Transport-related injuries are a leading cause of child and youth (0-19 years) hospitalizations and death in Canada, with ~17,200 injuries/fatalities in 2023 alone (Transport Canada, 2023a). These injuries are a significant burden on the healthcare system, with costs totaling $284 million among children aged 0-14 years in 2018 (Parachute, 2021). On a positive note, there has been decrease observed in transportation injuries in children and youth in Canada over the past two decades (Fridman, Fraser-Thomas, Pike, & Macpherson, 2018; Rothman, Macarthur, Wilton, Howard, & Macpherson, 2019; Schwartz, Rothman, Howard, To, & Macarthur, 2022) which may be attributed to advancements in child safety seats, graduated licensing for teenagers and youths, improved vehicle designs and the adoption of the safe system approach in many jurisdictions (World Health Organization, 2023). According to the Transport Canada, National Collision Database (NCDB), transport injuries in children and youth ages 0-19 decreased 26% in the last 10 years from 2014 (23, 027) to 2023 (1,701), with a 5% drop in fatalities (Transport Canada, 2023b).

With the onset of the COVID-19 pandemic in March 2020 there were, however, substantial shifts in people’s mobility patterns which would have changed their exposure to traffic injury. According to the NCDB, in 2020, there were notable increases in pedestrian and decreases in motor vehicle collision (MVC) injuries and fatalities, with a small peak in cyclist injuries in 2021 (Transport Canada, 2023b). Policy responses to the COVID-19 pandemic, such as physical distancing and lockdown periods, may have influenced these trends by changing how people interacted with their environments (Tan, Wang, Xu, Zhang, & Luo, 2023). In Ontario, children and youth transportation patterns were influenced by multiple policies including stay-at-home orders, closures to schools, early childhood education centres, daycares, recreation and outdoor play spaces, and changes to the roadway-built environment to facilitate active transportation (i.e. walking and cycling, AT) (de Lannoy, Rhodes, Moore, Faulkner, & Tremblay, 2020; Szpunar et al., 2021).

This study examined the incidence and temporal trends of transport-related ED visits and hospitalizations in Ontario by mode, age, sex, and level of marginalization. We found that the burden of transport ED visits for child and youth VRU was comparable to those motor-vehicle related. Notably, the majority of VRU ED visits and hospitalizations were cycling-related, and over 60% were non-traffic-related cycling ED visits and hospitalizations. Males, older and more marginalized children were generally more likely to experience transport-related ED visits and hospitalizations. The exception was cycling injuries where more marginalized children had lower rates ED visits and hospitalizations than the least marginalized children. Monthly ED visits for traffic-related motor vehicle and all pedestrians were lower than expected, and non-traffic motor vehicle and all cyclists were higher after the beginning of the pandemic, based on pre-pandemic trends; with no differences for transport hospitalizations overall or by age and sex. The least marginalized group of children appeared to be more sensitive to changes during the pandemic compared to the most marginalized, as indicated by greater differences in observed versus expected ED visits after the emergency declaration.

Previous studies show mixed findings regarding the preponderance of cycling injuries as compared with pedestrian injuries in health services data. Using the same data sources in Ontario from 2012 to 2021, but for all ages, our previous study found that cyclist health care visits were also substantially higher than pedestrians, with cyclist ED visits three times greater than pedestrian visits and almost six times greater for hospitalizations (Macpherson et al., 2024). Conversely, between 2015 and 2019 in British Columbia, all-ages pedestrian hospital admissions were three times higher than those of cyclists (Branion-Calles et al., 2025a) . This study included only on-road injuries as a result of interactions with motor vehicles, falls, and unknown causes. Another study using a national U.S. sample of 0–19-year-olds from 2006 to 2012, examining just motor vehicle-related injuries, also found that pedestrians represented the majority (73%) of pedestrian and cycling motor vehicle-related injuries (Wheeler-Martin, Mooney, Lee, Rundle, & DiMaggio, 2017). These contradictory results may be due to differing case definitions, with some studies looking at traffic and non-traffic, and others with and without the involvement of motor vehicles. This difference points to the importance of using the appropriate case definitions to address study objectives and to confirm case definitions when doing cross-study comparison. The results might also suggest that the type of VRU burden varies by location. Ontario, British Columbia, and a US national sample represent very different road environments in, for example, cycling infrastructure and motor vehicle traffic volumes and speeds. Different jurisdictions also may have different laws and policies related to, for example, helmets and distracted driving.

