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Energy Drinks Can Damage a Healthy Heart; Plus When Anxiety Symptoms Are Really Cardiac · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  Part is that there's a local high school that has a vending machine for the
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  high school students to purchase these in school, on campus. What?
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  And a lot of the high schools have coffee bars now. Anyway. I know. I know.
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  I'm Holly Wehment, and this is Pediatrics Now, brought to you by UT Health's
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  Department of Pediatrics.
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  A recent case involving the death of a teenage cheerleader has raised new questions
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  about energy drinks and cardiovascular health in young people.
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  Although a direct link has not been established, it's an opportunity to review
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  what we know and what we don't know about these increasingly popular beverages.
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  And we know pediatricians are being asked about this.
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  I'm thrilled today because Dr. Elaine Maldonado is joining me here in our podcast
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  studio, and she has been a pediatric cardiologist since 2005 on faculty.
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  Dr. Maldonado, thank you so much for being here today in the podcast studio.
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  Thanks, Holly. It's good to see you. My son was saying to me,
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  Mom, most of my friends, what is the most common is to drink energy drinks.
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  He's 18 years old, and it's uncommon if one of his friends doesn't ever drink
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  the energy drinks. I just, I couldn't believe that. It's, I mean,
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  it sounds like they're wildly popular.
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  Yeah, I think that's true, Holly. My experience has been, you know,
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  parents bringing their children into the clinic and having concerns about energy
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  drinks, caffeine intake, all of the above.
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  And it's a very common thing nowadays for kids.
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  And a lot of the energy drinks, they come in these cans. It's a slender can,
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  and it's kind of the in thing to drink them, but it can have so much caffeine in just one can.
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  That's true. Yeah. And I think recently, one of the concerns that folks have
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  had is marketing and how the energy drinks are marketed towards kids.
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  You know, the cans have all this colorful marketing on them and.
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  It's been a concern. Do you have any advice when parents are asking pediatricians
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  about the cheerleader who passed away and they're asking about that case?
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  What do you say? Yeah, it's such a sad situation when you think about that young
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  lady. So tragic. So tragic.
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  We obviously don't know exactly what led to her death.
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  But when parents come in with specific questions about energy drinks,
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  I think the easy answer is to let parents know that there really is no benefit
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  for children to drink those energy drinks.
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  There is no nutritional benefit.
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  And caffeine intake for kids, if you look at our American Academy of Pediatrics
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  website and recommendations on caffeine intake, especially for younger children,
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  there really is no nutritional benefit for them.
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  And it can potentially have an impact on their growth and their development
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  because they're still growing so much. Their brains are changing.
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  So the easy answer is they just shouldn't have it.
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  And I think that could be something that could really resonate with kids.
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  This could affect your growth.
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  Yes, and your brain development, your performance.
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  A lot of the kids that I know drink caffeine just on a daily basis just to function,
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  just to get through the day, get through school. And unfortunately,
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  most of us as adults drink caffeine on a regular basis, too.
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  Yes, they're seeing us do that.
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  Right. So that makes it hard. It does. And most of these energy drinks in particular,
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  it's okay for kids to purchase them. It's legal.
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  Do you think that it should be illegal? Personally, I think it probably should
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  be. I don't think kids have any reason to be drinking energy drinks or that much caffeine.
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  A lot of those cans or bottles can have over 200 milligrams of caffeine each
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  or per serving. And some of the cans are two to three servings per can.
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  So the amount of caffeine in those is pretty significant at times.
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  It depends on the brand and, you know, how big the can is.
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  And there's a high school here in town that has it in their vending machines.
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  A lot of people may not realize the dangers, right? Right. There are some high
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  schools that have those in vending machines here in San Antonio.
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  It has become more and more popular across the country for high schools to have
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  coffee bars for kids available to them.
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  The whole time they're at school, they can just go and get free coffee.
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  Yes, and then at the fundraiser for my daughter's school, they had a coffee
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  bar was part of the main fundraiser throughout the day at school.
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  I was so surprised. Yeah.
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  So we're seeing more children and teens consuming these energy drinks.
