Perinatal Circumstances Research Articles

AETIOLOGY OF CEREBRAL PALSY IN PATIENTS UNDERGOING ORTHOPAEDIC SURGERY FOR MUSCULOSKELETAL DEFORMITIES

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit.A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed.Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%).Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition.

The developmental origins of health and chronic kidney disease: Current status and practices in Japan.

The concept of the developmental origins of health and disease (DOHaD) views unfavorable perinatal circumstances as contributing to the development of diseases in later life. It is well known that such unfavorable circumstances play an important role as a risk factor for chronic kidney disease (CKD) in infants born with prematurity. Low birthweight (LBW) is believed to be a potential contributor to CKD in adulthood. Preterm and/or LBW infants are born with incomplete nephrogenesis. As a result, the number of nephrons is low. The poor intrauterine environment also causes epigenetic changes that adversely affect postnatal renal function. After birth, hyperfiltration of individual nephrons due to low nephron numbers causes proteinuria and secondary glomerulosclerosis. Furthermore, the risk of CKD increases as renal damage takes a second hit from exposure to nephrotoxic substances and acquired insults such as acute kidney injury after birth among infants in neonatal intensive care. Meanwhile, unfortunately, recent studies have shown that the number of nephrons in healthy Japanese individuals is approximately two-thirds lower than that in previous reports. This means that Japanese premature infants are clearly at a high risk of developing CKD in later life. Recently, several DOHaD-related CKD studies from Japanese researchers have been reported. Here, we summarize the relevance of CKD in conjunction with DOHaD and review recent studies that have examined the impact of the upward LBW trend in Japan on renal health.

Translational insights into mechanisms and preventive strategies after renal injury in neonates

Adverse perinatal circumstances can cause acute kidney injury (AKI) and contribute to chronic kidney disease (CKD). Accumulating evidence indicate that a wide spectrum of perinatal conditions interferes with normal kidney development and ultimately leads to aberrant kidney structure and function later in life. The present review addresses the lack of mechanistic knowledge with regard to perinatal origins of CKD and provides a comprehensive overview of pre- and peri-natal insults, including genetic predisposition, suboptimal nutritional supply, obesity and maternal metabolic disorders as well as placental insufficiency leading to intrauterine growth restriction (IUGR), prematurity, infections, inflammatory processes, and the need for life-saving treatments (e.g. oxygen supplementation, mechanical ventilation, medications) in neonates. Finally, we discuss future preventive, therapeutic, and regenerative directions. In summary, this review highlights the perinatal vulnerability of the kidney and the early origins of increased susceptibility toward AKI and CKD during postnatal life. Promotion of kidney health and prevention of disease require the understanding of perinatal injury in order to optimize perinatal micro- and macro-environments and enable normal kidney development.

The Developing Human Connectome Project: typical and disrupted perinatal functional connectivity.

The Developing Human Connectome Project is an Open Science project that provides the first large sample of neonatal functional MRI data with high temporal and spatial resolution. These data enable mapping of intrinsic functional connectivity between spatially distributed brain regions under normal and adverse perinatal circumstances, offering a framework to study the ontogeny of large-scale brain organization in humans. Here, we characterize in unprecedented detail the maturation and integrity of resting state networks (RSNs) at term-equivalent age in 337 infants (including 65 born preterm). First, we applied group independent component analysis to define 11 RSNs in term-born infants scanned at 43.5–44.5 weeks postmenstrual age (PMA). Adult-like topography was observed in RSNs encompassing primary sensorimotor, visual and auditory cortices. Among six higher-order, association RSNs, analogues of the adult networks for language and ocular control were identified, but a complete default mode network precursor was not. Next, we regressed the subject-level datasets from an independent cohort of infants scanned at 37–43.5 weeks PMA against the group-level RSNs to test for the effects of age, sex and preterm birth. Brain mapping in term-born infants revealed areas of positive association with age across four of six association RSNs, indicating active maturation in functional connectivity from 37 to 43.5 weeks PMA. Female infants showed increased connectivity in inferotemporal regions of the visual association network. Preterm birth was associated with striking impairments of functional connectivity across all RSNs in a dose-dependent manner; conversely, connectivity of the superior parietal lobules within the lateral motor network was abnormally increased in preterm infants, suggesting a possible mechanism for specific difficulties such as developmental coordination disorder, which occur frequently in preterm children. Overall, we found a robust, modular, symmetrical functional brain organization at normal term age. A complete set of adult-equivalent primary RSNs is already instated, alongside emerging connectivity in immature association RSNs, consistent with a primary-to-higher order ontogenetic sequence of brain development. The early developmental disruption imposed by preterm birth is associated with extensive alterations in functional connectivity.

