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AimTo undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies.MethodsArticles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards).ResultsThis state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration).ConclusionsResearch conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.

BackgroundInjury prevention report cards that raise awareness about the preventability of childhood injuries have been published by the European Child Safety Alliance and the WHO. These report cards highlight the variance in injury prevention practices around the world. Policymakers and stakeholders have identified research evidence as an important enabler to the enactment of injury legislation. In Canada, there is currently no childhood injury report card that ranks provinces on injury rates or evidence-based prevention policies.MethodsThree key measures, with five metrics, were used to compare provinces on childhood injury prevention rates and strategies, including morbidity, mortality and policy indicators over time (2006–2012). Nine provinces were ranked on five metrics: (1) population-based hospitalisation rate/100 000; (2) per cent change in hospitalisation rate/100 000; (3) population-based mortality rate/100 000; (4) per cent change in mortality rate/100 000; (5) evidence-based policy assessment.ResultsOf the nine provinces analysed, British Columbia ranked highest in Canada and Saskatchewan lowest. British Columbia had a morbidity and mortality rate that was close to the Canadian average and decreased over the study period. British Columbia also had a number of injury prevention policies and legislation in place that followed best practice guidelines. Saskatchewan had a higher rate of injury hospitalisation and death; however, Saskatchewan’s rate decreased over time. Saskatchewan had a number of prevention policies in place but had not enacted bicycle helmet legislation.ConclusionsFuture preventative efforts should focus on harmonising policies across all provinces in Canada that reflect evidence-based best practices.

To assess whether children and youth with concussion receive follow-up visits in accordance with the recommended guidelines.We conducted a retrospective, population-based study using linked health administrative data from all concussion-related visits to emergency department and physician offices by children aged 5 through 18 years (range, 5.00-18.99) in Ontario between 2003 and 2013. We analyzed the percentage of children and youth seen for follow-up. The Mann-Kendall test for trends was used to assess a monotonic increasing trend over time in concussion follow-up visits.A total of 126 654 children and youth were evaluated for an index concussion visit. The number of children and youth assessed for concussion follow-up (N = 45 155) has increased significantly over time (P .001). In 2003, 781 of 7126 patients (11.0%; 95% CI, 10.3-11.7) with an index visit for concussion had a follow-up assessment. By 2013, 6526 of 21 681 (30.1%; 95% CI, 29.5-30.7) patients received follow-up care.The proportion of children and youth receiving follow-up after an acute concussion has significantly increased between 2003 and 2013. Nevertheless, more than two-thirds of all patients do not seek medical follow-up or clearance as recommended by current concussion guidelines, suggesting that ongoing efforts to improve and monitor compliance with recommended guidelines by patients and physicians are important.

Despite improvements in occupant safety, traffic fatalities are the leading cause of death for 5–14 year olds in high income countries; representing 19% of all fatalities. Child pedestrian motor vehicle collisions (PMVC) are a particular issue, as although the majority of child fatalities occur in vehicles, pedestrian fatality rates are increasing in some locations. Children are especially vulnerable due to their small stature and developmental abilities to negotiate road traffic and high vehicular speed. These major risk factors are not equally distributed across society; children in lower income and racialized communities are at increased risk of injuries and death as pedestrians. Vehicle speed is the key variable in terms of determining injury severity-slowing down traffic is the most important variable that can be changed to reduce injuries and fatalities. Because of growing parent perceptions of traffic danger, active transportation in children has decreased over time, which has effects on children’s physical activity and health, as well as traffic congestion near schools. This chapter summarize these issues and restates the importance of modifying the roadway built environment, creating appropriate regulatory changes and enforcing compliance to establish safer roadways and encourage active transportation for our children.