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  What happens physiologically when a child consumes a high amount of caffeine
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  or stimulant-containing beverages?
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  Yeah, that's a great question. You know, a lot of times when patients come into
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  my clinic, the complaints are things like palpitations or feeling an irregular
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  heartbeat or a fast heartbeat.
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  Other times they come in with concerns about chest pain. So there are many cardiac
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  symptoms like those that I just mentioned that caffeine can cause or exacerbate.
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  And so when they come in with those symptoms, that's one of the first things
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  we talk about is, you know, I phrase it as, are you a big caffeine drinker?
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  Do you enjoy Starbucks? Do you like your Cokes? And all of those questions,
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  when we talk to kids about that, I try to correlate their caffeine intake as
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  a potential cause for the symptoms that they're coming in with.
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  Because it's so common, so that's kind of what you're, you know,
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  this could be causing it.
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  Is it difficult with adolescents because they may not necessarily be telling
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  you, or with patients in general, you don't know if they're telling you exactly
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  what they're drinking, what the intake is, how much it is. Their parents right there, they may.
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  That's right. That's right. Yeah. And especially with older teenagers,
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  you know, you want to give them some degree of autonomy.
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  They're growing up. They're going to be young adults soon.
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  But I try to stress to them how that can affect them.
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  And maybe they could feel better if they at least cut back on their intake.
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  Because even if they're sleeping, the sleep might not be as deep of a sleep,
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  if you have caffeine in your system.
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  Yeah, potentially. And depends on what time you're drinking caffeine.
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  I remember one particular patient who was telling me she was having coffee late
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  into the night to study and then was wondering why she couldn't go to sleep.
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  Right. And you're like, well, this is why. That's right.
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  Can energy drinks affect heart rhythm, blood pressure, or the cardiovascular
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  system in otherwise healthy children?
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  So we know the answer is yes. Absolutely.
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  Yeah, because of the caffeine and the caffeine content.
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  Are there certain children who may be at greater risk, such as those with an
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  undiagnosed heart condition?
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  Yes. You know, if you have an undiagnosed congenital heart disease that can
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  potentially impact your cardiac output, which would affect your blood pressure, absolutely.
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  If you have an excessive amount of caffeine in your system and it affects your
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  heart rate, it could definitely affect your cardiac output and your ability,
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  to have enough cardiac output for your body to function.
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  When you hear about that tragic case, like the Texas teen, what is the most
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  important message for physicians regarding association versus causation?
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  When patients come into our clinics, we obviously need to make sure that there
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  isn't an underlying cardiac etiology as the primary reason for them to be having their symptoms.
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  But part of our job is to include a very detailed history and to educate patients.
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  You know, just because you have a normal heart and it's functioning normally
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  and you're doing well, that doesn't mean that,
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  if you intake a certain amount of caffeine or lots of energy drinks or do things
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  that maybe you shouldn't be doing, that it won't affect your heart and how it
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  functions in the future.
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  And so it's important for them to understand that. Mm-hmm.
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  So it could be dangerous for anyone. For anyone. For anyone. Yeah.
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  And it's also tough, too, because especially teenagers, if they're not supposed
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  to be doing something then and the parent is telling them not to do it,
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  then they might want to do it more.
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  But maybe they'll listen to the pediatrician. I feel like my kids listen to
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  their pediatrician. They'll follow what their pediatrician says to do.
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  And I had been saying it for weeks.
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  That's interesting you mentioned that because that's a very common occurrence, I think, in my clinic.
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  You know, we'll go through the entire process of, you know, a history and a
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  physical and all the diagnostic testing. And then we come to the end where we're counseling.
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  And parents will often say, you know, it's interesting because everything you
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  just told them, I have been telling them for months, sometimes even years.
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  And it does, sometimes it just hits different when it's coming from someone
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  who's not your mom or your dad, especially for teenagers.
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  That's not true for all teenagers, but yes, that's a very common thing that parents tell me.
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  And pediatricians have the power.
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  It's amazing the difference that you all are making in kids' lives and our listeners.