Although we found that the majority of VRU ED visits for child cyclists were non-traffic related, we did not find similar results for child pedestrians. As early as 1999, Stutts & Hunter noted that the majority of all-age cycling ED visits did not involve a motor vehicle (70%) when including all ages traffic and non-traffic injuries in the US (Stutts & Hunter, 1999). Brannion-Calles et al. (2025) found that close to 50% of all-age cycling hospital admissions were due to falls, 1.8 times more than motor vehicle injuries, and 20% with an unknown mechanism (Branion-Calles et al., 2025b). This study also found that 69% of pedestrian hospital admission injuries were due to falls, 2.3 times greater than those involving a motor vehicle. These findings reinforce the importance of considering case definitions, as our results may be different, as our analysis was limited to children and youth, versus other studies, which included all ages. Generally, however, all findings highlight the importance of including injuries sustained due to falls on roadways and off-road conditions, as well as a result of a on-road motor vehicle interaction.

Older children, males and more marginalized children were generally more likely to experience transport-related injuries related to ED visits and hospitalizations, with two exceptions: traffic-related motor vehicle ED visit injuries, where females experienced higher rates than males, and hospitalizations due to non-traffic-related pedestrian injuries, where no statistically significant difference was observed between age groups. Our results that indicated older children and youth and males have a higher risk of transport injuries, support findings of previous studies (Mannocci, Saulle, Villari, & La Torre, 2019; Peden et al., 2022; Swedler et al., 2024). Older children and youth may experience higher risk due to immaturity and low impulse control, their emerging independence to travel without supervision, and inexperience with traffic and potential substance abuse (Hammig & Davis, 2022; Spirito, Rasile, Vinnick, Jelalian, & Arrigan, 1997; Twisk, Bos, & Weijermars, 2017). However, we found that there were two exceptions to the general finding of higher risk for males; there were no differences in hospitalizations due to non-traffic-related pedestrian injuries between the sexes, and females experienced higher rates of traffic-related motor vehicle ED visits. Research consistently shows that women have a greater rate of severe injury and fatality in motor vehicle collisions (Abrams & Bass, 2024; Evans, 2000; Kahane, 2013). This may be due to anatomical and physiological differences, and the result of vehicle design issues (Abrams & Bass, 2024; Ryan et al., 2020). The development and use of female-specific crash test dummies is still evolving, and male crash dummies still tend to be the norm (Ryan et al., 2020).

The finding that more marginalized children had higher rates of transport-related injuries than less marginalized children has been well supported by previous research (Birken, Parkin, To, & Macarthur, 2006; Laflamme & Diderichsen, 2000; Rothman et al., 2017; Rothman et al., 2019; Naomi Schwartz et al., 2022). There is some evidence that differences in road traffic environments, with more marginalized areas having fewer road safety features and higher speed roadways, may contribute to this inequity (Rothman, Cloutier, et al., 2020). It appears that there is some discrepancy related to the risk of bicyclist injury in more marginalized children, with some studies indicating a higher risk as opposed to our study which found a lower risk (Carlin, Taylor, & Nolan, 1995; Embree, Romanow, Djerboua, Bourdeaux, & Hagel, 2016; Gagné & Hamel, 2009). This points to the importance of local context, as there are different road safety and cycling infrastructure in different cities, with potentially different access to bicycles.

The result of the trend analyses indicated that ED visits were more sensitive than hospitalizations to pandemic-related changes. We found that there were substantial decreases in motor vehicle-related and pedestrian ED visits after the state of emergency was declared, which returned to expected values by the end of the study period. However, the ED visits related to cycling increased during the pandemic. These results may be linked to changes in children’s exposure to traffic and mobility patterns because of school and daycare closures and stay-at-home orders, with more children cycling for recreation, and an increase in the number of novice cyclists. Previous research has found that cycling to school is rare, for example, in Toronto schools, with 61% of children walking and 2 % of children cycling (Rothman et al., 2021). Hospitalizations for transport injuries, however, remained consistent throughout the study period except for a slight decrease in the initial phases of the pandemic. Declines in visits to the ED likely reflected hesitancy to go to the hospital for more minor injuries during a pandemic, whereas more severe injuries necessitated a hospital visit (Boserup, McKenney, & Elkbuli, 2020; Kwok, Clapham, & Calder-Sprackman, 2021).

The marginalization analysis indicated that the least marginalized group was more sensitive to changes due to the pandemic related to ED visits for transportation injuries than the more marginalized groups. It is suggested that activities changed more for the less marginalized children, as they generally have more engagement in extra-curricular activities, which were cancelled during the pandemic, resulting perhaps in less motor vehicle travel (Richmond et al., 2022). Less marginalized children are also likely to have more opportunities for cycling due to affordability and living in more cycling-friendly environments than more marginalized children.

