My archives might be a little outdated especially the older blogs.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.

Wednesday, October 3, 2012

This is the doctor I want to be!!!

I've been working long hours talking to the corporate lawyer, accountant, banker, advisors (both formal and informal) to branch out on my own.... Punger Family Medicine LLC.

Tonight I accidentally ran into the group of Independent Physicians Association. Like the door was waiting for me to walk in!

I came home and my husband asked, "Wouldn't it be nice to not have to worry about any of that administrative stuff and just sell the practice to HCA or Wellcare (or MM or Peds Assoc.. etc...)?"


It would NOT be nice. That's not who I want to be. I do not want to be told what I can and can not do.

I want to be the doctor who comes home to this (this was all yesterday) without restriction to practice what I believe:

"I love love LOVE our new pediatrician!!! She is an hour away, but Dr Punger is SOOOO worth the drive!!! We had an awesome visit with her this morning with well-visits for all 4 kids. Maggie has already gained 13 ounces! WOOO HOOOO!!!"

"Just picked up, "Permission to Mother" by Dr. Denise Punger at the library!  I just read the first page....I still have forcep marks on my cheeks. Can't wait to read more!"  

"I wanted to thank you so much for fixing our little tongue issue! I came into your office after a harrying visit to a pediatric surgeon and a husband with a million questions.  You didn’t back down and you helped us get things on track. Caden is now over 15LBS and 25” fully aware and I think a very pleasant little man. Thank you for helping us get the job done."

This is the doctor I want to be! Thank you for choosing my practice.

(It makes all the professional advisory meetings worth it!)

Tuesday, September 18, 2012

Yes, You are in the right place!

We have a new look at the office. When you walk in, "Yes, you are in the right place!" (Thank you, Denise Dinocola for taking this great photo and a few others. Check out more of her photography.) Some are my snapshots (They are easy to identify).

This is the sign you see when you walk in. I truly believe in trusting your instincts.

I thought David, my son, was going to stay all day and play. He was fascinated with old fashioned games.
David thought the playground built by Crystal and Amber was for 8 years and under. (He just turned 9.) TTT and HS is for "my age."

If you want to know why the room was updated, Here is something to help you remember the old seating.
The ugly fountains are gone. Hopefully more great changes to come!!!! Thanks to everyone who had ideas and moved these ideas forward.

Thursday, August 23, 2012

Toddler Breastfeeding & Frenotomy and Upper-tie Release (Two Success Stories)

Alicia J. Hill is my guest blogger today! I am posting the speech she presented for WBW at W.I.C in Martin County. I met her when she accompanied her step-sister to my office for a consult.

Breastfeeding for me has been an amazing journey that has brought me a closer relationship to my daughter and my fiancĂ©. I was extremely determined to breastfeed early on in my pregnancy and I researched everything I could find on the subject. I prepared myself for the worse, just in case. I found that in the beginning it was so easy and natural. It was always convenient and ready; I thought, gee this is a piece of cake. My first real ruff patch was when she was about 7 months old; she had 2 teeth. She wanted to use her new found tools on me and I was in agony. I reached out and found as many people as I could to talk with on the subject. I even found the “secret unofficial La Leche page” on facebook, a resource I still use daily. Everyone said, give it a few days, this too shall pass – and it did. We are now at 18 months. She’s only nursing at this point for her nap and bedtime (and the middle of the night nursing she seems determined to sneak in). We are trying to wean and not having much luck so next year I might have more information on my adventure with that.

One of the best side effects of breastfeeding has been that it has made her such a healthy child, she’s had only 1 ear infection and 1 cold. Breastfeeding has also helped ease the pain of teething, the agony of shots, the bruises of crawling and the bumps and scrapes of learning to walk. As soon as she was upset in anyway by one of these things we would immediately nurse and all the worries and cares of these things immediately seemed to slip away.

There are so many other benefits too but I don’t have time to list them all. I want to tell you about my step-sister, not to scare you but to inform you. Her journey has not been so easy and she wanted me to tell you about it so that if you know someone like her or you start down her path, you seek help immediately and not wait. She is an intensely private person, so much that I didn’t even know she decided to breastfeed. I felt bad we hadn’t really discussed it but I kinda threw out there that if she did breastfeed and needed anything please don’t hesitate to call. When her son was a MONTH old I finally heard from her. She had been having pain with her latch from the very beginning. In the hospital they did not have a big education program about breastfeeding nor did they have knowledgeable staff. They basically told her to work on her latch and gave her a nipple shield and sent her home. She was extremely determined to breastfeed her son despite the pain (and there was a lot of pain for her) and despite the fact that she wasn’t really getting much help.

By the time she called me she was missing skin on one nipple and she had open sores on the other. She didn’t want me to make the 1 hour drive to her home so I was trying to help her over the phone with different hold positions and correct latch technique. 24 hours later, I was so frustrated with not seeing her; I could hear the pain in her voice that I drove to her home despite her nagging that she was ok. When I got there I took a look at her first. I noticed she had started to develop mastitis on one side and I told her she really needed to seek medical assistance. I couldn’t get a good look at her latch due to the pain level she was in. Stubborn as she was she said she would wait until the end of the week when he was scheduled for his circumcision. As luck would have it, she developed a fever that night. She of course sought medical attention at that point. They gave her antibiotics and told her that the pain should go away with that and she should see improvement.

She did not. At this point I got her in touch with an LLL leader in St. Lucie County. This leader encouraged her (as had I) to either attend a meeting to check her latch or to seek professional help. She made an appointment with Dr. Punger. Dr. Punger determined that she was doing everything correctly but that the baby was not only tongue tied but lip-tied, something that could have been determined much earlier for her had she sought help in the beginning, before the sores, before the mastitis, and certainly before she had to go through so much agony. They did a simple procedure for him and his latch was almost instantly improved. She healed very quickly after that and is now enjoying breastfeeding her son. There are occasions of lingering pain but she calls it more of an aggravation now than actual pain.

