pediatrics
March 2011, VOLUME127 /ISSUE 3

Health Effects of Energy Drinks on Children, Adolescents, and Young Adults

  1. Sara M. Seifert, BS,
  2. Judith L. Schaechter, MD,
  3. Eugene R. Hershorin, MD,
  4. Steven E. Lipshultz, MD
  1. Department of Pediatrics and the Pediatric Integrative Medicine Program, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida

Abstract

OBJECTIVE: To review the effects, adverse consequences, and extent of energy drink consumption among children, adolescents, and young adults.

METHODS: We searched PubMed and Google using “energy drink,” “sports drink,” “guarana,” “caffeine,” “taurine,” “ADHD,” “diabetes,” “children,” “adolescents,” “insulin,” “eating disorders,” and “poison control center” to identify articles related to energy drinks. Manufacturer Web sites were reviewed for product information.

RESULTS: According to self-report surveys, energy drinks are consumed by 30% to 50% of adolescents and young adults. Frequently containing high and unregulated amounts of caffeine, these drinks have been reported in association with serious adverse effects, especially in children, adolescents, and young adults with seizures, diabetes, cardiac abnormalities, or mood and behavioral disorders or those who take certain medications. Of the 5448 US caffeine overdoses reported in 2007, 46% occurred in those younger than 19 years. Several countries and states have debated or restricted energy drink sales and advertising.

CONCLUSIONS: Energy drinks have no therapeutic benefit, and many ingredients are understudied and not regulated. The known and unknown pharmacology of agents included in such drinks, combined with reports of toxicity, raises concern for potentially serious adverse effects in association with energy drink use. In the short-term, pediatricians need to be aware of the possible effects of energy drinks in vulnerable populations and screen for consumption to educate families. Long-term research should aim to understand the effects in at-risk populations. Toxicity surveillance should be improved, and regulations of energy drink sales and consumption should be based on appropriate research.

  • energy drink
  • caffeine
  • taurine
  • children
  • adolescents
  • overdose

“Energy drinks” are beverages that contain caffeine, taurine, vitamins, herbal supplements, and sugar or sweeteners and are marketed to improve energy, weight loss, stamina, athletic performance, and concentration.1,,3 Energy drinks are available in >140 countries and are the fastest growing US beverage market; in 2011, sales are expected to top $9 billion.4,,10 Half of the energy drink market consists of children (<12 years old), adolescents (12–18 years old), and young adults (19–25 years old).7,,10

Although healthy people can tolerate caffeine in moderation, heavy caffeine consumption, such as drinking energy drinks, has been associated with serious consequences such as seizures, mania, stroke, and sudden death.6,,8,11,,14 Numerous reports exist in the popular media, and there are a handful of case reports in the literature that associate such adverse events with energy drink consumption; it is prudent to investigate the validity of such claims (Appendix). Children, especially those with cardiovascular, renal, or liver disease, seizures, diabetes, mood and behavioral disorders, or hyperthyroidism or those who take certain medications, may be at higher risk for adverse events from energy drink consumption.6,,8,14,,24 Although the US Food and Drug Administration (FDA) limits caffeine content in soft drinks, which are categorized as food, there is no such regulation of energy drinks, which are classified as dietary supplements.1,,3 Despite the large, unregulated market for energy drinks and reports in the literature and popular media of serious adverse events associated with their consumption, research into their use and effects has been sparse.25 However, schools, states, and countries increasingly are exploring content and sales regulations of these drinks.1,8,13,26,,35

Given the rapidly growing market and popularity among youth, we reviewed the literature to (1) determine what energy drinks are, (2) compile consumption data of energy drinks by children, adolescents, and young adults, (3) compile caffeine and energy drink overdose data, (4) examine the physiologic effects of the ingredients in energy drinks, (5) identify potential problems of energy drinks among children and adolescents, (6) assess the marketing of energy drinks, (7) report current regulation of energy drinks, and (8) propose educational, research, and regulatory recommendations.