This study has several strengths and limitations. The strength is that it was a large population-based study using routinely collected health service and census data and, therefore, may be less subject to bias than single-study research. However, the inability to assess children’s exposure to the different modes of transportation and the changes in exposure due to the pandemic was a limitation. The relatively low number of child pedestrian injuries limited our ability to evaluate changes in pedestrian injuries by marginalization. Other Canadian studies have shown that children in poorer areas are more likely to suffer pedestrian injuries (Cloutier et al., 2017; Rothman, Fridman, Cloutier, Manaugh, & Howard, 2020; Rothman et al., 2019; Naomi Schwartz et al., 2022).

The results have several important implications for public health, transportation safety, health equity, and policymaking. Understanding the burden of injury and the injury trends by transportation mode, age, sex, and marginalization can provide essential insights to inform future injury preventive efforts, considering significant population-level events, such as pandemics, that might change children’s mobility patterns. First, interventions directed at VRU injury among children must be equity-informed, ensuring safe recreational and commuting options across sex and age and all marginalization levels.

Second, there is a need for injury prevention strategies and policies to focus on cycling safety, not solely on reducing interactions with cars, but also on preventing falls and on off-road infrastructure in parks and trails where many children ride, particularly as they get older and gain more independent mobility. Appropriate surveillance of these injuries must use health services data, as typically municipalities use police-reported data to monitor transport injuries, and police do not generally attend injuries not involving a motor vehicle or off-road. This also points to the need for cities to focus on developing safe cycling infrastructure for all ages, not only on-road but also off-road.

Third, the pandemic led to a decrease in pedestrian injuries, and an increase in cycling injuries, which indicates a need for awareness regarding the potential effects of future events that may lead to changes in child mobility, including a possible shift of regular commuting to school patterns (usually by walking) to more recreational mobility which may include more cycling and more novice riders. In addition, the observed drop in ED visits emphasized that the injury burden may be underrepresented during a pandemic, but the consistency in injury hospitalizations highlights the need for consistent trauma care capacity even during a public health emergency where there may be pressure to redirect resources elsewhere.

These findings provided a picture of variability in child and youth transport ED visits and hospitalizations, and the effects of a pandemic that influenced mobility patterns. The results highlight the need for road safety infrastructure that can adapt to changing patterns of children’s (and the population as a whole) mobility in the future. This work also highlights the importance of safe infrastructure addressing non-motor vehicle cycling injuries, as well as the continued surveillance of injuries and adequate healthcare during potential disruptive events in the future.

Linda Rothman: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft. Ian Pike: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing. Adrian Sammy: Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Visualization, Writing – review & editing. Saroar Zubair: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing. Alex Zheng: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – review & editing. Shazya Karmali: Funding acquisition, Investigation, Methodology, Project administration, Writing – review & editing. Brice Batomen: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – review & editing. Andrew Howard: Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – review & editing. Natasha Saunders: Funding acquisition, Investigation, Methodology, Resources, Writing – review & editing. Shelina Babul: Funding acquisition, Investigation, Methodology, Resources, Writing – review & editing. Omidreza Sadrmanesh: Investigation, Visualization, Writing – original draft. Fahra Rajabali: Funding acquisition, Investigation, Methodology, Writing – review & editing. Pamela Fuselli: Funding acquisition, Investigation, Methodology, Writing – review & editing. Alison K. Macpherson: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft.

This study was supported by ICES, which is funded in part by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). This study was based on data compiled by ICES. However, the analyses, opinions, and statements expressed herein are those of the authors and not necessarily those of ICES no endorsement is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors, and not necessarily those of CIHI. This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. We thank the Toronto Community Health Profiles Partnership for providing access to the Ontario Marginalization Index.

The authors have no conflicts to disclose.

The authors declare that no generative AI was used in this work.

An earlier version of this paper was presented at the CARSP/ICTCT conference, held in Québec city, Canada, on 20–23 May 2025.

This study has been approved by the University of British Columbia, Children’s & Women’s Health Centre REB (H22-00166) and the Toronto Metropolitan University REB (REB 2022-106).

This research was funded by an operating grant from the Canadian Institutes of Health Research (UIP-179228XX).

Handling editor: Nicolas Saunier, Polytechnique Montréal, Canada.

Reviewer: Désirée Hagmann, Zurich University of Applied Sciences (ZHAW), Switzerland.

Submitted: 28 August 2025; Accepted: 25 May 2026; Published: 5 June 2026.