Bottom line is this, no one wants to see you succeed at breastfeeding more than the people in this very room. PLEASE, if you, or someone you know, are having any pain, discomfort, or simply need some advice – YOU NEED TO ASK. We are all here for that very reason but we do not always know you need help. Don’t go it alone. We have all sought the advice and help of others that have gone before us in this journey. They say it takes a village to raise a child and I firmly believe that. We encourage you to find what resource works best for you and USE IT. Whether you be intensely private or very outgoing, there is something or someone out there for all you. Breastfeeding will be an adventure but remember, you are giving your child the best start in life possible and we are very proud of you for making that decision in your life.

Tuesday, August 21, 2012

A Suprisingly Long List of Why One Would Come in to See Me!

 Breastfeeding support can come from a variety of different disciplines (volunteer, allied health, medical) and within a discipline the services vary; I may not provide the same services another breastfeeding medicine practice does.
We all work as a team providing different kinds of support.

These are reasons why one would come to me:

You (and/or baby) need an assessment quickly.
Baby won't latch (even if other breastfeeding support have watched a full latch).
Mother is in persistent pain (breast, nipple, perineum, incision, other).
Baby is exclusively bottle feeding, using a shield, or finger feeding; and mother desires to breastfeed.
Another health care provider told you to stop breastfeeding because X, Y, and Z reasons (or told you to supplement). There is usually a way to make it work.
For your breastfeeding evaluation, you or your baby need labs, cultures, x-rays, or medical prescriptions.
Abscess of the breast and diagnosis of other dermatological conditions of the breast and infants mouth (wounds, rash, viral& yeast)

Management of chronic breastfeeding issues
Supervision of breastfeeding while another specialist manages other medical problem
Integrated approach to postpartum depression and other psychiatric disorder or hormonal problems
Counseling after traumatic birth
Grieving Lactation Failure
Too many breastfeeding issues

You'd rather not post personal scenarios on networking sights and forums.
You're uncomfortable with Google/forums/phone.
You're in need of a confirmation pregnancy test; you want to discuss pregnancy plan and referral to midwife, OB, doula and resources.

Pre-conception planning
Birth control planning (or not)
Prenatal visit; planning for the actual birth/well child care
Support for unassisted birth 
Birth Plan to optimize breastfeeding
Idealistically, scheduling the prenatal appointment and at least the first appointment after birth to get breastfeeding started with the fewest complications possible

Over the counter/herbal remedies not working or endorsement of proper use
You need help sorting out conflicting information from many sources

Mother has history of unsuccessful breastfeeding
Chronic low milk supply in successive babies
Individual counseling on how to supplement (Lact-Aid vs bottle, Haberman or other), what to supplement (formula, home-made formula, donor milk, milks, mylks)
Prior breast surgery

DCF is involved.
You've been discharged from another medical practice.
Mother or baby is in hospital (for any other reason other than routine childbirth and routine newborn care).
2nd opinion on jaundice, allergies, rash, digestive problems, etc.
Tongue-tie and upper tie, corrected in office
Opinion on vaccination (medical exemption)

Needs support from a medical professional
Well child care and care for the whole family

Teething resources :)

Needs research for a preemie, NICU situation, or other unusual and anticipated congenital situation
Needs a medical clearance note "ok to breastfeed" ei, after dental work, surgery, or diagnostic test
Needs a prescription for banked donor milk
Medical clearance to donate your milk to a bank
Slowly but surely building a local network with specialists who respect my input on breastfeeding

Slow weight gain/failure to thrive/developmental delay
Support for extended breastfeeding/bedsharing/co-sleeping lifestyle
Support for vegan, vegetarian, elimination diet, etc
Maternal weight loss supervision
Maternal newly diagnosed medical condition

Just wants to establish just because (I like easy, too)
I empower you to take charge of your health. Thus, down the line less visits are needed to the doctor.
You take pride in supporting mom (and pop) business; in medicine it is no different than any other business.
I'm not owned by the gov't, university, hospital, or medical association and like other local business I support the local economy  (sports, recreations, educational, religious, other local health providers).
Chances are good that I have seen your particular problem and more than once.

My certifications and experiences:

I've earned more than 75 formal hours of breastfeeding CME and CERPS in the past year, way beyond my requirements for family medicine.
I have clinically mentored CLC/IBCLC/Midwives/LLL/ ARNP students.
14 years CONTINUOUSLY breastfeeding my own children, nursing through 2 pregnancies, seven years tandem nursing, full-time employment x 2, and self-employment x 1, pumping, donation, extended co-sleeping, babywearing, and experiencing my own children needing sedation for [fortunately] minor surgery.
Fluent in Google, Facebook, blogging, and technology in general; knows what current issues are relevant to moms today.
MD for 20 years
IBCLC for 12 years
Member with LLL, FLCA, ABFM, ILCA for 12 years

Thursday, August 2, 2012

Breastfeeding and Hysterectomy

I helped Kim with some early breastfeeding problems with 2 babies. She is very committed to breastfeed as long as possible. I am familiar with her medical situation through the years leading up to the most recent surgery.

I am going to skip the explanation of why she needed a hysterectomy and hernia repair. My focus is preserving breastfeeding (but when I know an alternative for hysterectomy, I like to present it.). Not only did she come to me to discuss her specialists recommendations "should she go through with it." At that same meeting she told me that she was warned that she couldn't breastfeed in the hospital. She expected to be in the hospital for a week. This is very traumatic and insensitive news to a mom breastfeeding an active toddler.

I had an injury once (very, very, very minor in comparison to open abdominal surgery). Before going to the walk-in my biggest fear was that I would not be allowed to breastfeed or being denied pain medication because I was breastfeeding. Although my fear never came to be, it brings up the point of the powerful protective force we have as mothers to be allowed to nurse or babies. Nursing is healing all the way around. Even though I couldn't bear weight on my ankle, it was a relief to know that I could provide everything my baby needed right by bedsharing and by keeping a glass of water for me and a diaper close by.

