Pediatric emergency departments (PED) are very busy clinical units. About 50% of their clientele presents with conditions triaged 4 or 5 on the Canadian Triage and Acuity Scale. Hypotheses for this phenomenon are that parents feel more comfortable and confident that their child’s needs will be met in an establishment specialized for this age group; others point to the fact community services are scarce and sometimes unavailable for this clientele. In this edition of CJEM, Samman et al. [1] report their survey results on the reasons parents with low-acuity conditions presented to ED for treatment before and during the COVID pandemic.

The results are unsurprising: parents would prefer to have their child assessed in a community clinic environment; limiting the burden of spending long hours in an ED with missed work, childcare worries or expenses for other children. The fact that many waiting rooms do not provide furniture designed to make sick children and their parents comfortable is another advantage of a dedicated time slot for an appointment.

Looking at the demographic of the study population with over two thirds of respondents having lived 11 years or more in Quebec [1, Table 1], the great majority of parents have education above secondary school. Thus, we cannot attribute the choice of going to a PED by the lack of knowing the workings of the system due to new arrival in the area or insufficient education to understand how to access care. One of the exclusion criteria for this study was the lack of fluency in French or English; therefore, we do not know, with these results, how refugees or neo-Canadians were able to navigate our healthcare system before or during the pandemic. Canada’s immigrant population features many families with young children and a dedicated study of this specific population could be worthwhile. Based on the systematic review from Nicholson et al., immigrant parents are typically more likely to seek healthcare in the ED, this was observed in studies from Australia, Brazil and the USA [2]. Furthermore, lower literacy and ability to interact in the native language are also associated with higher ED use [2]. How well equipped is our system to answer the needs of our vulnerable young citizens or refugees when it is obviously unable to answer those of many parents that have been living here for over a decade?

Another feature of this study was the recruitment schedule between 9h00 and 21h00 when outpatients' clinics are expected to be available. Is this really the case? How many clinics, primary care physicians (PCP) or nurse practitioners (NP) offer emergency appointments within a short time frame after regular business hours (9–17) or on weekends? Almost a quarter of parents presume that their primary care physician will be unable to meet their urgent needs. Even before the pandemic, only half of parents even attempted to book an appointment with their PCP or a walk-in clinic such is the perceived unavailability of the person who is supposed to be their first contact for health care needs for low-acuity conditions. This is consistent with the published results from the USA, UK and Australia [2,3,4,5].

It could be interesting to explore what instructions PCP or NP provide to their clientele on what to do when they have an unplanned urgent need to seek medical attention? Do they inform them when they are available or are parents rather faced with automated messages to “go to the emergency”? How easy is it to book an appointment? With the multiplicity of booking systems to secure a clinic appointment seems a very challenging task unless parents can navigate the lotto-like systems requiring lots of time on the computer or mobile phone while their priority should be to care for their child?

Once parents presented to the ED, only 36.1% answered that they would accept a clinic appointment at that moment. This result highlights the need to offer user-friendly and timely alternatives to the ED, well before parents arrive at the emergency department.

The pandemic also increased the prevalence of mental health conditions in children. If resources were scarce and difficult to access for physical conditions, how are we, collectively going to address the rest of the iceberg of mental health issues facing our youngest generations of citizens? How are their parents’ current behaviors to often choose to go to the ED first, without exploring alternatives, are going to shape their future behavior?