To evaluate whether neighborhood-level opportunity, measured by the Child Opportunity Index (COI), is associated with short- and long-term outcomes following pediatric extracorporeal membrane oxygenation (ECMO).

Retrospective observational cohort study.

Single quaternary academic children’s hospital.

Children supported on ECMO between 2009 and 2023 (n = 472).

None.

COI quintiles were derived from geocoded residential addresses at the time of ECMO cannulation. Primary outcomes were survival to discharge and one-year survival. Secondary outcomes included ECMO duration, hospital length of stay, and one-year functional morbidity (gastrostomy tube, tracheostomy, or residence in a facility). Multivariable logistic and Cox regression models adjusted for age, sex, race, ethnicity, weight, and comorbidities. Children residing in the lowest COI quintile had lower adjusted odds of survival to discharge (aOR: 0.60, 95% CI: 0.38-0.95) and one-year survival (aOR: 0.57, 95% CI 0.35-0.93). Survival differences emerged early and persisted over time (adjusted HR for mortality 1.36, 95% CI 0.99-1.87). Among cardiac ECMO patients, low COI was associated with significantly higher odds of gastrostomy tube placement and residence in a facility at one year.

Neighborhood opportunity is independently associated with survival and long-term morbidity following pediatric ECMO, particularly among cardiac patients. These findings highlight the importance of incorporating social context into prognostication, post-ECMO planning, and survivorship care in pediatric critical illness.