right to say a baby shouldn't need formula, so often breastfeeding just needs a tweak to improve gain, not a breastmilk substitute.  I see babies that are gaining fine, but mums are told they need to top them up to get to a specific centile, or because baby is waking more than expected.   And, in a case like the above, if the problem had been identified early when milk is abundant why top up with formula instead?

However that's not the situation for many.  Instead they receive passive breastfeeding support, and eventually when weight becomes concerning enough, are advised to supplement to protect the health of the baby. Beyond positioning and attachment, even the health professionals might not figure out why baby isn't gaining and so aren't sure what else to do.

There is also a significant difference between an older baby gaining slightly less than expected, and a newborn struggling to take enough to survive; both in terms of the urgency of the situation, and the most appropriate course of action

The mum above gave a supplement slowly, the baby's eyes popping open as he swallowed hungrily.  We set a plan to gradually increase the volumes over the next 48 hours, along with an expressing plan to start to swap the formula for breastmilk.  The feed assessment highlighting baby hadn't been feeding well, along with the suggested supplement plan, were printed and added to baby's notes before mum set off to the hospital

The consultant did the usual health checks, said the plan was agreeable, saw baby rouse and take a feed with a supplement and basically if mum felt happy baby was taking the top ups, didn't need to stay in - he would instead see them at a follow up appointment 48 hours later.  The baby had gained significantly by this point and they were discharged.  (In case you're interested, baby was tongue tied - mum had no pain or nipple damage at all).

The fact is breastfeeding mums are passionate.  Many have succeeded with sheer grit and determination, and now realise just how important breastfeeding is to them, and how many booby-traps exist.  They get that there is pervasive marketing and an unsupportive society, undermining breastfeeding at every turn - and without these mums, breastfeeding support would collapse in the UK.

The volunteer helplines take tens of thousands of calls per year, support groups across the country are typically heavily volunteer led, mums at home try and help online via groups, and even offer to pop round if local.  As Ayala Ochert said on Facebook in response to the "mummy wars" advert currently circulating:
"The real "sisterhood of motherhood" is all the breastfeeding peer supporters who voluntarily give up their time to help other mums achieve their breastfeeding goals."
So, if we're ditching giving a gazillion suggestions, what should we do?

Encourage, support, empathise, and help them obtain effective, qualified support.  Be that a Facebook group of peer support workers (who have the structure in place to refer to a breastfeeding counsellor or lactation consultant as needed), an NHS infant feeding advisor, a local group run by the NHS or a breastfeeding charity, or an independent lactation consultant.  Groups that include other local mums can be invaluable, as they often know who to see and where, and when the best groups run.  Share resources that parents can use to identify themselves if baby is getting enough, and what to do if not, recognise what the red flags are there might be a more significant problem and if you're not sure, always suggest they see someone who is.

Stick Your "Mummy Wars" Advert Up Your.....

If another person tells me I MUST see the "mummy wars advert", I might just spontaneously combust.

First, I have (as I said on Facebook) got to acknowledge from a marketing perspective,  the genius that is this advert.  It's so clever that whoever had this brainchild, deserves the mother of all bonuses and a good month or two all inclusive in the Caribbean.

It's so good that midwives and breastfeeding advocates who would never share a formula advert, have passed it on around.

"Oh, I didn't realise it was for formula" I've repeatedly been told.  Nope that's right, some versions have been edited to remove all traces of the brand before sharing.

So how, you might be wondering - can an advert be so incredibly sensational, when you don't even take away from it what product it's for?  Isn't that pointless?  What's my beef if it doesn't even give the name of a formula company?

The reality is if you're one of two leading USA brands, it doesn't really matter if you name your product.
Anything that undermines breastfeeding is a win for them.  And this does that so spectacularly on a subliminal level, that they don't need to blaze a logo.  In fact, it's far better if you don't make that connection, because many people I've seen share this would never share something clearly advertising formula.

Making it all just seem benign, harmless, fun.  It's only asking everyone to be nice to each other, and we all support that right?  Isn't that a message that needs sharing?  Surely if not you're one of the uptight, judgy mothers depicted in their ad?