That's why I wrote this letter for her to take to the hospital:

I approve Kim and L to breastfeed as soon as Kim feels up to it. In the event that her daughter is not present, Kim’s breasts need to be pumped so she does not risk getting mastitis which would complicate her surgical recovery. (Also, her milk supply would likely be compromised after a week of not nursing.) I have spoke to Kim about positioning her daughter as not to interfere with the wound and to make sure her partner, assistant, or hospital IBCLC is present to get her positioned to the side. At L’s age this should not be difficult. Eighteen-month-olds are accommodating.
Being allowed to breastfeed L as soon as Kim is comfortable is the best thing that can happen to ease her overall well-being and benefit her recovery.

With all the concerns of major surgery, the desire to breastfeed is still innately strong. The day after surgery Kim posted this photo to my facebook wall. There weren't any big dialogue with the photo. (They probably didn't need my letter either.) The picture was 1000 word. It made my day! It brought me to tears knowing that she got to meet her little one's needs. She later told me that as soon as her daughter latched, she Kim was able to fall asleep.

I don't know too many new mom's who need hysteretomies. This surgery inspired mom to form a new support group on facebook:

This blog post is my perspective and you can read more on the facebook group from Kim's perspective and many of the other real problems recovery presents.

Another photo to show how to position an 18 month old as to not interfere with the incision.

Wednesday, August 1, 2012

World Breastfeeding Week/ Back to Bed

Natacha and son at LLL parenting Conference
For World Breastfeeding Week I thought I'd ramble on this blog. I'll try for most days. I want to cover the topic of bedsharing while I ramble on.

I am proud of my local community for all the breastfeeding events going on in this area. We have a Latch-on event at the Civic Center this Saturday, Aug 4th at 10. Our facebook LLL group has over 450 members. I expect there will be a good show. I helped sponsor it and was offered a table. I didn't want to commit to a table. I thought if I can make it, I just want to have fun without responsibilities.  The latch-on is an event to break the record for how many babies can be breastfeeding at one time. Maybe I am jealous that I don't have a nursling, but I do think it is a little strange that only latched babies count. I'd like for all supporters to count, but it's not such a big deal to me to make a big deal about it.

Once upon a time I couldn't wait till the monthly LLL came. We have so many LLL events (babywearing, ITAV, play groups, birth-ed and more in our community), that one could practically go to a meeting everyday. Most of these Treasure Coast groups have a group on facebook which keeps us in touch 24/7. It is really exciting to see.

By reading the groups myself I learn so much about what concerns mothers. One big concern is bedsharing. I literally mean with the baby in the crook of your arms or on top of you all night (or most of the night.) Some are scared that the baby is too little. I understand that, but your baby will grow. Some are concerned that the baby will be spoiled or never out grow it. You can't spoil a child by providing reassurance and human touch. Does it really matter if your older child wants to cuddle with you at night, be read to, laugh with you in the morning. Don't you want to see that angelic sleeping face? I love when my kids have slept near me. One day recently I wasn't feeling well and stayed in bed and my older child was reading a page turner and brought the dog and book in to be near me. I love watching my older child read and comfort me with his presence and availability. It was like my nurturing came full circle.

For World Breastfeeding Week reconsider your sleeping arrangements and do what is best for your family.

Thursday, May 24, 2012

TIME - You know the one....

Photo of woman with breast-feeding child

Yes of course, I agreed, offensive and controversial.... I went on to tell them my passion is to help mothers succeed at breastfeeding and it really wasn't a big deal to see a mom nurture her kid, but many people think it is. My son who is embarrassed by every thing I say, didn't think twice about any of this.So, I haven't read the article, yet. I've only seen the cover.

 I went to Publix tonight ( a few weeks ago, this sat in draft mode), I thought I'd better get a copy of that TIME issue and weigh in as an early mothering expert. You guys want to know what I think, right? They didn't have the issue. There was a May 14th issue. At check out with my 15 year old, I asked to the cashier and carry-out people, if they knew if there were any more around. They said they never saw it. They thought that the store probably wouldn't put something out like that because it might be offensive. So I haven't read the article. I have only seen the cover.

When I first saw the cover of TIME, I first thought, big deal, it could have been me....A photo of a mother with her kid standing next to her reaching for her breast to breastfeed.

I could have been on the cover!
Photo by Bernadette Clark
In the course of my daily work, it is not so unusual for me to see children breastfeeding. It's not really a thing that phases me.

However, I never did a professional poised photo shoot with my three year old(s). Most of the time, when I fed a boy the same age as the one in the photo, it was in bed, on the couch, in a chair, in PJ's or something cozy ... and I was overweight .... Most often, my hair was wet, in a towel... definitely no make-up. And there was eye-to-eye contact, laughter, happiness and connection. My boys also were often in over sized T's or some other comfy houseclothes, barefoot and suited for cuddle time. Most of the time.

But  at times, the boys stood and see if they were big enough to nurse or just because they could. If they could they were happy. By three years old  if I pulled out a camera in a propped situation they would have ran. The boy in the TIME newspaper looks a little stressed. His mouth is just there.

Breastfeeding a three year old is about so many different things. It's hard to condense the value of nursing a three year old into one photo or one short news article and condense the years that lead to such a journey.

I want to help mother's overcome the common obstacles society places on them that interfere with breastfeeding.

It's OK to speak up for your birth.
It's OK to hold your baby after birth. No one should rob you of that time.
It's OK to co-sleep.... in the same room... in the same bed... even if you have a dog.
It's OK to hold your baby and Babywear. It's OK to stay at home with your baby (or get out if you prefer.)
It's OK to be the most natural mother you can be if you desire. You are mom enough, you are doing a fantastic job. Traditional Medicine shouldn't make you feel guilty. A cover of TIME shouldn't make you feel guilty either.

Yet, it's nice to see breastfeeding and Dr. Sears get some coverage in TIME.
Breastfeeding Meeting in PSL
I love seeing anything that supports the upper durations of breastfeeding.
Nursing a three year old is more common than you think. Even in Port Saint Lucie, Florida.
All the power and honor to the mom who got the opportunity to be on TIME's cover.

As a new mom you only have to take it day-by-day and not worry about nursing your child till he can tell you he wants to join the military. The moms I see on a daily basis are doing an excellent job attending to their children's needs.

