My archives might be a little outdated especially the older blogs.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

Showing posts with label breastfeeding medicine. Show all posts
Showing posts with label breastfeeding medicine. Show all posts

Saturday, March 5, 2011

Posterior Tongue-tie

It's often very satisfying to help a mom with a tongue-tied baby because there is almost INSTANT relief.
If I suspect tongue-tie, I recommend taking care of it as soon as possible, if the mom wants to continue breastfeeding.

This past week a mom came in with her two month old. She had constant nipple pain almost from the first latch. She described her baby as clenching and intense. She has been treated for several rounds with anti-fungals. The baby never showed any symptoms of thrush. Out of desperation, baby was treated, too with anti-fungals. The only thing that consistently relieved nipple pain was to pump and give the nipples a rest from the baby's latch. The focus of treatment was on thrush and keep giving mom more anti fungals. Mom was also doing elimination diets wondering if something in her diet was upsetting the baby making him intense.

What made me suspect tongue-tie?
1. Nothing else helped.
2. I always think of tongue-tie because it's what I do.
3. Yeast doesn't occur at the first or second latch. (However with nipple damage, she could have at some point had an infection.) Also, yeast is hard to treat, but not impossible to treat.
3. The only time she got a break was when the baby wasn't latching.

Okay, so I looked at the baby's mouth. I wasn't that impressed, but there was a posterior frenulum. It wasn't long. It wasn't particularly noticeable. I could see how other professionals not so focused on tongue-tie could easily overlook this. I recommended clipping it because the mom's history was right-on: nipple pain from birth, baby was intense and clenching.

Mom nursed baby right away after frenotomy. As suspected she noticed a decrease in pain, good milk transfer, a satisfied baby, a relaxed snugly baby. And he wasn't very intense anymore.

What  do I learn from this. Tongue-tie may be suspected by just listening to what the mother is saying. A baby who is not getting adequate milk transfer, seems to be biting, clenching, and intense is probably a baby that would benefit from a frenotomy. (especially when "everything" else isn't helping.) Obviously, confirm suspicions of tongue-tie by checking the baby.

My approach to tongue-tie may not be very scientific based, but it's one that works for the families that come to me.

I found this relatively new professional group uniting tongue-tie professionals, International Affiliation Tongue Tie Professionals. 

Tuesday, January 4, 2011

Tongue-Tie Discussion on Doctors TV

I was glad to have it called to my attention that Tongue-Tie was discussed on Doctors TV by Dr. Jim Sears. I don't watch much TV and it's the first time I heard of the show, but I do know Drs. Sears (the father and 2 sons, all authors of many parenting books), and I knew it would be a great resource for trying to self-recognize if their baby has tongue-tie, making the decision to find a physician who will do the simple procedure, and seeing what all is involved.

Most new parents have no idea what tongue-tie is. It was my mother that was watching the show and told me about it. She said, if it wasn't for me, she wouldn't have known what it was, but because she knew I took care of breastfeeding problems and tight frenulums, it made her pay attention.

It is very intimidating to a new parent to think about "someone" making a little snip under their baby's tongue. All to often, it's the Pediatrician who tells the parent that nothing needs to be done when a parent thinks their baby may be tongue-tie. The mother goes on continuing to not be able to breastfeed. Her baby may not latch. It may be a painful latch, or it may be poor milk transfer with a failure to gain  weight. Without the Pediatrician to concur, I find parents are reluctant to pursue treatment. I find that if a Pediatrician confirms the concerns, the parents will often follow through. Far too many Pediatricians blow off tongue- tie issues, and new vulnerable parents don't know to keep questioning. That's why I am so glad this topic was covered on TV programing. I find the more (main stream) information parents have on tongue-tie and frenotomy empowers them to trust their instincts and follow through finding resources.

Dr. Sears video is here.

I take care of frenulums for breastfeeding problems. The earlier the better, but I have no age limit. I do it right in the office, parents can be present and in constant contact with their baby. After the quick procedure, if the baby is hungry, I like the baby to go to breast or at least have some skin-to-skin time while I answer questions and make some recommendations for success.

If you have sore nipples from the first latch like the baby is biting or gnawing, a tight frenulum should be evaluated for. If there is poor milk transfer with weight loss, jaundice, or decreased urine or stooling, consider checking for tongue-tie. If your IBCLC, midwife, or postpartum nurse nurse tells you they think your baby has tongue-tie, especially if you live in my area, they are usually right-on as I have been working with them for over 12 years and many of our breastfeeding supportive have been around long before me.

Wednesday, February 10, 2010

Well-child Care Appointments-- Are they Necessary?

I am often asked this question:

What is your opinion of well baby visits? I was recently reading "How to raise a healthy child in spite of your doctor" and that guy is totally against them. We decided against immunizations and I've gone twice to the ped and it just seems totally pointless. I know nothing is wrong with my baby so why am I taking him to the doctor?

Capt'n Amazing Wife specifically asked this time. She is out of state and I am going to answer this question in that context.