Child pedestrians make up a significant proportion of all road traffic deaths. Our primary objective was to examine the association of driver characteristics with child pedestrian injuries with a secondary objective to broadly describe the road characteristics surrounding these collisions.We included drivers involved in child (18 years old) pedestrian motor-vehicle collisions (PMVCs) in Calgary and Edmonton, Alberta (2010-2015). These drivers were compared with not at fault (Alberta adaptation of a Canadian culpability scoring tool) drivers involved in vehicle-only collisions. The data were analyzed with unconditional logistic regression.Seven hundred ninety-three drivers collided with 826 children. One quarter of child PMVC drivers were 40-54 years old (25.2%). Younger drivers, 16-24 (adjusted odds ratio [aOR] = 1.62, 95% CI: 1.27-2.09), and older drivers, ≥55 (aOR = 1.57, 95% CI: 1.24-1.99) were more likely to be involved in a child PMVC. Time of day between 06:01 - 09:00 (aOR = 1.46, 95% CI: 1.16-1.85) and 18:01 - 24:00 (aOR = 1.68, 95% CI: 1.30-2.17), no seatbelt use (aOR = 2.30, 95% CI: 1.09-4.85), having a child passenger in the vehicle (aOR = 2.15, 95% CI: 1.56-2.96), and impairment including 'had been drinking' (aOR = 7.70, 95% CI: 2.85-20.86) and 'fatigued/asleep/medical defect' (aOR = 27.15, 95% CI: 8.30-88.88) were also associated with being a driver involved in a child PMVC.Age, time, impairment and distraction were risk factors for being a driver involved in a child PMVC. Because child PMVC driver characteristics differ from the general driver population, driver-based interventions are a rational additional means of preventing child PMVCs.

Background Toronto introduced a Vision Zero Road Safety Plan (RSP) in 2017 with a goal of eliminating road traffic fatalities and serious injuries by 2021. A series of policies were published alongside the RSP with a focus on pedestrians, school children, and cyclists. While these documents provide insight into plans for future interventions targeted at vulnerable road users, little is known about the types of interventions that are most frequently recommended by policymakers and whether they are effective at reducing injuries. Objective The purpose of this study was to identify and categorize the types of interventions outlined in city plans and/or policies directly related to traffic safety in Toronto, Canada. Methods We performed an environmental scan of policies/plans that outline interventions such as regulatory changes and awareness campaigns with a focus on road traffic safety. Results Our search yielded 26 policies with a purpose/objective statement on topics including the built environment, urban design, and active school transportation. Almost half (46%) were identified as being directly related to road traffic safety and were further summarized by intervention type, target population, cost, and whether the intervention was outlined in Toronto’s Vision Zero RSP. A total of 107 interventions were identified in policy documents in Toronto. Forty three percent of interventions recommended modifications to the built environment (e.g. traffic calming measures). Interventions requiring a reduced speed limit from 50 km/h to 40 or 30 km/h were mentioned in 58% of policy documents in Toronto. Conclusions Most interventions outlined in road safety policy documents in Toronto align with Vision Zero. Having identified the policies/plans that are recommended most often for implementation, these results will be used to prioritize naturalistic (quasi-experimental) research studies that demonstrate the effectiveness of specific interventions (e.g. speed limit reductions). Future studies will examine inter-municipal policy comparisons between Canadian provinces.

Background Road traffic injury is the leading cause of death for children in Canada. Lower speed roads are correlated with lower pedestrian injury severity. Pedestrians are 8 times more likely to die after being struck by a motor vehicle going 50 km/h compared with 30 km/h. Few studies have examined the effect of speed limit reductions on vulnerable road users such as bicyclists or pedestrians. Given the recent increase in the number of pedestrian motor vehicle collisions (PMVC) in Toronto, it is important to describe the effectiveness of interventions such as speed limit reductions. Objective To examine the effect of lowering residential speed limits to 30 km/h on police reported child PMVCs in Toronto, Canada between 2014 and 2018. Methods We will investigate the influence of implementing 30 km/h speed limits on 387 km of residential streets that occurred in January 2015. We will calculate the number of police reported child PMVC per km per month along these streets for two years before and two years after the speed limit change. We will use comparator streets with a constant 40 or 50 km/h limit to isolate the effect of the intervention from that of secular trends, controlling for other built environment characteristics (e.g., speed humps, pedestrian crossovers). Expected findings We hypothesize that the rate of PMVC will decrease after the implementation of 30 km/h speed limits. pedestrian safety, including speed limit reductions. It is important to evaluate and quantify the effect of these changes on child pedestrian injury rates. Policy implications Results may provide evidence to support the implementation of speed reductions to make our roads safer.