They discuss cloth versus disposable, work versus stay at home mum, breastfeeding versus bottle.

Because that's all feeding is right?  Another case of a simple parenting choice - there is no right or wrong, everything is equal.  If you don't agree, you're part of "the mummy wars".

And that's exactly how the advert is being received.  From Facebook:
"To me it just made the point that deep down there's no difference, whatever our choices. We're all just out to do what we believe is best for our own."
But let me tell you how the "mummy wars" came to be.

First you really need to read this post by dou-la-la, to understand where "breast is best" came from, and how we move from there to a belief "perfect parents breastfeed".  This by default makes those who don't breastfeed potentially feel inferior/judged/as though others are "smug".  Please also take a minute (if you really are genuinely interested in stopping the "mummy wars") to read this too.

From there, this post explains how when we have pressure to "perfect parently", this in itself generates behaviour that becomes divisive.  It sets people against each others and indeed the resulting behaviour can look a lot like bullying.

Formula companies get this.  You don't generate a $50 billion dollar industry by not understanding your market.

Adverts tell mums "you're doing great", "we understand you", ignore those breastfeeding police because it doesn't really matter anyway.

And mums tell us, this makes them feel better.  To hear that - even when it from someone selling, it makes them feel good.

In fact, even more ironic is that mums are actually paying to be told they're doing OK, because who do you think funds the adverts?  It's the parents who pay the extortionate mark up rates when buying a can.

The ultimate irony of course is that you only have to read the recommended above, plus maybe "The politics of breastfeeding", to see how formula manufacturers work to sabotage breastfeeding from every angle.

The news can report that formula cans are overloaded with aluminium at unsafe levels for babies, or that the excessive iron in follow on milk (only ever invented to get around the marketing restrictions of first milk) is linked to developmental delays.  Yet loyal users still believe the formula companies give an actual damn about anything but billions in profit.

This "faux empathy" is sucked up and in turn it builds a trust between supplier and customer, and further increases the divide between parents - who by now all believe the "mummy wars" exist.

And if we read everything believing it's a personal dig at us, or a judgement, it's really easy to take almost anything personally.  If I've seen the word "judgy" once online in the last few years, I've seen it a million times.  In fact it pissed me off so much I blogged about it here.

Just today on Facebook, I got accused of fuelling the mummy wars a couple of times myself.
"And it is comments such as your status which help create these 'mummy wars' and the feeling of guilt for mums who, for whatever reason, don't breastfeed their babies."  with clarification "I was referring to your comment about public health."
" I think using the term 'public health issue' is too divisive and puts too much pressure on mums who don't bf for whatever reason. That's why those of us ardent bf supporters get some of the labels we so vehemently deny - like bf Mafia. "
Wendy replied
" No - we need to label it for what it is, regardless of how this labelling makes adults feel. Many women fail to stop smoking in pregnancy despite trying very hard. Should we stop calling prenatal smoking a public health issue to cushion women who can't or won't stop smoking from feelings of guilt? 
What about childhood obesity? I've got an overweight child. Should I ask people not to call childhood obesity a public health issue because I'm struggling to reduce my child's weight and it makes me feel guilty? 
Can I repeat - we are adults. We need to take responsibility for our choices and for our emotions, and not ask other people to change their language in order to shield us from things we do as parents which we may feel uncomfortable about."
Touché.

I'm still confused that anyone could consider stating breastfeeding impacts on health to be guilt inducing and inappropriate.  Formula feeding mothers cannot (apparently) handle facts? we should all pretend actually breastfeeding doesn't matter?  Stating it's a public health issue makes someone the "breastfeeding mafia".

Oh that neatly brings us back to the ad doesn't it - because what this is actually saying is to stop the war, we have to stop talking about breastfeeding.

I think various people have summed this up well on Facebook, so here goes:

Michelle, an International Board Certified Lactation Consultant, posted a fantastic public status, which includes the following excerpt:
"Effectively, (this formula company, edited to remove name) is tricking people into silence. They are saying that every decision is equal, every choice is fine, and to talk about these choices is combative. Who wants to be any one of the judgy, sanctimonious people that they portray in the clip? 