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  So can you tell me again, what does the American Academy of Pediatrics recommend
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  regarding energy drink consumption in children and adolescents? Bottom line.
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  Specifically related to caffeine, which we know is part of energy drinks.
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  The American Academy of Pediatrics statement tells parents, families,
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  patients, there's really no role for a caffeine intake in children.
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  It just, there's no benefit, and they recommend that kids just don't intake caffeine.
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  You're the mom of two adult sons. What would you say to your sons about this, or what do you say?
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  Energy drinks just really are something you shouldn't have.
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  I am fortunate that my adult children just don't really enjoy drinking coffee.
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  They've never had energy drinks that I know of.
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  But they are not coffee drinkers. I myself do drink coffee about a cup a day.
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  But yeah, my stance is there's no need to have energy drinks.
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  What about for our pediatrician listeners who work long hours,
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  any guidance there for the pediatrician? I love coffee, too,
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  but what guidance can you give us?
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  I mean, as adults, obviously, we have to be smart. We have to keep our heart
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  health in mind, probably more so than younger kids.
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  I think some caffeine intake is okay. We just have to be mindful about the amounts.
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  How many milligrams is okay?
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  You know, in general, for a normal, healthy adult, under 400 milligrams a day is what's recommended.
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  I think probably people should stick to well below that amount, if possible.
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  I noticed an energy drink can a few weeks ago. It was in our recycle bin.
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  So I'm assuming it was my 18-year-old son who drank it. And he didn't mention it.
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  I had no idea. I didn't see it before then. And it was just,
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  you know, and I brought it up and he said that it was before a test or something.
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  And I remember him asking me if I, before the SAT, if I drink a Red Bull,
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  will it help my performance? And I said, no, I don't see how it would.
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  But do you have any advice there?
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  Yeah, it's so hard because it has become so commonplace. But,
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  you know, there are alternatives that are probably a little bit healthier and
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  have much less caffeine.
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  Things like green tea, where there probably are some health benefits to the
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  tea, maybe not the caffeine.
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  There are choices that they can make. It is tough. You know,
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  there are so many other factors that affect kids' cardiac symptoms.
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  You know, and nowadays kids are under so much stress.
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  Right. It's tough, but sticking to habits, having a routine,
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  getting a good amount of sleep, drinking plenty of water, all of it sounds like
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  common sense stuff, but it helps kids to do better in school and to just feel better.
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  Elaine, many energy drinks, as you know, contain not only caffeine,
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  but other ingredients like taurine and alcohol.
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  Garana? Am I saying that right? I don't know. Anyway, do these combinations
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  raise additional concerns?
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  So there's these ingredients we can't even pronounce that are in there.
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  And who knows how much caffeine, but it's more caffeine than even is in coffee.
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  Yeah, and that's a good point that you bring up, Polly, because depending on
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  the energy drink and how it's being marketed, that will determine if there's
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  any oversight from the FDA or from another agency or any oversight at all into the ingredients.
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  And so that does complicate things when it comes to energy drinks because you
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  sometimes just don't know what's in there and how much.
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  And I guess some of them, I don't know if all of them would have in tiny writing,
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  should not be consumed by someone under 18. Exactly. Yeah.
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  Actually, most of the ones that I've seen, and in particular the ones that I
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  know are being sold in some of the high schools here in town,
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  It says that on the can, not intended for kids under 18 years of age. Wow.
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  And it's in the vending machine. Correct.
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  What are the key take-home points every pediatrician should communicate to families?
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  You know, I think the common sense points that we talked about,
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  you know, try to help your children to have a routine.
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  It's tougher as they get older, but it is important for them to try to go to
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  bed at the same time and wake up at the same time.
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  You know, get a set amount of sleep every night.
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  Try to have regular meals. Drink water regularly. Exercise on a daily basis if you can.
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  All of those things are important to keep kids engaged and help with their school performance.
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  And all of those things actually help them as opposed to energy drinks and caffeine,
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  which really have no benefit to them.
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  And it's not going to make them do better on the test. No. No,
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  unfortunately. Okay, I was right.