Background There has been an increase in cycling over recent years in Toronto, Canada and the risk of injuries associated with various cycling infrastructures have yet to be fully understood. More specifically, cycle tracks (painted bike lanes with a physical separation from traffic) have become more prevalent in Toronto’s cycling network and may offer additional protection for cyclists. However, there has been little research examining the effects of these new cycle tracks in Toronto. Objective To examine the impact of the implementation of cycle tracks on the rate of cycle-motor vehicle collisions (CMVC) on tracks in Toronto, Canada. Methods Using a naturalistic experimental design, CMVC rates per month were calculated for 2 years pre and post-installation of six cycle tracks. Collisions reported to the Toronto Police Service between 2000 and 2016 were mapped using ArcGIS. A repeated measures Poisson model was used to evaluate the effect of cycle track implementation on rates of CMVC adjusted for season and cycle tracks upgraded from painted bike lanes. Results A total of 20,632 CMVC were reported in Toronto between 2000 and 2016, of which 190 collisions occurred on the six cycle tracks (3 upgraded from lanes) included in the analysis. The crude CMVC incidence rate before and after cycle track implementation was 0.42 collisions/month and 0.90 collisions/month respectively. The rate of CMVC significantly increased more than 2-fold following the implementation of cycle tracks (IRR=2.18, 95% CI: 1.42 to 3.33, p=0.003).The implementation of cycle tracks may result in an increased number of cyclists which may lead to greater risks for collisions. Conclusions Further investigation is required to examine the change in cycling volume on these tracks. In addition, the area-wide effects of cycle tracks should be explored to determine whether CMVC rates change on surrounding roadways without any cycling infrastructure.

Background The number of child pedestrians killed or seriously injured on Canada’s roadways increases annually. One third of individuals who die on the roads are children. Research has focused on trying to change the behaviour of children who cross the road; this approach is not effective and can lead to victim blaming. Identifying characteristics of drivers who collide with pedestrians (pedestrian motor vehicle crashes-PMVC) and built environment (BE) risk factors can potentially influence policies that affect drivers and infrastructure; creating safer walking spaces for children. Objective To examine the characteristics of 1) drivers involved in a child PMVC in Calgary or Edmonton, Alberta; 2) the BE in which child PMVC occur. Methods Using police reported traffic collisions, we will examine characteristics of motorists involved in child PMVCs. These motorist’s characteristics will be compared with motorists who were involved in a collision with at least one other vehicle, but were assessed to be not at fault. This ‘not at fault’ control group will represent the source population of all motorists allowing us to highlight differences in driver and built environment characteristics between them and the drivers involved in PMVC. Expected findings We hypothesize that the characteristics of drivers who hit a child pedestrian (i.e. behaviour, driver action) and the BE will significantly differ from the control population of non-culpable drivers. Conclusion Expecting children to behave ‘appropriately’ on the road is unrealistic and trying to modify their behaviour with pedestrian training programs is ineffective. A more promising strategy to prevent PMVC relates to policies affecting drivers (e.g., distracted driving laws, speed limit reductions) and BE modification (e.g., traffic calming strategies). Policy implications This innovative study will provide information that can be used to create conditions for safer walking for children and youth potentially leading to better long- term population health.

Objectives To perform an interprovincial comparison of unintentional population-based injury hospitalization and death rates for Canadian children ages 0–19 years and compare trends between 2006 and 2012. Methods Annual population-based hospitalization rates per 100,000 from unintentional injuries were calculated for children/youth (< 19 years) using data from the Discharge Abstract Database between 2006 and 2012. Annual mortality rates were analyzed using provincial coronial data. The mean annual change in the rate of hospitalizations due to unintentional injuries was reported for each province. Results The average annual rate of hospital admissions for unintentional injuries was 305.10 per 100,000 population between 2006 and 2012, and this decreased by − 11.91 over time (p < 0.01, − 15.85; − 7.77). Saskatchewan had the highest average annual morbidity rate (550.76 per 100,000) from all unintentional causes, and Ontario had the lowest average annual rate (238.89 per 100,000). Saskatchewan had the highest average annual rate for all subcauses except for drowning. Ontario was the only province with an average annual injury morbidity rate that was consistently below the Canadian average. The average annual mortality rate from all unintentional injury was highest in Saskatchewan (17.51 per 100,000) and lowest in Ontario (5.99 per 100,000) when compared to Canada (7.97 per 100,000). Conclusion Injury prevention policies vary considerably among provinces. Although the unintentional injury hospitalization rate is decreasing over time, some subcauses such as choking/suffocation have shown an increase in certain provinces. Evidencebased childhood injury prevention policies, such as playground equipment safety and four-sided pool fencing among others, should be standardized across Canada.

