Health Guide

Asthma : symptoms, trigger factors & management

Written by Mystic on Monday, July 25, 2011

Asthma is a common airways disease affecting 30% of all Australians - one third are adults and two thirds are children.

What is an asthma attack?
An asthma attack happens when the airways (bronchial tubes) in the lungs narrow. In asthma the airways are more sensitive than normal and when exposed to a "trigger" they overreact and become inflamed and narrow due to:

• Swelling of the airway lining
• Squeezing or spasm of the airway's muscle walls
• Increased mucus

Symptoms
Asthma may be indicated by one or more of the following:

• cough -especially at night
• wheezing
• tightness in the chest
• shortness of breath

Trigger factors
Certain triggers bring on asthma attacks in some people:

• allergy to house dust mite, pollens, moulds and pets
• irritants like cigarette smoke, dust or chemical fumes
• viral infections such as colds or flu
• vigorous exercise (medication may be needed before exercising)
• certain medicines such as aspirin and NSAIDS
• emotional stress or excitement
• cold air or a sudden temperature change
• some food additives

Medications
Preventers treat airway inflammation. They are the first-line defence and need to be taken every day to prevent attacks. Typical preventers are Becotide, Pulmicort, Intal, Intal Forte, Becloforte, Aldecin, Tilade and Flixotide.Relievers treat airway narrowing. They are rescue medications usually given by inhaler when symptoms occur. These typically include Ventolin, Bricanyl, Berotec, Aldecin, Respolin, Atrovent, Asmol, Respax and Serevent.

Managing asthma
Any asthmatic condition should be referred to your doctor for advice.Your doctor or pharmacist will assist you with a six-step management plan which is aimed at abolishing symptoms, maximising lung function and achieving the best quality of life. The plan will:1. Assess the severity of the asthma2. Achieve the best lung function - ensuring that medications and devices are being used correctly and effectively3. Maintain the best lung function by avoiding trigger factors4. Maintain the best lung function with optimal medication5. Assist with developing a written action plan for management, and handling acute attacks and deterioration.6. Educate and review condition regularly via checkups

Respiratory System and Asthma

Written by Mystic on Sunday, July 24, 2011

Asthma

Other names :
Wheezy bronchitis.


Introduction :
Asthma is a temporary narrowing of the tubes through which air flows into and out of the lungs.


Types :
Asthma may be spasmodic for no apparent reason (intrinsic), induced by exercise or other known trigger factors (extrinsic), or may be relatively silent and have few symptoms.


Cause :
Asthma is caused by a narrowing of the airways in the lung caused by a spasm in the tiny muscles which surround the air tubes. The problem is further aggravated by the excess production of phlegm in the lungs and swelling of the lung tissue through inflammation. The absolute cause of asthma is unknown, but certain triggers can start an attack in susceptible individuals. The triggers include colds and other viral infections, temperature changes, allergies, exercise, smoke, dust and other irritants. The tendency to develop asthma runs in families along with hay fever and some forms of eczema. If you have a parent with asthma, you have a 15 times greater chance of developing it than the average person.


Incidence :
One of the most common problems dealt with by general practitioners. It affects at least one in ten people in the population to some extent.


Prevention :
Avoiding known trigger factors (eg: foods, fumes, temperature changes), and taking preventative medication on a regular basis.


Investigations :
If asthma is suspected by a doctor, the first step is to perform tests on the lungs to assess their function. This involves blowing into a number of different machines which either draw a graph a doctor can interpret, or give a reading on a gauge. These tests are performed on several occasions at different times of the day before a definite diagnosis of asthma is made. The patient's response to medication is also checked on these machines.


Course :
The narrowing of the airways causes shortness of breath and wheezing. Asthmatics usually find they cannot breathe out easily because as they try to exhale, the lung collapses further, and the small amount of space left in the airways is obliterated. Asthmatic symptoms also include coughing, particularly in children, or a mild tightness and discomfort in the chest. Attacks may build up slowly over many weeks, and the individual may be unaware of the deterioration in his lung function until it is measured. In other cases severe attacks may develop in a matter of seconds after exposure to an irritant.


