Search

Les troubles anxieux sont les problèmes de santé mentale les plus courants chez les enfants et les adolescents canadiens. La Société canadienne de pédiatrie a préparé deux documents de principes qui résument les données probantes à jour sur leur diagnostic et leur prise en charge. Ces documents contiennent des conseils fondés sur des données probantes afin d’aider les professionnels de la santé à prendre des décisions à l’égard des soins aux enfants et aux adolescents atteints de ces troubles. La deuxième partie, qui porte sur la prise en charge, vise à 1) passer en revue les données probantes et le contexte de diverses approches cliniques qui combinent des interventions comportementales et pharmacologiques pour traiter les atteintes de façon appropriée; 2) décrire le rôle de l’éducation et de la psychothérapie pour la prévention et le traitement des troubles anxieux; 3) décrire l’utilisation de la pharmacothérapie, y compris les effets secondaires et les risques qui s’y rapportent. Les recommandations sur la prise en charge de l’anxiété reposent sur les lignes directrices à jour, une analyse bibliographique et un consensus d’experts. Il est à souligner que, dans le présent document, le terme « parent » (au singulier ou au pluriel) inclut les personnes qui s’occupent principalement de l’enfant et toutes les configurations familiales.

Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 1, which focuses on assessment and diagnosis, are to: (1) review the epidemiology and clinical characteristics of anxiety disorders and (2) describe a process for assessment of anxiety disorders. Specific topics are reviewed, including prevalence, differential diagnosis, co-occurring conditions, and the process of assessment. Approaches are offered for standardized screening, history-taking, and observation. Associated features and indicators that distinguish anxiety disorders from developmentally appropriate fears, worries, and anxious feelings are considered. Note that when the word ‘parent’ (singular or plural) is used, it includes any primary caregiver and every configuration of family.

RésuméLes troubles anxieux sont les problèmes de santé mentale les plus courants chez les enfants et les adolescents canadiens. La Société canadienne de pédiatrie a préparé deux documents de principes qui résument les données probantes à jour sur leur diagnostic et leur prise en charge. Ces documents contiennent des conseils fondés sur des données probantes afin d’aider les professionnels de la santé à prendre des décisions à l’égard des soins aux enfants et aux adolescents atteints de ces troubles. La première partie, qui porte sur l’évaluation et le diagnostic, vise à1) passer en revue l’épidémiologie et les caractéristiques cliniques des troubles anxieux; 2) décrire un processus d’évaluation des troubles anxieux. Des thèmes précis sont abordés, y compris la prévalence, le diagnostic différentiel, les affections concomitantes et le processus d’évaluation. Des démarches sont proposées pour standardiser le dépistage, recueillir l’anamnèse et observer le patient. Des caractéristiques et indicateurs connexes, qui distinguent les troubles anxieux des peurs, inquiétudes et sentiments d’anxiété adaptés au développement, sont examinés. Il est à souligner que, dans le présent document, le terme « parent » (au singulier ou au pluriel) inclut les personnes qui s’occupent principalement de l’enfant et toutes les configurations familiales.

Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 2, which focuses on management, are to: (1) review the evidence and context for a range of clinical approaches that combine behavioural and pharmacological interventions to effectively address impairment, (2) describe the roles of education and psychotherapy in the prevention and treatment of anxiety disorders, and (3) outline the use of pharmacotherapy, with side effects and risks. Recommendations for managing anxiety are based on current guidelines, review of the literature, and expert consensus. Note that when the word ‘parent’ (singular or plural) is used, it includes any primary caregiver and every configuration of family.

Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty.This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED.Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively).Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.

Background: There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario. Methods: We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017–Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset. Results: Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77–0.82) of expected in Ontario and 0.82 (95% CI 0.79–0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods. Interpretation: During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study.

