How to Take Appropriate Pictures for Tongue Tie or Lip Tie Evaluation

This post has one basic goal: to teach you how to take appropriate pictures of the tongue or lip to help others evaluate your baby from a distance.

1) taking good pictures requires 2 people. A tongue selfie does no one any good. One person lifts the lip or the tongue and the other snaps the picture.

2) get good illumination - a decent LED headlight now costs less than $20.

3) Proper positioning - the lip and the tongue should move up for normal breastfeeding. Getting your fingers under the lip or under the tongue is important for testing if you can easily pick the tongue up. Position yourself from above so that the baby's feet are moving away from you.

4) Here’s a video on how to elevate the lip or the tongue: https://vimeo.com/

5) For the person taking the picture, make sure you position yourself so you can bring the entire frenulum in view. One trick is to have the focus already set by focusing on the mouth before you do the elevation. On iPhones (and possibly Android phones), holding your finger on the desired area of focus for several seconds will result in a locked “autofocus/autoexposure”, so that it won’t try to refocus as the baby moves. Another trick is to just hold the shutter down and take a rapid burst of photos to see if you can find a suitable picture. Along similar lines, you could take a video and then choose a screen shot later.

Tongue tie vs lip tie: which is more to blame?

As awareness about the impact of tongue tie and lip tie on breast-feeding has become more widespread, more and more people are having questions about how to best evaluate babies with breastfeeding problems. Many people focus on lip tie as the major problem with breastfeeding. I receive many pictures of babies' lips from parents who are wondering whether a simple lip revision will take care of their problems.

Why is there such a focus on the lip? I have several theories:

1) It's an easy structure to evaluate.

2) Many parents and practitioners are confused about the difference between a normal labial frenulum and a lip tie. I've written about that previously.  

3) The procedure and the recovery are relatively easy. The stretching exercises for the lip are well-tolerated and the reattachment rate is extremely low. 

Wouldn't it be great if such a simple lip procedure took care of so many problems? I do think that the upper lip plays a role in normal breast-feeding. With a lip tie, the child has difficulties flanging the upper lip, and this can cause muscular tension that can make opening the mouth widely very difficult. The result is a shallow latch, a small mouth (baby can't open widely), nipple pain and nipple trauma. In my experience, if a baby comes to my office with breastfeeding problems and has a tie, 99% of the time that child will have a tongue tie. They may also have a lip tie (about 50-60% of the time) accompanying the tongue tie but isolated lip tie is very uncommon - it makes up less than 1% of the babies that I treat. Those few babies have normal tongue function; the lip restriction is the only obstacle to achieving a normal latch. For most babies, however, a tongue restriction is the problem.

Why do I think that the tongue is usually to blame?

1) The tongue is the active muscle in breastfeeding. It is responsible for the creation of negative pressure that is necessary to nurse normally. The lip, on the other hand, is a relatively static/passive component of normal breastfeeding. It can get in the way, but a normal lip doesn't guarantee normal feeding. A normal tongue, on the other hand, is much more predictive of normal breastfeeding. 

2) Almost every published paper demonstrating the benefit of frenotomy on breastfeeding included patients who only had a tongue tie release. Most ignored the lip. Despite ignoring the lip, the available evidence shows that lingual frenotomy alone was beneficial. 

3) When the tongue is tethered, it can affect the lip's function. If the tongue does not form the peristaltic wave necessary for vacuum generation, the baby can forcefully try to suck the breast in. This can cause the upper (and lower) lip to get sucked in, again causing the mouth to stay closed. This can mimic a lip tie because many people equate a rolled-in lip with a lip tie when it's really the tongue's fault. Think of the lip motions necessary to use a straw: the lips must purse with strength to hold suction. In people with facial paralysis (like with Bell's Palsy or who have suffered a stroke), they are unable to purse the lips on the affected side and the suction is weak and liquid can dribble out. How does this relate to a baby? If a baby's tongue isn't working appropriately, they will often purse their lips to hold on tightly to the breast - this can result in the upper (and lower) lip turning in, even if there's no true lip tie.

Remember, most of the symptoms common to tied children are caused by the tongue's inability to move up: clicking, poor suction, poor breast drainage, leaking out the sides of the mouth, slipping to the end of the breast, popping on and off the breast, poor weight gain, falling asleep prematurely only to wake up hungry later, reflux/colic symptoms and pain/nipple trauma. The one major overlapping symptom set with isolated lip ties occurs in moms who have lots of pain and nipple damage without the other tongue symptoms. If the tongue has good superior movement in the mouth, then I will treat the upper lip alone and wait to determine if something else needs to be done.

If a practitioner focuses on a lip tie without evaluating the tongue or determines that the tongue is "normal" even in the presence of the aforementioned symptoms of tongue restriction, it may be an indication of inadequate education or experience in diagnosing or treating tongue ties. In my mind, the tongue should be the first place a practitioner should look before even worrying about the lip. Quite often, I will only treat the tongue if I'm not sure of the impact of the lip on the breastfeeding relationship. In those instances, I usually never see those babies back because the tongue release alone is sufficient to improve that relationship.

