Canadian Paediatric Surveillance Program Research Articles

46 Micronutrient deficiencies in children and youth with autism spectrum disorder: Findings from a national surveillance study

Abstract Background Children and youth with autism spectrum disorder (ASD) may be at risk of micronutrient deficiencies secondary to feeding problems such as limited dietary repertoire and high-frequency single food intake. The epidemiology of micronutrient deficiencies in the paediatric ASD population has not been studied. Objectives To determine minimum incidence, clinical characteristics, and health care utilization for four micronutrient deficiencies in children and youth with ASD in Canada: (1) vitamin A deficiency/xerophthalmia, (2) scurvy, (3) severe, symptomatic vitamin D deficiency, and (4) severe iron-deficiency anemia. Design/Methods We conducted a study via the Canadian Paediatric Surveillance Program, an active, population-based surveillance platform, between January 2020 and December 2022. More than 2,500 paediatricians and paediatric subspecialists were asked, monthly, to report cases of children and youth <18 years of age with ASD and one or more of the micronutrient deficiencies under surveillance. Case information was obtained via a detailed clinical questionnaire. Descriptive statistics were used to summarize the data. For average yearly minimum incidence estimates, we used case counts over the 3 year surveillance period, 2021 census data and recent ASD prevalence estimates (2% of children/youth aged 1 to 17 years living in private dwellings in Canada). Results Twenty-seven children and youth met the case definition (most male; median age 7.7 years, range 1.8–14.9 years). Multiple deficiencies were diagnosed concurrently in 9/27 (33%). Minimum incidence, per 100,000 children and youth with ASD per year, was 5.1 for scurvy (17 diagnoses); 3.0 for severe iron deficiency anemia (10 diagnoses); 2.1 for severe, symptomatic vitamin D deficiency (7 diagnoses); and <1 for vitamin A deficiency/xerophthalmia (<5 diagnoses). Restricted diet/limited food repertoire, attributed to the patient, was universal (27/27). Number of different foods in the patient’s diet was <10 in nearly all (20/23, 87%). Most patients were non-verbal (19/27, 70%) and of normal weight (18/26, 69%). Two-thirds (18/27, 67%) were admitted to hospital (median duration 8 days, range 3–32 days). One-third (9/27, 33%) underwent an invasive procedure as part of their diagnostic workup. Conclusion This surveillance study represents the first population-level examination of the epidemiology of micronutrient deficiencies in children and youth with ASD. Results suggest that micronutrient deficiencies in ASD are rare but clinically important, leading not infrequently to hospital admission and invasive investigations. Clinical characteristics of cases should inform anticipatory guidance and prevention efforts tailored to the paediatric ASD population.

44 Spotting the clotting: a 3-year national surveillance study of paediatric pulmonary thromboembolism

Abstract Background Pulmonary thromboembolism (PE) is a rare event in the paediatric population but can be acutely life-threatening and result in chronic complications. Awareness of contemporary patterns of clinical presentation, diagnostic modalities, and management may aid clinicians in ensuring that patients are promptly identified and treated. Objectives To describe the risk factors, symptoms, diagnostic modalities, therapeutic interventions, and short-term outcomes in paediatric patients (neonate up to 18 years) with PE through national surveillance. Design/Methods Between January 2020 and December 2022, monthly surveillance was conducted with over 2,800 paediatricians and sub-specialists through the Canadian Paediatric Surveillance Program. Voluntary reporting of cases meeting a standardized definition of PE was followed up with a detailed questionnaire. Results 58 confirmed cases were reported; 33 (57%) were females age 15 to 18 years. Detailed information was available for 31 (53%) of 58 cases. At least 1 risk factor was identified in 28 (90%) cases and 12 (39%) patients had 2 or more risk factors. The most common risk factors were oral contraceptive use (n=10 of 31; 32%) and obesity (n=9 of 31; 29%). Presentation was symptomatic in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. The most common symptoms were chest pain (n=18; 58%), dyspnea (n=13; 42%) and tachycardia (n=13; 42%). The most common diagnostic modality utilized was computed tomography pulmonary angiography (n=25; 81%). Initiation of systemic anticoagulation was reported for 24 (77%) of 31 cases; thrombolysis and surgical interventions were uncommon (< 5 cases). Treatment complications were common (n=8; 29%). Mortality was reported, but in fewer than 5 cases. Conclusion PE in children often presents with non-specific symptoms, but usually occurs in patients with known risk factors. Clinicians should maintain a high index of suspicion in symptomatic patients, particularly those with risk factors and in cases when other diagnoses that may explain symptoms have been excluded. Anticoagulation is the mainstay of treatment; complications can occur. Prompt recognition and management presumably reduce morbidity and mortality, but this cannot be inferred from our data.