Treatment :
Asthma cannot be cured, but doctors can control the disease very effectively in the vast majority of patients. The treatment of asthma is a team effort involving the doctor, physiotherapists and other health professionals, as well as the vital cooperation of the patient and his/her parents and family. Many people who have asthma never see a doctor, even though they may be aware of the diagnosis. Although they may feel well, they often do not have their asthma under adequate control. Their quality of life and exercise tolerance could be improved dramatically if a doctor saw them regularly to keep their asthma under review. Once the diagnosis has been established, it is important to identify any trigger substances which might start an attack. This can often be done by the patient on a trial and error basis, but an allergist is usually called upon in severe cases to help in the identification of potential risk factors. The treatment of asthma is divided into two broad categories; prevention of attacks, and treatment of the acute attacks when they occur. Prevention is always better than cure, and all but the mildest of asthmatics should be using one or more of several different types of sprays, inhalers or tablets to prevent attacks (see Medication Table). If one form of prevention does not work, other types should be tried, or combinations used. The best way to treat an attack is by aerosol sprays which take the drug directly into the lungs where it is needed. These can be in the form of pressure pack sprays, inhalers, motor or gas driven nebulisers, or capsules which can be broken and their powder inhaled (see Medication Table). Mixtures and tablets are also available for the treatment of asthma attacks, but they work more slowly and have greater side effects.


Diet :
Any food that triggers attacks should obviously be avoided, but this varies from one patient to another, and there are no general dietary restrictions.


Complications :
Permanent lung damage can result from recurrent attacks of asthma.


Outcome :
Most patients can be adequately controlled, but rarely death from asthma can occur in severe cases. Research into asthma and its control is continuing apace, with the assistance of the Asthma Foundation and other research organisations, and new treatments and control methods are being marketed every year. Asthma is no longer the torture of years past, and the future is looking brighter all the time.


Further information:
The Asthma Foundation is one of the largest and best organised disease related charities in Australia, and can offer a wide range of assistance to patients and their families. Patients with severe asthma should consider wearing a bracelet or necklet with the engraved details of their condition. These are available from the Medic Alert Foundation.


Related conditions
Allergies, Eczema, Hay Fever

I have heard several times said that Ventolin sprays are dangerous, and people should use different things. I have used a Ventolin spray for my asthma for many years without trouble, but now I am worried. Should I stop my Ventolin?

Ventolin, and other similar sprays, were introduced more than twenty five years ago. Over that time they have helped millions of people around the world, and saved the lives of countless asthmatics. Today, these medications remain the principle form of treatment for acute asthma. The side effects are minimal and rare, and they are so safe that they can be purchased from a pharmacy without a prescription, but all asthmatics should have their asthma regularly monitored by a doctor to ensure they are receiving adequate treatment. Prevention is always better than cure, and those who have regular asthma attacks, should be using other medications all the time, in a dose that is sufficient to prevent their asthma. You should not stop your Ventolin, and provided your GP checks your lungs regularly, and you follow his/her advice on further treatment, you have nothing to fear.

I took my son to the doctor with a cough, and she said that he had asthma. I can't believe that this is true. Why would my son develop asthma at the age of 12?

Asthma can develop at any age, but the most common times are at about 2 years, 5 to 7 years of age and at puberty (12 to 14 years). Asthma may be triggered by infections (eg: common colds), allergies, exercise, temperature changes, emotional changes or hormonal changes (different times of the month in women). One of the most common presenting symptoms in children is a persistent dry cough. Once asthma is diagnosed, attacks may occur regularly, seasonally, or very rarely. If regular attacks occur, medication will be given to prevent them. If attacks are infrequent, medication can be used when required. It is very important to receive adequate treatment for asthma, to seek further help if the cough or wheeze continues, and to follow your doctor's instructions carefully. Poorly treated asthma can lead to growth retardation and other long-term problems.

Life Threatening Allergies

Written by Mystic on Friday, July 22, 2011

Introduction :
An allergy is excess sensitivity to a substance that produces a reaction in the body.


