Adequately Addressing SDOH Could Alter Risk of Pediatric Long COVID

Despite pressures from other economic challenges, being food secure served as a buffer against greater odds of developing long COVID, but overall social risk factors for the disorder are largely unknown, making them a top concern in the effort to decrease the rate of long COVID in children and adolescents, according to a study published online today in JAMA Pediatrics.1

Loss of smell or taste, muscle or joint pain, fatigue, postexertional malaise, cognitive issues, and mood changes are common symptoms of long COVID, a postacute chronic condition lasting at least 3 months.2,3 As potential nonmedical contributors, social determinants of health (SDOH) have been linked to an increased risk of worsened health outcomes in children, one of which is chronic disease, the authors noted.

“Adverse SDOH act as chronic stressors that activate the hypothalamic-pituitary-adrenal axis, triggering glucocorticoid production that modulates cardiovascular responses, metabolic activity, cognitive or emotional responses, and immune function,” they wrote. “Long COVID is especially concerning in pediatric populations because of the potential for long-term physical and mental health effects that could persist into adulthood.”

To gain a greater understanding of the cross-sectional association between SDOH and risk of long COVID, they used data from the Researching COVID to Enhance Recovery (RECOVER) initiative on children aged 6 to 11 years (n = 903) and 12 to 17 years (n = 3681) with a history of SARS-CoV-2 infection between 2022 and 2024. Fifty-one percent of the included patients were assigned male at birth; White non-Hispanic (54%) and Hispanic, Latino, or Spanish (25%) were the top races/ethnicities represented; and most patients were recruited from an existing non–COVID-19 research or clinical cohort (59%) and had been infected before widespread appearance of the Omicron variant (53%). Represented by their caregivers via baseline long COVID symptom surveys, 91% of whom were their mothers, top vaccination statuses among the participants were fully vaccinated (39%) or not eligible for vaccination (37%).

Among the 5 SDOH considered—economic stability, social and community context, caregiver education access and quality, neighborhood and built environment, and health care access and quality—most participants were placed into latent class 1 for each (65%, 59%, 60%, 88%, and 68%, respectively), meaning they did not experience an adverse result from that SDOH. The researchers used latent classes in their regression models to delineate level of correlation with long COVID. Drilling down, the fewest participants with long COVID also were placed into latent class 1 (12.8%, 13.0%, 14.2%, 15.9%, and 14.1%).

As potential nonmedical contributors, SDOH have been linked to an increased risk of worsened health outcomes in children, one of which is chronic disease. | Image Credit: © Elnur-stock.adobe.com

The most participants with long COVID were in latent classes 2 through 4, and therefore associated with a higher unadjusted chance of an adverse health outcome:

• Economic stability: 36% (class 4) (OR, 2.96; 95% CI, 2.23-3.92)
• Social and community context: 39.6% (class 3) (OR, 3.13; 95% CI, 2.60-3.77)
• Caregiver education access and quality: 21.0% (class 2) (OR, 1.44; 95% CI, 1.19-1.74)
• Neighborhood and built environment: 24.2% (class 2) (OR, 1.23; 95% CI, 0.96-1.57)
• Health care access and quality: 30.7% (class 3) (OR, 2.09; 95% CI, 1.55-2.82)

With the exception of neighborhood and built environment, adjusted risks were also greater for each of the domains among participants in the highest classes when adjusted for (1) other SDOH domains, sex, age group, timing of infection, and referral source or (2) other SDOH domains, sex, age group, timing of infection, referral source, and race and ethnicity:

• Neighborhood and built environment: class 2, OR, 0.90 (95% CI, 0.73-1.12); OR, 0.94 (95% CI, 0.75-1.16)
• Economic stability: class 4, OR, 2.39 (95% CI, 1.73-3.30); OR, 2.52 (95% CI, 1.82-3.49)
• Social and community context: class 3, OR, 2.17 (95% CI, 1.77-2.66); OR, 2.18 (95% CI, 1.79-2.67)
• Caregiver education access and quality: class 2, OR, 1.12 (95% CI, 0.96-1.3); OR, 1.18 (95% CI, 1.01-1.38)
• Health care access and quality: class 3, OR, 1.14 (95% CI, 0.82-1.59); OR, 1.20 (95% CI, 0.86-1.66)

There was also a 57% greater risk of long COVID when adjusting for economic instability characterized by difficulty covering expenses, poverty, receipt of government assistance, and food insecurity (adjusted OR [AOR], 1.57; 95% CI, 1.18-2.09), as well as a 117% greater risk when considering high levels of discrimination and low social support (AOR, 2.17; 95% CI, 1.77-2.66).

However, there are limitations on these results. Selection bias, a lesser likelihood of enrollment by families more affected by SDOH, that the studies were conducted in English and Spanish only, potential symptom miscategorization, and lack of objective neighborhood-level data were cited as limiting generalizability.

Still, the study authors conclude that economic instability and adverse social and community circumstances are associated with a greater chance of developing long COVID, a finding that echoes the same association confirmed by the American Academy of Pediatrics in 2021.4

“For children with long COVID, the combined effect of a serious viral infection and adverse social conditions may have increased their risk, as chronic stress can lead to abnormal cortisol responses and immunologic derangements,” they emphasized. “Thus, mitigating the potential impact of poverty and other adverse SDOH on child health is critical.

References

1. Rhee KE, Thaweethai T, Pant DB, et al. Social determinants of health and pediatric long COVID in the US. JAMA Pediatr. Published online January 5, 2026. doi:10.1001/jamapediatrics.2025.5485
2. Gross RS, Thaweethai T, Kleinman LC, et al; RECOVER-Pediatrics Consortium; RECOVER-Pediatrics Group Authors. Characterizing long COVID in children and adolescents. JAMA. 2024;332(14):1174-1188. doi:10.1001/jama.2024.12747
3. Rao S, Gross RS, Mohandas S, et al. Postacute sequelae of SARS-CoV-2 in children. Pediatrics. 2024;153(3):e2023062570. doi:10.1542/peds.2023-062570
4. Schickedanz A, Szilagyi PG, Dreyer B. Child poverty and health in the United States: introduction and executive summary. Acad Pediatr. 2021;21(8S):S81-S85. doi:10.1016/j.acap.2021.09.003