This is not for kids?

Last month I wrote a post on the causes of poor sleep in adolescents, as well as the myriad problems that can result in this high-risk population. Fortunately there is a system-wide public health measure proven to work, and now groups like the American Academy of Pediatrics are fully endorsing it. In that post, I briefly mentioned the increasing popularity of energy drinks and shots as caffeine delivery devices, and their role as both a potential cause of sleep deprivation and a means of temporarily ameliorating the effects.

I have been planning on addressing in greater detail the intentional, and unfortunately often accidental, ingestion of energy drinks in the pediatric population and the various associated risks for quite a while. What finally motivated me to get to work on this topic was the recent spate of media coverage regarding the results of a study presented this week at the American Heart Association’s Scientific Sessions 2014. The research, which involved the analysis of data obtained from the National Poison Data System for October 2010 through September 2013, supports concerns that pediatricians and other pediatric healthcare professionals have had for a very long time. Energy drinks are dangerous, particularly in young children, and a large part of the blame falls on the shoulders of manufacturers as well as the 1994 Dietary Supplement Health and Education Act (DSHEA) so frequently discussed on SBM.

Before I break down the scary numbers from the study, first a little background on energy drinks.

What are energy drinks/shots, who drinks them and what’s actually in those things?

Unless you have recently emerged from a lengthy coma that began sometime prior to the late 1980’s, then you will have been exposed, likely many thousands of times over just the past few years, to the existence of energy drinks and shots, and the lofty claims made by their manufacturers. These are extremely popular beverages, with sales in the United States alone coming in at more than $12.5 billion in 2012. Their popularity is also skyrocketing with a 60% increase in consumption from 2008 to 2012.

Not surprisingly, the typical customer looking for an energy drink is young, with 2/3 being between ages of 13 and 35 years. Also not very shocking is the fact that about 2/3 of overall consumers are male. Just look at the marketing, which is largely tied to sports teams, “extreme” athletics/stunts (skydiving from the stratosphere!) and television shows popular with male teens and young adults. Manufacturers are trying to reach out to other groups however by increasingly marketing energy products as health drinks that are low-calorie or that boost the immune system as well as cognitive performance, in addition to simply granting miraculous increases in energy and stamina “without the crash.” Oh, and don’t forget the antioxidants! These things are often lousy with antioxidants.

Energy drinks and shots contain caffeine of course, often in absurd amounts and for no apparent reason other than to be able to brag about being the most powerful drink on the block. They also contain a number of other ingredients (which Scott Gavura has discussed previously). Some of these other ingredients, particularly guarana, amount to nothing more than additional caffeine. In fact, because of the limits imposed on the FDA (thanks, DSHEA), energy drinks aren’t regulated in regards to the accuracy of their labels. So the amount of caffeine in an individual energy drink may be hidden behind “proprietary blend” on the label, and even when listed can be inaccurate by more than 20%.

Additional ingredients often mixed in with caffeine are sugar, amino acids like taurine, ginseng and the ubiquitous B vitamins. These are often described as the “energy vitamins.” There are many more ingredients incorporated into the hundreds of different energy drink/shot products. I won’t list them all but will add that more than a few can potentially add to the caffeine content, stimulant effect and overall side effect profile. None of these have been studied for safety or efficacy in children or in combination in any age group.

In general, there is a wide range of caffeine amounts found in energy drinks when studied, with some containing very little and relying more on the hype of useless vitamins and herbs to grab the consumer’s interest. With thanks again to DSHEA, however, the consumer can’t trust that what is in the product is accurately represented on the label. Other caffeine containing products are more regulated and the amount of caffeine listed on the label can be trusted. Cokes (and as a Southerner, by coke I mean any carbonated cola-type beverage) and over-the-counter caffeine pills like Vivarin and NoDoz contain what they say they do because they don’t masquerade as a supplement in order to avoid accountability.

As I mentioned earlier, the amount of caffeine in some of these products is shocking. For comparison, a standard 6.5 ounce cup of coffee contains anywhere from 80 to 120 mg of caffeine depending on the brewing method. 12 ounces of cola can’t contain more than 65 mg of caffeine by law, so even Mountain Dew is wimpy compared to most energy drinks. The typical energy drink contains at least as much caffeine as a standard cup of coffee, while some have significantly more per serving. Let’s look at the two most popular brands, Red Bull and Monster, which share well over half of the energy drink market.