Types :
Hay fever, eczema, asthma, itchy eyes and hives may all be caused by an allergy.


Cause :
Allergies may occur on exposure to almost any type of chemical. Animal hair, dust, milk, eggs, pollen, fish, fruit, insect bites, moulds and parasites are just a few of the thousands of possible allergic substances. An allergen is a substance that causes an allergic reaction. When the body first encounters an allergen, the defence mechanisms of the body are triggered, but there is usually no detectable effect. On the second and subsequent occasions of exposure to the allergen, the defence mechanism over reacts, causing effects that may be merely a nuisance, or severe and life threatening, in different areas of the body. Pollens, dusts or chemicals may start the allergic reaction, causing the release of a substance (histamine) from special (mast) cells in the nose, skin, eyes etc. Histamine causes rapid swelling of the tissue, which may secretes copious amounts of watery fluid, and become intensely itchy.


Prevention :
Avoiding foods, chemicals, other substances and situations that are known to trigger the allergy. Antihistamines may be taken on a regular basis if avoidance is not possible.


Investigations :
Tests may be performed to determine whether or not you are allergic to a particular substance, but because there are so many possibilities, you must have some idea of what is causing the problem before the tests are commenced. The tests may take the form of skin pricks with a number of suspected substances, or blood tests that can detect the bodies reaction to an allergen.


Treatment :
The body gradually breaks down the histamine itself, and the reaction disappears, but this process can be speeded up by the use of anti-histamine drugs (see Medication Table) that are taken by mouth or injection to destroy the histamine that is causing the allergy reaction. In some cases, nasal or inhaled sprays (see Medication Table) can prevent the release of the histamine by the cells, and therefore prevent any allergic reaction, but these must be used all the time, as the problem will probably recur if they are ceased. If someone is found to be highly allergic to a specific substance, they can be desensitised so that they do not react as strongly, or sometimes do not react at all. This process is often long and involved, and unfortunately does not always work, but many people have had life threatening and disabling allergies cured or reduced by this procedure. Allergists, who are specially trained doctors, usually undertake allergy desensitisation. The patient has prepared an individualised mixture of the substance to which they are allergic. This mixture is extremely dilute, and the patient is gradually exposed to stronger and stronger concentrations until the body no longer responds to cause an allergic reaction. The desensitising mixture is usually given by a series of small injections at regular intervals over several months.


Diet :
Avoid any foods or drinks that are known to trigger an allergy reaction.


Complications :
Allergies in most people are annoying rather than serious, but in a small number of victims, they may be life threatening. Those who know of a life threatening allergy should always carry adrenaline with them, to be self-injected if they have an attack.


Outcome :
Allergies should not be severe enough to significantly alter your lifestyle if adequately treated by you and your doctor.


Further information:
Allergy Associations exist in several states. People with severe allergies should wear a bracelet or necklet carrying information about the allergy to warn doctors in an emergency. These are available through the Medic Alert Foundation.


Related conditions
Asthma, Conjunctivitis, Eczema, Hay fever.

Does Stress Cause Acne

Written by Mystic on Thursday, July 21, 2011

Other names:
Pimples, zits.


Introduction :
A skin disease causing disfiguring pimples, which usually occurs in teenagers.


Types :
Varies from the very occasional spot, to a severely disfiguring form known as acne vulgaris.


Cause :
Pimples are due to a blockage in the outflow of oil (known as sebum) from the thousands of tiny oil (sebaceous) glands in the skin. This blockage can in turn be caused by dirt (uncommon in our super-clean society), dead skin left behind during the normal regular regeneration of the skin surface, or a thickening and excess production of the oil itself. Once the opening of the oil duct becomes blocked, the gland becomes dilated with the thick oil, then inflamed, and eventually infected. The result is a white head, with the surrounding red area of infection. Eventually this bursts, sometimes leaving a scar. The hormonal changes associated with the transition from childhood to adult life is the major aggravating factor in acne. Hormonal variations later in life can also cause changes to the thickness of oil in the skin, and may worsen or improve acne. Pregnancy, menopause and the oral contraceptive pill may all influence pimples in this way. Stress in the patient, either psychological or disease, may cause pimples to worsen. A simple cold, or the onset of exams may see the number of spots increase dramatically. Pressure from spectacles on the bridge of the nose or tight collars, increases in skin humidity from a fringe of hair or nylon clothing, and excessive use of cosmetics that further block the oil duct openings, can all cause deterioration in a person's acne. If your father or mother had acne, you have a greater risk of developing them. Acne is not infectious.


