My archives might be a little outdated especially the older blogs.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

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.

Thursday, February 9, 2012

Community Events


Join us for our next ITAV (It Takes a Village) meeting on Wednesday, Feb. 29th, co-hosted with Dr. Denise Punger, MD, IBCLC; and author of "Permission to Mother". Informal discussion with Dr. Punger Copies of Dr. Punger's book will be available for sale that night. FREE mtg for parents, parents-to-be, extended family members, midwives, doulas and anyone interested in pregnancy, childbirth and parenting. Meeting will be held in the Cafe at the PSL Civic Center on US1, from 7:00pm - 8:00pm. 

Jupiter La Leche League- March 16th at 10:30am, Jupiter Medical Center, Enrichment Meeting and informal discussion with Dr. Punger on your personal "Permission To Mother" your children through childbirth, breastfeeding, mothering and more. This is also free.

Please share with anyone that you think might be interested!! ♥

I look forward to meeting you!!

Saturday, February 4, 2012

Updated 6/13/12
I am reflecting on my E-mail Communication program and how it has worked the past 18 months since I started it.

I don't know that everyone realizes I offer this professional service. I started with about 15 initial families that opted-in.

I have maintained about 26- 40 since.
 I am open to new enrolls. I appreciate you opting-in voluntarily(without me sending a bill) upon approaching me electronically.

All but two are young families. I have one single man and one couple without children.

Six local families. Several two or more hours. North, South, and West: Palm Bay, Miami and Lakeland. I have a family in Arkansas! Some families have moved away and come back. Many are an hour, plus, minus away. I find the geographic diversity interesting!

All families have contacted me at least once.  One contacted me twice. Most have contacted me 6-8 times. A few --I have lost count.

Getting an appointment quickly is a benefit.Often I can e-mail you right back.

I have been able to start treatments for mastitis, bronchitis, after hours, often with quick relief with early intervention and appropriate follow-up. Many times breastfeeding is taken in to consideration. I find it very empowering to be able to help families quickly. I can reassure them quickly it is OK to continue breastfeeding. It always is....

I have been able to guide families to the walk-in or ER when symptoms are justified for that care.

I am not a phone person. E-mail is good. I find my patients can clearly explain what's going on.

I only took 5 days off from e-mail this year: Yom Kippor and holiday vacation out-of-the country. For my 24 hour break, I gave 3 days advanced noticed to all enrolled. For 5 days away, I gave a week notice. I didn't want anyone to hold off on a question that I could answer right away. For travel in the country I am still available, I don't sleep with the sound on. Technically I could miss a call, but it all has worked out.

I decided to update the structure slightly for upcoming renewals. I have posted the updated program.

A better name for it would be E-care. Reflecting that it is my commitment for electronic communication. I feel like my practice for all patients is as good as any concierge or VIP service. It's just that I take insurance. Everyone gets treated well in a holistic, minimal intervention environment and respected for their knowledge and experience they bring to their care. I don't even know if holistic concierge exists??

Several people have asked if it's an insurance replacement. It is not.  Nor is it a replacement for not being insured. I suppose that would be a full-on concierge program and something totally new for me. I would consider that on an individual basis.

I want to add a label on to my blog "E-care"  to share some stats and thoughts. I might also like to add success stories to help future patients know if it is beneficial service. It is also a place to elaborate and update.

Any feedback or concerns you have that I should take into account?

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