Right, no one. X wants you to see the video and think, "Am I like that? Oh, I don't want to be like that. I'll keep my mouth shut about breastfeeding (etc.) from now on." 
So the message is that we are all to accept everything and not say anything about parenting to anyone, just smile and glow. 
Except that's not to anyone's benefit, except the formula company that is so embattled by breastfeeding advocates that every marketing campaign is an effort to discredit every scientific and social advance back to the biological norm. If the public blames themselves for mommy-wars and accepts every feeding choice as equal and acceptable, then the formula company can take the next step to reassert their product in the marketplace.
Hannah said:
"Their goal is to clear the field for their marketing, by silencing any criticism as judgy. Free speech for marketers only."
Julie said:
"The way I look at it is a formula company putting out a video to bring all parents together is a bit like The Sun newspaper releasing a female empowerment video - you have to ask what their motives are."
Sara said:
"That's why governments should ban all formula advertising. It isn't fair that decisions affecting your child's wellbeing should be based, even partly, on subtle psychological manipulation."
Samantha said:
"Exceptionally well played by X marketers. Dare to disagree and you're just another one of those bullies. Very, very clever."
By pretending feeding is "just another choice", I actually think this does a huge injustice to the parents for whom breastfeeding did matter (whether or not they continued).  I'm often told by parents, that they didn't feel they had a choice, and I doubt I would hear many grandmas sobbing years later that they felt forced to use a pram instead of a sling?

I absolutely believe we should support parents who don't want to breastfeed, or who want to stop for whatever reason - nobody should have to justify how or why they feed their baby.  I know better than most what some women endure trying.

We live in a breastfeeding un-friendly society, where mothers are expected to feed a squirmy newborn whilst "being modest", are told to "just give a bottle" by friends and healthcare professionals alike, and breasts are allowed everywhere for sexual gratification, as long as a baby isn't on the end.

If we really believe it doesn't really matter to mums, because we have an alternative sold to us as "nearly as good" what then?  We don't need to put effective support in hospitals to help mums who do want to try, we don't need to treat tongue ties in a timely manner, we don't need to improve the milk bank situation so mums have the option of human milk if they need it, we don't to strive to make anything any different than it is right now - we can just accept that's how it is with a shrug.

And the formula companies keep counting the profit.

Upper Lip Tie, Fall Guy...

Labial Frenu,
doctorspiller.com ©
Or the "maxillary labial frenum" if you want to be technically correct.

Before I get started I want to stress now that some babies absolutely do have a restrictive  upper labial frenum.  Some babies and children need it releasing to have appropriate function.  This blog isn't intended to try and deny a problem exists, but we have gone beyond that to the point it seems every baby has lip tie, tongue tie or both!

Recently "I think my baby has upper lip tie and it's causing feeding problems", is the most common phone call I receive. Whilst I've often blogged about tongue tie, I've avoided lips until now. I wanted to research, discuss with those treating, and experience working with parents who have decided to get treatment, and those that didn't.

To be fair I can see why it seems the obvious answer.  Mum experiences feeding problems, pushes back the top lip, sees a frenulum and bingo - it's clearly the cause.  If things were only so simple...

So let's start at the beginning.

What is a lip tie?


Firstly we need to recognise that the adult and infant mouth are different.

I think many people are looking for adult dentition in a baby's mouth.  In adults the frenum is typically high up the gumline, well away from teeth.  This is because for the vast majority of people, the frenum regresses during the early years of life:
"In little children, the maxillary labial frenum is often attached between the two central teeth. In most cases, this attachment migrates away from the teeth as the child approaches the age of 8 or 9.
Children generally have a large space between their central incisors during the "ugly duckling" years, but by the time the adult canine teeth are fully erupted, between the ages of 11 and 12, the space should close." (1)
and
"The attachment of the frenum to the gingiva moves progressively upwards and thins out as the alveolar process enlarges and maxillary incisors and canines erupt" (2)
and
"Labial frenal attachments are thin folds of mucous membrane with enclosed muscle fibers originating from orbicularis oris muscle of upper lip that attach at the lips to the alveolar mucosa and underlying periosteum. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration." (3)
and

"For most children, the medial erupting path of the maxillary lateral incisors and maxillary canines, as described by Broadbent 3, results in normal closure of this space. For some individuals, however, the diastema does not close spontaneously" (4)


 So what are we expecting to see when we push back the lip of a baby?