A typical Red Bull is made with Alpine spring water (fancy!), taurine, B vitamins, sugar and 80 mg of caffeine in an 8.4 ounce can. Not bad, although many teens and young adults drink more than one serving at a time and mix Red Bull with alcohol, an extremely risky combination which I’ll get to shortly. Monster doesn’t provide a list of ingredients on their website. According to a few online resources, a standard Monster energy drink contains similar ingredients but has a proprietary “energy blend” which has about the same amount of caffeine in it as Red Bull, with 160 mg in their 16 ounce can. But because it also contains guarana, and whatever else is in their stimulant cocktail, who really knows?

Monster sells a number of additional products with names like “Assault” and “Anti-Gravity.” The latter apparently contains nitrous oxide and additional energy blend components like the herb yerba mate that serves as an additional source of caffeine and other potential stimulants. This product contains 160mg of caffeine in a 12 ounce bottle so is a bit more concentrated. It is also important to point out that Monster is in league with Satan.

Okay, now on to the big dogs in the world of energy drinks. While Red Bull and standard Monster energy drinks contain roughly 10 mg caffeine (that we know of) in every ounce of product, another Monster product called M3 starts getting silly. It’s their most potent product, containing much larger doses of stimulant herbs and 160 mg of caffeine in its 5 ounce non-twist off cap covered glass bottle. That is 32 mg of caffeine per ounce if you are keeping score. 5 ounces of sweet syrupy liquid that a young child could easily down in a gulp and end up in the hospital.

The next product I’ll feature shows how scary this stuff can be. Redline energy drink is marketed to body builders and contains, in addition to almost 40 mg of caffeine per ounce in the 8 ounce bottle, and typical herbal stimulants, a number of additional ingredients like guggulsterone and vinpocetine. I honestly don’t even want to know what those are, but I can guarantee you that they haven’t been tested for safety in kids or likely anybody else. This product could kill a toddler or anyone with an underlying heart condition.

Moving on to the energy shot category there are several that contain dangerous amounts of caffeine and other stimulants. The king of energy shots is a product known as DynaPep. It contains no less than “adrenaline inducing phytochemicals”, but more importantly 714 mg of caffeine in one measly little ounce. In case you missed that, it contains 714 mg of caffeine per ounce. It comes in a .14 ounce bottle however, so while a young child who happened upon several containers could easily suffer toxic effects if each was consumed, it is less likely than with ALRI Hypershot for instance. This product contains, among some of the usual additional ingredients, 500 mg of caffeine in a 2 ounce bottle. The much more popular 5-Hour Energy’s extra strength formulation lists 200 mg of caffeine in their 2 ounce bottle but hides behind a proprietary blend so, once again, who really knows? But it’ll be more than enough to cause harm to young children if ingested in full. (5-Hour Energy’s claims and contents have been addressed by our own Harriet Hall previously on SBM.)

How much caffeine is too much?

Caffeine is a central nervous system stimulant and is extremely popular around the world. In the United States, about 90% of adults consume caffeine in some form every day. The reasons for its popularity are straightforward. It can increase mental alertness, especially when sleep deprived, and can provide a mild-to-moderate boost to athletic performance. And long-term ingestion at reasonable levels may have other benefits, such as decreasing the risk of developing Parkinson’s disease. But it is also associated with a number of common side effects, particularly jitteriness, anxiety, insomnia, headaches and heart palpitations. These can occur with even reasonable amounts of caffeine in some individuals secondary to differences in metabolism.

Long term daily use of caffeine can lead to physical dependence and withdrawal, making it a common cause of chronic headaches, and the development of tolerance can lead to a need to ingest increasing amounts over time. Sadly, many regular caffeine users believe that they use it to feel a boost when in reality they crave it just to feel normal. It is not uncommon for neurologists caring for patients with frequent headaches to discuss intake of coffee in pots rather than cups each day. I use caffeine myself, but strategically so by avoiding caffeine intake except when needed for an occasional boost in alertness. And I only take caffeine in the form of regulated caffeine pills. Well, that and chocolate.

The amount of daily caffeine that is widely considered safe in adults is up to 400 mg, although some experts recommend trying to stay between 100 to 200 mg. Of course depending on an individual’s state of health, any amount of caffeine may be unsafe. Patients with underlying cardiac disease who may not tolerate sudden sharp increases in blood pressure and heart rate should probably avoid it altogether. And some people are very sensitive to even small amounts of caffeine. But most people consume caffeine without any major issues.