To synthesize and appraise economic evaluations of vision screening to detect vision impairment in children.Literature searches were conducted on seven electronic databases, grey literature, and websites of agencies conducting health technology assessments. Studies were included if they (1) were full, comparative economic evaluations that used cost-utility, cost-benefit, cost-effectiveness, cost-consequence, or cost-analysis methods; (2) described screening services designed to detect amblyopia, strabismus, or uncorrected refractive errors in children under 6 years of age; and (3) published after 1994. High-quality studies were synthesized descriptively. Currencies were reported in 2019 Canadian dollars. Quality was assessed with the Pediatric Quality Appraisal Questionnaire (PQAQ).Vision screening services were conducted by paid staff, volunteers, or health care professionals in schools or clinics. Thirteen studies were published from five countries: China (n = 1), United States (n = 4), United Kingdom (n = 1), Canada (n = 1), and Germany (n = 6). Analytical techniques included cost-utility/cost-effectiveness combination (n = 2), cost-effectiveness analysis (n = 7), cost-utility analysis (n = 1), cost-benefit analysis (n = 1), cost-consequence analysis (n = 1), and cost analysis (n = 1). Incremental cost-effectiveness ratios ranged from C$1,056 to C$151,274 per additional case detected/prevented and from C$9,429 to C$30,254,703 per additional QALY gained, depending on the type of screening service and comparator. Six studies were determined to be of high quality.Vision screening to detect amblyopia for young children may be cost-effective compared with no screening if amblyopia reduced quality of life. Studies varied significantly in the type of screening services and comparators used. Methodological limitations were common. Future studies would be aided immensely by prospective studies on the impact of amblyopia on the health-related quality of life of young children and guidelines on the effective conduct of vision screening.RéSUMé: OBJECTIF: Synthétiser et évaluer des évaluations économiques de dépistages visuels visant à détecter la déficience visuelle chez les enfants. MéTHODE: Nous avons interrogé sept bases de données électroniques, la littérature grise et les sites Web d’organismes effectuant des évaluations des technologies de la santé. Nous avons inclus les études correspondant aux critères suivants : (1) évaluations économiques comparatives exhaustives utilisant l’analyse coûts-utilité, coûts-bénéfices, coûts-efficacité ou coûts-conséquences ou l’analyse des coûts; (2) décrivant des services de dépistage visant à détecter l’amblyopie, le strabisme ou les anomalies de la réfraction non corrigées chez les enfants de moins de six ans; et (3) publiées après 1994. Nous avons fait la synthèse descriptive des études de haute qualité. Les devises ont été converties en dollars canadiens de 2019. Nous avons évalué la qualité des études à l’aide de l’outil PQAQ (Pediatric Quality Appraisal Questionnaire). RéSULTATS: Les services de dépistage visuel étaient offerts par du personnel rémunéré, des bénévoles ou des professionnels de santé dans des écoles ou des cliniques. Treize études ont été publiées dans cinq pays : Chine (n = 1), États-Unis (n = 4), Royaume-Uni (n = 1), Canada (n = 1) et Allemagne (n = 6). Les techniques d’analyse employées étaient la combinaison analyse coûts-utilité/analyse coûts-efficacité (n = 2), l’analyse coûts-efficacité (n = 7), l’analyse coûts-utilité (n = 1), l’analyse coûts-avantages (n = 1), l’analyse coûts-conséquences (n = 1) et l’analyse des coûts (n = 1). Les rapports coût-efficacité différentiels s’échelonnaient entre 1 056 $ CA et 151 274 $ CA par cas supplémentaire détecté/prévenu et entre 9 429 $ CA et 30 254 703 $ CA par année de vie pondérée par la qualité (AVPQ) supplémentaire gagnée, selon le type de service de dépistage et le comparateur. Six études ont été jugées être de haute qualité. CONCLUSION: Comparativement à l’absence de dépistage, les dépistages visuels pour détecter l’amblyopie chez les jeunes enfants peuvent être efficaces par rapport à leur coût lorsque l’amblyopie réduit la qualité de vie. Le type de services de dépistage et les comparateurs utilisés variaient considérablement d’une étude à l’autre. Les contraintes méthodologiques étaient courantes. Les études futures seraient grandement favorisées par des études prospectives des incidences de l’amblyopie sur la qualité de vie liée à la santé chez les jeunes enfants et par des lignes directrices sur l’exécution efficace des dépistages visuels.