I am in Family Medicine because I enjoy relationships with my patients and families. Getting to know my patients when they are well goes along way. When an illness or injury comes along, often I am able to accommodate you quicker and provide more individualized care because I know your preferences. This applies especially in the evening hours. I am much more likely to initiate an evening or weekend treatment (or reassurance) until I can see you if I have current records. I have come into my office or practice medicine on the go (whereever I am! ) after hours to help someone out who has taken the time to keep their appointments. Much of my practice emails and texts me (I prefer email, btw, for medical questions.) Someone with a current chart probably will get a fast evening response from me. If you are way overdue for an appointment (or have missed appointments), I am more likely to ask my staff to handle it in the morning. It just depends. After living in the area for over 15 years I have come to know many families who have active "medical" times and fortunately quiet times. I really respect the families who take good care of themselves.

I am happy to give some advice or initiate evening treatment. In fact I tend to think of myself as accessible and can help nip things in the bud before they get worse or lost sleep. I have a few local families ask if they need to keep a well-child schedule or can they come in just when they need something. I've been right upfront and told them if they don't bring a baby for well-care don't expect me to take call for their baby in the evening. It's not fair to me (and my family )to answer questions about a baby who changes so quickly whom I am available for during the day and family chooses not to keep appointments. Fortunately most of those families pretty much understand that and don't take issue with that negotiation. It's kind of like what they are looking for anyway.

I have read that book 11 years ago. The book was out-of-date then and removed from the LLL library. I understand that the author is trying to reform pediatric care. Just be careful because 1/2 the specific issues didn't apply anymore when I read it.

I happen to disagree with him on weights checks. I think they are very important. Sure I can eyeball a baby and see if he is growing. I look at the baby before I look at the weight. Weight questions is one of the most common questions parent have-- about adequate weight gain and poor gain. It is also important for physicians to know what to do with the weight checks and when to worry. And many physicians don't (so I understand his desire for pediatric care reform).
The biggest impact I can make at a well-child visit is preserving the breastfeeding relationship. I didn't do a study, but I am pretty certain my breastfeeding rates are the highest in my area. :)How it irks me when a mom who doesn't believe in well visits finally comes in later for a sick visit and stopped breastfeeding because of some simple-to-resolve problem. I suppose if she really was interested she would have asked. But there is also other issues that come up that parents don't recognize as a breastfeeding issue, but is, For example colic, gas, loose stools may be oversupply, NOT lactose intolerance or reflux. There is also some things not likely to be breastfeeding related. For example, baby acne will pass and is not an allergy to breastmilk. For many families I am the only voice (or the first voice) reminding mothers of their inner strength and reminding them to listen to their heart and their baby and not to others.

As far as the well-child schedule. I imagine my schedule is much more relaxed compared to the AAP's. I have seemed to find what works in my office. 1st week, 2nd week, 4 weeks, 2, 4, 6, 9, 12 months. 15, 18, 24, yearly after that. I am flexible yet. First breastfed baby may require more visits initially. I often reduce the schedule for an experienced mom or one coming a very long distance if all is well. It also depends where the mom is on her journey with all the current issues surrounding well-child care and how her emotional recovery from birth is going. I do a lot of work with healing. All moms with babies under one have an active chart in my practice so I can get to know them too.

All this and we haven't gotten to vaccines yet because not having vaccines is not a reason to keep well-child visits. I answer lots of vaccine questions in the office. ( I do not take vaccine questions via blog.)

As far as my boys go, I worked for the big dominant hospital system when William and Scott were babies. I was programmed to have well-child visits from residency. They kept their appointments because it was easy. It was there. I was showing my babies off to my colleagues at the same time. I often felt like I had to remind the pediatricians that breastfeeding works and for them to prioritize it. I left interesting pamphlets with them hoping to leave an impact. I guess you can say I was hoping to do them a favor. When David was born, I had a likeable and popular pediatrician in Rome, Georgia who previously was a classmate. We kept a few visits for David. Scott had a visit once that year.

I often wonder who I would go to if I had to take my kids somewhere now. They each have had one peds visit in the last 5+ years at the time when one of them needed clearance before dental work. I understand the pointless part. ( I wonder what physician I would go to if I needed something.) Fortunately the minor things that come up, are the kind of things I have access to supplies and pharmacists knowledge. Prior to this practice I was employed in urgent care and didn't necessarily have access or the well developed skills of well-child care I have now. As you know from reading my blog we do a lot of prevention in my house. Exercise, eat better than most, breastfeed for years and years :), avoid large crowds of sick kids. Our house, car, and property are NO SMOKING ZONES. Smoking is absolutely not tolerated. I know a lot of my readers feel the same way.

Like everything else, keeping well-child visit is a parents decision. Explaining how I see things may help you locate one in your area who may share ideals and you could have a better rapport with. Ideally there would be a physician in your area that you could have a good relationship.

Saturday, December 26, 2009

Mastitis Consult-- finding solutions

I have hesitated posting this case of chronic breast pain (mastitis) because it might scare you off from seeking help or continuing breastfeeding. But I tend to admire the mom's who make breastfeeding a priority under all circumstances and go to unusual lengths to preserve their breastfeeding. It is important for you to know how strongly I support breastfeeding through just about any circumstance. You can imagine how many times this mother has been told to stop breastfeeding.