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  So also I've noticed adolescents, if you're not in a sport, you might be going
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  throughout the whole day without any exercise because a lot of schools don't have P.E.
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  For adolescents or maybe they'll have it half the year. But by a certain age,
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  you're just going from sitting to sitting to sitting.
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  That's right. Yeah. And that's another thing that we talk to families about,
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  you know, having a scheduled time where even as a family, you guys do some sort
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  of physical activity together.
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  That's huge because the link between physical activity and good mental health is clear.
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  And so that really helps kids in terms of not only their school performance,
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  but just their general happiness.
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  Yes. And energy level. Right.
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  What about red flags to look forward to? Yeah, that's, you know,
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  it's tough, you know, because you can't be with your children 24-7.
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  But I think having a good relationship where you have open communication with
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  your kids, especially teenagers, that's important because then they understand
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  that you're on their side in terms of communicating the lack of any benefit
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  in drinking these energy drinks.
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  So in the case of in general, when a child should go to the ER immediately.
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  So some red flag symptoms are, you know, feeling a fast heart rate that just
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  won't go away, even if you're resting.
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  And it's just if kids will tell you, especially older children and adolescents
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  will know if that's an issue.
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  You've tried resting and it just, the heart rate won't budge.
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  That's a sign that you probably need to get to see someone in an urgent care or an emergency room.
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  Because that could be a sustained arrhythmia that's not going away.
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  Significant chest pain that just won't go away even when you're at rest.
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  That's another reason to probably head to the emergency room.
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  That's pretty rare in adolescents or kids.
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  Those are probably the two big red flags. What's the youngest age of child that
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  you've seen who is consuming energy drinks?
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  Sadly, I've had some 11, 10-year-olds who were drinking energy drinks.
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  Wow. In part because they had older siblings.
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  You know, so then it just makes it a little bit easier for them to have access
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  to that. And sometimes the parents weren't aware that that was happening.
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  And what do you say? You know, I try to build a rapport with my patients so
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  that they understand that I'm trying to educate them to be their best self.
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  And usually once they hear that and they understand the correlation with their
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  symptoms, I think they tend to do much better.
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  Moving on to our next topic, anxiety symptoms, but really it's cardiac symptoms.
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  Many parents assume symptoms like a racing heart or feeling suddenly overwhelmed.
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  Those are simple anxiety symptoms, especially in teens.
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  But in some cases, similar symptoms can be a sign of an underlying heart issue.
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  It's difficult sometimes for parents to be able to tell the difference because
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  those symptoms do overlap.
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  If parents and our patient have tried all those other things that we talked
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  about, you know, kids are trying to do the right thing, have a routine,
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  they're sleeping well, they're drinking plenty of water.
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  If those symptoms persist, those are reasons to probably get further evaluation,
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  so that we can try to help them differentiate what's going on.
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  And we can do that with our evaluation and diagnostic testing.
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  And we see many, many patients for those reasons. And thankfully,
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  most of the patients we see in clinic don't have any significant structural
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  or congenital heart disease.
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  Most of the time, it's lifestyle and modifications that they can make to feel better.
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  Lifestyle modifications do you recommend? Is it what you've been saying about
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  getting enough sleep, drinking enough water,
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  eat regular meals, all the things that our mothers and grandparents used to
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  tell us that were important, it still stands true today.
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  You know, you have to, the way you treat your body is the way your body's going to treat you.
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  And so just practical, common sense things.
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  And a lot of times I think it's easy for, especially for teenagers, to forget that.
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  Because the teenage brain thinks that it's invincible.
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  And so we have to help them to remember those things.
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  And pediatricians see so many kids who have anxiety and depression.
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  We're in that epidemic, as we all know.
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  So bottom line, how would you know? What would be a case where you would say,
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  well, this looks more to me like cardiac symptoms that need to be checked out?
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  Yeah, that's a great question.
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  It's difficult to differentiate, but persistence of symptoms,
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  you know, despite trying everything else, and perhaps you've tried therapy or
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  medical management for anxiety, and things just aren't getting better.
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  I think those are reasons to come
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  see us. And many times what we do is put patients and families at ease.