METHODS

We searched PubMed by using “energy drink,” “sports drink,” “guarana,” “caffeine,” “taurine,” “ADHD” (attention- deficit/hyperactivity disorder), “diabetes,” “children,” “adolescents,” “insulin,” “eating disorders,” and “poison control center” singly or in combination. We limited searches to English-language and foreign-language articles with English-language abstracts and selected articles by relevance to energy drink use in children and adolescents. We similarly searched Google for print and trade media. We reviewed articles and Internet sources by the above search through June 2010 and updated sections as new information became available through January 2011.

RESULTS

Two-thirds of the 121 references we found on energy drinks were in the scientific literature, although reports by government agencies and interest groups also contained much useful information (Table 1). Most information came from the United States, but European, Canadian, Australian, New Zealand, and Chinese sources are also represented.

TABLE 1

Primary Literature and Media Sources Selected for Review, According to Relevance

DISCUSSION

What Are Energy Drinks?

Energy drinks may contain caffeine, taurine, sugars and sweeteners, herbal supplements, and other ingredients (Table 2) and are distinct from sports drinks and vitamin waters (Table 3).6,8 In 2008, the National Federation of State High School Associations, while recommending water and sports drinks for rehydration, specifically did not recommend energy drinks and cited potential risks, the absence of benefit, and drug interactions (Table 4).36,37

TABLE 2

Common Ingredients, Therapeutic Uses, and Adverse Effects of Energy Drink Ingredients8,14,25,30,49,53,82,83

TABLE 3

Characteristics of Sports Drinks, Vitamin Drinks, and Energy Drinks1,4,8,14,37,115,117

TABLE 4

Potential Pharmaceutical Supplement Interactions With Energy Drink Ingredients30,82,83

Caffeine is the main active ingredient in energy drinks; many of them contain 70 to 80 mg per 8-oz serving (∼3 times the concentration in cola drinks) (Table 5).8,31 Caffeine content can be nearly 5 times greater than that in 8 oz of cola drinks when packaged as “energy shots” (0.8–3 oz) or as 16-oz drinks.6,29,38

TABLE 5

Caffeine Content Reported by Manufacturers and Selected Additional Ingredients of Selected Products6,29,46

Energy drinks often contain additional amounts of caffeine through additives, including guarana, kola nut, yerba mate, and cocoa.6,7,14,25 Guarana (Paullinia cupana) is a plant that contains caffeine, theobromine (a chronotrope), and theophylline (an inotrope).7,8,14,39 Each gram of guarana can contain 40 to 80 mg of caffeine, and it has a potentially longer half-life because of interactions with other plant compounds.7,14 Manufacturers are not required to list the caffeine content from these ingredients.7,14 Thus, the actual caffeine dose in a single serving may exceed that listed.9,29

Consumption of Energy Drinks by Children, Adolescents, and Young Adults

In the United States, adolescent caffeine intake averages 60 to 70 mg/day and ranges up to 800 mg/day.24,40 Most caffeine intake among youth comes from soda; however, energy drinks are becoming increasingly popular.7,24,41,42 Several self-report studies have examined energy drink consumption by children, adolescents, and young adults.7,24,41,42

One study found that 28% of 12- to 14-year-olds, 31% of 12- to 17-year olds, and 34% of 18- to 24-year-olds reported regularly consuming energy drinks.5,43 Shortly after energy drinks were approved in Germany, a study of 1265 adolescents found that 94% were aware of energy drinks, 53% had tried them, 23% drank <1 can per week, and 3% drank 1 to 7 cans per week.44 Among 10- to 13-year-olds, 31% of girls and 50% of boys had tried energy drinks, and 5% of girls and 23% of boys reported drinking them regularly but at a rate of <1 can per week.44 Most children in the study consumed energy drinks in moderation, but a small group consumed extreme amounts.44

A survey of 496 college students found that 51% of those surveyed regularly consumed >1 energy drink per month; the majority of them habitually drank energy drinks several times per week.9 Insufficient sleep (67%) and the desire to increase energy (65%) were the most common reasons for use.9 In this study, 54% of the respondents reported mixing energy drinks with alcohol, and 49% drank ≥3 of them while partying.9 Another study of 795 college students found that 39% of the respondents had consumed an energy drink in the previous month and that, on average, men drank energy drinks 2.5 days/month, whereas women drank 1.2 days/month.45

