Kay Rhee, MD, discusses adverse social determinants linked to higher odds of pediatric long COVID

A large national cohort study found that children and adolescents experiencing economic instability, food insecurity, discrimination, and low social support had significantly higher odds of long COVID compared with peers experiencing fewer social hardships. The findings highlight the role of social determinants of health in pediatric postacute SARS-CoV-2 outcomes and suggest that social conditions may influence recovery trajectories.

The cross-sectional analysis included 4584 children aged 6 to 17 years enrolled across 52 US sites as part of the National Institutes of Health–funded RECOVER-Pediatrics study. Caregiver-reported symptom surveys conducted at least 90 days after infection identified 17% of participants as having long COVID based on validated research indices.

Social determinants of health were evaluated across 5 Healthy People 2030 domains: economic stability, social and community context, caregiver education, neighborhood environment, and health care access. Researchers found that economic instability characterized by food insecurity and financial hardship was strongly associated with pediatric long COVID. Children in the highest-risk economic instability group had more than twice the odds of long COVID compared with those experiencing the least adversity (adjusted odds ratio [aOR], 2.39; 95% CI, 1.73-3.30).

Notably, economic hardship alone was not associated with increased risk unless accompanied by food insecurity. Children experiencing economic instability without food insecurity did not have higher odds of long COVID (aOR, 0.93; 95% CI, 0.70-1.23).

Investigators also observed a strong association between adverse social and community context—including discrimination and low social support—and long COVID risk. Children in the highest-risk social context group had more than twice the odds of long COVID compared with those in the lowest-risk group (aOR, 2.17; 95% CI, 1.77-2.66).

Kyung (Kay) Rhee, MD, MSc, MA, FAAP, professor of pediatrics and chair of the Division of Adolescent Medicine and Child and Community Health at the University of California, San Diego, and medical director of the Medical Behavioral Unit at Rady Children’s Health, said the findings underscore the importance of social conditions in pediatric health outcomes.

“It’s one of those things that I think people forget that the social environment, your exposures are things that can also affect your health,” Rhee said. “And so we really wanted to highlight, or just examine, how much these social conditions were also impacting health outcomes, especially during the early days of the pandemic.”

Nutrition and inflammation may influence recovery

The analysis provided new insight into the potential biological mechanisms linking social adversity to prolonged symptoms. Chronic stress associated with poverty, discrimination, and limited social support may alter immune function, increase inflammation, and impair recovery from viral infections.

Rhee noted that nutrition emerged as an important factor in the study.

“I think there’s a lot of conversation now around the importance of good nutrition and how that impacts your just physical functioning, your biochemical functioning,” she said. “And I think it really does impact inflammation and immune responses. And so just having a healthy diet helps you to feel better, your body to function better, your immune system to work better.”

These findings suggest that food security and access to adequate nutrition may represent modifiable risk factors in pediatric long COVID outcomes.

Chronic stress and social adversity may affect immune response

The investigators also emphasized the broader impact of chronic social stressors on immune function and disease susceptibility. Stress resulting from discrimination, economic hardship, and other adverse experiences may impair immune responses and increase vulnerability to persistent symptoms.

“I think this is also one of these areas in medicine that maybe hasn’t gotten as much attention as we probably should,” Rhee said. “No matter what form of stress we’re experiencing, if it manifests in our body as stress, then I think we start to trigger an immune response or greater inflammation that, again, just affects our ability to fight infections and things like that.”

Importantly, these associations persisted even after adjustment for race and ethnicity, suggesting that social conditions themselves—rather than racial identity alone—were independently associated with long COVID risk.

Implications for clinical care and health equity

The findings have important implications for clinical practice, particularly as physicians continue to evaluate and manage pediatric patients with persistent post–COVID-19 symptoms.

“I think it’s something for health care providers to be aware of, because it may affect how somebody can get treatment, or how effective the treatment can be,” Rhee said. “If you're getting some treatments, but still living in these social contexts that are very stressful, or you don’t have access to good nutrition, you’re almost kind of fighting whatever the treatment is.”

The results suggest that screening for social determinants of health—including food insecurity, discrimination, and access to social support—may help clinicians identify pediatric patients at higher risk for prolonged symptoms.

Although the study cannot establish causality due to its cross-sectional design, it represents one of the largest investigations to date examining social determinants of health and pediatric long COVID. Investigators emphasized that addressing modifiable social risk factors may represent an important strategy for improving long-term outcomes.

“These findings suggest that addressing adverse social drivers may mitigate future disease risk,” the authors concluded.

Disclosure

Rhee reports no relevant disclosures.

Reference

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