Background The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. Methods This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. Results Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). Interpretation Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Objective To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. Method Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1–18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. Results In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P Conclusions Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Injuries in children and youth from non-powdered firearms are a significant public health concern in Canada and other high-income countries. Injury burden, healthcare utilization and costs related to non-powdered firearm use in Ontarians under 25 years of age were analyzed using ICES data. They demonstrate the need for effective policy interventions and awareness campaigns to improve the safety of these popular "toys."

Objective To examine the association between Muslim religious affiliation and suicide and self-harm presentations among first- and second-generation immigrant youth. Methods We performed a population-based cohort study involving individuals aged 12 to 24 years, living in Ontario, who immigrated to Canada between 1 January 2003 and 31 May 2017 (first generation) and those born to immigrant mothers (second generation). Health administrative and demographic data were used to analyze suicide and self-harm presentations. Sex-stratified logistic regression models generated odds ratios (OR) for suicide and negative binomial regression models generated rate ratios (aRR) for self-harm presentations, adjusting for refugee status and time since migration. Results Of 1,070,248 immigrant youth (50.1% female), there were 129,919 (23.8%) females and 129,446 (24.2%) males from Muslim-majority countries. Males from Muslim-majority countries had lower suicide rates (3.8/100,000 person years [PY]) compared to males from Muslim-minority countries (5.9/100,000 PY) (OR: 0.62, 95% CI, 0.42–0.92). Rates of suicide between female Muslim-majority and Muslim-minority groups were not different (Muslim-majority 1.8/100,000 PY; Muslim-minority 2.2/100,000 PY) (OR: 0.82, 95% CI, 0.46–1.47). Males from Muslim-majority countries had lower rates of self-harm presentations than males from Muslim-minority (Conclusion Being a male from a Muslim-majority country may confer protection from suicide and self-harm presentations but the same was not observed for females. Approaches to understanding the observed sex-based differences are warranted.

Individuals who experience assault are at high risk of being re-assaulted. Our objective was to identify reported incidences of re-assault and associated risk factors to better inform prevention strategies.We conducted a scoping review and searched databases (MEDLINE, PsychINFO, CINAHL, Cochrane Reviews, and Scopus) and grey literature. We performed abstract and full-text screening, and abstracted incidence of re-assault and information related to age, sex, socioeconomic status, mental illness, and incarceration.We included 32 articles. Studies varied based on setting where index assaults were captured (n=18 inpatient only, n=13 emergency department or inpatient, n=1 other). Reported incidences ranged from 0.8% over one month to 62% through the lifetime. Important risk factors identified include young age, low socioeconomic status, racialized groups, history of mental illness or substance use disorder, and history of incarceration.Rates of re-assault are high and early intervention is necessary for prevention. We identified notable risk factors that require further in-depth analysis, including sex, gender and age-stratified analyses.Key risk factors identified should inform timely and targeted intervention strategies for prevention.

Objective We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic. Methods This population-based repeated cross-sectional study of children and adolescents (3–17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017–2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status. Results Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata. Conclusion During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.

