My archives might be a little outdated especially the older blogs.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, 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: 
 
http://www.facebook.com/groups/hysterectomymommies/

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.


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