45 Home-based phototherapy for neonatal hyperbilirubinemia: A one-time Canadian Paediatric Surveillance Program Survey

Abstract Background Home-based phototherapy (HP) has gained popularity as a viable alternative to hospital-based treatment for neonatal hyperbilirubinemia, with longstanding use internationally and availability in specific regions of Canada. HP has been shown to be cost-effective and beneficial for parent-infant bonding, but its safety remains unclear, especially with current use in Canada. Objectives The primary objective of this study was to identify adverse events related to HP within Canada over the past 12 months. Secondary objectives included identifying risk factors associated with these adverse outcomes and gathering information on the current status of HP in Canada. Design/Methods A one-time survey, distributed through the Canadian Paediatric Surveillance Program, collected retrospective data from paediatricians. The survey included questions about adverse events associated with HP and associated risk factors and outcomes, as well as the provision of HP. A descriptive statistical analysis was conducted. Results The survey response rate was 31% (844/2741). Among the 497 respondents providing care for neonatal hyperbilirubinemia, 15 (3%) physicians reported a total of 28 cases of adverse events associated with HP in the preceding 12 months. Most adverse events resulted in admissions or readmissions to the hospital for in-hospital phototherapy with no serious adverse events or long-term consequences. Risk factors were identified in 67% of cases, with infant-related factors being the most prevalent. HP was offered at the centre of 12% of the responding physicians, with formal protocols for patient assessment and follow-up at most centres. Conclusion This survey revealed no serious adverse related to HP in the preceding 12 months. The survey also revealed that while HP is available in Canada, there is a lack of standardization in its administration across the country. This study provides valuable insights into the safety and practice of HP for neonatal hyperbilirubinemia in Canada, contributing to evidence-based decision-making and optimization of care protocols.

42 Clinical features and severity of COVID-19 with respiratory virus coinfections versus SARS-CoV-2 monoinfection in hospitalized children: A Canadian national surveillance study

Abstract Background The co-circulation of SARS-CoV-2 alongside other respiratory viruses has led to the risk of coinfections, potentially intensifying the severity of cases, especially in children. Objectives This study examined the epidemiology, clinical characteristics, and outcomes of SARS-CoV-2 respiratory virus coinfections in comparison to SARS-CoV-2 monoinfections in hospitalized children. Design/Methods A nationwide surveillance study was conducted to assess paediatric COVID-19-related hospitalizations across Canada from April 2020 to May 2022. Data were captured through two datasets covering ~90% of all Canadian tertiary-care paediatric beds: The Canadian Paediatric Surveillance Program and the Canadian Immunization Monitoring Program, ACTive. Coinfections were defined as the simultaneous detection of SARS-CoV-2 and ≥1 other respiratory virus. Severe infection was defined as intensive care, ventilatory, or hemodynamic support needs, organ systems complications, or death. Variables and outcomes were summarized and compared, and risk ratios were computed using Poisson regression, adjusting for age, gender, comorbid conditions, SARS-CoV-2 lineage, and vaccination status. Results Out of 1501 COVID-19-related hospitalizations, 163 (10.9%) had documented coinfections with 44/163 [27%] involving SARS-COV-2 plus ≥2 other respiratory viruses. The majority of SARS-CoV-2 monoinfections (1176/1501, 87.9%) and coinfections (139/163, 85.3%) belonged to the Omicron era (Figure A). RSV (66/163, 40.5%) and Enterovirus/rhinovirus (61/163, 37.4%) coinfections were the most common. Coinfection cases were significantly younger than monoinfection cases (median age 1.2 [IQR:0.3-3.3] vs 1.6 [IQR:0.3-7.0] years, p=0.04). Overall, severe disease was more common among cases with any coinfection (38.0%) than SARS-CoV-2 monoinfection (25.7%; adjusted risk ratio 1.45, 95% confidence interval 1.17-1.80) (Figure B). In particular, we observed that severe outcomes were significantly higher in SARS-CoV-2 coinfections compared to monoinfections during the Omicron era (Figure C-D). Overall, 26/61 (42.6%) Enterovirus/Rhinovirus and 20/66 (30.3%) RSV coinfections were associated with severe outcomes. Conclusion Children with documented coinfections had more severe respiratory disease compared to SARS-COV-2 monoinfections. However, children with severe COVID-19 may have been more likely tested for multiple viruses, leading to a risk of underestimation of coinfections among children with milder disease. Further work is needed to assess how different virus coinfections may affect children and which, if any, may be a predominant driver of disease severity. 1Severe disease was defined as intensive care, ventilatory, or hemodynamic support requirements, organ system complications, or death. 2Lineage was first assigned based on available genetic sequencing data. If missing, lineage was imputed based on the dominant circulating lineage at the provincial level according to the GISAID database.

