My archives might be a little outdated especially the older blogs. My links above are all new and current.

I have only positive things to say about Permission to Mother, an autobiographical account of a thoughtful mother and clinician who courageously writes from her heart, soul, brain, and personal experience; who is open to change in her views and opinions and is not guided by the safety of rules of any group or the status quo; she is guided by love and openness to the experiences life brings her and her family. Her process benefits her and those around her and those who read her words. And to add to that, the writing style and story telling ability here make it a very enjoyable read speckled with both the humor and seriousness of life. ~Laura Keegan RN FNP, author of Breastfeeding with Comfort and Joy

Readers enjoy your feedback and Reviews (82!) on amazon. Kindle Version Available!

Please Join me on Facebook at Punger Family Medicine.

Thursday, October 30, 2008

My Presentation at LLL Conference

Five years ago while I was pregnant with David, I attended Toastmaster's, an international speaking and leadership group. I have always had stage-fright and I didn't have any impending plans to do a talk, but still, I figured I would need some speaking training for the future.

After David was born, I never found the time to attend toastmaster's again. I have always stayed away from opportunities to speak. Mary has asked me a few times to speak at LLL conference. Last year, I was putting final touches on the book and quite pre-occupied with the details, so I told her next year...

"Next year" came quickly and the conference committee sent me a flattering letter and invitation way back in Febuary. October seemed so far away...

But by September it dawned on me that this thing I committed to was really approaching. It seemed that especially on weekends I dwelled on what this committment meant and I was wishing I'd called Mary a long time ago and backed out. Stage-fright was definatly setting in along with my long to-do list of all the things I had to do to prepare a talk and slideshow (This was my first time preparing powerpoint. I never used the program before.), and get myself and my family ready to go out of town. For at least 6 weeks (no-kidding) I felt like a zombie trying to get stuff done.

As we are gettting down to the final wire, the last week, I am really wondering if I can do this talk or will I just pass out when I get put in the spotlight. My fear was overpowered by all the other last minute details of getting packed and out, and taking care of the practice, and final touches on the talk.

The night before the talk I went to bed early to make sure I get enough rest (it WAS NOT a slumber party that night). Sure enough at 3:00 a.m. I awoke, and tossed and turned, and my lines went round-n-round in my head. I dreamed Lauren went to my old Toastmaster's meeting with me. They (the toastmasters) evaluated my speaking-- the ums, the ahs, the subject, visuals, speech, enunciation, affect, body languague and opening line... oh, they are a tough, but friendly, group of critics... Also, in my dream the purpose of Lauren going with me to evaluate my speech for the appropriateness for this conference. (Perhaps, one would expect me to talk more about breastfeeding than birth?) Am I paranoid?

In the morning, other experienced speakers told me they were also tossing and still preparing through the night. I was not alone!

I enjoyed Mary's workshop in the morning and then went back to my room and went through my talk twice(!) reading it aloud in my room.

Fifteen minutes before the scheduled talk, I met up with the computer-donor-guy to make sure the power point was working. It worked, but my thumb was shaking almost too much to turn the dial on the remote control (why couldn't it just be a button?). I wondered how I was going to hold a Mike, my index cards, and the power point remote control. I decided to forgo the Mike and make sure I talk loudly.

By now, the stage-fight was gone because I was so numb.

I think there was 40-60 women at any one point in the room.

Everyone was smiling at me.

I was thinking about the e-mail, I received last night from my doula and friend with regrets that she couldn't attend and this encouragement:

I realize you like one-on-one, but, when you step outside your comfort zone with a talk like this, you're going to have a real sense of accomplishment and satisfaction when it's over. That alone will entice you to do more conference speaking. You know your subject matter well. Be encouraged! I'm praying for you. G-d will be with you.
Warm hugs,

Bernadette's always reminding me of Higher Purpose at the right time.

Mary gave me such a nice introduction. My thumb was really shaking, but I managed to get the power point going and used my BIG opening line ("Thank you for being here!") and with everyone smiling at me and nodding at me to go on, I did. It was nice to have Mary, Sandra, Lauren, Tach, Alyssa, Anne, Lisa, Pam, and Jen (did I miss anyone) present. Your encouragement help me! Jayne, Christy, Bernadette, Sharon, Courtney, Sam, Gerrie, you were there in spirit.... I mean your breasts or pregnant bellies were in my power point.

