Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into 2 groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 arrived by ambulance, while 64,556 self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group, and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0% ), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance was 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were respiratory (22.7%), orthopedic (14.7%), and general/minor (10.3%). Among self-presenting patients, the top three were general/minor (22.5%), respiratory (18.0%), and gastrointestinal (15.7%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that EMS staff responsible for transporting children be well trained in managing critically ill children. Given the low proportion of pediatric transports, consideration must be given to how best to train EMS services in managing these children.