A clinical study of neonatal birth injuries in a tertiary care hospital-NICU, Bijapur

Background: Neonatal birth injuries are the third major cause of neonatal mortality in most developing countries. Very few studies have been done in India on birth injuries and its relation to various factors such as undesirable presentations and parity. Aim: The present study was conducted to analyze the birth injuries in our setup to know the various perinatal circumstances leading to birth injuries. Materials and Methods: An observational study was done in which 100 cases of birth trauma were noticed among 850 consecutive viable births during the study period of 2 years. Details of the health status of the mother, antenatal, intra-natal, and postnatal particulars, including the age, sex, weight, mode of delivery, type of presentation, and nature of the birth injury in different modes of delivery and type of presentation of the baby were taken. Results: It was found that of 850 newborn babies, 100 babies were found to have birth injuries, thus giving an incidence of 11.76% per 100 live births. Asphyxia formed the major groups which were noted in 45 babies. Cephalohematoma was the next common injury being noted in 32 cases. A total of 18 babies had soft tissue injuries and 4 babies had neurological injuries. Conclusion: Our findings support to use data on neonatal birth injuries as an indicator to assess the quality and safety of maternity units.

PIH53 EXAMINING OF PERINATAL CIRCUMSTANCES IN CHILDREN WITH COW’S MILK PROTEIN ALLERGY

Nutritional allergies in children are a frequent topic of studies, considering the increasing number of affected individuals and the diversity of symptoms. Cow’s milk protein allergy (CMPA) is the most common food allergy in children, with a prevalence of 2-6%. The aim of our study was to examine the perinatal circumstances in children with cow’s milk protein allergy. The study was conducted at the Pediatric Gastroenterology Department in Szekszárd, Hungary. The research population (n=47) included children (0-18 years) with cow’s milk protein allergy. This research subtopic analyses questionnaire data. Beside the various clinical presentation, demographic, socio-economic and medical data of the research population and their families were also reviewed. 47 children were included (57.4% male, mean age: 7.36 years, SD: 4.22). 23.4% of mothers and 25.5% of fathers were diagnosed with either atopy or an inflammatory bowel disease; examining the siblings of the affected children, 45.7% have one of these conditions (12 children do not have any siblings). In the study population, 8.5% were born prematurely and 85.1% were born at term (6.4% did not answer). 46.8% were exclusively breastfed in the first 6 months. The introduction of dairy products before 12 months was observed in 46.8% of the study population, 48.9% received dairy between 12-24 months, and 4.3% first consumed milk after 24 months. Based on our results, a positive family history for atopy and/or inflammatory bowel disease can increase the risk of developing cow’s milk protein allergy; siblings with affected parents showed a higher prevalence of food allergy. A significant effect of feeding or gestational age on the risk of developing CMPA was not observed. The time of introduction of dairy to the child’s diet did not represent a significant difference in our research population.

Staircase-pattern neonatal line in human deciduous teeth is associated with tooth type