So, yes, the talk--my performance-- went well. I was well rehearsed-- Jayne's delivery, William's birth, Scott's birth and finally David's birth. No obvious mistakes in the power point. I flipped the photos at the right time. My index cards were in the right order. No repetitive ummms or ahhhs. I didn't need to hide behind the podium (there wasn't one anyway).

I was asked very appropriate questions after the talk. None caught me by surprise. Questions about breech, and breech turning techniques, and the political climate of birth and options. I got a few "what-if" questions, like what if I have GBS, can I still have a natural birth (yes, you can). All these are fairly typical things that I get asked and mostly have addressed before.... mothers have choices.

Mary and Sandra, the two midwives-in-training, said I handled all the questions well. I can tell by the questions that I was heard in the back.

The next morning a leader who attended gave me one-on-one feedback, "My affect fit each boys birth and she felt like she was taken back in time to my births." (The old toastmaster critics would be happy). It's true, my mind was there and to do a successful talk you have to tune everything around you out.

This was hard work and perhaps my stage-fright isn't as much stage-fright as it is questioning the time commitment and what all is involved doing something like this. Is it worth all this energy? I am glad its over. I am glad I am behind my computer tonight, networking and socializing in my comfort zone.

I would love feedback. Not toastmaster's type critique (although I am open to anything you want to share). I want to know if all this effort helps you. I'd really love to know if listening to this (me!), normalized the circumstances around your birth and gives you hope and healing. Please let me know.

(Mary said she would send some photos this weekend. She is studying now.)

Wednesday, October 29, 2008

The LLL Slumber Party

I hardly ever get a chance to take great nursing lying down photos. A LLL slumber party is a great opportunity. So here is Lauren and Ruby.
And Natacha and Michael. I lovethe eye-to-eye contact and all the white...
(It should be on the cover of a book.)
...and the cotton and the smile.

I didn't get to stay all night because my big boy John was crying for me to
come back to my room.

Mary's Birth Workshop

I enjoyed Mary Rainer's Birth Workshop. She and two other childbirth educators shared information on doulas, Bradley, hypnobirthing, Birthing From Within (BFW) and other labor techniques for coping with pain. I like how children were free to be themselves. Another speaker Diane Wiessinger came to Mary's class. Diane is very well known among lactation consultants for teaching how to watch your language. Its not just what you know, but its how you say it! It's worth checking out Diane's handouts.
The Birthing From Within Instructor brought a few projects for us to do. I read BFW after Scott was born. I wasn't going to be pregnant for a few years. I loved the art/expressive part of BFW. My pregnancy photos went from snaps shots to art after I read her book and I was AWARE.

Everyone was shown how to draw a labyrinth. I chose to take photos and not draw. Anne and Jen are in this workshop. Can you see them? What was interesting about this was that some woman's labyrinths was OPEN and Free and I noticed others were TIGHT and perfect. I won't mention any names, but you know who you are and I want an OPEN labyrinth from you soon. :)
Perhaps if you click on the photos you can see what a labyrinth is. What does it say about me, since I didn't even attempt one. Yikes.

Here I am sneaking in another meet the author photo.
Thank you Mary for an informative and relaxing childbirth class.

Tuesday, October 28, 2008

Meeting the Experts: Dr. Bob

Going to conference I got to meet a lot of great people who contribute to birth and breastfeeding.

One of the cool thing about me being an author at the LLL Florida Conference is that it was like having an "express pass" to the front of the line to meet the other authors. (It looks like we are having way too much fun.) Thanks Mary Rainer for taking such a great photo.

Dr. Bob Sear's "The Vaccine Book" has been such a useful resource in my practice that getting to meet him at the book signing breakfast was especially fun.

I get many hits off his blog to mine and I get new patient from the hits. I thanked him personally. His book makes many parents THINK and READ. And I like that.