Pediatric pulmonary thromboembolism: a 3-year Canadian Pediatric Surveillance Program study

BackgroundPediatric pulmonary embolism (PE) is a rare event associated with significant morbidity and mortality. Awareness of clinical presentation and practices unique to children may aid clinicians in prompt identification and treatment. ObjectivesTo describe the incidence, risk factors, clinical presentation, diagnostic and therapeutic practices, and short-term outcomes of pediatric PE. MethodsWe conducted a 3-year national surveillance study through the Canadian Pediatric Surveillance Program. Over 2800 pediatric specialists and subspecialists were contacted monthly from 2020 to 2022 and requested to report all new cases of PE in patients up to 18 years of age. Case-specific data were obtained through voluntary completion of a detailed questionnaire. ResultsFifty-eight cases (78% female, n = 45) were reported (2.4 cases per million children), with rates highest in adolescents 15 to 18 years (6.6 cases per million). Detailed information, available for 31 (53%) cases, documented at least 1 risk factor in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. Computed tomography pulmonary angiography was used for diagnostic confirmation in 25 (81%) cases. Anticoagulation was initiated in 24 (77%) of 31 cases; fewer than 5 patients underwent thrombolysis or surgical interventions. Of 28 patients who received therapeutic interventions, 8 (29%) experienced treatment-related complications. Fewer than 5 mortalities were reported. ConclusionPediatric PE is a rare event, with female adolescents at the highest risk. Although the presentation is often nonspecific, clinicians should maintain a high index of suspicion, particularly in patients with risk factors and when other diagnoses that may explain symptoms have been excluded.

Assessing Dietary Practices of Children with Avoidant Restrictive Food Intake Disorder (ARFID) - A Cross-Sectional Study

OBJECTIVE: The current study aimed to find children's dietary patterns with Avoidant Restrictive Food Intake Disorder (ARFID) and its characteristics in children. METHODOLOGY: This mixed-method cross-sectional study was conducted in April 2021 among children with Avoidant Restrictive Food Intake Disorder. Thirty participants of the age group (5-12 years) were selected from the Pediatrics and Children Ward of Ittefaq Hospital, Lahore, with a purposive sampling technique. Outpatient children aged between 5 and 12 years were included, whereas the children who had any congenital disabilities and were diagnosed with any other eating disorder were excluded. A focus group discussion was held for the formulation of the questionnaire. A diagnostic criteria questionnaire for ARFID was taken from the Canadian Pediatric Surveillance Program 2017, including anthropometric data and general characteristics/behavioral features. A self-structured food frequency questionnaire was used. Informed consent was taken from all participants. Qualitative interviews were reported as thematic analysis, and Quantitative data were analyzed using SPSS version 25 as statistical analysis for data visualization, simple statistics to generate summary charts, and customized graphs. RESULTS: Patients with ARFID were primarily female and relatively young, with a mean age of 8.35±0.46. Most of the participants were underweight (77%). The mean BMI (kg/m2) of the children was 13.7±0.26. Most patients with ARFID also reported a lack of interest in eating, loss of appetite, aversion due to sensory characteristics and avoidance of certain foods. CONCLUSION: ARFID is prevalent in all populations, but the lack of awareness among healthcare professionals and the general population makes the diagnosis difficult. KEYWORDS: ARFID, Eating Disorders, Food aversions, Food Frequency Questionnaire, Loss of appetite, Underweight

Identifying child maltreatment during virtual medical appointments through the COVID-19 pandemic: A physician-based survey.

Throughout the COVID-19 pandemic there has been a documented decline in reports to child protective services, despite an increased incidence of child maltreatment. This is concerning for increasing missed cases. This study aims to examine if and how Canadian paediatricians are identifying maltreatment in virtual medical appointments. A survey was sent through the Canadian Paediatric Surveillance Program (CPSP) to 2770 practicing general and subspecialty paediatricians. Data was collected November 2021 to January 2022. With a 34% (928/2770) response rate, 704 surveys were eligible for analysis. At least one case of child maltreatment was reported by 11% (78/700) of respondents following a virtual appointment. The number of cases reported was associated with years in medical practice (P = 0.026) but not with the volume (P = 0.735) or prior experience (P = 0.127) with virtual care, or perceived difficulty in identifying cases virtually (Cramer's V = 0.096). The most common factors triggering concern were the presence of social stressors, or a clear disclosure. The virtual physical exam was not contributory. Nearly one quarter (24%, 34/143) required a subsequent in-person appointment prior to reporting the case and 32% (207/648) reported concerns that a case had been identified late, or missed, following a virtual appointment. Some commented that clear harm resulted. Many barriers to detecting child maltreatment were identified by paediatricians who used virtual care. This survey reveals that virtual care may be an important factor in missed cases of child maltreatment and may present challenges to timely identification.

