Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children’s Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Background: Primary care physicians and child and adolescent psychiatrists often treat sleep disturbances in children and adolescents with mood disorders using medications off-label, in the absence of clear evidence for efficacy, tolerability and short or long-term safety. This study is the first to report Canadian data about prescribing preferences and perceived effectiveness reported by child and adolescent psychiatrists regarding medications used to manage sleep disturbances in children and adolescents with depression. Methods: Canadian child and adolescent psychiatrists were surveyed on their perception of effectiveness of a range of medications commonly prescribed for sleep disturbances, their ranked preferences for these medications, reasons for avoiding certain medications, and perceived side effects. Results: Sixty-seven active child and adolescent psychiatrists completed the survey. Respondents reported noting significant sleep issues in 40% of all their patients. Melatonin and trazodone were identified as the first treatment of choice by 83% and 10% of respondents respectively, and trazodone was identified as the second treatment of choice by 56% of respondents for treating sleep disturbances in children and adolescents with depression. Melatonin (97%), trazodone (81%), and quetiapine (73%) were rated by a majority of respondents as effective. Doxepin, zaleplon, tricyclic antidepressants, zolpidem, or lorazepam were rarely prescribed due to lack of evidence and/or concerns about adverse effects, long-term safety, suitability for youth, suicidality, and dependence/tolerance. Conclusions: Melatonin and certain off-label psychotropic drugs are perceived as being more effective and appropriate to address sleep disturbances in children and adolescents with depression. More empirical evidence on the efficacy, tolerability and indications for using these medications and newer group of sleep medications in this population is needed.

Background: Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. Methods:Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. Results:We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5).Interpretation: Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.