Since his book has been out, I often get asked if I can provide MMR seperatly in 3 different vaccines. I think that's what Dr. Bob "did" in his practice, but he informed me that it is no longer available that way. However, if that changes and moms can find a pharmacy or medical supply to fill a prescription for the 3 seperate components. I'd be glad to divide the shot up into mump, measles, and rubella, each given seperately. I also haven't been able to get the Hib. Although it may be available in combination, he confirmed that he can't get it seperately either because it is back ordered. If anyone has different info let me know.

I hope to share more conference stuff soon.

Sunday, October 26, 2008

Today is my Blog's One-year Birthday and a Give-away

Today my blog is one year old! I am so happy that I have documented important events, the boys activities, and how I feel about what is going on around me this past year. I realize all my accomplishments.

My sister, Carrie, in celebration, is hosting a Permission to Mother give-away. Go check out the details at her blog, fitncrafty. It's easy to enter!

I have lots to say about this weekend's Florida LLL Area conference. I'll save it for later this week. So please come back...

Wednesday, October 22, 2008

Evidence- or Intuitive- based based care?

The standard-of-care is a legal term, the level at which the average, prudent provider, in a given community would practice. It is how similarly qualified providers would manage care under the same or similar circumstances.

The standard-of-care comes from the evidence. The evidence is what research "proves."

Personally I like forming my own opinions and I really like getting "beyond the standard of care." Are my thoughts just some random crazy doctor thoughts?

I carefully consider everything I put in writing and the advice I give to my patients in the office. What I learned in school never seemed to apply to my births and my own kids. The more and more I read, I realize I need to read opposing positions. I often find that the evidence is conflicting, out-dated, biased, manipulated, and mistakes are often made in publishing and printing the facts.

"Evidence" is what holds up in court. Despite all the problems with the evidence, few professionals can get beyond the legal aspect. They live in fear of constant law suit when they take care of patients and make recommendations. They can't be flexible.

I prefer to develop relationships with my patients and take the intuitive and individualized approach based on all the evidence available to make a recommendation. That is why the subtitle of my book is "beyond the standard-of-care." I guess I am not average or prudent. Oh-well. :/

Sunday, October 19, 2008

Post Weaning Question from a Reader

I received this question tonight and thought I'd bring it to the top in case anyone had any ideas:

I am not even sure which post to leave this comment but I have a question that I think you can help me with. I found your blog when I wanted help with my sons "reflux" and have loved reading it since.

I stopped nursing about three months ago, not by choice, but because my milk had dried up. I got pregnant when my son was 5 months old and my milk supply dropped.

I miscarried a month later and I dried up. He was getting nothing but frustrated.
To my surprise three months later, out of the blue, I am engorged. There has been NO stimulation or demand. What is going on? How can this happen?



My initial thoughts:
Are you pregnant?
Change in medication?
Could it be mastitis?
Are you able to express milk? If so give it to your baby!

I realize that none of these really explain what's going on, hopefully its helpful.

Saturday, October 18, 2008

So, who is going to this conference?

So who is going? They inform me that 55 are signed up for my session.
Mary, Lauren, Jen, Pam, Christy, Lisa? Who else?

La Leche League
Oct 23-26, 2008
at the beautiful Daytona Oceanfront Resort in Florida

Positive Parenting: A Timely Treasure October 23-26 Guest speakers include: Dr. Robert Sears, Naomi Drew, Jim Weiss, Diane Weisssinger, Rae Davies, Dr. Denise Punger and Dr. Carolina Ceron

My Saturday afternoon session is

Birth and breastfeeding can be two of the most empowering experiences of a woman's life. Discuss how our experiences impact our ability to fulfill our roles as mothers and ways to ensure your Permission to Mother.

Sunday morning Breakfast Buffet with Book Signing. Meet and greet authors Naomi Drew, Denise Punger, Bob Sears, Jim Weiss and Diane Wiessinger.

Conference registration is:

Friday, October 17, 2008

I am stocked UP!