 Those who are members of our Facebook Group will know I have shared this study a lot over the last few years, as we absolutely need to establish what is normal, to identify what isn't...
"Oral examinations were performed of 1021 newborn Swedish children
The upper labial frenum was attached to the crest of the alveolar ridge in 76.7% of the children, palatally in 16.7% and buccally in 6.7%." (1)
Which means, should you go and push the lips of many babies back, over 3/4 will have a frenum attaching on the gum-line, with another chunk going through to the palate. This clearly highlights it is the physiological norm for a baby.

This means that for a baby, the frenum attaching close to, or on the gum or palate - does not confirm a lip tie. Let's say that twice.  Seeing your baby's frenum attached to the gum or palate, does not automatically mean they have a lip tie.

It simply means they have an upper frenum, which the vast majority of people do. In fact absence of an
upper frenum can indicate it is worth ruling out other genetic abnormalities.(3)

I decided to ask for photos online, from parents who had not experienced problems.  So babies who had always breastfed wonderfully since birth, gained weight well, slept well day and night, no reflux, colic or wind ie the definition of a typical "easy baby" that Gina Ford and co would be proud of - can you please flip their lip and take a picture?

Here are the first six I received, the rest were no different:


So photographs aren't a reliable way of assessing the function of the lip. What else?

Lip Tie Myths:

  • If baby's lip does not flange when feeding, stays straight or even curls inwards - it suggests lip tie.
A baby transfers milk effectively by making a seal with the lips and tongue.  This seal allows them to create a negative pressure, as the tongue lifts and drops.   If a baby has tongue tie, the tongue may not be reliably playing its part in this process, and so in my experience the baby will very often attempt to compensate by gripping extra hard with their lips.

If they didn't/can't compensate enough they can constantly slip off the breast.  I have seen babies do this who have no upper frenum as it has already been removed.  You can often spot babies doing this as the mum tends to hold her breast, baby's head and sit holding the two together. 

Furthermore if a baby is reliant on the grip from their lips, they will frequently be so tight mum is unable to flick the lip to a more comfortable position, or if they can it may gradually pull back under.

Post feed both lips can look blanched, swollen or "shiny" from the pressure.  Baby can also develop a red stripe above the top lip and below the bottom (this tends to happen more when using a bottle)

Photo courtesy of theleakyboob.com
There is also a misunderstanding in the "non breastfeeding world" as to what the top lip actually should be doing during feeding.  

It is now common to hear "both lips should flange like a duck".  This actually isn't true, and as lactation consultants many have commented we often see this "duck positioning" when baby is shallow.

When a deep latch is achieved, the top lip typically sits in a neutral position - as can be seen on this animated latch clip here and the photo on the right.

In contrast lets look at the lips of a baby with a shallow attachment:

Catherine Watson Genna, author of the fantastic "Supporting Sucking Skills in Breastfed Infants", agrees and touches on this in her book:


Whilst Catherine often writes about tongue tie, I was interested to hear whether she felt lip ties were a significant cause of breastfeeding issues. She replied:
"I think the upper lip frenulum is infrequently an issue when breastfeeding.  I am concerned that the term "lip tie" causes parents to be overly concerned about this issue and could increase doctors' skepticism of frenotomy."
  • Sucking blister on the top lip
So we have a baby gripping hard with its lips, if the tongue is thrusting, rather than undulating (as we frequently see with a tongue tie), it can cause the baby to move back and forth like a piston.  This can often be more easily seen when baby is sucking a finger or bottle, ie it physically moves in and out of their mouth, like Maggie sucking her pacifier in the Simpsons...