Incidence :
Usually starts in early teenage years. Acne is generally more severe in teenage males, but starts earlier in females. It may strike later in life too, particularly in women. It affects Caucasians (whites) more than Negroes or Chinese races.


Prevention :
The risk of acne may be reduced by keeping the skin clean, but not by excessive washing or scrubbing.


Course :
Acne can vary from the annual spot, to rarely a severe disease that causes significant disfigurement. Usually settles by late teens, but may persist into mid twenties, and rarely may be lifelong.


Treatment :
Although a cure for acne is not normally possible, medical science can usually control the condition adequately. The steps to follow are :- Gently wash the face with a cloth and non-perfumed non-medicated soap twice a day. Use over the counter chemist preparations that work by drying out the oil in the skin, removing any excess skin flakes, and reducing inflammation. A variety of different prescription creams, lotions and pastes that prevent infection, dry up excess oil and reduce inflammation. Antibiotics (see Medication Table) prescribed by a general practitioner, either short or long term, are successful in controlling more severe acne. Some types of oral contraceptive pill (see Medication Table) and other hormones are very useful in controlling the condition, but only in women. In rare cases, the very potent Roaccutane tablets (see Medication Table) may be prescribed.


Diet :
There is no evidence that diet,stress, vitamins or other herbs have any effect on pimples. A small number of sufferers may find that one particular food causes a fresh crop of spots, but these people usually quickly realise this and avoid the offending substance. There is no truth in the old wives tale that acne is worsened by chocolate.


Complications :
Picking acne spots can cause serious secondary infections. Occasionally secondary infections can develop in acne to cause deeper skin infections that require immediate medical attention with antibiotics.


Outcome :
Usually settles with age and medication, but may cause both skin and psychological scarring.


Medical curiosity :
A century ago, doctors believed that constipation was a cause of acne.

Identifying Asthma

Written by Mystic on Friday, November 28, 2008

Q: How do I know if I might have asthma?

A: The small airways in your lungs both swell up and become smaller when an asthma attack strikes. This leads to increased mucus production and decreased flow of the air in the lungs. Wheezing, shortness of breath, and coughing result. In mild cases, these symptoms may be mild and infrequent. If your case is moderate or severe, they may come often.

You should ask your doctor whether you may have asthma if you cough after exercise or after exposure to cold winter air. If you commonly have a cough that persists for more than 2 weeks after a common cold, you may have a mild form of asthma. Likewise, you may have asthma if you wheeze or cough after exposure to dust, animal hair, cigarette smoke, or pollen.

If you experience shortness of breath unrelated to extreme exertion, you should contact your doctor. This requires prompt medical evaluation, because there are many serious causes for shortness of breath other than asthma.

Asthma may develop for the first time at any age, even in people in their 60s or 70s. At older ages, however, patients and their physicians must carefully consider the possibility of other explanations for cough, shortness of breath, or wheezing. These include cardiac disease, chronic lung diseases (such as emphysema), anemia, respiratory infection, and cancer.

This information, prepared by physicians at Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, is not medical advice and should not replace consultation with your doctor. Staff at BIDMC provide Ask an Expert responses to consumers for educational purposes only. Always consult your own doctor about any opinions or recommendations with respect to your symptoms or medical condition.

Statistics and Risk Surrounding Breast Cancer

Written by Mystic on Thursday, November 27, 2008

Q: As each year passes, I seem to know more and more women with breast cancer. What is the chance that I will develop breast cancer myself?