My 15 year old finally saw the cover to TIME. He said, "That's not natural." He meant the pose. He knows breastfeeding is natural. He KNOWS.

Since seeing the cover my younger son has found mommy-stuffed-animals for his baby-stuff-animals. Thank you TIME for reminding my 8 year old how his little babies need their mommy's night-nights.

 I have a copy now. I'll let you know soon what I think of the article, itself.

Non-Specific Hormone Problems

I refer out to compounding pharmacist often. I am willing to try cutting edge approaches to help balance non-specific hormone problems. Some people call it Anti-aging Medicine (or Bio-identicals). I find those titles too limiting to describe the full-spectrum of what I do as I help teens with issues; preconception & lactation; and weight-loss, fatigue, and libido in all ages(both genders).

I should have been an Endocrinologist?
Maybe, but I like being a primary care physician who can work with open-minded specialist. There are like-minded endocrinologist, but they are hard to find.

Patients don't understand the relationship I have with the Pharmacist I consult with and patients often go to my nurses to ask if I will transfer the recommended prescription hormone to a different pharmacy. I wrote out a dialogue for my nurses to share with callers why I won't transfer locally. I decided to share my reasons with you. Pardon me for talking about myself in third person.

"Dr. Punger refers you to the best resources for  your circumstances. She uses the PharmD, Doctor in Pharmacy, (the compounding pharmacist) as her clinical extender which means you are getting expert team approach care. It is not likely she will call your hormones locally if she made a referral that you agreed to. The pharmacist is a part of your medical care team. She relies on him and his team to gather information about hormones and endocrine disorders not so always readily accepted by other MD's and drugstore pharmacists. The PharmD attends continuing education and meetings when she can not. She relies on him to make recommendations about dosage and delivery route (for example, SL, sublinguals are not available locally). The Pharmacist also is available to you for on-going opinions and adjustments in dosage often after hours. That will save you face-to-face visits. At the current time, Dr. Punger prefers to keep up with her primary care skills and she can extend you the specialized hormone balance by keeping the pharmacist on the team. It is rare to find a physician who continues primary care AND extends services to hormones to the extent she does. By using the same pharmacy team, medial errors are reduced, as compared to having different pharmacies and different protocols for her to keep up with. 

She has no disclosures. She does not receive kick-back from the pharmacy. Nor are PharmD's employed by the practice. She simply refers you to the best resource for your circumstances at the time. In the meantime you are not paying high fees for anti-aging or weight loss clinics. Most of the consult is handled by phone call after initial face-to-face appointment with Dr. Punger. The teamwork between the PharmD and the MD is a highly specialized one and patients come from all over seeking this kind of care.

Dr. Punger won't refer you to the Pharmacist if she doesn't think you need that approach. If you simply need straight forward Vit D, or Synthroid, you will be directed to the locally pharmacy from the get-go. She will send you to an ENT, GYN, thyroid specialist right-off if that is what she thinks is best. 

If you don't like the team approach Dr. Punger has with the PharmD you may seek on your own a GYN or endocrinologist (who will likely tell you that what Dr. Punger does doesn't work) and offer you other options. Understandably not all patients will respond to Dr. Punger's treatment and you are free to seek any opinions you want. At that point, you will be under the specialist care and Dr. Punger will no longer be responsible for your hormone balance/weight loss/bleeding etc.... 

Dr. Punger has had good results with her approach and thus she continues to use all the resources available to her."

Thursday, April 19, 2012

Amber Bead Necklaces

Photo by Susie Faughnan
I've learned a lot about Amber Bead Necklaces recently. Like everyone else, I wondered if they really worked when I first was aware of the crunchy moms in my practice putting them on their babies. That was several years ago. Since, I've heard many  moms insist that the teething necklaces decreased the drool and fussiness and improved their baby's quality of sleep. I kept hearing how  it had to be Genuine, Raw, Baltic Amber, Light as possible is the best for teething. Before I placed my second order I reconsidered if it had to be raw and "as light as possible." When you start re-questioning, the moms have said they all get the job done.

From all the feedback I get about the necklaces, I honestly think it doesn't matter raw vs polished, dark vs light. 

I hear how adults want a necklace too for carpal tunnel, neck pain, help them sleep better.

I have found out is is very hard to find raw necklace 18 inches and above. Everything I have found in longer lengths is polished. If you have found them let me know.  For adults who truly wanted raw, they have screwed two shorter ones together.

At least from this Lithuanian company. There may be "imitators" out there? I say you should get what ever your personal preference is and that's why I got more variety with my second order. I'd love your opinion on this.

Perhaps, the amount of anti-inflammatory activity in the light may be "a little" more than in the dark, but is it significant. Doubtful.

The most popular question I get is; "Can you leave it on at night?" They baby ones are designed for 2 months old and above. They work when your skin warms the amber to reduces inflammation. At night when you are warm seems to me to be the most beneficial time to wear a necklace. Removing for sleep seems to me to be reducing the optimal benefit. I believe disclaimers "not intended for sleep" are legal disclaimers. Yet, you have to what your instincts and comfort level are. Take it off at night if you want, but you may lose some benefit. I know that some moms keep it on the baby's ankle at night. That is a compromise. An ankle doesn't seem to be as warm as the neck and chest and certainly not the same proximity for teething benefits. There is a knot between each bead. It is not a chain that can snap and the beads go everywhere.

They can be cleaned with damp cloth and warm water.

So my husband decided to give it a try and twisted two 12 inch ( dark chips) chains together to make a 24 inch chain. Within 10 minutes like he discovered gold, he said "it works"! Then he went to sleep. :) I was happy.

My office is well stocked and the best bet is to come by during office hours.

Tuesday, April 3, 2012

More About Pre-Folds

I am so excited by how many babies I see in cloth diapers... more are in cloth than in paper.

Since my post I realized how little is known about pre-folds-

Prefolds (the flat rectangle):

Pros: Tried and true, not a fad. They are cost effective and customizable. They easily fold into thirds and a velcro or snap cover (bumkins or bummis are examples of two brands) holds them in place (no pins required). As long as the cover is clean it can be used again. The covers dry quickly. It is easy to fold into thirds. For boys any extra is doubled (6 layers) in the front. For girls the extra length would be folded in the back.