48 Congenital Syphilis in Canada: Findings of a Canadian Paediatric Surveillance Program Study

Abstract Background Since 2015, the incidence of congenital syphilis (CS) in Canada has increased significantly. Vertical transmission of syphilis can be prevented through timely treatment of infected pregnant persons; however, difficulty engaging in prenatal care can preclude diagnosis, and consequently treatment. Canadian data on sociobehavioural risk factors associated with poor engagement in prenatal care is limited, yet needed to inform prevention efforts. Objectives Our primary objective is to identify sociobehavioural risk factors of mothers with infants affected by syphilis, as well as describe the screening and treatment they receive. Our secondary objective is to describe the presentation and management of affected infants in Canada. Design/Methods Cases of confirmed and probable CS were elicited from paediatricians through the Canadian Paediatric Surveillance Program between June 2021 and October 2022. Survey responses were analyzed using descriptive statistics. Results In total, 143 cases were reported: 78% originated from the prairies (Alberta n=39, Saskatchewan n=50, Manitoba n=23) and 34% resided rurally. The median age was 27 years (range 17-39). Among the 143 women, 94 (66%) reported substance use, 42 (29%) child protection involvement with a previous child, and 25 (17%) housing insecurity; however, “unknown” responses were frequent for many variables. Of those reporting substance use, methamphetamines (n=46/94, 49%) and opioids (n=34/94, 36%), were the most common. Most women (n=73/143, 51%) had no known sexually transmitted co-infection, but among those who did, chlamydia was the most common (n=38/70, 54%). Only 22% (n=32/143) reported at least one prenatal visit per trimester. Of the 85/143 mothers known to have a positive syphilis screen, 22% (n=19/85) did not receive treatment. Of the 28 cases where specific barriers to accessing prenatal care were reported, 8 reported substance use, 6 reported housing insecurity, and 6 reported attitudinal barriers. Most affected infants had no physical exam findings of CS (n=83/143, 58%), but among those who did, rash and hepatomegaly were the most common findings (n=17/143, 12% and n=15/143, 11% respectively). Of the 136 with long bone x-rays completed, 70% (n=95) were normal. Most cases (138/143, 96%) were identified within the first month of life, and 89% (n=127/143) began antibiotic treatment within a week of life. Conclusion Substance use during pregnancy is common in mothers of children with CS; however, the presence of other sociobehavioural risk factors is often not known by reporting paediatricians. Most affected infants are asymptomatic but are diagnosed and treated early. Findings will inform public health strategies for preventing CS and combatting the current epidemic.