If you read and are familiar with my last post, this mom was referred to me after her OB did an excellent evaluation and had done several cultures on her milk and offered her several rounds of commonly prescribed antibiotics and she still had pain. Her cultures showed that she should have responded to some of the meds she tried (Augmentin, Bactrim DS, Dicloxicillin). She also had an ultrasound prior to seeing me to rule out abscess. Seeing that she did not improve with those antibiotics, I suggested a Quinolone antibiotic with continued breastfeeding. Most physicians don't prescribe Quinolone type antibiotics to breastfeeding mothers. Having tried everything else, her OB's recommendation was IV antibiotics per PICC line (a short term needle providing access to bigger veins that you can receive daily IV medication and go home).

Mom chose to accept both courses of treatment. My Quinolone and her OB's antibiotics (Or she could have chosen one option and if no result the other option.). She got the PICC line inserted and than she had a complication (clots in her arm) as a result of having the procedure and then needed anti coagulation (blood thinners).

At one time she was on Fragmin, Coumadin, Diflucan, Vancomycin, and Levaquin Domperidone and Motherlove herbals.
Putting her case aside for a minute, some moms stop feeding because they take just ONE medication. It drives me crazy to hear a mother tell me she stopped feeding for Tylenol, Amoxil, Zithromax. Keep breastfeeding while you are checking your facts!

The Fragmin and Coumadin were the blood thinners. The Fragmin particles are too big to pass into the breastmilk. The Coumadin binds strongly in the mother's circulation and is approved by the AAP for breastfeeding mothers. The Diflucan use is to prevent a fungal infection. Vanc is given IV. If it gets into the breastmilk it won't get absorbed by the babies stomach because if it could it would just be given to the mother by mouth and not IV (Fragmin also gets destroyed in the stomach.). The Levaquin my idea is not my first line of antibiotic, but I consider it case-by-case. The Domperidone and herbs to protect her milk supply during the breast pain, procedures, hospitalization.

The current medications are Coumadin, Domperidone, and More Milk Plus. The pain was better while finishing the course of medication. The clot resolved and the PICC line removed. In one update mom told me some pain came back. But she is still breastfeeding and working with me, and her local IBCLC and oral motor therapist.

Both moms with breast pain/mastitis are reading along and I/we welcome any feedback.

Friday, December 25, 2009

Mastitis Consult-- giving the courage to ask for what you need

This past week I worked with an out-of-state mom (and her 10 month old) referred by a local (in Coco Beach) oral motor therapist whom mom had been in contact with. This is the history I received:

· frequent bouts of plugged ducts (but not mastitis)
· constant pain ranging from sharp to deep to burning beginning with feeding and up to 15 minutes afterwards.
· Shooting pains deep in the breast tissue
· Mom is on week 2 of Diflucan 100mg, 600mg Motrin, occasional Nystatin on nipple (which burns according to Mom) and most recently alternating ice/heat per her ob/gyn with further instruction to wean entirely and “if the pain continues, a referral to a breast specialist for a possible ultrasound”.
· Baby, 10 months of age, receives Nystatin 4 times/day and is receiving increasing amounts of formula due to the ‘unbearable’ pain of nursing yet weaning is described as painful as well.
Mom had been treated with one round of Augmentin.


After talking to the mom, made these recommendations:

Bilateral Breast Milk Cultures, Gram stain, sensitivity, fungal elements. ( I can make specific recommendations compatible with continued nursing a 10 month old after I see culture results). I explained to mom how simple it is to send milk off for these tests. In my office we use a sterile urine cup. One for each breast. Labeled right and left. The lab only needs a small amount to complete the tests. I suggest a cluster of milk about the size of a dime or nickel collected on the bottom of the cup. (With this history I am less suspicious of a yeast infection and more suspecting a sub clinical (chronic ) mastitis requiring a prolonged course of antibiotic or stronger more uncommonly used antibiotic.

Bilateral Breast Ultrasound and breast exam (Rules out a mass causing the problem or an abscess that needs to be drained.)

The dose of Diflucan wasn't as high as I usually use. Diflucan 400mg first day and 200mg each day for a minimum of two weeks. I often treat up to 4 weeks.

Probiotics (Mom later told me she is also using Grape Seed Extract which re-establishes a normal flora and I agree with.)

All Purpose Nipple Ointment (APNO) per Jack Newman MD's website.

FYI- Lecithin is a supplement to help prevent plugged ducts. (Lecithin's value during an active infection may be minimal, but may be preventative towards future plugged ducts.)

Good Nutrition-- High Quality Grains and Raw Fruits and vegetables.

Attend La Leche League Meetings

The mom brought these recommendations to her ob/gyn and sent me an update.

Dr. Punger, Good news. My doctor agreed to test my milk today and also ordered me an ultrasound. I also am currently getting a prescription for APNO filled at a compounding pharmacist and also received a 2 week prescription for 100mg (2x a day) of Diflucan. I have asked to receive a copy of the culture and will forward you any interesting information. I thank you again for your time and giving me the courage to really ask the doctor for what I need. I am hopeful that these next steps will bring me closer to resolving this.

Wednesday, June 24, 2009

Ordinary and Fun Wednesday

I started out this morning with Scott's lessons. We are working on Level 4, Lesson 14. The closer to the end of this level we get the longer it seems to drag on. As the world of reading opens up for Scott, I see him being occupied with books and magazines more.

I prepared my crockpot with Tam's split pea soup and made Bok Choy cole slaw per Gerrie. I usually can season veggies to my taste if I make it. Not this slaw. It did not turn out well.