They come in 4 sizes and you never out grow the previous size. The smaller sizes become liners for the bigger sizes or for most of the modern diapers. As a liner it also makes it possible to use the next size up All-in-One by lining it to fit. And as you know they also can be used as burp clothes, car rags, house dusters, forever. They are easy to wash, dry, and store. The first 2 sizes work best for under 10-15 pounds. Five pound babies can be clothed diapered without leaking. This is the best diaper for small babies. The largest size goes for beyond 35 pounds if you have a late bloomer or bed wetter. You can even layer 2 large ones to make them have more coverage ( I know this too well.)

It's a great way to start cloth diapering if you are unsure since it is inexpensive. It is also a great way to inexpensively add a little more fluff to your stash in case you miss a laundry day.

They look great on a clothes line(they do!)

If you are motivated to use Diaper pins, these are the ones you want! I can help you with your pre-folds under covers, but I can't help you with the pins.

Cons: Watch out for imitators that are filled with polyester and not layers of absorbent cotton. Only skill necessary is folding into thirds. The biggest mistake is not moving up to the next size.


Current Inventory and Prices (updated 6/22/12)

Bumkins, print, double gusset at legs
Photo by Kim Williams

Quick Drying Covers  (Bummis and Bumkins, vecro and snaps, single and double gussets) white and print, boys, and girl!!)   $10 each
(use over bamboozle, prefolds, or use smaller bumkins size as swim diaper)

preemie 6-10 pounds                       5
newborn 9-16                                 2
medium 15-23                                14
large      22-35                               18                           
toddler    over  35 pounds                 7

All-in-Ones (whites and prints) $10 each!!! (you may use all alone)

Bumkins (mostly white, a few prints left)
All-in-One      5 mediums 12-22 pounds
                    6 grande     32-42 pounds

Photo by Christine Lopez
Bamboozle   only 7 left
size 2 (fits 12-35 pounds) $18.00 each, 10% off 5 or more

Swim diapers  $10 each
I have 2 small prints ones, 9-15 pounds 
Bumkins covers in a smaller size could be used as Swim Covers--More in the next post.

Cotton liners for extra absorbency to fit inside other diapers. $0.50 each 

Four sizes of pre-folds
1) Preemie (up to 10 pounds) 1.00 each
2) Newborn(up to 15 pounds) 2.00 each
3) Regular (over 15 pounds)   2.50 each
4) Toddler  (over 35 pounds)  3.00 each

A preemie can be fully clothed diapered with 3-4 covers and 20 diapers.  That is $60 or under and a great way to get started. And a baby under 15 pounds can get started for $80 or under. 

Once you get used to cotton, you won't what to go back to scratchy paper.

All the diapers I have has been a big secret, because I've been way to busy. With all the interest in cloth diapers, I don't expect any of this inventory to last long. 

Thursday, March 29, 2012

Activities (Vero and Delray)


Delray Beach Palms Birth House – April 27th 10:30

Vero Beach – May 17th 10:30 (Dr Max Cohens Chiropractic office3730 7th Terrace Ste 302, Seacoast Bank Building, third floor)

Informal discussion with Dr. Punger on your personal "Permission to Mother" your children through childbirth, breastfeeding, mothering and more. This is free. Appropriate for mother's with babies under two and who are pregnant. Babies and toddlers welcome.

Permission to Mother available after meeting and at the office for $10 for meeting attendees.

                                                                 Abby and I look forward to meeting you!  

Saturday, March 24, 2012

Cloth Diaper Benefits and Accessibility

I am hooked! Sad, I didn't start earlier,
it's so much easier than I expected.
I know many of you are using cloth diapers.

I have them in stock. When I first started my practice I introduced many moms to diapering and I was the only place they could get to touch and feel (and try on) in real life before purchasing. With the busy-ness of my practice through winter season in Florida, I didn't spend a lot of time on showing you the beautiful inventory of soft natural diapers that I have. I wanted to take a moment to remind you. Please let me or Crystal know if you need more info.

1. I have cotton pre-folds for small babies including newborn and preemies (just in-case your baby was smaller than expected).
2. I have large absorbent pre-folds for over 35 pounds. Great for toddler who  is still night wetting (or won't train yet).
3. I have four different sizes of pre-folds (these are the basic rectangle diaper). Pre-folds are classic not fad. They passed the test of time.
4. Pre-folds make good burp clothes and rags.You never out grow them. They just go to other uses.
5. Pre-folds with a few covers are the least expensive way to get started in cloth diapering with a brand new stash.
6. Pre-folds can cushion your supply of diapers inexpensively, just so you have a little flexibility to space out your washings.
7. Pre-folds can be used as liners inside many of your other modern cloth diapers. Again, you don't outgrow your investment.
8. I have organic bamboo fitted with snaps for 12-35 pounds. These are about the softest diapers I have felt.
9. I have many beautiful covers to go over fitted or pre-folds and fitted; white, print, velcro, snaps, single and double gusset.
10. Nothing in my inventory needs diaper pins.
11. I have a few remaining All-in-One Bumkins in neutral plain white and some really cute prints.

Every style I have, I used on my own son. David was exclusively diapered in these styles. They are durable, absorbible and designed for success. There was no going back to paper once I felt how soft they were. Also, they are very photogenic when it comes to portraits. I didn't have as many options as you have today. I diapered him right through the hurricanes,  traveling, and stomach bugs. I left the All-in-Ones for the teen sitter and older boys to use up first when I was away. When I do something, I do it 100%. This variety got me through all situations. I  never liked the popular pockets you had to stuff, but I am impressed by the variety in diapering options today.

If you are new to cloth diapering, you will find it very rewarding. I started with my third baby, but if you start with your first baby, you save over the years. You can start off cloth diaper part time if you are hesitant.

With these styles I can provide you with 100% support because I was so successful with them.

If you are an experienced cloth diaper user, there might be another print or style to add to your stash and experience.