The estimated caffeine exposure of consuming energy drinks or energy shots was calculated for New Zealand children (5–12 years old), teenagers (13–19 years old), and young men (19–24 years old) (Figs 13).46 After consuming a single retail unit, 70% of the children and 40% of the teenagers who consumed caffeine were estimated to have exceeded the adverse-effect level of 3 mg/kg body weight per day beyond their baseline dietary exposure.46 An average child, teenager, or young man would all, on average, exceed the adverse-effect level after consuming a single retail unit of energy drink/energy shot above their baseline dietary caffeine exposure.46

FIGURE 1

Mathematical model estimates for dietary consumption of caffeine and energy drinks in children aged 5 to 12 years (A), adolescents aged 13 to 19 years (B), and young males aged 19 to 24 years (C) using caffeine-concentration data from food and beverages combined with 24-hour diet-recall information from the 1997 New Zealand National Nutrition Survey and the 2002 New Zealand National Children's Nutrition Survey. A, Distribution of dietary baseline caffeine-exposure estimates for children (5–12 years old).46 P95 indicates the 95th percentile exposure and represents a high consumer. Caffeine-exposure units are mg/kg of body weight per day. B, Distribution of dietary baseline caffeine-exposure estimates for teenagers (13–19 years old).46 C, Distribution of dietary baseline caffeine-exposure for young males (19–24 years old).46 Reproduced with permission from David Crowe, manager of consumer communications for the New Zealand Food Safety Authority.

FIGURE 2

A, Estimated distribution of caffeine exposure for children (5–12 years old) after the consumption of 1 to 4 retail units of energy drinks or energy shots.46 B, Estimated distribution of caffeine exposure for teenagers (13–19 years old) after the consumption of 1 to 4 retail units of energy drinks or energy shots.46 C, Estimated distribution of caffeine exposure for young males (19–24 years old) after the consumption of 1 to 4 retail units of energy drinks or energy shots.46 Caffeine-exposure units are mg/kg body weight per day. An adverse effect level of 3 mg/kg body weight per day is shown as a basis for risk evaluation. The area under the curves to the right of the adverse-effect lines represents the proportion of consumers potentially at risk from adverse effects of caffeine or the probability of a random consumer exceeding the adverse-effect level. Reproduced with permission from David Crowe, manager of consumer communications for the New Zealand Food Safety Authority.

FIGURE 3

A, Cumulative probability curves of children (5–12 years old) consuming 1 to 4 retail units of energy drinks or energy shots in addition to baseline dietary exposure.46 B, Cumulative probability curve for teenagers (13–19 years old) consuming 1 to 4 retail units of energy drinks or energy shots in addition to baseline dietary exposure.46 C, Cumulative probability curve of young males (19–24 years old) consuming 1 to 4 retail units of energy drinks or energy shots in addition to baseline dietary exposure.46 Caffeine-exposure units are mg/kg body weight per day. An adverse-effect level of 3 mg/kg body weight per day is shown as a reference point. The portion of each curve to the right of the adverse-effect level represents the proportion of the population group potentially at risk from adverse effects of caffeine. The exposure of any percentile may be read off the x-axis by extrapolating from the intersection of the selected percentile on the y-axis with the curve of 1, 2, 3, or 4 retail units consumed; cumulative probability = 0.2 represents the 20th percentile, 0.4 = 40th percentile, etc. Reproduced with permission from David Crowe, manager of consumer communications for the New Zealand Food Safety Authority.

Caffeine and Energy Drink Overdoses

US poison control centers have not specifically tracked the prevalence of overdoses attributed to energy drinks, because exposures were coded as “caffeine” or “multisubstance exposures” and combined with other caffeine sources (Table 6) (American Association of Poison Control Centers Board of Directors, personal communication, 2010).47 Energy drinks were recently given unique reporting codes, so their toxicity can now be tracked (American Association of Poison Control Centers Board of Directors, personal communication, 2010).47

TABLE 6

American Association of Poison Control Centers' Data on Caffeine Toxicity, 2006–200847