ImportanceScreening for amblyopia in primary care visits is recommended for young children, yet screening rates are poor. Although the prevalence of amblyopia is low (3%-5%) among young children, universal screening in schools and mandatory optometric examinations may improve vision care, but the cost-effectiveness of these vision testing strategies compared with the standard in primary care is unknown.ObjectiveTo evaluate the relative cost-effectiveness of universal school screening and mandated optometric examinations compared with standard care vision screening in primary care visits in Toronto, Canada, with the aim of detecting and facilitating treatment of amblyopia and amblyopia risk factors from the Ontario government’s perspective.Design, Setting, and ParticipantsAn economic evaluation was conducted from July 2019 to May 2021 using a Markov model to compare 15-year costs and quality-adjusted life-years (QALYs) between school screening and optometric examination compared with primary care screening in Toronto, Canada. Parameters were derived from published literature, the Ontario Schedule of Benefits and Fees, and the Kindergarten Vision Testing Program. A hypothetical cohort of 25 000 children aged 3 to 5 years was simulated. It was assumed that children in the cohort had irreversible vision impairment if not diagnosed by an optometrist. In addition, incremental costs and outcomes of 0 were adjusted to favor the reference strategy. Vision testing programs were designed to detect amblyopia and amblyopia risk factors.Main Outcomes and MeasuresFor each strategy, the mean costs per child included the costs of screening, optometric examinations, and treatment. The mean health benefits (QALYs) gained were informed by the presence of vision impairment and the benefits of treatment. Incremental cost-effectiveness ratios were calculated for each alternative strategy relative to the standard primary care screening strategy as the additional cost required to achieve an additional QALY at a willingness-to-pay threshold of $50 000 Canadian dollars (CAD) ($37 690) per QALY gained.ResultsSchool screening relative to primary care screening yielded cost savings of CAD $84.09 (95% CI, CAD $82.22-$85.95) (US $63.38 [95% CI, US $61.97-$64.78]) per child and an incremental gain of 0.0004 (95% CI, −0.0047 to 0.0055) QALYs per child. Optometric examinations relative to primary care screening yielded cost savings of CAD $74.47 (95% CI, CAD $72.90-$76.03) (US $56.13 [95% CI, $54.95-$57.30]) per child and an incremental gain of 0.0508 (95% CI, 0.0455-0.0561) QALYs per child. At a willingness-to-pay threshold of CAD $50 000 (US $37 690) per QALY gained, school screening and optometric examinations were cost-effective relative to primary care screening in only 20% and 29% of iterations, respectively.Conclusions and RelevanceIn this study, because amblyopia prevalence is low among young children and most children in the hypothetical cohort had healthy vision, universal school screening and optometric examinations were not cost-effective relative to primary care screening for detecting amblyopia in young children in Toronto, Canada. The mean added health benefits of school screening and optometric examinations compared with primary care screening did not warrant the resources used.

Little is known about the health care and economic burdens of nonfatal firearm injuries for children/youth beyond the initial admission. This study sought to estimate health care utilization and total direct health care costs of nonfatal firearm injuries one-year post-injury. Using administrative data from 2003 to 2018 on all children/youth 0-24 years old in Ontario, Canada, a matched 1:2 cohort study was conducted to compare children/youth who experienced a firearm injury with those who did not. Mean and median number of health care encounters and costs, and respective 95% confidence intervals (CIs) and interquartile ranges (IQR), were estimated for both groups as well as costs by weapon type and intent. This study found that children/youth who experienced a firearm injury had a higher number of health care encounters per year than those who did not, particularly for medical hospitalizations (0.25 [95% CI 0.23-0.27] versus 0.01 [95% CI 0.01-0.02]) and emergency department visits (1.74 [95% CI 1.69-1.80] versus 0.38 [95% CI 0.36-0.40]). Mean and median one-year costs for those with a firearm injury were $5,442 (95% CI $5,022-$5,863) and $1,464 (IQR = $600-$4,720), and $781 (95% CI $638-$925) and $137 (IQR = $24-$401) for those without. One-year costs were highest for handgun firearm injuries ($12,875 [95% CI $9,941-$15,808]), for intentional assault-related injuries ($11,035 [95% CI $9,722-$12,348]) and intentional self-injuries ($9,658 [95% CI $5,509-$13,808]). Conclusion: Firearm injuries have substantial health care and economic burdens beyond the initial injury-related admission; this should be accounted for when examining the overall impact of firearm injuries.

Purpose Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic. Methods Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3–17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates. Results In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41–1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25–1.50) increase in risk for emergency department visit and hospitalization, respectively. Conclusions Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.