I was in the office in the afternoon. It's nice to have a steady flow of young mothers. This week I've talked to mom's about adoptive breastfeeding, VBACs, reviewed prior birth records for appropriateness of homebirth referral, co-sleeping & SIDS ( I don't fall for the Back to Sleep campaign) and frenotomy amongst other topics. I've had one patient drive 2 hours from Boca and another 3 hours from Ormond Beach, several from Jensen Beach and Stuart. It's nice to have families so receptive.


With dinner prepared ahead of time, we got to spend a few hours at the Cabin this evening. We threw bread crumbs to a turtle in the river from our deck, watched some big blue crabs peek out their tunnels in our yard. David was great at spotting wobbly flying fruit bats once we showed him what to look for. The other day we saw an iguana on our deck. We harvested some mangoes and mananza bananas from our trees. I am keeping a good eye on our trees before the critters get to them. Not sure if I'll get everything before the raccoons do.

Monday, April 20, 2009

How late is too late to re-lactate?

I have previously wrote an unfortunate post, an example of a mother who brought in her 2 month old for me to fix the latch and milk supply. I have seen a few of these types of dyads, since, where I know right from the start (often before I enter the exam room), I am wasting my time; I know the baby will never latch and I am doubtful the milk supply will increase. Sometimes I can even tell from attitudes and what is said via the phone, non-verbal clues, and what's written on the new patient forms. Some just want the correct information to see if it's possible. I try never to give up on anyone.

This past week, I saw a 2 month old who needed help latching and who's mother's supply had dwindled. Mostly he was being fed formula by bottle. While I couldn't promise a fully latching breastfed baby, I thought I could significantly help her milk supply by reinforcing positive attachment parenting skills, her nutrition, and herbal and prescription galactogogues. I thought her baby might latch when the milk supply increased.

So what's so different about this mother with a 2 month old and the previous mother?

For one thing the babies behaviors are different. In the optimistic situation, the baby is rooting and turning towards the breast and showing signs of being very frustrated at not being able to latch. The mother, likewise, was also frustrated that the baby wouldn't latch. In the other circumstance the baby had no clue what a breast was for and totally disinterested.

In the hopeful situation, the mother interactions with the baby was totally different and probably most likely accounted for the difference in the baby's behavior. Mom was responsive to the baby, she was emotionally sensitive to the time loss in breastfeeding and the birth plans that went awry. She took her shirt and bra off to feed. In other words, she was comfortable with skin-to-skin. She was mostly practicing attachment parenting all along and feeling the loss of not being able to provide for her baby. She didn't have an argument and a pity story in retort to my every suggestion. She came in open minded for information. She did not expect me to wave a magic wand. She expected to make the effort herself after receiving individualized guidance. I also really liked her interaction with the baby when I peeked in to the waiting room. I would have not guessed what her reasons for coming in were.

On to another point. A LLL Leader referred her to me. This mom had never been to a LLL meeting. The information LLL meetings provides about mothering through breastfeeding is so important, especially when breastfeeding is NOT working. I can provide medical guidance, but the mother-to-mother support comes from LLL. She had tentative, hesitant plans to attend her local meeting that I inquired about. I've been to enough LLL meetings to anticipate how awkward it would be to go in and bottle feed and didn't want this to deter her.

So I said, "I imagine it will be really hard to sit through a LLL meeting and feed your baby with a bottle."

She had also anticipated this and told me how she planned to excuse herself for the baby's nap, the bathroom or whatever when it came time to bottle feed.

I feel so strongly that mothers need the information provided at LLL and I feel they will glean so much just by observing the interactions between other mothers and babies that she needs to be upfront with why she is there and STAY. I prepared her for what to expect. There is always introductions first and she just needs to come right out and say that until her milk supply comes in she needs to feed her baby with supplements and a bottle. Honesty, I anticipated, should get the support she needs.

I can't pin-point an exact age where its too late to make the effort to breastfeed. I am always ready to give a mother with an open-mind the correct and individualized information, but there must be internal motivation.

Sunday, February 15, 2009

Breastfeeding with Comfort and Joy (a book review)

A brand new photographic breastfeeding guide has caught my attention.

If you are (or will be) nursing a baby or you are in the position to help a mother nurse a baby, and you have any qualms at all about how to recognize good position and latch, Breastfeeding with Comfort and Joy is for you.

There are already quite a few how-to manuals (with drawings) and videos (which did not solidify it for me, despite my preconception of a video being the gold-standard for this purpose) out there.


Family Nurse Practitioner, photographer, and mother of four, Laura Keegan has done an incredible job combining (mostly) her own professional quality photography with descriptive text to describe how to attain the perfect latch.

The photos are amazing. They tastefully convey the tender intimacy of the breastfeeding relationship while instructively showing the steps to obtain proper position and latch. The photos capture very specific moments in time, for example, all the details of the mother's posture, the baby's position, direction of the nipple in relation to baby's mouth, up close latch photos, and more. There are lots of happy satiated babies (from a few days to a few weeks old) shown after a feed near the breast and all the mothers are breastfeeding with comfort and joy. I noticed the photos of dyads breastfeeding with comfort and joy that didn't necessarily "pair" with the text about clinical concerns, but I liked that because as I read about a clinical problem, the photo reminded me of the emotional rewards of why it's worth it to hang in there.