24 Characteristics and Outcomes of Hospitalized Children by SARS-Cov-2 Lineage: An IMPACT Surveillance Network Analysis

Abstract Introduction/Background Changes in relative virulence of SARS-CoV-2 lineages among children remain poorly understood, yet are important considerations for vaccination and health resource management. Further evidence is needed to assess the burden of severe paediatric COVID-19 due to the Omicron variant. Objectives In this study, we aimed to compare presenting features and disease severity among hospitalized children with COVID-19 in Canada by SARS-CoV-2 lineage. Design/Methods Data were collected during two national surveillance studies: the Canadian Paediatric Surveillance Program (April 2020–May 2021) and the Canadian Immunization Monitoring Program, ACTive (June 2021–May 2022). Cases were included if children were <17 years old and hospitalized for COVID-19 (excluding incidental SARS-CoV-2) at one of thirteen sentinel paediatric hospitals. SARS-CoV-2 lineages were classified as “Ancestral”, “pre-Delta” (Alpha, Beta, or Gamma), “Delta”, or “Omicron” based on genetic sequencing or the predominant lineage across Canada at the time of hospitalization. Severe disease was defined as intensive care, ventilatory or hemodynamic support requirements, organ system complications, or death. Results We identified 1357 children hospitalized with COVID-19, including 254 (18.7%) ancestral, 105 (7.7%) pre-Delta, 175 (12.9%) Delta, and 823 (60.6%) Omicron (Table). Median age at hospitalization was highest for Delta (3.0 years, interquartile range 0.2–11.1) and lowest for Omicron (1.3 years, interquartile range 0.3–5.4; p<0.001). The proportion of children with comorbid conditions did not differ significantly by lineage, ranging from 44.9% (ancestral) to 54.3% (Delta, p=0.149). COVID-19 vaccination (≥1 doses) was received by <5 pre-Delta cases (<4.8%), six Delta cases (3.4%), and 98 Omicron cases (11.9%). Among unvaccinated patients (n=1251), severe COVID-19 was most common among Delta lineages (34.3%) versus other lineages (24.0% ancestral, 22.3 pre-Delta, 24.8% Omicron; p=0.049). Conclusion Our results show more children were hospitalized during Omicron waves than all other waves combined, though Delta was relatively more severe. These findings underscore the substantial burden of Omicron in children. Potential competing interests Jesse Papenburg received consultant fees/honoraria from Astra-Zeneca, Merck, and Seegene, and is site PI for industry trials by Astra-Zeneca, MedImmune, Merck, and Sanofi (all outside current work). Rupeena Purewal is a consultant for Verity Pharmaceuticals. Manish Sadarangani has been an investigator on projects funded by GlaxoSmithKline, Merck, Moderna, Pfizer, Sanofi-Pasteur, Seqirus, Symvivo, and VBI Vaccines (all outside current work). Fatima Kakkar received salary support from the FRQS Chercheur Boursieurs Program, and honoraria from the Association des Pédiatres du Québec. Shaun Morris has received honoraria for lectures from GlaxoSmithKline and was a member of ad hoc advisory boards for Pfizer Canada and Sanofi Pasteur (all outside current work). No other competing interests are declared.

86 Incidence of Pulmonary Thromboembolism in Canadian Children: A 3-Year National Surveillance Study

Abstract Introduction/Background Pulmonary thromboembolism (PTE) is a rare but life-threatening event for which adequate epidemiological data in paediatrics are lacking. Best estimates regarding the epidemiology of PTE in Canadian children were published over two decades ago, using information obtained from a national registry of paediatric thromboembolic disease which only examined pulmonary embolism as a related complication. It is likely that the true rates of pulmonary thromboembolism in Canadian children are higher. Objectives To determine the minimum national incidence of PTE in children (neonate up to <18 years) by age, gender, and province / territory of residence using an existing national surveillance system. Design/Methods Through the Canadian Paediatric Surveillance program, over 2,800 paediatricians and subspecialists practicing in Canada were contacted monthly from January 2020 to December 2022. Using a standardized definition of PTE and pre-specified diagnostic criteria, clinicians were requested to report all new suspected or confirmed cases. Results During the 3-year study period, 58 cases of PTE were reported, documenting a minimum average annual national incidence of 2.4 per million Canadian children. Females accounted for 77.6% (n=45) cases. Patients ranged in age from 2 months to 17.9 years (median age 15.8 years; interquartile rate 13.3 to 16.7 years). Incidence rates (reported as average annual per million children) varied by age: 0-4 years, 0.7; 5-9 years, 0.2; 10-14 years, 2.0; 15-18 years, 6.6; and also by province: Newfoundland, 21.3; Saskatchewan, 4.6; British Columbia, 4.5; New Brunswick, 4.4; Alberta, 3.5; Nova Scotia, 1.8; Ontario, 1.6; Manitoba, 1.0; Quebec, 0.9. Conclusion Although the overall minimum average annual national incidence of PTE in Canada is 2.4 per million children, adolescents, particularly females, appear to be at highest risk of disease. It is not clear whether geographic distribution of cases disproportionate to provincial census may be related to regional differences in diagnostic practices, population-related risk factors (e.g., obesity, genetic thrombophilias, OCP prescribing), or reporting of cases.

A Canadian Paediatric Surveillance Program study to guide safe integration of virtual care for children.

A Canadian Paediatric Surveillance Program study to guide safe integration of virtual care for children.

Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage.

Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU). Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression. We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU. Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages. We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.

Interim Federal Health Program: Survey of use of supplemental benefits by paediatric health care providers.

The Interim Federal Health Program (IFHP) provides temporary healthcare coverage to refugees and refugee claimants. Previous research demonstrates that paediatric healthcare providers poorly utilize the IFHP, with low registration rates and limited understanding of the program. The objective of this study was to examine paediatric provider use of IFHP-covered supplemental benefits, and their experience with trying to access these benefits. A one-time survey was administered via the Canadian Paediatric Surveillance Program in February 2020. Of those who had provided care to IFHP-eligible patients, descriptive tables and statistics were created looking at provider demographics, and experience using the IFHP supplemental benefits. A multinomial logistic regression was built to look at provider characteristics associated with trying to access supplemental benefits. Of the 2,753 physicians surveyed, there were 1,006 respondents (general paediatricians and subspecialists). Of the respondents, 526 had recently provided care to IFHP-eligible patients. Just over 30% of those who had recently provided care did not access supplemental benefits as they did not know they were covered by the IFHP. Of those who had tried to access supplemental benefits, over 80% described their experience as difficult, or very difficult. Paediatric providers have a poor understanding of IFHP-covered supplemental benefits, which is cited as a reason for not trying to access supplemental benefits. Of those who do try to access these benefits, they describe the process as difficult. Efforts should be made to improve provider knowledge and streamline the process to improve access to healthcare for refugee children and youth.