Germany has tracked energy drink–related incidents since 2002.33 Reported outcomes include liver damage, kidney failure, respiratory disorders, agitation, seizures, psychotic conditions, rhabdomyolysis, tachycardia, cardiac dysrhythmias, hypertension, heart failure, and death.33 Ireland's poison center reported 17 energy drink adverse events including confusion, tachycardia, and seizures and 2 deaths between 1999 and 2005.25 New Zealand's poison center reported 20 energy drink/shot–related adverse events from 2005 to 2009; 12 cases were referred for treatment of vomiting, nausea, abdominal pain, jitteriness, racing heart, and agitation.46 The minimum and maximum symptomatic caffeine levels were 200 mg (4 mg/kg) in a 13-year-old with jitteriness and 1622 mg (35.5 mg/kg) in a 14-year-old. The maximum volume consumed was fifteen 250-mL cans (11.5 mg/kg caffeine) during 1 hour.46 One 23-year-old chronic energy drink consumer had a myocardial infarction.46

Physiologic Effects of the Ingredients in Energy Drinks

Caffeine Pharmacology and Physiology

Caffeine, the most commonly used psychoactive drug worldwide, may be the only psychoactive drug legally available over-the-counter to children and sold among food and beverage products.39,48 Caffeine is an adenosine and benzodiazepine receptor antagonist, phosphodiesterase inhibitor, and central nervous system stimulant.29,38,49 In healthy adults, a caffeine intake of ≤400 mg/day is considered safe; acute clinical toxicity begins at 1 g, and 5 to 10 g can be lethal.29

Physiologically, caffeine causes coronary and cerebral vasoconstriction, relaxes smooth muscle, stimulates skeletal muscle, has cardiac chronotropic and inotropic effects, reduces insulin sensitivity, and modulates gene expression in premature neonates.9,29,50,,52 Large amounts of caffeine increase urine flow and sweat excretion and alter blood electrolyte levels.11,53 Although caffeine is a mild diuretic, consumption of ≤500 mg/day does not cause dehydration or chronic water imbalance.54,55

Caffeine is a ventilatory stimulant with anti-inflammatory and bronchoprotective effects.56 Caffeine has been linked to dyspnea on exertion from central and peripheral chemoreceptor stimulation.56 In addition, increased breathing work may divert blood flow away from locomotor muscles and negate any ergogenic advantage.56 Caffeine's cardiovascular effects include decreased heart rate from stimulation of medullary vagal nuclei and increased blood pressure.24,57,,61

Adults who consume low-to-moderate amounts of caffeine (1–3 mg/kg or 12.5–100 mg/day) have improved exercise endurance, cognition, reaction time, and mood with sleep deprivation.9,24,56,62 However, these studies typically involve habitual caffeine consumers, and results reflect withdrawal-symptom reversal.58

Consuming 4 to 12 mg/kg of caffeine has been associated with undesirable symptoms, including anxiety and jitteriness.63 Headache and fatigue, common withdrawal symptoms, can occur after short-term, high-dose use.64 Caffeine intoxication is a clinical syndrome of nervousness, irritability, anxiety, insomnia, tremor, tachycardia, palpitations, and upset stomach.6,7,9,14,26,65 Additional adverse effects include vomiting and abdominal pain, hypokalemia, hallucinations, increased intracranial pressure, cerebral edema, stroke, paralysis, rhabdomyolysis, altered consciousness, rigidity, seizures, arrhythmias, and death.1,2,8,29,48

Caffeine intakes of >300 mg/day have been associated with miscarriage and low birth weight.38,66,67 Long-term caffeine consumption relates to a lower risk of Parkinson disease and a slower age-related cognitive decline.58

Effects of Caffeine in Children and Adolescents

Adolescent and child caffeine consumption should not exceed 100 mg/day and 2.5 mg/kg per day, respectively.7,38,63 For example, 8 oz of Red Bull (Fuschl am See, Austria) provides 77 mg of caffeine, or 1.1 mg/kg for a 70-kg male or 2.2 mg/kg for a 35-kg preteen.40 Whether the effects of caffeine in adults can be generalized to children remains unclear.63 In a study of 26 boys and 26 men, the same dose of caffeine affected blood pressure similarly, but heart rate was significantly lowered in boys, whereas there was no effect on heart rate in men.68 Boys also exhibited more increased motor activity and speech rates and decreased reaction time than did men.69