Background The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia. Methods We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012–2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes. Results Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82–0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71–0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services. Conclusions Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal–child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Objective:To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes.Methods:Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario ( N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).Results:We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants ( n = 130 suicides, 3.3/100,000) than long-term residents ( n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male–female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants ( n = 2,256 events, 4.4/10,000) than long-term residents ( n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000).Conclusion:Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Background The general health check, which includes the periodic health visit and annual physical exam, is not recommended to maintain the health of asymptomatic adults with no risk factors. Different funding mechanisms for primary care may be associated with the provision of service delivery according to recommended guidelines. We sought to determine how use of the periodic health visit for healthy individuals without comorbidities, despite evidence against its use, differed by primary care model. Methods Population-based cross-sectional study using linked health and administrative datasets in Ontario, Canada, where most residents are insured for physician services through Ontario’s single payer, provincially funded Ontario Health Insurance Plan. Participants included all living adults (> 19 years) in Ontario on January 1st, 2014, eligible for the Ontario Health Insurance Plan. Primary care enrollment model was the main exposure and included traditional fee-for-service, enhanced fee-for-service, capitation, team-based care, other (including salaried), and unenrolled. The main outcome measure was receipt of a periodic health visit during 2014. Age-sex standardized rates of periodic health visits performed during the one-year study period were analyzed by number of comorbid conditions. Results Of 10,712,804 adults in Ontario, 2,350,386 (21.9%) had a periodic health visit in 2014. The age-sex standardized rate was 6.1% (95% confidence interval [CI] 6.0, 6.1%) for healthy individuals. In the traditional fee-for-service model, the periodic health visit was performed for 55.3% (95% CI 54.4, 56.3%) of healthy individuals versus 10.2% (95% CI 10.0, 10.3%) in team-based care. Periodic health visit rates varied by primary care provider models. Traditional and enhanced fee-for-service models had higher rates across all comorbidity groups. Conclusions Patients whose primary care physicians are funded exclusively through fee-for-service had the highest rates of periodic health visits in healthy individuals. Primary care reform initiatives must consider the influence of remuneration on providing evidence-based primary care.

Key Points Question What proportion of individuals aged 16 years and older seeking care at an emergency department (ED) for mental health or addiction-related reasons have had no access to outpatient services in the preceding 2 years? Findings In this cohort study, 659 084 adults had a first ED visit, among whom 298 924 (45.4%) had no prior outpatient contact. Characteristics associated with poor access to mental health care generally, such as male sex, living in a rural area, presenting with a substance use disorder, and no usual primary care clinician, were associated with a first ED visit for mental health or addiction-related reasons with no prior outpatient contact. Meaning Nearly half of incident psychiatric ED visits were first-contact visits, which may have been avoidable with better access to outpatient mental health and addiction services., This cohort study estimates the proportion of individuals aged 16 years and older in Ontario, Canada, with incident psychiatric emergency department (ED) visits who have not previously accessed outpatient mental health or addiction services in the prior 2 years., Importance Psychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use the ED itself as a key point of access is largely unknown. Objective To describe the extent to which the ED is a first point of contact for mental health care among adults, and identify key factors associated with this outcome. Design, Setting, and Participants This cohort study was conducted from 2010 to 2018 in Ontario, Canada. Using health care administrative data, all individuals aged 16 years and older with an incident psychiatric ED visit were included. Statistical analysis was performed from September 2019 to February 2021. Main Outcomes and Measures The primary outcome was no outpatient mental health or addictions contact in the 2 years preceding the incident ED visit. The study also measured predisposing (age, sex, immigrant status, comorbidity), enabling (neighborhood income, rurality, continuity of primary care), and need factors (diagnosis from incident ED visit) associated with the so-called first-contact ED visits, generating adjusted odds ratios (aORs) and 95% CIs. Results The cohort included 659 084 patients who visited the ED. Among these patients, 340 354 were female individuals (51.6%), and the mean (SD) age was 39.1 (18.5) years. The incident ED visit was a first contact for 298 924 individuals (45.4%). Patients who had increased odds of first-contact ED visits included older individuals (aged 65-84 years vs 16-24 years; aOR, 1.13; 95% CI, 1.12-1.14), male individuals (aOR, 1.14; 95% CI, 1.13-1.15), immigrants (eg, economic class immigrant vs nonimmigrant status: aOR, 1.20; 95% CI, 1.18-1.21), rural residents (aOR, 1.21; 95% CI, 1.20-1.21), and in those with minimal primary care (aOR, 1.68; 95% CI, 1.67-1.69). All diagnoses had a higher likelihood of first-contact ED visits than mood disorders, particularly substance and alcohol use disorders (aOR, 1.66; 95% CI, 1.65-1.68). Conclusions and Relevance This study’s results suggest that nearly half of incident psychiatric ED visits were first-contact visits, which may be avoidable. Targeted efforts to improve outpatient access should focus on populations with risk factors for first-contact ED presentations, including men, older adults, rural residents, those with poor primary care connectivity, and those with substance-related diagnoses.