ObjectiveThe staircase (Sc) pattern enamel microstructure is an expression of an impaired ameloblast function. It has been reported to appear in the neonatal line (NNL), the accentuated stria evincing live birth in deciduous tooth enamel. Our objective was to investigate the prevalence of Sc NNL in deciduous tooth types and its possible association with perinatal circumstances. DesignSc in the NNL of 88 teeth, a collection derived from a long-term, prospectively followed population cohort, was recorded with linear polarised transmitted light and analysed for tooth type, duration and mode of delivery, and pain medication used during labour. ResultsSc prevalence in the NNL differed highly significantly between tooth types (p < 0.0001). An increase in Sc prevalence was significantly associated with an increased ratio of prenatal to total crown enamel (p < 0.001), when buccal and lingual crown walls were analysed separately. No significant association was found between Sc prevalence and duration or mode of delivery or pain-relieving medication (p = 0.57, p = 0.65, p = 0.58, respectively). ConclusionThis research indicates that the NNL location within tooth crown enamel has a strong impact on microstructural changes along the NNL. Considering our results of Sc prevalence, deciduous canines, having the least Sc appearance, could be used in studies that aim to investigate factors associated with NNL width. In addition, Sc prevalence variation in first deciduous molars might enable to investigation of physiological stressors strong enough to cause ameloblast impairment, such as Sc.

Neuroinflammation in the Developing Brain: Risk Factors, Involvement of Microglial Cells, and Implication for Early Anesthesia.

Microglia cells, the resident macrophages of the central nervous system, are key actors for specific brain functions that are critical for development and health. Microglial reactivity and functions, even when immature, play a major role if the developing brain is subjected to abnormal perinatal events. Brain exposure to general anesthesia, surgery, or analgesic drugs during early infancy may adversely affect its maturation and plasticity after injury. A better understanding of the regulation of microglial activation in the developing brain and interactions with specific anesthetic drugs is expected to give novel insights into the mechanisms underlying their potential adverse effects. This review recapitulates the most frequent perinatal circumstances associated with exacerbated systemic inflammation and neuroinflammation together with the double-edged role of microglia associated with subsequent brain damage. A role for microglial reactivity in both potential anesthetic toxicity and neuroprotection is emerging. However, further preclinical experiments are needed to better understand regulatory mechanisms of the developing microglia, and interaction between anesthesia and neuroinflammation in the developing brain.

Response of cord blood cells to environmental, hereditary and perinatal factors: A prospective birth cohort study

BackgroundMany studies investigating the impact of individual risk factors on cord blood immune cell counts may be biased given that cord blood composition is influenced by a multitude of factors. The aim of this study was to comprehensively investigate the relative impact of environmental, hereditary and perinatal factors on cord blood cells.MethodsIn 295 neonates from the prospective Basel-Bern Infant Lung Development Cohort, we performed complete blood counts and fluorescence-activated cell sorting scans of umbilical cord blood. The associations between risk factors and cord blood cells were assessed using multivariable linear regressions.ResultsThe multivariable regression analysis showed that an increase per 10μg/m3 of the average nitrogen dioxide 14 days before birth was associated with a decrease in leukocyte (6.7%, 95% CI:-12.1,-1.0) and monocyte counts (11.6%, 95% CI:-19.6,-2.8). Maternal smoking during pregnancy was associated with significantly lower cord blood cell counts in multiple cell populations. Moreover, we observed sex differences regarding eosinophilic granulocytes and plasmacytoid dendritic cells. Finally, significantly increased numbers of cord blood cells were observed in infants exposed to perinatal stress. Cesarean section seems to play a significant role in Th1/Th2 balance.ConclusionsOur results suggest that all three: environmental, hereditary and perinatal factors play a significant role in the composition of cord blood cells at birth, and it is important to adjust for all of these factors in cord blood studies. In particular, perinatal circumstances seem to influence immune balance, which could have far reaching consequences in the development of immune mediated diseases.

Association of Maternal Exposure to Childhood Abuse With Elevated Risk for Attention Deficit Hyperactivity Disorder in Offspring.