Caffeine can improve attention, but it also increases blood pressure and sleep disturbances in children.24,63,70,71 After cessation in children who habitually consume caffeine, attention decreases and reaction time increases transiently.24,39 Similarly, reaction time has been shown to decrease as the dose of caffeine in children increases.24

In a study of 9- to 11-year-olds with habitual (mean intake: 109 mg/day) and low (mean intake: 12 mg/day) caffeine consumption given 50 mg of caffeine after overnight abstention, habitual caffeine users reported withdrawal-symptom (headache and dulled cognition) reversal. The children who did not habitually consume caffeine reported no marked changes in cognitive performance, alertness, or headache.63

Caffeine may affect future food and beverage preferences by acting on the developing child's brain reward-and-addiction center; this effect may be gender specific.5 A study of 12- to 17-year-olds revealed that boys found caffeinated soda more reinforcing than did girls regardless of usual caffeine consumption.72

Physiologic Effects of Other Ingredients in Energy Drinks and Potential Synergistic Effects

Popular media and case reports have associated adverse events with energy drink consumption (Appendix). Yet, few studies have examined the physiologic effects of individual ingredients or potential synergistic effects; furthermore, results of experimental studies have been inconclusive and occasionally contradictory.24,25,59,73

Some studies of adults revealed improved mental alertness, reaction times, and concentration with energy drinks59,74; others revealed no improvement compared with caffeine or glucose alone.73 One study of 14 young adults compared a complete energy drink mixture to the glucose fraction, the caffeine fraction, and the herbal fraction.9,59 Although individual components did not enhance cognition, the combined ingredients did.9,59 Caffeine and taurine combined may synergistically decrease heart rate initially; one study found that 70 minutes after consumption, heart rate returned to normal and blood pressure increased.25,75 Taurine similarly produced a reflex bradycardia when injected into the rat cerebroventricular system.75 Another study of 15 healthy young adults in a 7-day trial in which they consumed 500 mL of an energy drink each day with 160 mg of caffeine and 2000 mg of taurine, reported an average increase in systolic blood pressure of 9 to 10 mm Hg and an average increased heart rate of 5 to 7 beats per minute 4 hours after consumption.25,38

Caffeine- and taurine-containing beverages increased left atrial contractility in 13 athletes, thereby increasing left ventricular end-diastolic volume and stroke volume.76 The caffeine-only group showed no changes in left ventricular function.76 Taurine may cause this increase in stroke volume by suppressing sympathetic nervous stimulation and influencing calcium stores in cardiac muscle.8 Results of human and animal studies have suggested that long-term taurine exposure may cause hypoglycemia25 but a decreased risk of coronary heart disease.77 In animal experiments, taurine also has shown anticonvulsive and epileptogenic properties.25

Among 50 young adults who drank one sugar-free energy drink, hematologic and vascular effects included increased platelet aggregation and mean arterial pressure and a decrease in endothelial function.78 Guarana has antiplatelet aggregation properties in vitro, but how it functions physiologically in energy drinks is unknown.79 A study of 20 healthy subjects revealed that caffeinated espresso had no effects on endothelial function.80 Caffeine alone did not affect platelet function.81

Ginseng, a common ingredient in many energy drinks, may lower blood glucose levels, but its actions in energy drinks are unclear.82

Potential Problems of Energy Drinks Among Children and Adolescents

Cardiovascular Effects of Energy Drinks on Children and Adolescents

High doses of caffeine may exacerbate cardiac conditions for which stimulants are contraindicated.17,18,83,,86 Of particular concern are ion channelopathies and hypertrophic cardiomyopathy, the most prevalent genetic cardiomyopathy in children and young adults, because of the risk of hypertension, syncope, arrhythmias, and sudden death.11,86,87