A: Breast cancer is the most common cancer in US women and is greatly feared. However, many women overestimate their risk. One widely quoted statistic--"one in nine"--refers to the cumulative lifetime risk of breast cancer for a woman who lives past the age of 85. The risk of breast cancer for a woman in any given year or decade of her life is much lower than one in nine. The chance a woman will develop breast cancer in the next 10 years is one in 250 for a 30-year-old woman, one in 77 for a 40-year-old woman, one in 43 for a 50-year-old woman, and one in 38 for a 60-year-old woman. Some subgroups of women have higher than average risk. Factors that increase an individual woman's chance of developing breast cancer include older age, previous breast cancer, relatives with breast cancer (especially if mother, sister or daughter is affected, or if cancer was found before menopause), previous breast biopsies (especially if precancerous tissue was found), previous uterine or ovarian cancer, past radiation treatment to the chest, having a first pregnancy after 30, having no children, having an early first period (before age 12), having a late menopause (after age 55), postmenopausal obesity, and moderate alcohol intake. Current birth control pill use raises breast cancer risk slightly. Many (but not all) studies suggest that long-term (more than 5 years) hormone replacement may slightly increase breast cancer risk.

Multiple Pregnancy Week by Week

Written by Mystic on Wednesday, October 01, 2008

There are two distinct camps in the multiple pregnancy debate, is it better to have or to have not?

To many in the general population, multiple pregnancy resulting from infertility treatment sounds like a wonderful outcome, the "instant family" after years of involuntary childlessness. This is reinforced by magazine articles and television programmes in which readers and viewers are invited to marvel at the rows of beds, shoes, school lunches etc., in families coping with raising triplets, quads, quintuplets or more.

As an IVF embryologist, I fell into this category. After the couple had a positive pregnancy test it was not common to hear any more about them. In the absence of any further information, it was normal to assume that things were running smoothly, and that the worst the parents would have to cope with, would be a few sleepless nights after the children were born. But over the past ten or so years, I have come to understand exactly what a multiple pregnancy means to the family.


The pregnancy
I became pregnant when I was 27 years old. I had just lost a blighted ovum pregnancy and then conceived naturally in the subsequent cycle. This second pregnancy was a quadruplet implantation, with one embryo lost at 5 weeks' gestation (although this was not accompanied by any bleeding). The ultrasound examination showed tissue in the uterus, although evidence of a fetal heart was not conclusive.

7 weeks
A second ultrasound examination at 7 weeks gestation showed 3 fetal hearts, with two quite close together. Another ultrasound examination at 10 weeks gestation showed three separate sacs, although one was much larger than the other two.

16 weeks
At 16 weeks gestation, biophysical profiles of all the fetuses were made by ultrasound examination and showed that two of the fetuses were developing normally, while the third was smaller.

20 weeks
At 20 weeks gestation, I developed pregnancy induced hypertension and was placed on bed rest. There was an unequal distribution of amniotic fluid in the fetal sacs - one had a very high volume of fluid, while the others had very low volumes. This made it impossible to treat the condition medically, since treatment to increase or decrease the fluid volumes would cause problems for the others.

24 weeks
At 24 weeks gestation, I was spilling protein in my urine, my kidneys weren't functioning properly so I was accumulating fluid, and I had extremely high blood pressure. I was admitted to hospital because the doctors were concerned about premature labour. After a couple of days, my condition had stabilised, but there were still very unequal amounts of amniotic fluid. The only way to even up the amount of fluid was to physically remove some from the large sac. This was done trans-abdominally using an amniocentesis needle attached to a 60 ml syringe. A total of 1.3 litres of fluid was removed, 60 ml at a time (quite a painful procedure because the layers of tissue were moving relative to one another as the amount of fluid decreased, but the needle was left in place all the time to reduce the risk to the baby).

26 weeks
At 26 weeks gestation, another ultrasound biophysical profile of the babies was ordered. The third triplet showed an abnormal blood flow that could have been due to a heart defect and we had to face the possibility that she might not survive. Because of the uncertain outcome, we were asked to decide whether to continue the pregnancy or to deliver at 26 weeks to allow her to be operated on. There was no evidence that we could improve her prognosis by surgery (since nobody knew exactly what, if anything, was wrong), and we felt that the risk to the other babies' health was too great when there was such an uncertain outcome. We decided to continue with the pregnancy.