$10 Gift Certificate
Permission to Mother by Denise Punger is available on amazon. In appreciation for your thoughtful feedback on Permission to Mother’s amazon page, we will thank you with a $10 certificate, good towards the items above. That would be like a FREE cover or a few pre-folds. Confirm that your review published and come in to the office and pick out an item. Amber beads excluded.

Tuesday, March 20, 2012

(In Stock!!) Amber Beads for Teething and Pain

I have been impressed with the personal testimonies from mothers when their baby wears Baltic Amber Bead Necklaces. I've been hearing about calmer babies, less fussing, better sleeping, reduced need for medication. It takes about 25 days to get it when placing an order. They come from Lithuania, from now on I am going to keep stocked up on baby necklaces and occasionally mother (adult) necklaces and bracelets.  Baby can start wearing them when the drool starts at 8 weeks old. You may come by the office during regular hours. I will consider shipping either contact us at or 772-466-8884 ext 2. 

I am expecting the next order to arrive mid-April. 

Since remote times, the beauty of Baltic amber was attracting attention. Amber jewelry is a treasure to own, for centuries was worn only by nobility and not affordable to the masses. Amber jewelry is fashionable and soaring in popularity even today. Amber jewelry balances person's mood, pleases the eye, lessens depression.
Because amber was ascribed many healing properties it came to be used medicinally in many cultures. Wearing close to the skin is a traditional European remedy for teething. Its healing properties effects will calm your child without applying to drugs. Most of our amber teething necklaces are processed to softly rounded shape amber beads to keep intense healing effects to reduce stress but give general sense of wellness.
Baltic amber is an excellent natural antibiotic. Women suffering from goiter uses unpolished natural raw pieces of amber to wear close to neck. Amber stone produces positive effect on the heart, nervous system and the kidneys.

How it works? When a baby is wearing amber teething necklace on the skin, the skin's warmth releases healing oils from the amber (a resin) which are absorbed via the skin into the bloodstream.Amber is not a stone and therefore warm to the touch, as well as very comfortable and light to wear. Children wearing amber is a very old traditional custom in Europe and the Far East. Amber is known to reduce inflammation of the throat, ear and stomach and to fight inflammation, infections and respiratory disease. Traditional beaded amber necklaces are a less intrusive remedy for the pain and side effects of teething, such as lack of appetite, upset tummies, ear ache, fevers and colds. A natural analgesic, amber will help calm a baby without resorting to drugs. Amber's anti-inflammatory and therapeutic properties are also recognized by allopathic medicine. These necklaces are long known for the healing properties of amber which include calmative, analgesic, antispasmodic, expectorant, and febrifuge (anti-fever) functions. 
At the S&S restaurant in Ft. Pierce.

Whom are they for? Wearing Baltic Amber baby teething natural pain relief necklaces are suitable for babies (toddlers) and children. They are not designed for chewing them with teeth, parent supervision is recommended at all times when baby is wearing necklace. Amber is associated with sunlight and warmth and reputed to boost the immune system, reduce inflammation and accelerate the healing of wounds and is thus the perfect help for babies and toddlers who wear it when they are teething. Designed for boys and girls. These necklaces are a must have for teething symptoms. Baltic Amber is completely natural pain relief with no side effects.The necklace can be worn from 8 weeks and up. Although you can start you child wearing this necklace at any time, the earlier the better. If your child wears it at a young age they will not even know it is there and they will not touch it or pull on it. 

How are they made? What happen if necklace gets torn? Sizes colors and shape of stones and the length of the necklace may vary from necklace to necklace. All amber stones we use for our amber jewelry are genuine, authentic, natural Baltic amber stones. It is not artificial, plastic, synthetic, reconstituted or substitute for amber. Every bead is knotted in between to prevent choking hazard. Even if string got torn only one bead would come of. Strong silk, matching to amber color is used for every necklace uses twist screw closure, clasp or strong magnetic clasp for safety.String is very strong and breaking is unlikely to happen, even if the necklace would break only one bead would come of. The Baby Amber necklace beads are light and small. The bead is therefore too small for a baby/child to choke on. But, if a baby or child should swallow a bead from the Baby Amber necklace, it won't be harmful since it is not poisonous. It used to be ground up and swallowed in medicinal mixtures. 

Sunday, March 18, 2012

Scott and his Shuggie's

That's a sugar glider in Scott's pocket. They are nocturnal and it so hard to get a descent photo of them. This photo is precious if you ask his biased mother. If you look closely there is one in the back right pocket under his hand, also,  just barely peaking out. A shuggie, a sugar glider, is a little marsupial. Scott hates when I describe them as a small possums or bat-like with fur. Really they are more like kangaroos or koalas. When not in his pockets, they have a safe cage with a pouch, wheel and perch.

But the point is marcupial's have pouches to carry their young. And many other animal babies come equipped to know how to cling to their mom's back when traveling. Human moms don't have pouches and babies don't have the equipment to hang on. But our human babies do like being held in carriers that keep them close to mom's heart and when older they do like being held up on moms back gaining a great perspective (vs being in a stroller).

Scott's pets like being in the pockets of his shirt. That is how they bond with him. He also has fleece slings he can tote them around in together in the same pouch. .

Often mothers are afraid that babywearing, extended breastfeeding, extended co-sleeping "spoil" the baby. That's ok by me if "spoiled rotten" means a 14 year old (almost) understanding the importance of bonding and touch and applies it to raising and training his animals. We often only hear about bad outcomes of teenagers. The gentle love that babywearing, breastfeeding, babywearing in the early years may instill values that get paid forward.

Treasure Coast Babywearing Group

Do you know we have a Treasure Coast Babywearing group?  You can find the group on-line at facebook. You can find them in real life often at the  Treasure Coast Mall on many Tuesdays around noon in the food court/play area. They are also going to have a class room setting meeting towards Vero once a month. I love the idea of them meeting at the mall. I went to the mall to observe about mothering and strollers when I was pregnant 16 years ago. How I wish I ran into this group then.

