Long COVID associated with SARS-CoV-2 reinfection among children and adolescents in the Omicron era (RECOVER-EHR): A retrospective cohort study

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Published

September 2025

Journal

Lancet Infectious Diseases

Abstract

Background: Post-acute sequelae of SARS-CoV-2 infection (PASC) remain a major public health challenge. Although previous studies have focused on characterising PASC in children and adolescents after an initial infection, the risks of PASC after reinfection with the omicron variant remain unclear. We aimed to assess the risk of PASC diagnosis (U09.9) and symptoms and conditions potentially related to PASC in children and adolescents after a SARS-CoV-2 reinfection during the omicron period.

Methods: This retrospective cohort study used data from 40 children's hospitals and health institutions in the USA participating in the Researching COVID to Enhance Recovery (RECOVER) Initiative. We included patients younger than 21 years at the time of cohort entry; with documented SARS-CoV-2 infection after Jan 1, 2022; and who had at least one health-care visit within 24 months to 7 days before the first infection. The second SARS-CoV-2 infection was confirmed by positive PCR, antigen tests, or a diagnosis of COVID-19 that occurred at least 60 days after the first infection. The primary endpoint was a clinician-documented diagnosis of PASC (U09.9). Secondary endpoints were 24 symptoms and conditions previously identified as being potentially related to PASC. We used the modified Poisson regression model to estimate the relative risk (RR) between the second and first infection episodes, adjusted for demographic, clinical, and health-care utilisation factors using exact and propensity-score matching.

Findings: We identified 407,300 (87.5%) of 465,717 eligible children and adolescents with a first infection episode and 58,417 (12.5%) with a second infection episode from Jan 1, 2022, to Oct 13, 2023, in the RECOVER database. 233,842 (50.2%) patients were male and 231,875 (49.8%) were female. The mean age was 8.17 years (SD 6.58). The incident rate of PASC diagnosis (U09.9) per million people per 6 months was 903.7 (95% CI 780.9 - 1,026.5) in the first infection group and 1,883.7 (1,565.1 - 2,202.3) in the second infection group. Reinfection was associated with a significantly increased risk of an overall PASC diagnosis (U09.9) (RR 2.08 [1.68 - 2.59]) and a range of symptoms and conditions potentially related to PASC (RR range 1.15 - 3.60), including myocarditis, changes in taste and smell, thrombophlebitis and thromboembolism, heart disease, acute kidney injury, fluid and electrolyte disturbance, generalised pain, arrhythmias, abnormal liver enzymes, chest pain, fatigue and malaise, headache, musculoskeletal pain, abdominal pain, mental ill health, POTS or dysautonomia, cognitive impairment, skin conditions, fever and chills, respiratory signs and symptoms, and cardiovascular signs and symptoms.

Interpretation: Children and adolescents face a significantly higher risk of various PASC outcomes after reinfection with SARS-CoV-2. These findings add to previous evidence linking pediatric long COVID to multisystem effects and highlight the need to promote vaccination in younger populations and support ongoing research to better understand PASC, identify high-risk subgroups, and improve prevention and care strategies.

Funding: National Institutes of Health.

Authors

Bingyu Zhang, Qiong Wu, Ravi Jhaveri, Ting Zhou, Michael J Becich, Yuriy Bisyuk, Frank Blanceró, Elizabeth A Chrischilles, Cynthia H Chuang, Lindsay G Cowell, Daniel Fort, Carol R Horowitz, Susan Kim, Nathalia Ladino, David M Liebovitz, Mei Liu, Abu S M Mosa, Hayden T Schwenk, Srinivasan Suresh, Bradley W Taylor, David A Williams, Jeffrey S Morris, Christopher B Forrest, Yong Chen, RECOVER Consortium

Keywords

Not available