Effects of Energy Drinks on Children and Adolescents With ADHD

ADHD occurs in 8% to 16% of US school-aged children and may be more prevalent in children with heart disease.88,89 Some 2.5 million US children take stimulants for ADHD, which may increase heart rate and blood pressure.89,,91 Children with ADHD have higher rates of substance abuse, including the abuse of caffeine, which blocks the A2A adenosine receptors and thereby enhances the dopamine effect at the D2 dopamine receptor, similarly to the way guanfacine works for ADHD.92,93 For the subpopulation with methylphenidate cardiotoxicity, energy drink use may increase cardiac events.95,96 As with the ADHD stimulants, the combined effects of energy drinks and antidepressants are unknown.94

Energy Drink Use in Children and Adolescents With Eating Disorders

Children and adolescents with eating disorders, especially anorexia nervosa, may regularly consume high amounts of caffeine to counter caloric-restriction–associated fatigue, suppress appetite, and produce looser stools and some diuresis.97,,100 Given that children and adolescents with eating disorders have a propensity for cardiac morbidity/mortality and electrolyte disorders, consumption of high-caffeine energy drinks may put them at further risk for cardiac dysrythmias and intracardiac conduction abnormalities.97,,99

Effects on Caloric Intake and Diabetes

Because obesity is epidemic, caloric increases from energy drink consumption become important. Additional calories may increase blood pressure, blood glucose levels, BMI, calcium deficiency, dental problems, depression, and low self-esteem.4,101,102 Sugar and caffeine may also synergistically increase postprandial hyperglycemia, which is of concern for children with diabetes.38,51,52

Effects on Bone Mineralization

Early adolescence is the time of maximal calcium deposition in bone, and caffeine interferes with intestinal calcium absorption.103,104 It remains controversial whether caffeine itself has the most marked effect on bone acquisition during adolescence or whether replacement of milk intake by caffeinated beverages is the leading contributor.103,104

Marketing of Energy Drinks

Youth-targeted marketing strategies date to 1987 when Red Bull was introduced in Austria.100 When it took 5 years to get permission to export Red Bull to Germany, rumors about its legality and dangerous effects helped fuel its popularity, and it became known as “speed in a can,” “liquid cocaine,” and a “legal drug.”100

Energy drink marketing strategies include sporting event and athlete sponsorships, alcohol-alternative promotion, and product placement in media (including Facebook and video games) oriented to children, adolescents, and young adults.43,105 Newer alcoholic energy drinks, the cans of which resemble the nonalcoholic counterparts, target risk-taking youth.43

Contrasting with brand design is the voluntary fine-print warning label on some products, which state that they may not be safe for children, those who are sensitive to caffeine, or for pregnant or nursing women.105,,107

Regulation of Energy Drinks

The FDA imposes a limit of 71 mg of caffeine per 12 fl oz of soda.1,2,6 Energy drink manufacturers may circumvent this limit by claiming that their drinks are “natural dietary supplements.”1,2 Thus, safety determinations of energy drinks are made solely by the manufacturers, and there are no requirements for testing, warning labels, or restriction against sales or consumption by minors.1,,3 In contrast, over-the-counter dedicated caffeine stimulants (eg, No-Doz [Novartis Consumer Health, Parsippany, NJ]) must list the minimum age for purchase (12 years), adverse effects, cautionary notes, recommended dose, and the total daily recommended dose of caffeine. In November 2009, the FDA asked manufacturers of alcoholic energy drinks to prove their safety.108 The US Senate is considering a bill that would require supplement manufacturers to register annually with the FDA and allow FDA recalls of supplements suspected of being unsafe. Ingredients may also be restricted to those that have already been approved by the FDA.109

Regulatory controversies also extend internationally (Table 7). When France banned Red Bull, the manufacturers challenged the ban through the European Commission, which determined that the caffeine and taurine concentrations in energy drinks had not been proven to be health risks and ordered France to lift the ban; the European Food Safety Authority has encouraged international data-pooling to better assess risks in children, adolescents, and young adults.33,110 In 2008, authorities in Germany, Hong Kong, and Taiwan detected 0.13 μg per can of cocaine (average) in Red Bull Cola. Red Bull manufacturers insisted that active cocaine was removed from the coca leaf during processing and that the extract was used for flavoring. However, 11 of 16 German states banned the product.111