OBJECTIVE We aimed to compare the risk for injury overall and by intent (accidental injury, self-injury, and assault) among children born to women with versus without schizophrenia. METHODS Using health administrative data from Ontario, Canada, children born from 2003 to 2017 to mothers with (n = 3769) and without (n = 1,830,054) schizophrenia diagnosed prior to their birth were compared on their risk for child injury, captured via emergency department, hospitalization, and vital statistics databases up to age 15 years. Cox proportional hazard models generated hazard ratios for time to first injury event (overall and by intent), adjusted for potential confounders (aHR). We stratified by child sex and age at follow-up: 0-1 (infancy), 2-5 (pre-school), 6-9 (primary school), and 10-15 (early adolescence) planning to collapse age categories as needed to obtain stable and reportable estimates. RESULTS Maternal schizophrenia was associated with elevated risk for child injury overall (105.4 vs. 89.4/1000 person-years (py), aHR 1.08, 95% CI 1.03-1.14), accidental injury (104.7 vs. 88.1/1000py, 1.08, 1.03-1.14), for self-injury (0.4 vs. 0.2/1000py, 2.14 1.18-3.85), and assault (1.0 vs. 0.3/1000py, 2.29, 1.45-3.62). By child sex, point estimates were of similar magnitude and direction, though not all remained statistically significant. For accidental injury and self-injury, the risk associated with maternal schizophrenia was most elevated in 10-15-year-olds. For assault, the risk associated with maternal schizophrenia was most elevated among children in the 0-1 and 2-5-year-old age groups. CONCLUSION The elevated risk of child injury associated with maternal schizophrenia, especially for self-injury and assault, suggests that targeted monitoring and preventive interventions are warranted.

Introduction Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. Methods A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology – head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. Results Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. Conclusions This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

BACKGROUND: Firearm-related injury is an important and preventable cause of death and disability. We describe the burden, baseline characteristics and regional rates of firearm-related injury and death in Ontario. METHODS: We conducted a population-based cross-sectional study using linked data from health administrative data sets held at ICES. We identified residents of Ontario of all ages who were injured or died as a result of a firearm discharge between Apr. 1, 2002, and Dec. 31, 2016. We included injuries classified as assault, unintentional, self-harm or undetermined intent secondary to handguns, rifles, shotguns and larger firearms. The primary outcome was the incidence of nonfatal and fatal injuries resulting in an emergency department visit, hospital admission or death. We also describe regional and temporal rates. RESULTS: We identified 6483 firearm-related injuries (annualized injury rate 3.54 per 100 000 population), of which 2723 (42.3%) were fatal. Assault accounted for 40.2% (1494/3715) of nonfatal injuries and 25.5% (694/2723) of deaths. Young men, predominantly in urban neighbourhoods, within the lowest income quintile were overrepresented in this group. Injuries secondary to self-harm accounted for 68.0% (1366/2009) of injuries and occurred predominantly in older men living in rural Ontario across all income quintiles. The case fatality rate of injuries secondary to self-harm was 91.7%. Self-harm accounted for 1842 deaths (67.6%). INTERPRETATION: We found that young urban men were most likely to be injured in firearm-related assaults and that more than two-thirds of self-harm–related injuries occurred in older rural-dwelling men, most of whom died from their injuries. This highlights a need for suicide-prevention strategies in rural areas targeted at men aged 45 or older.