Caffeine in children is a different issue as they are even more sensitive to potential side effects, especially if they an underlying cardiac abnormality or neurologic disorder. It is not clear what amount should be considered safe in kids, and there are no FDA guidelines on safe consumption in this population. Most pediatricians agree that young children don’t need it and should not ingest it. The same can be said for older kids as well, but it is incredibly difficult to avoid all caffeine intake as children age.

According to the AAP, roughly three out of four non-infant kids get caffeine in some form every day. Mostly caffeine is ingested in the form of cola and candy, but energy drink intake is steadily increasing. Although the AAP doesn’t give specific guidelines other than avoidance, experts in other countries have done so. Health Canada, for example, recommends that 45 mg of daily caffeine be the limit for children aged 4 to 6 years, 62.5 mg for ages 7 to 9 years, and an 85 mg cap for kids 10 to 12 years. A 100 mg limit is widely thrown around when talking about a daily caffeine limit for teenagers.

When it comes to energy drinks, the total consumption in anyone, let alone young children, really should be none. Even forgetting for a moment the fact that what the label says likely does not accurately represent what is actually in the bottle, there are no ingredients found in any energy drink or shot that are required for a healthy diet and lifestyle, even caffeine, that can’t be obtained by eating a variety of fruits and vegetables. And when it comes to kids, it is extremely easy for them to accidentally or intentionally take in harmful amounts.

Mixing energy drinks and alcohol

Teenagers and young adults frequently mix energy drinks with alcohol. In fact, pre-mixed products containing large amounts of both caffeine and alcohol were available in stores until fairly recently. These products were clearly marketed to attract young and often underage consumer. After a number of deaths and a year-long investigation, they were effectively banned by the FDA in November of 2010. This ban has unequivocally saved lives.

Why is it so bad to mix alcohol and energy drinks? Don’t people mix alcohol and caffeine in colas all the time? Sure, but the difference is the amount of caffeine. One of the more popular versions of these now-banned combination products contained 12% alcohol by volume and 260 mg of caffeine in a 24 ounce can, for example, and people often didn’t stop at drinking just one.

The ingestion of such large amounts of caffeine leads to the drinker having an altered perception of just how drunk they really are. They don’t feel as impaired, and may not pass out when they normally would have at a certain blood alcohol level. This increased alertness, and decreased awareness of one’s degree of impairment, can result in the ability to continue drinking and the false belief that they are okay to drive. This has been described as being “wide-awake drunk.”

Now back to the research presented this week at the AHA conference.

What does the poison control data reveal about energy drink dangers?

During the three-year period looked at by the researchers, there were more than 5,000 documented exposures to energy drinks/shots that led to the involvement of a poison control center. It is important to point out that this very likely grossly underestimates the true number of events. This particular study didn’t include visits to emergency rooms for energy drink-related toxicity which did not result in a call to poison control. Also, parents of children with milder side effects may not have even felt the need to call, perhaps because they did not recognize a connection between the ingestion and the symptoms.

Of the roughly 5,000 poison control calls, 40% involved children less than 6 years of age and were considered unintentional ingestions. Moderate and severe outcomes were common overall, occurring in 42% of calls involving a combination of alcohol with an energy drink and 19% when only energy drinks were consumed. Of the serious outcomes, 57% involved dangerous rhythm disturbances in the heart and 55% reported seizures.

The researchers involved in the study, and pediatricians in general, have called for better regulation of these products for years. Why are manufacturers of energy drinks/shots allowed to hide behind misleading labels that cover up how much caffeine is actually in their products? This study further supports our concerns, and not just regarding kids. Many young adults, and in fact people of all ages, are at risk.


We need to fix or get rid of DSHEA and hold manufacturers accountable, or at least put warning labels on products that contain such high levels of caffeine. Healthcare professionals also need to be vigilant and ask about energy drink consumption, particularly in children with underlying conditions that would increase their risk of a poor outcome. Education is of course a key component of any response, and increased awareness of the dangers inherent in drinking unregulated drug delivery devices like these is important. Imagine if the energy spent by misinformed anti-GMO crusaders for changing food labels was able to be harnessed for this purpose.



Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.