The photos bring back lots of memories. My favorite is the content twins falling off the breast after a feed on page 113. It reminds me of my early days tandem nursing William and Scott. How I tried to capture that moment of contentment of both boys on film and never was successful at getting that recorded. Laura Keegan is an incredible photographer. These photos are technically correct and printed on high quality pages which emphasize every single positive element in the photographs. It won't take you long to read, but the photos will draw you back in for more information.

Beyond the photos and latch instruction, Laura anticipates common concerns and special situations the new mother may face. Laura and I both agree on one important fact--despite obstacles getting in the way of breastfeeding, the mother's desire and the correct technique is most important. Breastfeeding can be successful despite unfortunate (and sometimes necessary) early interventions and this is why I recommend this book.

If you are a mom or you are a helper and have doubts about your ability with latching skills, you need this book. If you are like me--confident in knowing a good latch by intuition--this book defines each step with words creating an organized approached.

Although many babies have the ability to nurse and extract milk in any position, the step-by-step approached becomes critical when you have a compromised baby such as twins or NICU grads or for some other reason won't latch correctly. Several success stories are included in the book and some can be found here.

Breastfeeding with Comfort and Joy is a self-published book. The best place to order a copy is at http://www.thebreastfeedingbook.com/ . I look forward to hearing back from you if you benefited from it as much as I did.

For my local readers the LLL of the Treasure Coast has this book in the lending library.

If you are near Dutchess County, New York (about an hour and a half south of Albany, 1 hour North of NYC), and need breastfeeding help or integrative family care, Laura Keegan, RN, FNP is the one to see.

Wednesday, February 4, 2009

Orlando Breastfeeding Presentation

-Remember this presentation is this Saturday

When Breastfeeding Seems Impossible

I will present several success stories (ei, women I am really proud of).

At the next Meeting of the Florida Lactation Consultant Association

February 7th at Business meeting at 10:00 PM, lunch at 12, my presentation and discussion at 1:00

Where? Orlando Regional Education Center, details and map

This is 2 hour CERPs awarded.

FLCA meetings are well attended (~40 IBCLC's and counselors ) from around the state and the meetings are always interesting. New attendees are aways welcome.

If you would like to read the current FLCA newsletter I'd be glad to email it to you. Just let me know.

I promise I won't be as nervous as my last talk ; ) . I am looking forward to sharing with the IBCLC's and others exactly what I can do!

Oh, and thanks to my mom for being my assistant at this talk: helping me set up and whatever I might need!

Saturday, January 31, 2009

Old Pump, New Life

I used my medela pump* to express milk for William and Scott while I was at work. I started expressing milk before I returned to work about 12 weeks post partum and continued to use the pump at work for the first year to replenish my supply, keep me comfortable, and nourish my babies while I was at work. I did not use the pump for David, my third baby, because I kept him with me. Yet all this time (its been ten years since I've used it), I've found it hard to get rid of. What if? What if I needed it again for something?

Well, I finally found a new life for my pump. A worthy destiny for a 12 year old medela Pump n Style.

I've donated it to a Pumper. The "Pumpers" is an affectionate term for all the mothers who have come together to pump milk for another mom who needs the milk. One of the Pumpers is using my pump. As much as I would love to donate my own milk, I am not in a mindset right now to concentrate on that effort to take herbs, medication, or take the time out to pump and wash pump parts and store and transport... I am happy that through my pump, I am able to enable another woman to do all this. She says the pumping is going well. Wow, my pump lasted all these years!


Actually it warms my heart to see how a group of woman have informally come together to donate milk. The burden doesn't fall all on one person. I like the team approach and the commitment! I like the sense of community. I like a happy mom and baby. (I also like a mom who takes a beautiful photo and gives me consent to use the photos.)


Let me take this opportunity to list out possible solutions for low milk supply depending on the circumstances:
Lifestyle counseling including skin-to-skin, babywearing, co-sleeping, co-bathing.

Correct latch and position.

Community Support including La Leche League (or other similar support group) meeting attendance and membership.

Prescribing herbs or medications for low milk supply. Indiviualizing the plan and monitor.

Optimal nutrition counseling and Vitamins.

Placenta capsules.

Planning for an optimal birth experience and medication free birth.

Lab testing for thyroid, other hormones and general medical. Consult and collaborate with breastfeeding specialists in other disciplines (IBCLCs, pharmacists, other physicians).

Breastfeeding books for mom to help chill, reinforce the correct information, keep a positive-mind set, and problem solve. Some current favorites and well-rounded group of books all offering somethig different that I recommend--
Permission to Mother, Breastfeeding with Comfort and Joy, Ultimate Guide to Breastfeeding, Making More Milk, Breastfeeding: A Priceless Gift.

Teach a mom how to supplement at the breast with lactaid* (pictured) or other
supplemental nursing system. Help them to decide which system and approach is best.

Teach a mom how to use the correct breastpump* if it is indicated. Hospital grade double electric pumps (the kind you rent) are the only pumps that are indicated for low milk supply. I really like for the mom to spend time with the baby and not the pump, if she doesn't need to pump. So the pump is my last resort.


*(Writing this, made me realize, I have all these supplies available in the office, but my twofloridadocs website doesn't show it.)