Children whose mothers experienced childhood abuse are more likely to suffer various neurodevelopmental deficits. Whether an association exists specifically for attention deficit hyperactivity disorder (ADHD) is unknown. We examined the association of maternal experience of childhood abuse with ADHD in offspring, assessed by maternal report of diagnosis and validated with the ADHD Rating Scale-IV in a subsample, in the Nurses' Health Study II (n = 49,497 mothers; n = 7,607 case offspring; n = 102,151 control offspring). We examined whether 10 adverse perinatal circumstances (e.g., prematurity, smoking) or socioeconomic factors accounted for a possible association. Exposure to abuse was associated with greater prevalence of ADHD in offspring (8.7% of offspring of women exposed to severe abuse vs. 5.5% of offspring of women not abused, P = 0.0001) and with greater risk for ADHD when the model was adjusted for demographic factors (male offspring, risk ratio (RR) = 1.6, 95% confidence interval (CI): 1.3, 1.9; female offspring, RR = 2.3, 95% CI: 1.7, 3.0). After adjustment for perinatal factors, the association of maternal childhood abuse with ADHD in offspring was slightly attenuated (male offspring, RR = 1.5, 95% CI: 1.2, 1.8; female offspring, RR = 2.1, 95% CI: 1.6, 2.8). We identified an association between maternal experience of childhood abuse and risk for ADHD in offspring, which was not explained by several important perinatal risk factors or socioeconomic status.

Early antecedents of suicide: the role of prenatal and childhood risk factors

Childhood trauma plays a significant role in the development of vulnerability to suicidal behaviour.1 In prospective and record linkage studies, adverse prenatal and perinatal circumstances and behavioural problems in childhood...

The Mutually Facilitating Maturational Matrix

The author discusses several significant points made by Dr. Lewis Aron in his rich discussion of birth fantasies and themes in relation to perinatal familial circumstances. Contributing a wide variety of clinical vignettes, Dr. Willock portrays the possibility (perhaps the necessity) of revisiting and revising these foundational fantasies as the patient’s internal object world is reconfigured. New birth fantasies often first see the light of day in dreams. As the transformative thrust gains momentum, constricted repetition yields to promising renaissance. New hope and enthusiasm begins replacing archaic, limiting, organizing principles. Embracing a comparative-integrative approach, the author considers a year of the analysis described by Dr. Aron from multiple perspectives. Each viewpoint contributes something unique to our understanding. Combined, these diverse frameworks shed valuable light on the nature of the presenting difficulties and the impressive analytic progress achieved by Dr. Aron and his analysand.

Prise en charge en maternité des nouveau-nés à risque d’hypoglycémie — CoFAM

To prevent neonatal hypoglycemia, it is recommended to avoid hypothermia circumstances (by valorising early “skin to skin” contact with the parents, the use of a cap), to ensure that extra uterine adaptability is correct and to start as soon as possible food supply for the neonate (particularly with all breastfeeding supports). Nevertheless, some neonates present real risks of hypoglycemia because of perinatal circumstances. For the “at risk” neonates, it will be necessary to screen for hypoglycemia: 1) if glycemia is lower than 1.1 mmol/l, a paediatrician must be contacted; 2) if glycemia is lower than 2 mmol/l, glycemia is not acceptable and it is necessary to correct it either, by maternal expressed milk or by infant formula that can possibly be fortified; 3) if glycemia is between 2 and 2.5 mmol/l, it is necessary to make sure of the quality of the feeding; 4) if glycemia is superior to 2.5 mmol/l and the quality of feeding is correct, the surveillance could be less frequent and be stopped after 24 hours. The scientific committee of the CoFAM has developed an algorithm for neonatal hypo glycemia for breastfed or bottle-fed neonates to help healthcare professionals in their taking care.

Association of maternal exposure to childhood abuse with elevated risk for autism in offspring.

Adverse perinatal circumstances have been associated with increased risk for autism in offspring. Women exposed to childhood abuse experience more adverse perinatal circumstances than women unexposed, but whether maternal abuse is associated with autism in offspring is unknown. To determine whether maternal exposure to childhood abuse is associated with risk for autism in offspring and whether possible increased risk is accounted for by a higher prevalence of adverse perinatal circumstances among abused women, including toxemia, low birth weight, gestational diabetes, previous induced abortion, intimate partner abuse, pregnancy length shorter than 37 weeks, selective serotonin reuptake inhibitor use, and alcohol use and smoking during pregnancy. Nurses' Health Study II, a population-based longitudinal cohort of 116 430 women. Nurses with data on maternal childhood abuse and child's autism status (97.0% were of white race/ethnicity). Controls were randomly selected from among children of women who did not report autism in offspring (participants included 451 mothers of children with autism and 52 498 mothers of children without autism). Autism spectrum disorder in offspring, assessed by maternal report and validated with the Autism Diagnostic Interview-Revised in a subsample. Exposure to abuse was associated with increased risk for autism in children in a monotonically increasing fashion. The highest level of abuse was associated with the greatest prevalence of autism (1.8% vs 0.7% among women not abused, P = .005) and with the greatest risk for autism adjusted for demographic factors (risk ratio, 3.7; 95% CI, 2.3-5.8). All adverse perinatal circumstances except low birth weight were more prevalent among women abused in childhood. Adjusted for perinatal factors, the association of maternal childhood abuse with autism in offspring was slightly attenuated (risk ratio for highest level of abuse, 3.0; 95% CI, 1.9-4.8). We identify an intergenerational association between maternal exposure to childhood abuse and risk for autism in the subsequent generation. Adverse perinatal circumstances accounted for only a small portion of this increased risk.