There is a paucity of information regarding descriptive epidemiology of paediatric concussions over time, and few studies include both emergency department (ED) and physician office visits.To describe trends in visits for paediatric concussions in both EDs and physician offices according to age and sex. A secondary objective was to describe the cause of concussion for children treated in EDs.A retrospective, population-based study using linked health administrative data from all concussion-related visits to the ED or a physician office by school-age children and youth (three to 18 years of age) in Ontario between April 1, 2003 and March 3, 2011 was conducted.The number of children evaluated in both EDs and a physician offices increased between 2003 and 2010, and this linear trend was statistically significant (P=0.002 for ED visits and P=0.001 for office visits). The rate per 100,000 increased from 466.7 to 754.3 for boys and from 208.6 to 440.7 for girls during the study period. Falls accounted for approximately one-third of the paediatric concussions. Hockey/skating was the most common specific cause of paediatric sports-related concussions.The increasing use of health care services for concussions is likely related to changes in incidence over time and increased awareness of concussion as a health issue. Evidence-based prevention initiatives to help reduce the incidence of concussion are warranted, particularly in sports and recreation programs.On possède peu d’information sur l’épidémiologie descriptive des commotions cérébrales en pédiatrie au fil du temps, et rares sont celles qui portent à la fois sur les visites à l’urgence et au cabinet du médecin.Décrire les tendances des visites à l’urgence et au cabinet du médecin par une population d’âge pédiatrique en raison de commotions cérébrales, en fonction de l’âge et du sexe. Un objectif secondaire consistait à décrire la cause des commotions cérébrales chez les enfants traités à l’urgence.Des chercheurs ont mené une étude rétrospective en population reliant les données administratives en matière de santé de toutes les visites d’enfants d’âge scolaire et d’adolescents (de trois à 18 ans) à l’urgence ou au cabinet du médecin en raison d’une commotion cérébrale en Ontario, entre le 1Le nombre d’enfants évalués à l’urgence ou au cabinet du médecin a augmenté entre 2003 et 2010, et cette tendance linéaire était statistiquement significative (P=0,002 pour les visites à l’urgence et P=0,001 pour celles en cabinet). Pendant la période de l’étude, le taux sur 100 000 enfants est passé de 466,7 à 754,3 chez les garçons et de 208,6 à 440,7 chez les filles. Les chutes représentaient environ le tiers des commotions cérébrales en pédiatrie, tandis que le hockey ou le patin était la principale cause de commotions cérébrales liées au sport.L’utilisation croissante des services de santé en raison d’une commotion cérébrale est probablement liée à l’évolution de leur incidence et à une plus grande sensibilisation à leurs conséquences sur la santé. Il faudra entreprendre des initiatives de prévention fondées sur des données probantes pour contribuer à réduire l’incidence des commotions cérébrales, notamment dans le cadre des programmes sportifs et de loisirs.

Background Over the past ten years, ED and physician office visits for paediatric concussion have more than quadrupled. Current concussion management guidelines recommend follow-upand clearance by a physician prior to resumption of contact activities. However, compliance with recommended follow-up is not well documented in the literature. Objective To examine trends in follow-up visits in accordance with current recommended guidelines for children with concussion. Design Retrospective population-based study. Setting Children and youth presenting to emergency departments (EDs) and doctors’ offices with concussion over a 10-year time period (2003–2013) in Ontario, Canada. Outcome measures We examined the percentage of children and youth who were seen for follow-up visit post-concussion. Trends in the percent of children with a follow-up visit following an index visit to either a doctor’s office or an ED were reported. Main results The proportion of children and youth assessed for concussion follow-up (N=45,150) has increased significantly (p Conclusions Despite increasing trends in the proportion of children being examined for concussion follow-up over a 10-year period, nearly half of all children with an index visit for concussion still do not receive follow-up assessment. This suggests that ongoing efforts to improve compliance with recommended guidelines will be important. Competing interests None.