TABLE 7

National and International Energy Drink Regulations

CONCLUSIONS

On the basis of this review, we conclude that (1) energy drinks have no therapeutic benefit, and both the known and unknown pharmacology of various ingredients, combined with reports of toxicity, suggest that these drinks may put some children at risk for serious adverse health effects11,16,24,25,38; (2) typically, energy drinks contain high levels of caffeine, taurine, and guarana, which have stimulant properties and cardiac and hematologic activity,7,8,11 but manufacturers claim that energy drinks are nutritional supplements, which shields them from the caffeine limits imposed on sodas and the safety testing and labeling required of pharmaceuticals7,8,11; (3) other ingredients vary, are understudied, and are not regulated; (4) youth-aimed marketing and risk-taking adolescent developmental tendencies combine to increase overdose potential; (5) high consumption is suggested by self-report surveys but is underdocumented in children (deleterious associations with energy drink consumption have been reported globally in case reports and popular media7,8,11,25,31,38); and (6) interactions between compounds, additive and dose-dependent effects, long-term consequences, and dangers associated with risky behavior in children remain to be determined.5,14,25,38

EDUCATIONAL, RESEARCH, AND REGULATORY RECOMMENDATIONS

In the short-term, pediatric health care providers need to be aware of energy drink consumption by children, adolescents, and young adults and the potentially dangerous consequences of inappropriate use.112 Diet and substance-use histories should include screening for episodic/chronic energy drink consumption, both alone and with alcohol. Screening is especially important for athletes, children with high-risk behaviors, certain health conditions (eg, seizures, diabetes, hypertension, cardiac abnormalities), and children with behavioral changes, anxiety, poor nutrition, or sleep disturbances.11

For most children, adolescents, and young adults, safe levels of consumption have not been established. Yet, heavy use may be harmful or interact with medications and cause untoward adverse effects. Health care providers should educate families and children at risk for the potential adverse effects of energy drinks.

Routine high school athletic physicals do not identify everyone at risk for sudden cardiac death.11,113 Children with cardiac conditions should be counseled regarding the risks of caffeine-containing products, including irregular heart rhythms, syncope, dysrhythmias, and sudden death.17,18,85 Community partners, including schools, athletic groups, and regulatory bodies, also need to promote risk awareness.113 The fourth edition of the “Preparticipation Physical Evaluation” monograph will feature a revamped health questionnaire focused on cardiac health problems that may be exacerbated by physical activity; thus, adding questions about stimulant use, including energy drink consumption, becomes important.113

Long-term research objectives should aim to better define maximum safe doses, the effects of chronic use, and effects in at-risk populations (eg, those with preexisting medical conditions, those who consume energy drinks during and after exercise, or those who consume them in combination with alcohol), and better documentation and tracking of adverse health effects.47 Unless research establishes energy drink safety in children and adolescents, regulation, as with tobacco, alcohol, and prescription medications, is prudent.11

This approach is essential for reducing morbidity and mortality, encouraging research, and supporting families of children and young adults at risk for energy drink overdose, behavioral changes, and acute/chronic health consequences.

Appendix

APPENDIX

Representative Sample of Adverse Events Reported in Association With Nonalcoholic Energy Drink Consumption

ACKNOWLEDGMENTS

This work was supported by National Institutes of Health grants HL072705, HL078522, HL053392, CA127642, CA068484, HD052104, AI50274, CA068484, HD052102, HL087708, HL079233, HL004537, HL087000, HL007188, HL094100, HL095127, and HD80002; Health Resources and Services Administration grant HCOF-C76HF15614; the Children's Cardiomyopathy Foundation; and the Women's Cancer Association.

Footnotes

    • Accepted December 3, 2010.
  • Address correspondence to Steven E. Lipshultz, MD, Department of Pediatrics (D820), Leonard M. Miller School of Medicine, University of Miami, Medical Campus MCCD-D820, 1601 NW 12th Ave, 9th Floor, PO Box 016820, Miami, FL 33101. E-mail: slipshultz{at}med.miami.edu
  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • Funded by the National Institutes of Health (NIH).

  • FDA =
    Food and Drug Administration
    ADHD =
    attention-deficit/hyperactivity disorder

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