I didn't do to good wearing my first son. I was getting better with the ring sling with Scott. When David was a baby I did ok in Georgia without support. When David and I moved down to Florida. He was about 8 months old, I had support and my doulas started experimenting with different patterns that I sold in the office. Then the Baby Wearing DVD came out and I was an expert in non padded ring slings. There are other options like the 5 yard woven wrap (as Jade is wearing). The Mei Tai is a good one. Then there are buckle varieties like Ergo. There are so many I can't keep up anymore.

If you go to any big event like the county fair, farmer's market, or the parade, you are likely to run into BABYWEARERS. Our group is getting big. Mom's are really catching on. Not that the group formally meets in all these places, but babywearing makes it easy for moms to get out and have fun. We are visible.

I don't currently have slings available in my office now because there are so many options to consider, But I am working on it and considering it. Let me tell you a story about the very last sling in my office... Jade came in and tried it on. It is a beautiful sling. In my heart I knew it was too long for her. She wanted it and I made peace with myself that she seemed satisfied but praying that she wouldn't twist an ankle over the long tail. Next time I see her she sewed on a button and loop so she doesn't trip over the end. The next thing I know she is attending Babywearing Certification. As my teens would say *facepalm*. I am so embarrassed that I sold a soon-to-be Babywearing Expert a ring sling way too long for her. Me and Jade can laugh about it now and she says it is one of the many things that that enticed her to pursue Certification in babywearing. I am still comfortable helping you with a ring sling-- really I am  and I will tell you honestly if it is too long. I am so glad to have Jade and the Treasure Coast Babywearing group to refer you to for all the new wraps and twists.

 In the first photo Jade is wearing her woven wrap. I just admire how securely and neatly she has it tied.  I have no more little baby. so I "stole" Maverik and Jade's textured ringsling to see if I can still "do it." I passed Jade's inspection. Whew! ( Seeing the photo, I'd put the rings a little higher.)

To the right is Maverik with his mom, Tara. He was happy to go back to her arms. And the other mom is Tara, too. They are both wearing locally made slings.Dr. Prann's mother made the one I tried on and Tara has on one by Marina. ( I hope I have given all credit wear credit is due.) Abby took some photos.

Baby's like to be held. Using a carrier is good. But some of them are crotch danglers and not good for the baby's hip and spine. So there is better and best. (Worst is not holding your baby at all. or just propping.) Treasure Coast Babywearing can help you with better and best.

Please join us on Facebook "Treasure Coast Babywearing."

Saturday, March 3, 2012

The "Shuggie" Feeling

William, my oldest, was savoring the Farmer's Market ham crescent, ribs, and other treats I brought home for him this morning ( I know, all kosher & healthy stuff, not.). As I told him it was such a delight, to watch him be totally immersed in his food, I remembered that it was with a similar pleasure that I felt with him as a baby relax at the breast. I didn't know much about breastfeeding when I had my first son (nor did I even know of the real importance) and it is this "spell" that seemed to cast over him when he got into his nursing rhythm that kept me going while I was suspicious of any real benefit.

That and my husband telling me he thought their was a chance that breastfed babies might be smarter. I really didn't start off my breastfeeding journey with a whole lot of facts to hang on to. If I had any significant difficulties, I could have easily been doomed.

Another story. My 13 year old has sugar gliders (a little furry marsupial) that he carries around in a fleece pouch (much like a sling). David, the youngest, likes to imitate being a glider. He cuddles in a fleece blanket (that my mom made for him) next to me and be "my shuggie." (shuggie = sugar glider).

I have long thought if I stopped breastfeeding, babywearing, co-sleeping before they could remember, they would not share my values. Even if some of this doesn't workout  for another mother/baby or they stop before a strong memory for any of it, taking photos, having a library of books, continuing to be involved in the community of mothering reinforces these values over and over.

Although, it is no guarantee of anything to come, I could only hope that the "shuggie" feeling is something he will remember when he is holding his baby and making parenting decisions.

Our dog looks after the boys, too.

Sunday, February 26, 2012

Albuterol is not a Steriod; it is not an antibiotic.

Wheezing and chest congestion is one of the most common illness that I see in babies. If your breastfed baby is wheezing, IT IS NOT A SIGN OF ASTHMA. It is a virus. Likely RSV. Adults get a cold. Babies manifest the same virus in their airways.  Babies who get bronchiolitis (wheezing) are not necessarily prone to asthma, at least I don't see it that way. I don't diagnose asthma based on one episode. Continue breastfeeding. Usually it is worse at night. In my experience, breastfed babies run the course without complication. That said, Albuterol via nebulizer is my preferred medical treatment for wheezing and cough due to inflammation in the airways.

Albuterol is NOT a steroid.

Albuterol is NOT an antibiotic.

Albuterol via nebulizer reduces airway inflammation immediately by acting on airway receptors, and REDUCES the need for antibiotics, steroids and hospitalization. It tends to be much quicker acting then inhalers or the pill or syrup. Proventil 2/5 liquid is another option, but it is more systemic (you are swallowing it rather than breathing it).If your household members are prone to wheezing, it's worth keeping a nebulizer handy in the house. I say if you suspect wheezing, use the nebulizer early on and follow up with the doctor. There really isn't a reason to hold off on treatment until seen.

I also get questions, "If my baby is coughing, and I don't want antibiotics, is there any reason to bring baby in." Yes, I would like to know if they are wheezing.

Other names for Albuterol are Ventolin and Proventil. Xopenex is similar. (I don't buy into the fact that it has less side-effects. it just has a stronger sales pitch as it is a newer medication.)

How often should you use the nebulizer? Initially you may need back-to-back treatments or more frequent. Maybe one treatment is enough to get you over the hump. As the symptoms reduce, you can back off on frequency. With a baby they can breastfeed and you can hold the mask or tubing close to their nose and mouth. (I don't like the pacifier version of delivery, especially in a baby that doesn't use the pacifier). If you need an initial treatment, you can expect that the coughing to run a course of up to 3 weeks. Thus you may need a nightly treatment for a few weeks.

I learned to use the nebulizer when I worked in urgent care. It brought immediate results most of the time. Of course if it doesn't you may need further evaluation. This post refers mostly to the exclusively breastfed baby.