I am glad I got into the habit of posting this on my blog because when I need ideas on what to do with my produce, I have a record of what I did previous times. I am stocked up with lots of fresh, organic produce because I special ordered ordered extra fruit. We seem to be going through our produce really fast these days. Here is what I've done so far with the stuff I got yesterday.

We got:
carrots - salad
cauliflower - steamed, it was delicious. I ate it all by myslef
red butter lettuce
cremini mushrooms - Traded with Lauren for her bananas
leeks- sauteed one batch with some scallions from last week and kale and apple, I had mine over brown rice topped with curry and nama shoyu.
green peppers- left on the bonus table and swapped out for more of the other stuff. I am so glad I get a chance to swap out what I can't use. I really feel like I get a good selection for the $.
garnett sweet potatoes - cut some into 1/4 inch slices and sauteed in coconut oil on the stove-these came out delicious
alfalfa sprouts- salad
green acorn squash - Delicous Moroccan Stew
roma tomatoes salad and avacodo sandwich
red delicious apples
green seedless grapes- snacking, smoothies, I froze many of them, so I'll have an on going
supply for smoothies. We juiced a few, but it wasn't my favorite way to have them.
bartlett pears- Juiced
bananas- snacking and Ihid some from the boys so I can make banana bread and have some for smoothies
kale- smoothie and sauteed. William and Scott drank this green smoothie this morning
spring mix - salad

Fruit Share:

Gala apples- juicing, snacks
strawberries- snacks and froze some.

And by special order, some extra strawberries, grapes, and apples
I made smoothies and froze them to bring to conference.

Tuesday, October 14, 2008

Cool Opportunity to Get Raw Almonds at Bulk Prices

First off, did you know that you can no longer buy raw almonds in this country? That's right; our gov't made it ILLEGAL (9/07) to sell almond and almond products labeled raw. They MUST BY LAW be pasteurized/cooked. The law requires almond producers to lie to you. There is a lot to be said for the nutrition and digestability of raw foods. I found a link to a local buyer in CA who can purcase and ship us 100 lbs of TRULY raw almonds. These would be sproutable and I would get us recipes for this, almond butter, etc. They would keep as is for a year, more with refridgeration. The catch is that I must order by 10/30 - they are harvested and available now, not later. If you are interested in a share contact my friend Gerrie who is willing to organize this or leave a comment.

I've been sprouting my own lentils, alfalfa and clover b/c sprouts are so good for us. A young plant is "live" nutrition. (Breastmilk is living and this is the closest to live nutriton I can find for myself.) I feel so good when I eat a variety of spouts. Its easy to sprout. Most are ready over night (like almonds) or within 2-3 days (alfalfa and clover). I've got plenty of on-line resources for what to do with almonds. I've noticed that when I buy what I think is "raw" almonds locally, what I am getting is "natural" almonds. I'm hoping to take advantage of the California harvest. Any other takers?

Saturday, October 11, 2008

How much produce do I go through?

Last week we got:

broccoli - steamed and eaten with pesto. I am going to start blending in a few chunks of broccoli into the pesto now that all my boys eat "yucky green pasta."

carrots - ginger/carrot salad from Lauren

cauliflower - roasted on the grill with other veggies

celery root - cubed and cooked in veg/bean soup

red chard - pesto, some froze and some eaten right away.

fennel - left it on the bonus table

green butter lettuce - didn't come in this delivery

green onion - sauteed in omelets

yukon gold potato - sliced and made fries in the oven, left overs get sauteed with green onions to make "has browns" with our eggs.

shallots- went into my marinara sauce. Did we only get one each?

roma tomatoes- made marinara sauce

gala apples -snacks and juice(with ginger and carrots), a way to get kids to eat carrots

valencia oranges - kids snacks

starkrimson pears - juiced with ginger and oranges. I can get the kids to drink this.

bananas -- these go quick.

Fruit Share:

strawberries - snacked on by William and David and gone before it hit the 'fridge.

honeydew - sliced and eaten immediately. one slice and a few seeds were saved for my smoothie in the morning. My blender grinds the seeds.

star fruit - Scott likes these. They are so hard to peel and eat, we decided to juice them with apples, ginger and carrots. Everyone had this.