Add together tight grip of the lips + moving = friction blister on upper lip/babies slipping off the breast as their own suck pushes them backwards.
  • Clicking when feeding
We discussed baby needing to make a seal above.  A tied tongue or shallow attachment can provoke "snap back",  breaking this seal and a loud clicking is often heard. As the tongue moves forward it briefly creates a seal, and as it slides back for the swallow it breaks.  Because it is linked with a shallow attachment, babies without tongue tie can click too.  
  • Small gape
It's easy to assume a smaller than typical gape is because the lips are preventing adequate movement, however tongue tie is king of the small gape.

Take a look at this picture:
The gape is wider than it is tall.  If a baby opens their mouth to cry, the tongue naturally lifts which in turn (if tightly anchored to the floor of the mouth), pulls the bottom jaw up = small gape.

Now let's consider feeding.

Baby comes to breast, if he gapes wide and the bottom jaw drops, in the case of tongue tie - so does the tongue.  However baby needs to bring their tongue forward to latch, if not they will need the breast/bottle placing right into their mouth, rather than latching on effectively.  Some babies develop a great "spaghetti style suck" - where the nipple is drawn in with a suck like a child with a long string of spaghetti :)

However if they lift the tongue, it pulls their mouth closed again.

We see many many babies who post tongue tie treatment open with a giant mouth compared to pre division.

Here is a before and after pic:

Again things other than tongue tie are linked with small gape.  A tight or stiff jaw, neck or base of the skull from delivery may also cause baby to be uncomfortable with a wide mouth.
  • The lip wont flange when pushed easily.
Now I'm half with this one.

If a baby has had their tongue tie released, isn't stiff or has any other obvious causes for increased oral tension such as say a forceps delivery, very rapid labour or suchlike - that's when we typically reassess the upper lip, if tightness is identified at the initial assessment.  IF mum continues to experience problems.

I don't believe it's often accurate to assess with a tongue tie in place, or within the first few weeks after birth for many babies.

Take a look at this picture:
The oral tension is significant throughout the whole mouth.  Sometimes this can be so significant in my experience it can be hard to even get in the mouth to assess - and the babies are often declared to have tiny mouths with a short tongue.

The bottom lip looks equally as pinched, as do the corners and even the area around the mouth looks tight.  Once the tongue is released a significant number of babies have "pop out lips" ie they suddenly have full, flexible function.


  • Toddler teeth
Again, it is common for people to expect to see adult dentition in young children, nice teeth neatly sitting together, without gaps.  

According to orthodontist, Glenn Carty:
"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. 
A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth".
Furthermore, it's well recognised they may have a gap:
"The permanent maxillary central incisors are flared laterally at this time because the unerupted lateral incisors constrain the roots of the centrals. The median diastema, which results from this flaring is normal and often is called the "ugly duckling stage" of the developing dentition. As the permanent maxillary lateral incisors and canines erupt, pressure is exerted medially, causing the space to close and the frenum to atrophy." (4)
"In some cases the series of events just described does not occur." (4)
In the UK it is common to treat an upper frenum around the ages of 10 or 11 if it has not regressed and is impacting on alignment of the upper teeth, a brace may also be used at this time to assist with closure.  And I think this reflects healthcare typically in the UK, and why treating upper lip frenums is much less popular here.  As a tax funded system, we treat something if and when it's a problem.

My understanding of US medicine is that it more heavily focusses on potential prevention.  Lip attachment appears to be removed at times because they might cause a problem later, or they might be causing a problem now, and the parents travelled across 8 states for four days to get here, and as we understand it we don't "need" an upper frenum, so lets remove them just in case; it's only a frenum!  And I'm sure there are both pros and cons to this approach too.

I also collected photographs from people kind enough to share of untreated upper lips and the normal regression that occurs:

The baby in the bottom image, is the sibling of the child on the right

















Despite treatment 2 1/2 years ago for the child on the right, the gap remains and looks remarkably similar to his sibling's pictured bottom left.

