Superior Labial Frenulum Attachment Site and Correlation with Breast Feeding Outcomes

Background: The benefits of breastfeeding are widely accepted. Early cessation of breastfeeding may occur secondary to maternal pain as a result of neonatal oral anatomy. The superior labial frenulum (SLF) has been identified as a possible cause of breastfeeding difficulty. Classification systems have been proposed to grade SLF attachment from superior (Grade 1) to inferior (Grade 3) but most have poor inter and intra rater reliability. Laser or mechanical frenulectomy of high grade SLF may be undertaken in an attempt to improve breastfeeding outcome but there is little empirical evidence to support this practice. Our research seeks to evaluate the incidence of SLF attachment site grade utilizing a modified existing system and investigate the correlation with breast feeding outcomes.

Methods: Two hundred and eight neonates and mothers were recruited from the newborn nursery at Brooke Army Medical Center. The neonate’s SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF attachment grading system (Grade 1-3) (Fig 1). Breastfeeding mothers completed surveys on attitudes and associated pain with feedings. Re-evaluation of breastfeeding status and survey re-administration was performed at 2 weeks and 2 months post-delivery.

Results: At 2 weeks, 86.8% were breastfeeding vs 72.8% at 2 months. There was no difference in breastfeeding at 2 weeks between SLF groups. At 2 months SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects [p= 0.0384]. At 2 weeks and 2 months there was no difference between SLF groups with regard to maternal breast feeding attitudes or pain scores (Table 3). There was no significant difference in terms of weight, referrals, or lingual/labial frenulectomy between SLF groups.

Conclusion: Our study shows no consistent correlation between higher SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system.