Ante- and perinatal circumstances and risk of attempted suicides and suicides in offspring: the Northern Finland birth cohort 1966 study

To investigate those ante- and perinatal circumstances preceding suicide attempts and suicides, which have so far not been studied intensively. Examination of the Northern Finland Birth Cohort 1966 (n = 10,742), originally based on antenatal questionnaire data and now followed up from mid-pregnancy to age 39, to ascertain psychiatric disorders in the parents and offspring and suicides or attempted suicides in the offspring using nationwide registers. A total of 121 suicide attempts (57 males) and 69 suicides (56 males) had occurred. Previously unstudied antenatal factors (maternal depressed mood and smoking, unwanted pregnancy) were not related to these after adjustment. Psychiatric disorders in the parents and offspring were the risk factors in both genders. When adjusted for these, the statistically significant risk factors among males were a single-parent family for suicide attempts (OR 3.71, 95% CI 1.62-8.50) and grand multiparity for suicides (OR 2.67, 95% CI 1.15-6.18). When a psychiatric disorder in females was included among possible risk factors for suicide attempts, it alone remained significant (OR 15.55, 8.78-27.53). A single-parent family was a risk factor for attempted suicides and grand multiparity for suicides in male offspring even after adjusting for other ante- and perinatal circumstances and mental disorders in the parents and offspring. Mothers' antenatal depressed mood and smoking and unwanted pregnancy did not increase the risk of suicide, which is a novel finding.

Perinatal and psychosocial circumstances associated with risk of attempted suicide, non-suicidal self-injury and psychiatric service use. A longitudinal study of young people

BackgroundPast studies using large population based datasets link certain perinatal circumstances (birth weight, parity, etc) with mental health outcomes such as suicide, self-harm and psychiatric problems. Problematically, population datasets omit a number of social confounds. The aim of this study is to replicate past research linking perinatal circumstances and mental health (suicidality and use of psychiatric services) and to determine if such associations remain after adjusting for social circumstances.MethodsA longitudinal school-based survey of 2157 young people (surveyed at age 11, 13, 15) followed up in early adulthood (age 19). At age 11 parents of participants provided information about perinatal circumstances (birth weight, birth complications, etc.) and psychiatric service use. Participants provided data about their mental health at age 15 (attempted suicide, suicidal thoughts) and at ages 19 (self-harm, psychiatric service use). In addition, data were collected about their social and psychosocial circumstances (gender, deprivation, religion, sexual behaviour, etc.).ResultsPredictably, social factors were linked to mental health outcomes. For example, those with same sex partners were more likely (OR 4.84) to self-harm than those without a same sex partner. With a single exception, in both unadjusted and adjusted models, perinatal circumstances were not or only marginally associated with mental health outcomes. The exception was the number of birth complications; young people with two or more complications were approximately 2-3 times more likely than those without complications to use psychiatric services.ConclusionsWhile we failed to replicate results found using large population based datasets, some of our results are compatible with prior research findings. Further, evidence from this study supports the influence of perinatal circumstances (birth complications) on later psychiatric problems, or at least higher than expected contact with psychiatric service.