Opportunities and challenges in capturing severe vaping-related injuries among Canadian children and youth

Although the long-term harms associated with vaping remain largely unknown, there have been numerous accounts of acute vaping-related injuries in the paediatric population. The study of vaping-related injuries is an important yet challenging undertaking, complicated by a lack of appropriate reporting mechanisms and the absence of consensus on definitions and diagnostic codes. We discuss the results of a 12-month national cross-sectional study from the Canadian Paediatric Surveillance Program conducted in 2021–2022 and situate these results within the broader context of other Canadian surveillance and reporting mechanisms. Fewer than five cases of vaping-associated injuries were reported, contrasting with previous surveys which had revealed much higher case numbers. Hypotheses for the low case numbers include decreased exposure to vaping in the context of COVID-19, changes in vaping products, increases in public awareness of vaping-related harms, as well as recent modifications in policies related to vaping product marketing and sales. There is a great need for a multi-pronged surveillance approach leveraging multiple data sources, including self-reported provider and consumer data, as well as administrative data to help inform clinicians and policymakers on how to prevent vaping-associated injuries among youth.

Severe obesity and global developmental delay in preschool children: Findings from a Canadian Paediatric Surveillance Program study.

The co-presentation of severe obesity (SO) and global developmental delay (GDD) in Canadian preschool children has not been examined. However, SO and GDD may require syndromic diagnoses and unique management considerations. To determine (1) minimum incidence; (2) age of onset and risk factors; and (3) health care utilization for co-presenting SO and GDD. Through the Canadian Paediatric Surveillance Program (CPSP), a monthly form was distributed to participants from February 2018 to January 2020 asking for reports of new cases of SO and GDD among children ≤5 years of age. We performed descriptive statistics for quantitative questions and qualitative content analysis for open-ended questions. Forty-seven cases (64% male; 51% white; mean age: 3.5 ± 1.2 years) were included. Age of first weight concern was 2.5 ± 1.3 years and age of GDD diagnosis was 2.7 ± 1.4 years. Minimum incidence of SO and GDD was 3.3 cases per 100,000 for ≤5 years of age per year. Identified problems included school and/or behavioural problems (n = 17; 36%), snoring (n = 14; 30%), and asthma/recurrent wheeze (n = 10; 21%). Mothers of 32% of cases (n = 15) had obesity and 21% of cases (n = 10) received neonatal intensive care. Microarray was ordered for 57% (n = 27) of children. A variety of clinicians and services were accessed. As reported by CPSP participants, challenges faced by families and health service access were barriers to care. Children with SO and GDD have multiple comorbidities, and require early identification and referral to appropriate services. These cases may also benefit from additional testing to rule out known genetic obesity syndromes.

50 Risk factors for severe COVID-19 in hospitalized children in Canada: A national prospective study from March 2020–May 2021