27 weeks
By 27 weeks gestation, my blood pressure was controlled, my kidneys were working again and I had lost the fluid that had accumulated in my tissues. The fetuses were growing well. I "saw" them most days during the routine ultrasound, and had started referring to them by name. The medical team was pleased with our progress, and foresaw no problems.

28 weeks
At 28 weeks gestation, the Monday morning ultrasound showed that the third triplet's heart had stopped beating. Because of the fused placenta, the babies had to be delivered by emergency Caesarean - since they were now at risk.

The delivery
There were 14 people in the delivery room (hardly an intimate and moving experience!). Baby 1 (Caitlin) weighed 1100g and had to be resuscitated, Baby 2 (Rebecca) was stillborn. She weighed 800g. Baby 3 (Sara) weighed 890g and was doing reasonably well. All of the babies were taken away immediately.

Our first joint parental decision was to allow Sara and Caitlin to be given lung surfactant - fortunately the decision to end the drug trials had been made 2 hours earlier!

Rebecca
The following morning, I had to make my first sole parental decision I had to sign the autopsy release form for Rebecca. The enormity of trying to come to terms with the loss of a child as well as having to understand the challenges faced by the surviving babies, at the same time I was recovering from surgery, is too painful and too hard to describe.

In that first week, we had to arrange for Rebecca's funeral while at the same time I had to start expressing breast milk for Caitlin and Sara. It was a week of sharp contrasts, pain and cofusion, instead of joy and happiness at the birth of three healthy babies.

Caitlin & Sara
During that week, Caitlin had to be given another drug to close the hole in her heart. The surfactant treatment worked very well and both Sara and Caitlin were breathing on their own (ie they didn't need ventilators) within a couple of days, although they still required oxygen treatment. In the following week, Sara was doing very well, and there was talk of moving her out of the intensive care unit. Meanwhile, part of Caitlin's gut had died due to lack of oxygen. This is a life-threatening condition. In other cases it requires surgery to remove the dead portion of the bowel. Rebecca's funeral was held that week. Caitlin recovered and did not require surgery. Her health improved quite quickly, and she was moved into the intermediate part of the intensive care unit.

Meanwhile, Sara had contracted viral pneumonia and her lung had collapsed. She had to be put back on the ventilator. On the same day, I was allowed to hold Caitlin for the first time. She was so small that her head rested in the crook of my elbow and her feet were at the end of my palm. Caitlin continued to do well and was moved to the special care nursery just to grow. She learned to suck and I could breastfeed her. She still had some lung damage and needed extra oxygen.

Sara
Sara was still very ill and her lung damage was worsening. The drugs she was on caused her a lot more damage and in the end, every system was affected. She was being given 100% oxygen but her levels were below 80% (they should be 85-95%). She stayed this way for weeks, until finally she crashed. Her oxygen levels were down to 28% and nothing was helping her. She was still in a humidicrib, and I still hadn't held her. I made a scene in the intensive care unit about how they couldn't let her die because they hadn't let me hold her. I was escorted out of the NICU. The following day, Sara was still alive but her oxygen levels were still extremely low, around 36%. The staff had decided that it couldn't hurt for me to hold her.

Everyone in the NICU knew what was happening and people came running from everywhere with tissues when they put Sara in my arms. As I held Sara, the oxygen saturation monitor alarmed. It was reading 96%. Sara improved slowly, but her oxygen saturation levels stayed relatively low (around 70%) for the next few weeks. The doctors didn't expect her to improve, and couldn't give us a prognosis - although they told us that nobody who had been that sick had ever survived. That week, the nurses put Caitlin and Sara together and took photographs. They thought it might be the only chance we would have to see them together.