Reference Limits for Reticulocyte Haemoglobin Content in Healthy Infants

Background: Iron deficiency anaemia remains a serious public health problem worldwide, especially in young children. There are many indicators of iron status, which are usually used in combination since they all have limitations. Reticulocyte haemoglobin content (RetHe) is a novel biomarker of iron deficiency but there is a lack of reference limits for RetHe in infants. Aim: To provide reference limits in healthy infants. Methods: Swedish infants (n=392) born vaginally, at term and in uncomplicated perinatal circumstances were included. RetHe was measured and correlated to Haemoglobin (Hb), mean cell volume (MCV), mean cell haemoglobin concentration (MCHC), ferritin, soluble transferrin receptor (sTfR) and transferrin saturation (TS). Results: Of the infants, 46% were boys, mean (SD) birth weight was 3575 (±479) grams and mean gestational age was 40,1 (±1,1) weeks. At 12 months, 324 infants (85%) remained in the study. RetHe is presented in Table 1. At 4 months, we found significant correlations (p< 0.001) between RetHe and MCV, MCHC, ferritin, sTfR and TS, and at 12 months between RetHe and Hb, MCV, MCHC, sTfR and TS. Table Conclusion: This is the largest study presenting RetHe reference limits for infants. Defining a reference range for RetHe is a first step towards standardizing RetHe as a pre-anaemic biomarker for iron-deficiency in children.

Fetal growth, early life circumstances, and risk of suicide in late adulthood

Recent studies in Sweden and Scotland have found early life conditions to be associated with increased risk of attempted and completed suicide in adolescence and young adulthood. It is not known, however, whether early life conditions affect suicide risk throughout the life course, from adulthood into old age. We examined the effects of early life conditions, including markers of fetal growth, and social and economic characteristics in adulthood, on risk of suicide by violent and non-violent methods in women and men aged 31-87 years using Cox regression. 11,650 women and men born at the Uppsala University Hospital in Sweden between 1915 and 1929 were followed from 1960 until 2002 using linked records from obstetric archives, Census, population and mortality registries. During 435,039 person-years of follow-up 161 completed suicides (104 in males, 57 in females) were observed. An inverse association was found between lower birthweight-for-gestational age and risk of violent suicide in females, although the association did not reach the conventional level of statistical significance (minimally adjusted HR 2.02, 95% CI (0.88-4.63); Table 4). Being male, unmarried, and in the "other or unknown" social class category in adulthood were independently associated with increased rates of suicide. There was a weak association between higher maternal parity and suicide rates. Our findings suggest differences in effects of fetal growth patterns and perinatal circumstances on suicide risk later in life, and suggest that suicide in adults and in the elderly may be influenced by a different combination of factors than those that influence suicide in adolescence and young adulthood.

Family size and perinatal circumstances, as mental health risk factors in a Scottish birth cohort

Higher maternal parity and younger maternal age have each been observed to be associated with subsequent offspring suicidal behaviour. This study aimed to establish if these, and other variables from the perinatal period, together with family size, are also associated with other psychiatric morbidity. Linked datasets of the Scottish Morbidity Record and Scottish death records were used to follow up, into young adulthood, a birth cohort of 897,685. In addition to the index maternity records, mothers' subsequent pregnancy records were identified, allowing family size to be estimated. Three independent outcomes were studied: suicide, self-harm, and psychiatric hospital admission. Data were analysed using Cox regression. Younger maternal age and higher maternal parity were independently associated with increased risk in offspring of suicide, of self-harm and of psychiatric admission. Risk of psychiatric admission was higher amongst those from families of three or more, but, compared with only children, those with two or three siblings had a lower risk of self harm. Perinatal and family composition factors have a broad influence on mental health outcomes. These data suggest that the existence of younger, as well as elder siblings may be important.

Thoraco-omphalopagus twins: different perinatal circumstances, different outcome

Two pairs of omphalopagus twins were encountered at the Polish Mother's Health Institution in Lodz, Poland during the past 15 years. In the first set the prenatal diagnosis was not established and the delivery of the twins in a regional hospital was a complete surprise. Both babies died. In the second case the conjoined twins were diagnosed prenatally, surgical separation was successful, and both twins survived. The prenatal identification of conjoined twins is of cardinal importance for the planning of delivery and possible separation.