This stuff came on Thursday, last week. I went to Sam's last weekend and go more fruit. John bought frozen fruit in the middle of the week, and we are going to the farmer's market this morning. I've made green smoothies everyday, but one. I use agave to sweeten the smoothies, so my kids will drink it. If there is a sitter in my house that morning they get some, too. I'd prefer no sweetener or very ripe banana and frozen grapes), but I have to do it for the kids. I try to drink a quart of smoothie everyday. Sometimes there is too much people to make the batch go around.

David doesn't always drink the green smoothie. Since he still gets the breast stuff, I don't push it too much. I've already special ordered apples, strawberries, AND grapes from the co-op for the next pick up. Since my kids eat them, I have a feeling it won't last long.

I've noticed my kids will scarf the fruit, but if my husband brings ice cream (or dessert) in the house, they won't want anything else. David is the worst. He insisted on ice cream for breakfast and cried and cried. I put the ice cream in a bag and brought it to work since he refused to eat real food. Then it wasn't an issue. And its amazing kids can do well when the option isn't junk verse junk. As you see we go through lots of produce and I am happy for that!

Tuesday, October 7, 2008

Bottlefeed? Me?

I wondered what would happen if I was ever in a situation if I would have to give someone else's baby a bottle. I don't think I could do it. Since there is no reason for me to be in that situation, I don't think about it much.

Until today.

An established but new mom in my practice, comes in today with her twins. She has been breastfeeding them until a few days ago when it became to painful. She's in tears. The babies are crying. I ask if she wants me to help her put them to the breast. With pain in her expression, she told me that she just wants to give them her pumped milk. And I truly understand. Just... which one was she going to feed.... and who was going to feed the other?

She gets both propped in her right arm (they are small). Whew (for me)!!! Then she props one bottle against her chest for the twin closest to her and holds the second bottle.

I am not off the hook yet. The "first" bottle doesn't stay propped and the baby is crying ((hunger)). I am sweating this. I have to make a move. I can sense that mom doesn't like this anymore than I do. I take the bottle and hold it up for the baby. I am sweating, more. At least it is breastmilk, I rationalize in my mind. The baby's milk drips out of the baby' mouth and the baby pushes the rubber teat out of her mouth:

"See, I don't know how to bottle feed." I said. That's it, I thought, I am off the hook.

"Oh, Dr. Punger, that's why I come here, because you don't know how to use a bottle!" I feel a lot better.

Fortunately, the baby settled down quickly. The Mom's exam shows a raging mastitis. There was a reason for the breastfeeding pain. I expect that these babies should be back to the breast soon.

Sunday, October 5, 2008

And the winner of the give-away is....

Well... there is three winners. My sons thought it was a good idea if they each drew a name.

Three happy books are going to:

William drew.... Tammy S.

Scott drew.... mama says.

David drew... KMDuff.

I need the three of you to let me know where to send it. If any of you are in the area and can do a pick-up, please let me know. I won't publish your address if you leave it on a comment. Others may appreciate your happy replies so don't include your address with comments that you intend for me to publish. (thanks :) ) I don't mind receiving a separate comment. One more stipulation: After you read it, I'd like your feedback, please. What you got out of it, How it helped you.

I'm glad I did this. I loved all the comments and found it very interesting to be reminded where you were referred from (and the diversity) and to hear from old and new friends. Come back!!

My sister (fitncrafty) wants to give-away my book on her blog next month. Stay tune. I will do it again soon, but I am glad my sister will "host" next month.

Now through Oct 24th, I will offer Permission to Mother through the office for $20 for pick-up in the office and for $23.00 if we are shipping (includes postal). That beats the amazon price of 26.95. The printer had an author promotional that allows me to do this, this month. I can take orders through the website (the price will manually be adjusted), phone 772-466-8884, or fax 772-466-8832. Coupon code = "Blog Oct2008"

Life - Keeping it Real

I am glad I had some relaxing times in August (after the August 1st exam) as you can tell from my posts that month.

Anticipating that the Board Exam was over, I accepted new promising challenges: like preparing for my first conference speaking, training a nurse practitioner student, enrolling William in 6th grade Virtual Math and wanting to promote the breastfeeding and nutrition part of my practice more.