Background Although injuries related to sports and recreation represent a significant burden to children and youth, few studies have examined the descriptive epidemiology of sports-related injury since 2005, and some sports such as ringette have not been evaluated to date. The primary purpose of this study was to provide the descriptive epidemiology of sports-related injuries treated in emergency departments for children and youth aged 5 – 19. Methods A retrospective data analysis was performed using data from the Canadian Hospitals Injury Reporting and Prevention Program [CHIRPP] from fiscal years (April – March) 2007/08 to 2009/10. CHIRPP is a computerized information system designed by the Public Health Agency of Canada that collects information about injuries to people evaluated in emergency departments across 11 pediatric hospitals and 5 general hospitals in Canada. Thirteen sports or activities were analyzed (baseball, basketball, cycling, football, ice hockey, lacrosse, ringette, rugby, skiing, sledding, snowboarding, soccer, and volleyball). Descriptive statistics, including frequency by sport, age and sex, as well as the percent of concussions within each sport were calculated. Results Out of a total of 56, 691 reported sports and recreational injuries, soccer accounted for the largest proportion of injuries with 11,941 reported cases over the 3 year time period. Of these, approximately 30% were fractures. The 10 – 14 year age group reported the greatest proportion of injuries in 10 out of the 13 sports analyzed. In addition, males reported a greater number of overall injuries than females in 11 out of the 13 sports analyzed. The largest percentage of concussions was reported in ringette; these injuries accounted for 17.1% of overall injuries within this sport. Conclusions Injury prevention programs in Canada should focus on improving evidence-based programs to reduce the burden of injuries in all sports.

Background Injuries are a serious but preventable health concern in Canada and a growing field of research, attracting a large number of graduate students and other trainees across Canada to identify injury prevention as their field of study. In 2009, the Canadian Institute for Health Research funded a team in Child and Youth (C&Y) Injury Prevention. With this support, the team was able to develop a model of practice involving researchers, stakeholders, knowledge users, and trainees as part of a multidisciplinary approach to reducing the burden of injury in youth. The C&Y team was successful at supporting and highlighting the work of over 40 team trainees. The efforts of this trainee team have resulted in the formation of the Canadian Injury Prevention Trainee Network (CIPTN). Objective The CIPTN aims to build a network of trainees interested in the science and practice of injury prevention (IP) from a multi-disciplinary perspective. Specifically, the goals include increasing opportunities for collaboration, professional development, mentorship and networking. Results The CIPTN has worked to develop a list of learning and research oriented catalyst activities for trainee members. The CIPTN has successfully collaborated with IP experts and organisations from across Canada in the development of a comprehensive IP resource, as well as updating the Canadian Injury Prevention Curriculum, a course for IP practitioners across Canada. Further, an executive board and governance structure has facilitated the identification of future collaborative activities (e.g., bi-monthly seminars, grant writing, and evaluating an injury methods workshop). Conclusions The CIPTN increases opportunities for junior researchers and trainees to work within a network of colleagues to share research, build collaborative projects, expand capacity, and provide training opportunities. This in turn, will develop the quantity and quality of IP science and practice across Canada for future generations.

Background Intentional and unintentional injuries are a significant and preventable health concern in Canada with 4.27 million Canadians ages 12 or older suffering an activity limiting injury. Knowledge translation and education among researchers, practitioners and policy makers as well as the continual development of trainees in the area of injury prevention, is paramount for the future health of Canadians. Methods The Canadian Injury Prevention Curriculum (CIPC) was designed to provide practitioners the understanding of the theory and practice of injury prevention along with the tools needed to develop and implement effective injury prevention programs. The CIPC is targeted toward adult learners (researchers, practitioners and/or policy makers) who develop, implement and/or evaluate programs aimed at reducing the frequency and severity of both intentional and unintentional injury. The last update of this curriculum was in 2010. This project aimed to update the CIPC, using an integrated knowledge translation approach to reflect an evidence-informed approach to injury prevention. Results The revision occurred over a series of phases: PHASE 1 – Update to the current curriculum to reflect an evidence-informed approach to injury prevention (what is injury prevention and defining the problem, risk and protective factors and key determinants of injury, designing/selecting an intervention, implementation and evaluation) in consultation with an adult learning expert; PHASE 2 – Modules were developed for practitioners to further knowledge and application of core knowledge; PHASE 3 – The updated curriculum was made available across Canada to researchers, practitioners and policy makers interested in preventing injury in Canada. Conclusions The CIPC was updated using an integrated knowledge translation approach. The result was an education tool using an evidence-informed approach to the prevention of injury, applicable for researchers, practitioners, policy makers, and junior trainees.