Breastfeeding Problems Can Affect the Emotional Health of Mom and Baby

As an ENT surgeon, my initial exposure to breastfeeding medicine focused on the technical aspects of frenotomy as it relates to breastfeeding problems. Early on, I would see babies for a specific purpose and beyond that, I relied on my community lactation consultants to begin the task of improving breastfeeding quality. However, as a father of tongue-tied children and as a husband to an amazing woman who suffered through breastfeeding our first child, I have always been aware of the toll that abnormal breastfeeding takes on a mom (and family). In this post, I want to look at some of the factors affected by breastfeeding that don’t necessarily focus on infant nutrition and latch quality. Some of what I will present will have references supporting my ideas, but there are also ideas I have about the impact of breastfeeding abnormalities that haven’t fully been studied.

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Emotional health for mom - I previously wrote about the importance of mom’s symptoms when considering whether a frenotomy is warranted. When a baby is having difficulty breastfeeding, mom’s stress is visible and almost palpable. Mom has an inherent instinct to nourish her child, and a disruption in that desire can have profound psychological impacts. An extremely important study tracking these impacts was published this year by Cristina Borra and colleagues. In this study, the rates of maternal postpartum depression (PPD) were measured in relation to breastfeeding success. The moms with the lowest rate of PPD were the moms who intended to breastfeed and successfully did so. The moms with the highest rate of PPD were the moms who intended to breastfeed but didn’t or couldn’t. Their risk of PPD was double that of the control group. That’s an alarming number that we cannot ignore. A similar study looks at what happens to breastfeeding when a mom has a diagnosis of PPD. Dr Stuebe and colleagues found that in instances of disrupted lactation, the median duration of breastfeeding was 1.2 months. The median duration of breastfeeding in those without disrupted lactation was 7 months. In the article, she also found that moms with a diagnosis of PPD had a higher incidence of disrupted lactation. The final article is, in my opinion, the most fascinating. While it is an animal study, Dr Hinde and colleagues examined rhesus monkey mother-baby dyads and measured cortisol levels in the mommy’s milk. They then demonstrated that the monkeys with high cortisol levels in their breastmilk had babies that were “nervous” and babies exposed to low cortisol breastmilk were more “confident”. Cortisol levels are often high in those undergoing some sort of physical or psychological trouble, so understanding the impact of cortisol is of particular interest to me. The cause of high cortisol levels and the downstream effects of these cortisol levels is very complex, and further information on the topic is found here and here. It's important to recognize that the cortisol implications regarding breastfeeding are still not completely clear, so more research is necessary.

Emotional health for baby - From a biological perspective, one of the most basic human instincts is the need to breastfeed. You may have seen a newborn crawl up a mother’s chest and latch on the breast without assistance. It’s an innate function for babies. When breastfeeding is disrupted, we know how it can affect how the baby feeds, but we don’t have data to show how much the baby suffers when this basic functional need is disrupted. One very interesting paper looking at how baby stress is measured was published in 2012 that studied infant and mom stress levels when they tried a self-settling sleep training program (like Cry It Out). What the paper found was when the mom and baby were actively struggling through the training program, their cortisol levels (an easily measurable hormone) were both very high. Once the baby was “trained” and mom moved into her own bedroom, her cortisol levels normalized, but the baby’s levels remained elevated even without signs of distress (apparently “successful” training). How does this relate to breastfeeding? I maintain that babies who have difficulty with breastfeeding are actively in distress, similar to the abandoned baby. A basic human function (like parental proximity during sleep OR breastfeeding easily) becomes disrupted, and cortisol levels can rise. At some point, we may be able to measure that. I routinely hear stories where moms email me shortly after a frenotomy and tell me that they “have a whole new baby”. These babies are often calmer, sleep better, and exhibit less body tension and just seem relaxed and happy.

It’s time that medical professionals start to look at breastfeeding as an important developmental process rather than a stair step to getting a baby to grow physically. The medical community is very good at measuring physical attributes - growth curves and physical milestones are part of well child visits. We need to focus on the neurologic and psychiatric well being of infants in addition to their moms. Our current system is failing the dyad from the emotional aspect, and we need to examine what happens as a result of that failure.

The Difference Between a Lip Tie and a Normal Labial Frenulum

The vast majority of those who read the posts on this site show an interest because of problems with breastfeeding. I have pointed out many of those symptoms before: pain, poor weight gain, poor latch mechanics, reflux and so forth. As our awareness about tongue tie and lip tie increases, more moms will be sharing their stories. We often underestimate the power of sharing a Facebook status, liking a Facebook page, or tweeting out information.

Sometimes, parents will come across information on social media that piques their interest, even if they aren't experiencing a specific problem with breastfeeding. One of the more common ways that manifests itself is when they see a picture of a lip tie. I wrote previously about how upper lip ties (ULT) can affect breastfeeding. Pictures of thick or tight lip ties seem to pop up everywhere. Not uncommonly, parents will see these pictures and then take a peek under their own children's lips. Some are surprised to find what they think is a lip tie. Some will come to see me for treatment; others will email me for advice. Hopefully, this post will clarify some misunderstanding to avoid unnecessary concerns for those parents.