Lucky me, I chose the women's module as part of my exam and I come to find that section was "defective," so the Board says. ((I knew, knew, knew there was something wrong with that test.)) They accept "responsibility" and there is no official record of me taking the exam and I get to do it again, the same test, December 2nd. I don't even have to pay the thousand dollar fee to take it again. They really have tried to make good. Ha. I am psyched out. Imagine that. I'm "just" a little moody to be around, so if I keep a friendly distance away with two computers between us we will get a long good. Taking the test in cycle with everyone else was one thing. I am really dragging now.

With the burden of the test and all the holidays, birthdays (mine, grandmas, the kids), anniversaries (mine), high holidays, 3 months of anticipating the consumerism Christmas season(a burden in my book) and all the pioneering things I WANT to do that I previously accepted to do, I'm in a little over my head. Just a little. Just a little.

I should take a blog break, but I probably won't because I have enough to say, I could easily fill another book and its really my only social life right now (and a blessing to be able to connect so easy). I feel relief journaling and accountability as I think my goals (and weaknesses) through and share them.

I never did start the virtual math curriculum. William's on his own. Er, I mean, we are definitely unschoolers right now with no curriculum. The boys have outside activities every night I'm trying to keep up with. I need to keep on this exercises and nutrition path for my sanity. Instead of reading review books to study, I got audio digests to plug into the CD while I walk and drive. Now I have to MOVE to get my studying in.

I also decided to limit my new patients to only breastfeeding, nutrition, and pregnancy until after I have my exam results. After the exam, I can open the door to all comers. I want to be able to take care of my established practice without taking on new responsibility. I've also cut back on my office hours some. John, my dear husband, already thought I hardly work. Now I hardly work, less, he says. A pain he can be demanding me to work more, but this time, it was actually his suggestion to lighten my load. Making this decision was really hard because I have never been one to deny an office visit.

Preparing for a talk is HARD work. I am finding that I am a perfectionist (to my own detriment). I want to go out and play today. But I am going to study and then fool around with the power point.... and I have to find a new dress. My nutrition is paying off. Nothing fits me (that's a good thing). Yet, its just another thing to do. I really don't like shopping, as much as people think I do(or generalize and think women do), for dresses and shoes, especially under pressure for an occasion.

My almost 93 year old frail Grandmother fell AGAIN yesterday morning. She is having hip surgery now, this morning. (She may be in recovery by now). I want to go see her on Wednesday in Orlando. There is a special reason for me to go on Wednesday.

I'm accepting that I am going to have a challenging few weeks a head of me. If I am not my usual self, now you know why. Getting that certified letter from the Board a week before they released the passing the scores on our profiles has eaten at me. I was feeling really good with my accomplishments and goals. I didn't think anything could beat me. I feel beaten.

Courtney has a prayer box--such a sweet thing to do with her kids. Can I go in it? Not on an index card. I mean can I go in it, shut the lid and come out after January 1st?

I'm glad I am surrounded by my kids in the morning. They know how bad I feel. I am really lucky because I start my day with three loving kid hugs. January 1st come fast, please.

Wednesday, October 1, 2008

Permission to Mother Give-Away

Because I am always so serious on my blog, to lighten it up a bit, I'm having a giveaway of awesome goodies (if I can keep up, I'll do it again). It'll be a matter of simply responding to a question or leaving a comment in order to have your name entered into a drawing to win.

For this first drawing, I'm giving away a complementary Permission to Mother book (take a look at it here) and all you have to do is simply answer the following question in the comment section of this blog. I'll enter every one's name who answered the question into a drawing and announce the winner on my blog next Monday. Comments need to be received before Sunday at 8:00 pm. I'll mail it to you if you are outside my county, otherwise I'll hold it for you at the office. Everyone is eligible, even if you already own a copy. They make a good present for the holidays, birthday, or new baby. You need to be available on Monday to give me delivery information if you are out of town.

Are you ready? I'm really excited about this...

A very easy Question:
How did you first hear about my blog?

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