Oesophageal atresia (OA) is often associated with anomalies of other systems. The genetic contribution to the formation of the VACTERL association is not clear. The objective of this study was to evaluate the incidence of associated anomalies in two different racial populations. The associated anomalies in neonates with OA managed in an Asian and a European paediatric surgical centre from 1982 to 1998 were reviewed. Non-Asian and non-European patients were excluded from the respective centres. The incidence of anomalies was compared using Fisher's exact test, taking #E5/E5# below 0.05 as statistically significant. Forty-eight consecutive Asian (25 boys and 23 girls) and 34 consecutive European patients (20 boys and 14 girls) were included in the analysis. The percentage of patients with at least one associated anomaly was 50% and 74% in the Asian and European populations, respectively, which was significantly different (#E5/E5#=0. 04). There was no statistically significant difference in the incidence of associated cardiovascular (29% vs 39%), anorectal (11% vs 18%), and musculoskeletal (16% vs 22%) anomalies, duodenal atresia (4% vs 3%), or Down's syndrome (3% vs 6%) between the two populations. However, the European patients had a significantly higher incidence of urogenital (UG) anomalies (26% vs 4%, #E5/E5#=0.006), the most common being agenesis (n=4) and dysplasia (n=3) of one or both kidneys. Hereditary factors may influence the incidence of associated anomalies in children with OA, particularly of the UG system. However, environmental factors cannot be excluded.