This isn't surprising.  To give you a potted history of the information I've gleaned about upper ties and diastema, and then a link to where you can read the full caboodle if you fancy.

In 1907 it was first suggested that a thick labial frenum was the cause of diastema.  By the middle 1900s, the it was believed to be correlation rather than a cause.  They found gaps without frenums, frenums without gaps, and several studies found no associations between the size of the gap and the frenum.  They also discovered that in some cases, the bone had not formed correctly - and that in such cases an abnormal frenulum was the result.  Ie potentialy the gap caused or correlated with an abnormal frenum rather than the reverse.
"A V-shaped bony cleft develops between two central incisors, and an "abnormal" frenum attachment usually results.16.  Transseptal fibers fail to proliferate across the midline cleft, and the space may never close.1 ' 18"" (4)
In short during conception, a tiny cleft forms in the bone, holding the teeth apart.
They even studied the effect of frenectomy on diastemas, and found "that although closure progressed more rapidly in the frenectomized group than in the unoperated group, there was no difference in the final results after 10 years. These results intimate that frena may exert passive resisting mesial pressure, but are not an important etiologic factor in midline diastemas.22" (4)
Thus we absolutely cannot say that ties cause gaps, or treating a tie will resolve or prevent one.

The next question logically therefore is does potential early closure of a gap affect placement of other teeth, and if so in a negative or positive way? 
This image on the left was sent to me by a dentist who got it third hand, so I'm not sure who it belongs to in terms of crediting/using here, there was no copyright notice displayed - therefore if it's yours please get in touch!  (I have tried reverse image searches etc to no avail)

You can see the gap quickly closes post revision.

The UK dentists I've spoken to all seem unsure and say they would rather wait until clear and obvious reasons for immediate intervention.  But then very few here regularly perform frenectomies on babies, and so have little experience.

Presumably the American dentists treating upper frenums don't notice an increase in problems?  But I haven't seen any written material addressing this, if you have please share :)

The issue of decay to infant teeth also arises in the case of a tight frenulum, which again seems to split dentists (even those who treat).  As one pointed out, if you know there's a frenum, simply wipe up each side instead of over the top as it's stray food particles than cause the problem - so make sure you remove them.  Others don't feel that is sufficient to prevent problems.  Reducing bottle use can also reduce the impact of milk plus food together, which is a known risk in terms of decay; brushing teeth after the last feed if using formula is also advised.

Any other risks?
Without studies, how can we know?  An ENT here in the UK who would treat upper frenum with a "half snip" only if the tongue tie didn't improve things, and only if a midwife or lactation consultant confirmed they believed it to be the cause (I speak past tense as he's now emigrated), used to ask parents to sign a document stating that there may be potential unforseen consequences, without research we cannot be sure.

He also theorised a risk of removing the upper frenum, may be that without the "anchor", the lip would then lift too high exposing gum.  I was assured by two different providers this absolutely wasn't the case, and in fact the opposite was true - a tight frenum pulled the lip.

As soon as I published this blog today, someone got in touch to say this is exactly what both she and her dentist felt happened to her, and she sent me the photo you can see on the left hand side.  Her upper frenum which extended onto the palate was removed at 10 years of age due to a huge gap.  As you can see this closed, but she states that whilst she does have long gums, her lip didn't lift to reveal them to this degree before surgery.  She has promised to dig me out some childhood pictures, and so I will update then.

I also believe there are increased risks to treating both areas at the same time.  For a baby with tongue tie, compensating with the lips as discussed, to make both the tongue and lip sore can be a step too far. Remember they have likely already found feeding difficult for sometimes months.

Helen Marshall IBCLC said:
"I am seeing a high incidence of breast refusal. Usually just for 24-48 hours but that is significant to the mother who was exclusively breastfeeding and is now having to bottle or cup etc"

Discussion:

In the UK we tend to like regulations, guidance and studies.  We have that in the form of NICE guidelines for tongue tie treatment, which confirms anaesthesia is not required, and has evaluate the risks benefits involved.  We don't have this for frenectomy, we don't even have any studies confirming if and when it helps feeding.