Saturday, January 24, 2009

I am a Guest Blogger at Adoption Connect Today

Learn more about adoptive breastfeeding and see more photos by visiting my guest post at adoption connect.

Friday, January 23, 2009

Night Nursing and Teeth

Question: I am nursing my 2 year old on demand- she nurses to sleep every night. We just went to the dentist and she suggested that I try to wean her from night nursing or at the very least wipe out her mouth when she falls asleep. Her teeth looked great no problems... I don't plan on weaning her but I am worried about her teeth... any insight on extended nursing and teeth? Thanks! Luanne

I am answering with an excerpt from Permission to Mother:

LLL recommends going within six months of the first teeth erupting. This preventive care hopefully lays the foundation for our dental health for the rest of our lives. The recommendation applies for all babies regardless of feeding method. I emphasize that breastfed babies are not exempt from meticulous dental hygiene. In my breastfeeding-skewed practice, I find more dental disease* in breastfed toddlers than I see ear infections ( I don't see much ear infections).

One of my moms, who survived multiple breastfeeding challenges to this point, was now upset after her 15 month old daughter’s visit to the dentist. Because her toddler had tooth decay, the pediatric dentist said she must stop breastfeeding at night. After all her struggle, she did not want to stop when she was finally enjoying the breastfeeding relationship.

I shared my sons’ dental history.

My first son has no dental problems. My second son who is eight years old now
had staining on his front baby teeth. The stains were there when they grew in. The
family dentist reassured me that they were just superficial and that his teeth were
solid without decay. When he was about three, he could sit still long enough for the
stains to be filed out. Neither of my two older boys had any major dental work.
Subsequently there was no reason to discuss night nursing and our family dentist
never told me to wean.

It is my third son with all the dental problems. His teeth grew in looking bad. At first I didn’t think much of it because they looked like the stains his older brother had on his front teeth. But his stains got bigger and the tips of his teeth disintegrated. Of all my sons, he was the latest to start solids and he never had a bottle (because he was with me at work). He was actually the one who was more likely to sleep through the night (or perhaps I just slept right through the nursing). I suppose I was in a sort of denial that his front teeth needed work, “Not my breastfed baby!”

His teeth looked really bad by the time he had them repaired. He was one- and-a-half. Fortunately, there is a minimally invasive pediatric dentist in town with five sons of his own who feels that breastfeeding is important to a toddler’s well-being. He will treat the decay and respect your right to continue breastfeeding. My son was sedated and caps were placed on his four upper front teeth. The dentist encourages good brushing, xylitol supplements (wipes or chewables), and nutrition (less sugar) as a part of the treatment program. Flouride treatment is individualized.

Our local La Leche League network helped me understand that breastfeeding through the night is entirely normal behavior for a toddler. If you stop breastfeeding at night, what beverage can you give that is healthier? Don’t necessarily expect any baby to sleep through the night at this age. They are not neurologically programmed for that. In fact, nursing at night is one of the best things for neurological and brain development. Formula and heavy foods may disrupt this built-in, sleep-hunger-wake feed cycle. If it’s important to you that your breastfed baby sleeps through the night, and he does, count yourself lucky.

If you have a toddler without dental problems you may get away with going to any dentist you want because breastfeeding won’t be an issue. If you have a breastfeeding toddler with caries, it becomes much more crucial to go to a breastfeeding-friendly dentist.

*Since, I wrote this two years ago, I have not seen much dental disease. David's dentist and I closely collaborate and many of my patients do get in to the dentist between the babies 1st and 2nd birthday. I'd like to think that the dental decay I see has decreased as we have worked together to provide preventative education.

Wednesday, January 14, 2009

Mothering at the Breast (adoptive breastfeeding)

I'm so lucky getting to meet a celebrity baby today. This 3 day old is adopted and will be breastfed. I am so excited. Mom said he took to the lact-aid much better than the hospital nipple, which he was gagging on. You can see her own words on her blog here.


The lact-aid works by holding a reservoir of expressed milk or formula and a little tube brings the liquid to the baby's mouth as he suckles. An easy regimen of a few medications prior to the arrival of the baby helps bring the milk in. The lact-aid provides a supplement while mom's milk supply is building up. A relaxed smile and the eye-to-eye contact between mother and latched baby is unmatched!

It is so inspiring to me to see mothering at the breast!

See more photos here.

Sunday, January 11, 2009

Where to find Breastfeeding Help

Where would one go to find a breastfeeding specialist doctor in my area?
I'd start by asking lots of mothers. Keep in mind that while there are more of "us" over time. You would likely have to drive a bit to get to one. Women in my location have to drive to get to other specialist in Orlando and Miami, don't give-up just because there is not one next door. It is worth traveling for the informed consult!

What organizations that you belong to might help with that? (all of these have directories and links in my resource list)

La Leche League has Medical Associates
Academy of Breastfeeding Medicine
Attachment Parenting International (I don't actually belong right now)
International Lactation Association
Florida Lactation Consultant Association


OK, I do have a question. My DIL was told by a lactation professional that she was not making enough milk. (Baby was sleeping a lot and mom was told that that is a sign, along with little weight gain, of not enough nutrition) The lactation consultant checked the baby's latch, said it was fine, and told mom to pump and suggested herbs to help increase her milk. She never got engorged (which she sees as evidence of her inability to produce sufficient milk), but nursed through pain and difficulties for weeks and finally stopped. (That girl is a trooper! most of us would have quit much sooner.)