Background Gender inequality varies across countries and is associated with poor outcomes including violence against women and depression. Little is known about the relationship of source county gender inequality and poor health outcomes in female immigrants. Methods We used administrative databases to conduct a cohort study of 299,228 female immigrants ages 6–29 years becoming permanent residence in Ontario, Canada between 2003 and 2017 and followed up to March 31, 2020 for severe presentations of suffering assault, and selected mental health disorders (mood or anxiety, self-harm) as measured by hospital visits or death. Poisson regression examined the influence of source-country Gender Inequality Index (GII) quartile (Q) accounting for individual and country level characteristics. Results Immigrants from countries with the highest gender inequality (GII Q4) accounted for 40% of the sample, of whom 83% were from South Asia (SA) or Sub-Saharan Africa (SSA). The overall rate of assault was 10.9/10,000 person years (PY) while the rate of the poor mental health outcome was 77.5/10,000 PY. Both GII Q2 (Incident Rate Ratio (IRR): 1.48, 95% Confidence Interval (CI): 1.08, 2.01) and GII Q4 (IRR: 1.58, 95%CI: 1.08, 2.31) were significantly associated with experiencing assault but not with poor mental health. For females from countries with the highest gender inequality, there were significant regional differences in rates of assault, with SSA migrants experiencing high rates compared with those from SA. Relative to economic immigrants, refugees were at increased risk of sustaining assaults (IRR: 2.96, 95%CI: 2.32, 3.76) and poor mental health (IRR: 1.73, 95%CI: 1.50, 2.01). Higher educational attainment (bachelor’s degree or higher) at immigration was protective (assaults IRR: 0.64, 95%CI: 0.51, 0.80; poor mental health IRR: 0.69, 95% CI: 0.60, 0.80). Conclusion Source country gender inequality is not consistently associated with post-migration violence against women or severe depression, anxiety and self-harm in Ontario, Canada. Community-based research and intervention to address the documented socio-demographic disparities in outcomes of female immigrants is needed.

Objective To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma. Methods In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009–2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis. Results Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21–1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02–1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23–1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04–1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86–0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder. Conclusion Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

Objective To test the association of material deprivation and the utilization of vision care services for young children. Study design We conducted a population-based, repeated measures cohort study using linked health and administrative datasets. All children born in Ontario in 2010 eligible for provincial health insurance were followed from birth until their 7th birthday. The main exposure was neighborhood-level material deprivation quintile, a proxy for socioeconomic status. The primary outcome was receipt of a comprehensive eye examination (not to include a vision screening) by age 7 years from an eye care professional, or family physician. Results Of 128,091 children included, females represented 48.7% of the cohort, with 74.4% living in major urban areas and 16.2% living in families receiving income assistance. Only 65% (n=82,833) had at least one comprehensive eye examination, with the lowest uptake (56.9%; n= 31,911) in the most deprived and the highest uptake (70.5%; n =19,860) in the least deprived quintiles. After adjusting for clinical and demographic variables, children living in the least materially deprived quintile had a higher odds of receiving a comprehensive eye examination (aOR 1.43; 95%CI 1.36, 1.51) compared with children in the most material deprived areas. Conclusions Uptake of comprehensive eye examinations is poor, especially for children living in the most materially deprived neighbourhoods. Strategies to improve uptake and reduce inequities are warranted.

Improved survival of children with life-threatening conditions has resulted in more children in need of caregiving support. For example, a child assisted by medical technology may need constant monitoring of a tracheostomy at home, often a role taken on by parents. Increased caregiving is also required for children with certain developmental or psychiatric conditions that have self-injurious or high-risk behaviours. Caregiving for a child with high needs can be a fulfilling experience, but can also pose substantial risks of burnout as well as poor mental and physical health. Caregivers face increased stress, financial burden and sometimes stigma and social isolation. Those stressors may increase the likelihood of depression and anxiety, as well as of premature maternal cardiovascular disease and mortality.1 Even if caregivers do not meet criteria for a mental illness but are struggling with high emotional distress, their parenting skills and ability to promote secure attachment may be affected. Children of parents with mental illness have elevated risk for poor growth, feeding difficulties, depression, behavioural challenges and poor learning.2 A child with a disability and high needs may be even more susceptible to these detrimental effects. Some adverse outcomes may be reversible with support for the caregiver. For example, therapy for depressed mothers has been reported to improve the child’s mental health, social and academic functioning and the mother–child interaction.3 4 Likewise, children exposed to adverse experiences—most commonly parental mental illness—have been shown to have improved language and behaviour, decreased injuries and more uptake of immunisation …