The other problem appears to be that both upper lips and tongue ties are treated at the same time - so how on earth do we establish which intervention helped?  At suggestion they could potentially study this I was advised it was unethical to do so, as it would mean leaving a baby with a known tongue/lip tie to test the theory.  Can't say I'm entirely convinced by that logic.

Undoubtedly as I said in the introduction to this article, there are times the attachment is restrictive.  I've seen several so thick and tight the lip is unable to function properly - and who wants to spend their life with their top lip stuck down?  But these, in terms of feeding problems, appear to be a small percentage of babies.

What's more, if we're not quite right with the diagnostic criteria, could we potentially miss those that are restrictive?  My son (8) for example has a thin upper frenum, well away from his teeth and with apparently normal "flangability".  However he has for several years intermittently told me it's "too tight", asked if they can "cut it off", struggled to clean a spoon for a long time, and I think has reduced movement when talking.

If you feel up inside his lip when it's relaxed - that's the point at which the frenum feels tight.  (I should add he does have a posterior tongue tie that wasn't diagnosed during infancy)

In short we know some, we are still learning, but there's a lot left to learn.  In my opinion anyone who talks in certainties about lip ties can only be speaking anecdotally, because there are no controlled studies.  Whereas tongue tie and the impact on infant feeding has been explored over decades, we have a hole where the lip tie studies need to be.

Yes it's a relatively minor intervention in the scheme of things, if there are clear issues the preservation of feeding is of course paramount, due to the health implications of early cessation of breastfeeding.  But if we are talking "every baby with a tongue tie has a lip tie" (as some webgroups claim), don't we need guidance?

Does the area need numbing?  What is appropriate pain relief? If you're into complementary medicine, an
acupuncturist once tol me the upper lip frenum is a key point as it apparently sits on a junction of two significant channels. This might mean more to you than me, but there's a little more information here.

It's a minefield for parents at the moment, in an age of trying to seek out answers via the internet, and simply wanting to resolve their baby's issues - they're vulnerable to the next quick fix or magic wand.  I get calls three days after a tongue tie treatment saying "it hasn't worked and should we now treat the upper lip?".  The reality is that there are no instant solutions for many babies, even once the tongue is free - being a muscle it often needs to develop strength to consistently perform well, particularly with posterior ties.  You wouldn't get a cast removed from your leg and expect to run a marathon 24 hours later.  Similarly there is no benefit to patiently waiting weeks if baby has another reason they're not feeding better, such as a supply dip, a stiff neck or reattachment.

This is why working closely with your lactation consultant or breastfeeding counsellor who specialises in tongue tie is key for some.  One look at the internet chatter tells us that removing a piece of skin before pushing parents out the door 10 minutes later simply isn't enough for many.  Babies and their barriers to feeding are more than bits of skin, but that's a blog for another day....

Note:  I got 3/4 of the way through this blog, when Dr Ghaheri posted this great article.  Worth a read as although there is some crossover, it's great to get another perspective.

References:

1.  http://doctorspiller.com/Childrens_Dentistry/Childrens_Dentistry.htm#adult_eruption_schedule

2. Tethered Labial Frenum With Midline Diastema, SANJEEV TULI, MD, DEEPA SUNKARI, MD, DALLAS McKAY, MD, MARIA KELLY, MD, and SONAL TULI, MD, University of Florida, Gainesville

2. Department of Pedodontics, University of Umeå, Sweden.International Journal of Paediatric Dentistry (Impact Factor: 0.92). 07/1994; 4(2):67-73. DOI: 10.1111/j.1365-263X.1994.tb00107.x

3. An overview of frenal attachments, M Priyanka, R Sruthi, T Ramakrishnan, Pamela Emmadi, N Ambalavanan, Department of Periodontology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India, Year : 2013 | Volume : 17 | Issue : 1 | Page : 12-15

4. The midline diastema: a review of its etiology and treatment Wen-Jeng Huang, DDS Curtis J. Creath, DMD, MS, American Academy of Paediatrics, Pediatric Dentistry - 17:3, 199