So: 1) are there or are there not some women who, while fully capable of growing a baby and giving birth well, are unable to make milk for that baby? I have heard both yes and no to this question and want to know the truth with data to back it up.

I think it is very rare that a mother can't make enough milk, although I occasionally have a mother whom I've worked with and still can't. Our cultural influence and prior experience affects breastfeeding (beliefs, motivation, misconceptions, initiation (or lack of) ,lack of support, labor medications, prior breast surgery, or other surgery like gastric bypass and nutrition). But there is still occasional times when all these conditions are optimized and a woman still can't make enough milk like inadequate glandular tissue, thyroid, pituitary disease (but can still be optimized ).

Here, I am considering the mother's side not the babies side which can include prematurity, immaturity, tongue-tie and suck disorders and other cranial facial disorders.

Pregnancy is not required to produce milk. Surrogate and adoptive mom can produce milk with support and proper information.

A mother who can't provide breastmilk can still mother at the breast (lact-aid, SNS) and provide skin-to-skin (co-bath, co-sleep, babywear). Recently one of our La Leche League leaders daughters asked, "What if I can't breastfeed. Will you be mad at me?" You can still provide mothering at the breast and skin-t0-skin. Many mother's who "give-up" breastfeeding, give-up on it all, too. A mother's desire to breastfeed is the most important factor.

And 2) what are the different kinds of lactation consultant people? There are the lay helpers like La Leche League, which do a lot of good, and there are some professionals and people like you who have letters after their names. What kind of help do these various people offer, and who would you expect to have the best, most helpful information? I want to know to whom I can direct moms when they are having trouble with nursing.

Remind me where you live. You can send me a comment or e-mail and I'll let you know if I know someone. I won't publish a comment with your location. There are many types of professionals who can help breastfeeding, and unfortunately there are many who think they are helping, but are causing harm. For example midwifes, doulas, physicians, nurses (and nurse practitioners), chiros, therapists, dietitians and dentists (and more) are in great positions to help breastfeeding, but its the rare few who take special interest to specialize in lactation. However, I can think of a few who provide exceptional help in all all of those professions. La Leche League leaders are great if the mother needs mother-to-mother support. It's great to refer all mothers to LLL. (Our local group is great. I am not sure that all areas have an active gr oup like we have.) They can often help locate a physician who belongs to LLL medical associates. But medical associates and members of the academy of breastfeeding medicine differ in the level of experience, knowledge, area of expertise and service (clinical, research-based, academic) and may not all be available. Some do primary care w/ breastfeeding and some have limited their practice to just breastfeeding.

In some areas WIC is a good place to ask for a lactation consultant. In some places WIC isn't as helpful.

It all goes back to asking lots of local mothers who the professionals are in an area.

There seems to be a lot of certifications and levels for various lactation providers and many certifying organizations. So many, I am sorry to say, I haven't kept up. I have kept a list of old favorites in my resource list in the navbar.

And 3) where can I go to get training in this myself?) Thanks.

Become a La Leche League leader or at least a paid member for now, so you get on the mailing list for meetings, conferences, journals. Join your state and/or local lactation group or Breastfeeding Task force. Contact the office certifying IBCLC's for reputable information.

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?

Sincerely,

Confused

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.

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.

Tuesday, September 30, 2008

More thoughts on Introducing a Bottle

I had more thoughts about introducing a bottle from the previous post. A few of these thoughts are copy and paste from comments in a previous post about sleep and daycare.

I wasted too much energy fussing over training my first son to take a bottle. Looking back at that part of my transition to work, it wasn't worth so much focus. I should have savored the time together more and just nursed.

When moms are going back to work at 6 weeks, 12 weeks, whenever... and ask me how to train a baby to take a bottle in preparation to go to back to work, I actually now am telling moms to nurse and feed their baby and don't loose precious bonding time training a baby to bottle-feed. If the baby has to take a bottle for the first time, it might as well be delayed as long as possible and max out the time the baby gets exclusive breast.

Now, I know how normal, it is to worry that your baby won't "take a bottle" when you are not there that first time. I was there. I worried too. But a bottle isn't the only way to feed a baby. How about give your sitter a syringe, dropper or even cup? If a syringe or a dropper is present, the baby won't starve. Syringe and dropper feeding is a passive activity from the babies side and requires no sucking to be fed. We are just programed to think that bottles are the alternative feed. If we made syringes and droppers in pastel colors and put cute animal on them it wouldn't look so "clinical" and would be more acceptable. Perhaps a syringe or dropper doesn't offer the adult the same convenience as the bottle does? All-in-all a syringe, dropper, or cup is less disruptive to breastfeeding than a bottle when the breast isn't available.

Because this topic has come up before, I know the next question that comes up: "What if the sitter/dad won't use a dropper or syringe?" As a parent, you have the right to know all the feeding options and make your choices weighing all the pros and cons. Maybe it's not the right sitter? Some dads you can't change, darn. The daycare dilemma is discussed in detail before. Maybe you're okay with the bottle. As a provider it is my responsible to share my observation and respect your choices. I just wish I was aware of my choices earlier on. It embaresses me to say I didn't know the options. Most breastfeeding relationships are negatively influenced by the bottle.