Abstract Background Children living with chronic comorbid conditions are at increased risk for severe COVID-19 disease, though there is limited evidence regarding the risks associated with specific conditions and which children may benefit from targeted COVID-19 therapies. Age-specific baseline indicators of COVID-19 severity are also needed to evaluate the effectiveness of SARS-CoV-2 vaccination strategies in the paediatric population. Objectives In this study, we aimed to 1) identify factors associated with severe COVID-19 in children, and 2) describe rates of hospitalization, intensive care unit (ICU) admission, and severe COVID-19 within specific pediatric age groups. Design/Methods We conducted a national prospective study on hospitalized children with microbiologically confirmed SARS-CoV-2 infection via the Canadian Paediatric Surveillance Program from March 2020–May 2021. Cases were reported voluntarily by a network of &amp;gt;2800 paediatricians and paediatric subspecialists. SARS-CoV-2 hospitalizations were classified as COVID-19-related, incidental infection, or infection control/social admissions. Severe disease was defined as intensive care, ventilatory or hemodynamic requirements, select organ system complications, or death. Outcomes were described among children aged &amp;lt;6 months, 6–23 months, 2–4 years, 5–11 years, and 12–17 years. Risk factors for severe disease were identified using multivariable Poisson regression, adjusting for child age and sex, coinfections, and timing of hospitalization. Results We identified 541 children hospitalized with SARS-CoV-2 infection, including 329 (60.8%) with COVID-19-related disease. Median age at admission was 2.8 years (IQR 0.3-13.5) and 42.9% (n=232) had at least one comorbidity. Among COVID-19-related hospitalizations, severe disease occurred in 29.5% of children (n=97/329), including a higher proportion of children aged 2–4 years (48.7%) and 12–17 years (41.3%) (Table 1). Comorbidities associated with severe disease are described in Figure 1, and included technology dependence (adjusted risk ratio [aRR] 1.96, 95% confidence interval [CI] 1.31-2.95), neurologic conditions (e.g. epilepsy and chromosomal/genetic conditions) (aRR 1.87, 95% CI 1.34-2.61), and pulmonary conditions (e.g. bronchopulmonary dysplasia and uncontrolled asthma) (aRR 1.66, 95% CI 1.13-2.42). Conclusion While severe outcomes were detected at all ages and among patients with and without comorbidities, neurologic and pulmonary conditions as well as technology dependence were associated with increased risk of severe COVID-19. Children aged 2–4 years more commonly experienced severe COVID-19 in this study, which was conducted at a time when no children were eligible for SARS-CoV-2 vaccines. Notably, this high-risk group remains without access to approved vaccines. These findings may help guide vaccination programs and prioritize targeted COVID-19 therapies for children.

31 Identifying Child Maltreatment in Virtual Medical Appointments - What Are We Missing?

Abstract Background Throughout the COVID-19 pandemic, concerns have emerged regarding missed cases of child maltreatment. Evidence suggests an increased incidence of child maltreatment despite a documented decline in reports to child protective services. In Ottawa, reports dropped by 30-40% at the start of the pandemic in 2020. Pediatricians play an important role in the detection of child maltreatment and many have shifted from in person to virtual care. However, there is a paucity of published literature on this topic. We hypothesize that the shift to virtual visits is a barrier to identifying cases of child maltreatment and may contribute to missed cases. Objectives Our survey assesses if and how Canadian pediatricians are identifying child maltreatment over virtual medical appointments, as well as the barriers and enabling factors to doing so. Design/Methods The Canadian Paediatric Surveillance Program (CPSP) is a joint effort with the Canadian Paediatric Society and Public Health Agency of Canada towards national pediatric surveillance through monthly surveys to 95% of Canadian pediatricians. Using their infrastructure, a one-time survey was sent to 2770 pediatricians between November 2021 and January 2022 with data analyzed for qualitative themes and descriptive statistics. Results There was a 34% response rate (n= 928) and 704 valid responses. Exclusions were for no provision of virtual care, incomplete surveys or no reported cases of child maltreatment in their career (n=93, 10%). The average number of years in independent practice was 17.5 years, and 69% had not provided virtual care prior to the pandemic. Based on a virtual visit, at least one case of child maltreatment was reported by 16% of physicians prior to the pandemic, and by 11% following March 2020. Nearly one-third (30%) of these cases required a subsequent in-person visit prior to making the report. Social stressors and clear disclosures from patients and caregivers were the main factors leading to reports. The virtual physical exam was not a factor that triggered concerns of maltreatment in any case. Respondents reported at a rate of 68% that it was slightly or much more difficult to detect child maltreatment over virtual visits. Concerns that a case had been missed or identified late in association with virtual care were reported by 29% of physicians (n=206) with some commenting that clear harm resulted. Conclusion This survey shows that virtual medical care presents barriers to identifying child maltreatment and may be an important factor in missed cases of child maltreatment.