Those of us who frequently diagnose and treat ULT use a classification system to describe where the frenulum attaches. Class 1 lip ties are quite rare (it indicates little to no visible attachment). To date, I've seen more than 1500 babies and have yet to see a class 1 tie. A class 2 ULT will insert somewhere on the gumline (gingiva) above the edge of the gumline. A class 3 ULT will insert at the edge of the gumline, adjacent to a structure called the anterior papilla. Finally, a class 4 ULT will wrap around to the hard palate.

Class 2 Frenulum (no restriction noted - good flanging)

Class 3 Lip Tie (Central restriction noted)

Class 4 Lip Tie (Central restriction noted, bone notching is present)

This classification system just describes anatomy. It does not determine severity, like a cancer staging classification does. A class 4 ULT isn't "worse" than a class 3 ULT - what matters is the degree of restriction.  This degree of restriction can be determined by feeling the lip and trying to elevate it, mimicking the flanging motion needed on the breast. Alternatively, an IBCLC (international board certified lactation consultant) can evaluate what the lip is doing on the breast.

The most important thing to recognize, therefore, is that the classification used to describe the attachment of the labial frenulum to the gum can describe normal labial frenula as well. Many times, I will get an email asking for opinions on a baby's "class 3 lip tie" in situations where neither the baby nor the mom experiences breastfeeding problems. So in this instance, the baby has a class 3 frenulum.

This video demonstrates how a normal frenulum can have a class 3 attachment but demonstrates no restriction - the baby sleeps through the examination

To illustrate the distinction, we will examine an important study out of Sweden from 1994 by Flinck et al. This study examined 1021 newborns were studied over 8 months to record normal oral findings. Keep in mind that these babies weren't having particular problems - they were just being observed. Of those 1021 babies, only 68 (or 6.7%) had "buccal" insertions of the frenulum (this would indicate a class 1 or 2 attachment). 782 (76.7%) had class 3 attachments and 170 (16.7%) had class 4 attachments.

Keeping this in mind, I maintain that the location of the frenulum's attachment to the gumline CANNOT be a deciding factor on whether or not a frenulum is tied. If that were the case, the Flinck study would justify treatment in 93% of babies, and we know that number can't be right.

If restriction is noted, and the restriction is from the frenulum itself, then treatment is warranted. But in what other situations would treatment be plausible if breastfeeding weren't problematic? The two most common instances are dental decay and a central gap in the teeth (diastema). 

The most important paper regarding the labial frenulum and premature dental decay comes from Dr. Larry Kotlow. In this study, he associates the presence of a prominent maxillary labial frenulum to premature dental decay of the two teeth on either side of the frenulum (the central and lateral maxillary incisors). The most likely mechanism of this premature decay is that a prominent frenulum can allow for pocketing of debris that cannot be cleared away, giving bacteria a reservoir of material to use. In my experience, the frenula that have a "hooding" appearance (like an awning over a patio) are the ones at highest risk. Because the majority of kids have class 3 or 4 frenula, but the majority of kids don't get this premature dental decay, I don't treat preemptively. I think that's bad medicine. But once decay is seen, treatment should be rendered.

The much more common question I get is about a central diastema or gap in the front teeth. Some parents are very worried about gap formation - they have brought otherwise asymptomatic babies to me before teeth have even come in, asking for revision. More commonly the gap is noticed once the front teeth come in. I still don't like to release those frenula at that stage - the gap can be temporary. As more teeth come in, the incisors can rotate forward, and the gap can be obliterated without the need for any intervention. My preference is to wait until all the teeth are in before deciding on a revision. Obviously, there are some exceptions - the severely thick frenulum or the ULT that is pulling on the gumline hard enough to cause notching of the border of the gumline will always have a gap, and treatment is reasonable. Other instances where treatment is helpful is when the child is experiencing pain from repeated minor trauma - this can occur during eating or brushing teeth.  Regardless, it's important to understand that both a lip tie and an untied normal frenulum can cause a gap between the teeth. It's often more about the presence of tissue that can cause the gap, even if that tissue isn't under tension. Finally, it's important for parents to understand that releasing a frenulum that's causing a gap may not result in closure of that gap. Dental spacing is much more complex than the simple presence or absence of a low frenulum. If parents want a frenulum released to "prevent the need for braces", I advise them that there's no guarantee in the result because of the variable causes of abnormal spacing.

A normal frenulum can act as a space holder between teeth and cause a gap, like elevator doors that close on you. The mere presence of tissue (like the guy in the red shirt) can hold the teeth apart. A lip tie, which can also have abnormal bulk, has added tension to keep the teeth apart, just like someone using active force to keep elevator doors open. Both a nornal frenulum and a tie can cause a gap in those teeth.

While some may argue that this is an issue of semantics, I feel that it's an important distinction to make. When parents realize that what their child has is considered normal, it makes non-treatment a much less stressful choice. My goal is to make sure that we are releasing the appropriate frenula for the appropriate reasons.