Protests by refugees and asylum seekers have become of increasing interest to scholars of forced migration, citizenship and political theory in recent years for the critical potential inherent in such acts of protest to reconfigure conceptions of ‘the political’, ‘the citizen’, and refugees as voiceless, a-political victims. This article turns to refugee and asylum seeker protest for a different reason. Rather than focusing on the act of protest, this article turns to the substantive content of such protests. Exploring the claims and demands of refugees and asylum seekers in two long-running protest movements, in Austria and Germany, the article argues that the protestors’ demands encompass more than the claim to asylum, and can fruitfully be understood as Universal Declaration of Human Rights Article 28 rights claims – claims to a social and international order for the realisation of human rights. The article argues that these claims are not easily addressed by existing approaches to responsibility for forced migration, and turns instead to Iris Marion Young’s conception of political responsibility for structural injustice as a potentially promising framework. Postprint

Background and objectiveDespite firearms contributing to significant morbidity and mortality globally, firearm injury epidemiology is seldom described outside of the USA. We examined firearm injuries among youth in Canada, including weapon type, and intent.DesignPopulation-based, pooled cross-sectional study using linked health administrative and demographic databases.SettingOntario, Canada.ParticipantsAll children and youth from birth to 24 years, residing in Ontario from 1 April 2003 to 31 March 2018.ExposureFirearm injury intent and weapon type using the International Classification of Disease-10 CM codes with Canadian enhancements. Secondary exposures were sociodemographics including age, sex, rurality and income.Main outcomesAny hospital or death record of a firearm injury with counts and rates of firearm injuries described overall and stratified by weapon type and injury intent. Multivariable Poisson regression stratified by injury intent was used to calculate rate ratios of firearm injuries by weapon type.ResultsOf 5486 children and youth with a firearm injury (annual rate: 8.8/100 000 population), 90.7% survived. Most injuries occurred in males (90.1%, 15.5/100 000 population). 62.3% (3416) of injuries were unintentional (5.5/100 000 population) of which 1.9% were deaths, whereas 26.5% (1452) were assault related (2.3/100 00 population) of which 18.7% were deaths. Self-injury accounted for 3.7% (204) of cases of which 72.0% were deaths. Across all intents, adjusted regression models showed males were at an increased risk of injury. Non-powdered firearms accounted for half (48.6%, 3.9/100 000 population) of all injuries. Compared with handguns, non-powdered firearms had a higher risk of causing unintentional injuries (adjusted rate ratio (aRR) 14.75, 95% CI 12.01 to 18.12) but not assault (aRR 0.84, 95% CI 0.70 to 1.00).ConclusionsFirearm injuries are a preventable public health problem among youth in Ontario, Canada. Unintentional injuries and those caused by non-powdered firearms were most common and assault and self-injury contributed to substantial firearm-related deaths and should be a focus of prevention efforts.

BackgroundUnintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.MethodsPopulation-based, cross-sectional study of children and youth (0–24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.ResultsThere were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).InterpretationThe observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

Background Immigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury. Methods Population-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0–5 years, intermediate: 6–10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries. Results 999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants. Conclusions Risk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4612-1) contains supplementary material, which is available to authorized users.

BACKGROUND Unintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth. METHODS We performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status. RESULTS Annualized injury rates were 11 749 emergency department visits per 100 000 population, 267 hospital admissions per 100 000 population and 12 deaths per 100 000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr). INTERPRETATION Rates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.