58 Clinical manifestations and disease severity of SARS-CoV-2 infection among infants in Canada

Abstract Background There are limited data on outcomes of SARS-CoV-2 infection among infants (&amp;lt;1 year of age). In the absence of approved vaccines for infants, understanding characteristics associated with hospitalization and severe disease from COVID-19 in this age group will help inform clinical management and public health interventions. Objectives The objective of this study was to describe the clinical manifestations, disease severity, and characteristics associated with hospitalization among infants infected with the initial strains of SARS-CoV-2. Design/Methods This is a nationwide prospective observational study using the infrastructure of the Canadian Paediatric Surveillance Program. All cases of infants aged &amp;lt;1 year of age with microbiologically confirmed SARS-CoV-2 infection were reported from April 8th 2020 to May 31st 2021, and were classified by disease severity and primary cause of hospitalization. Multivariable logistic regression was performed to identify infants' characteristics associated with hospitalization. Results A total of 531 cases were reported, including 332 (62.5%) non-hospitalized and 199 (37.5%) hospitalized infants. Among hospitalized infants, 141 of 199 infants (70.9%) were admitted because of COVID-19-related illness, and 58 (29.1%) were admitted for reasons other than acute COVID-19. Amongst all cases with SARS-CoV-2 infection, the most common presenting symptoms included fever (66.5%), coryza (47.1%), cough (37.3%) and decreased oral intake (25.0%). In our main analysis, infants with a comorbid condition had higher odds of hospitalization compared to infants with no comorbid conditions, and infants &amp;lt;1 month had higher odds of hospitalization than infants aged 1-3 months (Table). In total, 20 infants (3.8%) met criteria for severe disease. Conclusion We describe one of the largest cohorts of infants with SARS-CoV-2 infection. Overall, severe COVID-19 in this age group is uncommon with most infants having mild disease. Comorbid conditions and younger age were associated with COVID-19-related hospitalization amongst infants.

Clinical manifestations and disease severity of SARS-CoV-2 infection among infants in Canada.

There are limited data on outcomes of SARS-CoV-2 infection among infants (<1 year of age). In the absence of approved vaccines for infants, understanding characteristics associated with hospitalization and severe disease from COVID-19 in this age group will help inform clinical management and public health interventions. The objective of this study was to describe the clinical manifestations, disease severity, and characteristics associated with hospitalization among infants infected with the initial strains of SARS-CoV-2. This is a national, prospective study of infants with SARS-CoV-2 from April 8th 2020 to May 31st 2021 using the infrastructure of the Canadian Paediatric Surveillance Program. Infants <1 year of age with microbiologically confirmed SARS-CoV-2 infection from both inpatients and outpatients seen in clinics and emergency departments were included. Cases were classified as either: 1) Non-hospitalized patient with SARS-CoV-2 infection; 2) COVID-19-related hospitalization; or 3) non-COVID-19-related hospitalization (e.g., incidentally detected SARS-CoV-2). Case severity was defined as asymptomatic, outpatient care, mild (inpatient care), moderate or severe disease. Multivariable logistic regression was performed to identify characteristics associated with hospitalization. A total of 531 cases were reported, including 332 (62.5%) non-hospitalized and 199 (37.5%) hospitalized infants. Among hospitalized infants, 141 of 199 infants (70.9%) were admitted because of COVID-19-related illness, and 58 (29.1%) were admitted for reasons other than acute COVID-19. Amongst all cases with SARS-CoV-2 infection, the most common presenting symptoms included fever (66.5%), coryza (47.1%), cough (37.3%) and decreased oral intake (25.0%). In our main analysis, infants with a comorbid condition had higher odds of hospitalization compared to infants with no comorbid conditions (aOR = 4.53, 2.06-9.97), and infants <1 month had higher odds of hospitalization then infants aged 1-3 months (aOR = 3.78, 1.97-7.26). In total, 20 infants (3.8%) met criteria for severe disease. We describe one of the largest cohorts of infants with SARS-CoV-2 infection. Overall, severe COVID-19 in this age group was found to be uncommon. Comorbid conditions and younger age were associated with COVID-19-related hospitalization amongst infants.

The impact of the COVID-19 pandemic on children with medical complexity

BackgroundDescriptions of the COVID-19 pandemic’s indirect consequences on children are emerging. We aimed to describe the impacts of the pandemic on children with medical complexity (CMC) and their families.MethodsA one-time survey of Canadian paediatricians using the Canadian Paediatric Surveillance Program (CPSP) was conducted in Spring 2021.ResultsA total of 784 paediatricians responded to the survey, with 70% (n = 540) providing care to CMC. Sixty-seven (12.4%) reported an adverse health outcome due to a COVID-19 pandemic-related disruption in healthcare delivery. Disruption of the supply of medication and equipment was reported by 11.9% of respondents (n = 64). Respondents reported an interruption in family caregiving (47.5%, n = 252) and homecare delivery (40.8%, n = 218). Almost 47% of respondents (n = 253) observed a benefit to CMC due to COVID-19 related changes in healthcare delivery, including increased availability of virtual care and reduction in respiratory illness. Some (14.4%) reported that CMC were excluded from in-person learning when their peers without medical complexity were not.ConclusionCanadian paediatricians reported that CMC experienced adverse health outcomes during the COVID-19 pandemic, including disruptions to family caregiving and community supports. They also describe benefits related to the pandemic including the expansion of virtual care. These results highlight the need for healthcare, community and education policymakers to collaborate with families to optimize their health.