Sunday, September 28, 2008

Introducing a Bottle

Question from a reader in Responsibly Starting Solids:

Kristen's Raw said...
I received your book that I bought on Amazon! YAY! I'm reading about your journey right now... just finished the chapter "A Letter to My Third Son"... so beautiful. I can't wait to get pregnant :)I have a question, if you don't mind... at what point is it okay to start pumping breast milk so that the baby can be fed by both a bottle and still nurse naturally without getting confused by the two different nipples?Thanks!!!

Permission to Mother said...
Hi Kristen,I am so excited that you have my book in your hands! Before introducing a bottle, I would make sure your baby is thriving and breastfeeding is going very well--a part of your life and you are not thinking about every step. For example, like in learning to drive, at first you think about turning the keys and pushing the gas. Before you know it, you drive without thinking about those things.

However every baby is different. Introducing a bottle (or pacifier) is with risks.I don't think there is a magic age. In my experience most babies are affected by it either directly (confusion or having a choice) or indirectly (with mothers supply dwindling.)As you continue to read my book, I think you'll have a lot more insight. I'm going to take this to the top of the blog, to give my other readers a chance to answer.

Monday, August 4, 2008

The 362nd Baby on ECMO at MCG

My 2nd cousin, Preston Jefferson Deutsch is 8 days old today and he is the 362nd baby on ECMO at the Medical College of Georgia.

Geoff my younger cousin and I grew up together in Atlanta. We don't see much of each other now. Geoff and his wife Kristen also have a daughter. I saw Kristen early in this pregnancy at another family event. Last Sunday my mother told me that she delivered Preston quickly and easily at a community hospital 12 days before her due date. The baby was fine for 24 hours. He fed and got cuddled and loved, and then became short-of-breath after a day. My mother updated me that he was transferred to a regional hospital to be intubated, but continued to get worse. Next he was transferred to MCG for ECMO (a lung bypass). Neurological and Cardiac systems have been evaluated and from what I hear are intact.

This is the last update my mother sent me:

"Baby is still holding his own. Geoff & Kristen have been reading to him and talking to him. Kristen is pumping but Aunt Carol does not know if they are feeding the baby breast milk. They are going home for 2 days to be with Sydney… she starts school tomorrow."

Geoff and I both trained at MCG. He is a General Surgeon. Kristen is a health professional also. My training experience in this very NICU definitely shaped my future of working with mothers and babies. MCG provided ECMO services 15 years ago when I was in there. Being the 362nd baby gives you an idea of how often they need this technology(really not that much). I do remember them being proud and celebrating their ECMO grads. I do not remember them emphasizing how important providing nature's miracle drug--breastmilk--to these critically ill ones is, I just don't remember. It seems to me if you go the extreme to provide life saving technology, you need to include the simple things like skin-to-skin and mother's milk. From my mother's e-mail it sounds like my cousin and Kristen are having an opportunity to provide their best in the circumstances.

I wish I could do more then sit here and feel helpless and wonder how this precious baby got so ill. I wish I could be right there ((in between the babies mouth and mother's breast if I could get that close)) to make sure the milk goes where it needs to. I often think of going back to MCG for a visit and I think what sad circumstances it is for Geoff and Kristen to go back under these circumstances and away from their daughter and away from extended family. I wonder in tears if anything to prevent this could have been done while I feel out-of-control. I also wish I had a photo.

BUT I am encouraged by another little one who has touched my life. Colton who is a Miami ECMO graduate, who followed up with me in this practice. He has done remarkable well. ECMO stands for Extracorporeal membrane oxygenation. Kristi, his mother, answered some questions for me today:

...its definelty a last resort thing. When Colton went on they told me he had a 20% chance to live if they put him on it and that was about average for all kids going on it. There were two other kids on ECMO before and after Colton and neither one made it off. As far as breastfeeding, the kids are NPO, they are basically in an induced coma and intubated so nothing at all except IV. During this time I pumped and pumped and pumped. Colton was on 7 days....they told me that there is a great risk putting them on ECMO. They said the longer they are on the more chance of them not making it, as well as having infarcts (like colton did). They check their brain through ultrasound daily to see if they have a bleed, if not they keep them on, if they see anything, they have to take them off. Then gradually, they try to wean them off the machines to see if the heart and lungs can do their jobs. Colton, luckily, came off the first time and his body could handle it. I know of of the kids who didnt make it, they tried to take her off multiple times and her heart kept giving out so they needed to put her back on. Eventually they said enough was enough after 4 weeks or so. How long did u say your cousin was on for now? I hope everything turns out OK. Unfortunately, most ECMO kids have some issues when coming off, but Ive talked to many parents who have said their kids were a bit developmentally delayed at first, but later they are just fine. Its a very scary thing, thats for sure. I had to really forct the issue with breastfeeding...they wouldnt even let me do kangaroo care after ECMO when he was coming off the drugs and such. It was ridiculous. Then, it was every kid in the NICU was given a gtube before they were let go. That was Miami Childrens, so hopefully Georgia is better. Pleeeese let me know how it goes and the status, we are hoping for the best for your family.

Kristy
Natures Way Soy Candles & More

Related Posts Widget for Blogs by LinkWithin

Share it