I know many pediatricians reach for antibiotics and steroids in the same situation along with or in place of albuterol. Perhaps that has to do with many of their patients being formula fed and different lifestyle factors, running a more complicated course than what I see. If you have a baby prone to wheezing, you may want to consider allowing no one to smoke around your baby. If you're in a daycare setting, reconsider that situation. Probiotics is beneficial to immunity. If your baby is taking solids, you may want to make sure that the food does not contain dyes and processed ingredients. Chronic wheezing, asthma can be modified. That means you do have some influence.

On a slightly different note, but related observations about ill EBF babies, you do not have to give a sick baby Pedialyte. Breastmilk has everything they need. But if for some reason you need to supplement a sick baby over 6 months (even a formula dependent baby), coconut water is a great choice for hydration. Fever-all is a dye-free acetominophen supp used for fever and crankiness. Even in the breastfed, unvaccinated population, I do see wheezing. But mild usually.  Vaccine status (lack-of) did not cause this illness.

When you use the nebulized version don't take deep breaths and you may not have to use a long treatment. You only need a treatment to last as long as it takes to get relief.

For whatever reason, wheezing in babies is common. Breastfeeding is the best way to prevent or reduce the frequency.

I am not a rep for the medication or the machinery.

Saturday, February 25, 2012

Posterior Tongue Ties

Our community is getting better and better at recognizing "anterior" tongue ties. Now that more and more mothers are standing up for their right to breastfeed, I run into a wider variety of issues. I am suspecting that we are discovering more posterior tongue ties that are not as easy to recognize as the obvious anterior tie.  Posterior-ties cause lengthy feeds, tight, clenching latches, sore nipples, and poor transfer of milk, shield use. If you are having latch problems or help mothers who have latch problems here is a quick video to help you learn more about this.

I want to stress that I don't diagnose tongue-tie based on what it looks like. Well, I do, but the most important criteria for diagnosing tongue-tie is the description the mother gives:

Sore nipples
open wounds
better with a shield

reflux, food/stomach sensitivity
poor weight gain
lengthy feeds
intense baby
clenching down

It is still common for your health care professionals to not recognize anterior or posterior tongue-tie. It is up to YOU to take responsibility. In most cases your pediatrician is not going to take the lead with this. If everything else your Leader or LC has suggested has not helped your situation, consider tongue-tie. It is not always an easy diagnosis. Learn about tongue-tie and pursue treatment if you still feel, it may be what is going on. The sooner you get treatment and prevent further deterioration of breastfeeding (bad suck habits, low milk), the better off you will be able to provide breastmilk to your baby. Will babies out grow it? Some will. Only if the symptoms are mild...maybe will babyout grow it.

Posterior tongue-tie is easily treated in the office within minutes.

Most of the time no further treatment in the office is necessary.

Here is a link to learn more

Recent Feedback:

"My son was born tongue-tied on January 6th. The LC at the hospital was the only professional willing to "diagnose" him and explain our options. I wanted to breastfeed, and every session took approximately 90 minutes to drain both sides. With an 18 month old daughter too, I was beyond frustrated. I was guided towards an ENT specialist who wanted to put him under with full anesthesia as an outpatient procedure. I followed my mommy instincts and went to Dr Punger. She clipped him so simply and he latched on instantly. I cannot express how grateful I am for her care."

"When I went to see Dr. Punger, I was really not thinking tongue tie, but reflux for my 6 week old baby. I was very sore from the baby clamping down so hard on me. She had to suck very hard to compensate for the difficulty in swallowing that the very subtle posterior tongue tie caused. This caused gulping, gas, reflux, and her never seeming to get enough though I could see the milk dripping from me. Her strong, tense suck also created over active let down and foremilk/hindmilk imbalance=green, explosive diapers. Since the tongue clipping, baby is nursing so much better, finally gaining weight, and is smiling and cooing! Dr. Punger sent me home with some websites, my dh and I did the research and recognized that this was the issue. We acted pretty quickly because of the pain I was in. Dr. Punger clipped her tongue just before her growth spurt where she nursed every 1.5-2 hours and I'm so grateful! She put on nearly a pound within 10 days."

Herbs for Low Milk Supply

Without touch, skin-to-skin, which includes dad's touch, babywearing, co-sleeping, and co-bathing, nothing else will work.

You heard me say co-sleeping, right? This is so important. At least be open to the idea.

I am very familiar with Motherlove More Milk Plus with or without Goats Rue.

1)Goats Rue is actually beneficial in the last month of pregnancy if you have a good reason to suspect you will have a low milk supply. I have kept Motherlove  products at the office. It's all organic. Goat's Rue builds up glandular tissue. Motherlove herbs are in-stock.

2)Go-lacta. If you go to website there is a link to a study. In The Phillippine Journal of Pediatrics, done in 2000, N=68 pumping NICU moms. You can also take this the last month of pregnancy. Go-lacta is malungayy leaf, a herb. It is high in nutrients. You can use it alone or to compliment Gaia or Motherlove. I am beyond lactation. I am adding it to my green supplememnts I take because of it's nutrient profile as one of my vitamins. I am getting good feedback on this herb.

I have it in-stock at the office.

3)Fenugreek/Blessed thistle.  I am not stocking  Gaia Lactation Support yet, because I have in-stock Motherlove products with fenugreek in them. I was always told that tinctures were the best way to take these herbs.  You would only take one or the other. You can combine one of these with the other herbal and medicinal options. I get good feedback on Gaia and Gaia/Go-lacta combo. I plan on stocking this soon.

4) I am still learning about Leptagen, let me put it out there for you.

I would love your feedback if you use any of these herbs so I can continue to learn and recommend the best products to moms.

I would love to use prescriptions as galactogogues only as the very last resort.

On a forum I read:

"I would really be interested in seeing the iodine levels in women who have IGT, as "Iodine is crucial for proper thyroid functioning and formation of all glandular tissue, including the breasts, ovaries, prostate, and uterus, he explains. ” ("~ Jennifer Tow IBCLC

If you have low milk supply, and I have a reason to check your blood, for now on I will be consider checking Iodine Levels.

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