Coping with critically ill children
Finally, after 10 weeks, Caitlin was to be released from hospital. The day before Caitlin was to come home, the medical staff called us in for a conference. They told us that Sara was gravely ill, that they had evidence that she had sustained brain damage. They said that she was constantly in pain and that she would never have a good day in her life. They then asked us to support their suggestion that they withdraw care and allow her to die. This was too hard to face, and we asked for their personal rather than professional advice. We decided to put off the decision for another week.

During that week, Sara was treated with high doses of steroids, and she improved dramatically. Caitlin had come home on schedule, and she still needed oxygen. The day that Caitlin came off oxygen supplementation was the same day that Sara came off the ventilator. Sara had to stay in hospital for another 2 months, and she started to grow, although her lung damage was extreme. She was discharged from hospital when she was 5 months old. She was home for 2 days before she had to be rushed back to hospital with breathing difficulties. She ended up staying in hospital for 3 months, and she had surgery (after she got to 5.5 lbs) to stop her from vomiting constantly. A gastrostomy tube was also inserted through her stomach wall so that she could be tube fed when she was too sick to manage eating

When she was discharged from hospital this time, we had to give her nebulised drugs every 3 hours, followed by chest physiotherapy. The treatment that had kept her alive had taken away all the hairs in her lungs, so she couldn't get rid of the mucus on her own. She also had to be fed small amounts of high calorie formula via her g-tube every 3 hours, and she couldn't have been fed less than an hour before chest physio. She also had to be given drugs every three hours around the clock and she was fed via her g-tube overnight while she slept.

We had to be very organised about Sara's care and we devised lots of systems to make sure that she was given the right drugs and treatment at the right time. For example, when Sara was in bed at night she had her oxygen tubing as well as a feed line going into her stomach. This meant that she had two lengths of tubing running through her bed and there was a risk that she could get them tangled around her throat. We ended up putting both tubes inside her sleeper pyjamas and bringing them out at her foot, because then she would have to do somersaults to get the tubes around her neck.

Another problem was that she had to have drugs given to her in her g-tube at 8am, 11am, 2pm, 5pm, 8pm, 11pm, 2am and 5am. Some of these drugs were quite dangerous so we had to make sure that we weren't going to make a mistake in the middle of the night by giving the wrong dose or giving it at the wrong time, since she didn't get the same drugs at each time. Of a night, I'd give Sara her 10:30pm Ventolin etc., then chest physiotherapy, then put her back to bed and hook her up to the overnight feeding bag. There was a peristaltic pump which passed the formula into her stomach at a fixed rate. When the bag was empty, the pump would alarm - we set the flow rate so that the alarm would go off at 5am, so that I could get up, switch it off, give Sara her 5am drugs and then go back to bed. We had to work it so that I did the 11pm and 5am shift and my husband did the 2am shift, so that he could have 2 stretches of good sleep, since he was the one earning the money of a day.

The guilt and despair involved with having critically ill children is extreme, and certainly outweighs any perceived advantage of just having to have one pregnancy to complete a family.

Meanwhile, Caitlin was doing very well and we had to try to give her as normal a childhood as possible. This level of care continued for 2 years, with Sara in and out of hospital due to lung problems. At 2 years and 3 months, Sara was well enough to be weaned off supplementary oxygen and most of her drugs. She was unable to walk, and had developed an oral aversion, meaning that she didn't like eating. We then had another 2 years of intensive therapy (physiotherapy, occupational therapy, speech therapy) to teach her how to walk, how to move food around in her mouth, and to give her a sense of herself. The breakthrough with her eating was chocolate. She surprised us all by eating an Easter egg. It took her until she was 6 years old before she was confident in chewing and moving food around in her mouth. The girls continued to grow and Sara started to outgrow all of her problems.

Now we have two 10-year olds. They are both generally healthy and intelligent children. However, it took five years of virtually 24 hour nursing and caring to get us here. From my family's experiences, I could not recommend multiple pregnancy to anyone. The guilt and despair involved with having critically ill children is extreme, and certainly outweighs any perceived advantage of just having to have one pregnancy to complete a family. Finally, I would just like to say that we begrudge nothing that we have had to do but please remember my family's trials and hurdles when thinking about the 'rightness' of the "instant family" that multiple pregnancy brings.