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  We have looked at everything. Your heart looks good. It's functioning fine.
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  And interestingly, a lot of times that's all it takes for patients to feel a
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  little bit better and to kind of get to moving on with the process of healing,
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  when they know that they're actually okay. Mm-hmm.
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  Is it common for a teenager to have a racing heart sometimes?
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  It's not common for teenagers to have racing hearts at rest.
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  With activity, your heart rate obviously increases. It needs to.
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  But it's not a common thing for someone to just be sitting there and to suddenly
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  have a racing heart rate.
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  That's not common. And so if that persists and it's an ongoing issue,
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  then yes, you should get evaluated.
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  And if a child passes out while exerting his or herself, that's a red flag.
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  That's a huge red flag, yes.
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  We call that syncope. When patients pass out, and especially if it happens during
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  activity, that's definitely a reason to go see your pediatrician and potentially your cardiologist.
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  And for pediatricians that's happened to their patient that get in to see the
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  cardiologist as soon as possible or even go to the ER?
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  Absolutely. And our pediatricians in town are great. You know,
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  they understand that that's a huge red flag. Mm-hmm.
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  But passing out where there's a prodrum beforehand, where you're feeling slightly
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  dizzy and then you are weak and then you slowly pass out and you're not exerting
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  yourself, that's not a red flag.
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  Yeah, I mean, it could be, but usually those symptoms are more tied to something
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  that we call vasovagal syncope, where a lot of times patients potentially have
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  not been hydrating enough or eating well before physical activity.
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  And sometimes it's just an autonomic issue with your nervous system.
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  And kids are going through so many changes during puberty, and all of those
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  changes can impact their cardiovascular system, and that can impact their blood
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  pressure, which can then lead to these symptoms that we're talking about.
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  So lots of factors come into play for adolescents.
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  It's so true. And pediatricians have so much, as we know, on their plates,
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  and they may have, this is the 37th patient they're seeing that day.
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  Is there anything that you see that was missed that you want to mention?
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  Most of the time, you can figure out what's going on with a patient with a history
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  and physical and asking the right questions.
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  A lot of that comes with having a good rapport with your patients.
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  But your point is well taken. A lot of times the pediatricians are so busy seeing
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  patients that it's tough to, you know, get that stuff answered in great detail.
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  I have not seen anything in particular that was missed exactly.
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  If anything, I think that, you know, our pediatricians are so aware of these
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  things now that we see so many patients in our cardiology clinic for these issues now.
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  And rightfully so. You know, we've had unique cases, you know,
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  not unlike this cheerleader that you mentioned.
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  And so it's super scary for people.
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  There are several patients who come to my clinic whose parents eventually let
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  me know how many energy drinks they're having. And then we kind of talk about
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  that and realize, oh, maybe this is what was causing my symptoms to begin with.
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  That's not uncommon to see that in clinic. So are you seeing more and more adolescents
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  who are drinking energy drinks?
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  Coffee, energy drinks, all of the above. Yeah, it's much more common now.
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  And it's much more common that
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  they come in with cardiovascular symptoms because of the caffeine intake.
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  It used to be fairly uncommon for us to see that. And it's becoming more and more common now.
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  And kids like to hang out at coffee shops. Yeah.
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  Yes. For hours. This has all been so insightful. I really appreciate you being here.
• 23:36
  Yeah, I appreciate your time, Holly. Here on Pediatrics Now,
• 23:40
  I like to promote having a life outside of medicine.
• 23:43
  What do you like to do, Elaine, to unplug?
• 23:46
  I'm pretty boring outside of work. You like to walk? I definitely walk a lot. I do too.
• 23:52
  I live in a neighborhood that's pretty hilly, so it's a great workout.
• 23:55
  Nice. I love to watch movies and read.
• 23:59
  Is there a favorite movie you'd like to recommend? I don't generally like to
• 24:03
  reveal my favorite movie of all time, but I'm going to do it.
• 24:06
  It's The Goonies. Ooh, it's an old movie. Is that scary?
• 24:09
  No, I don't think it's scary. Why does it sound scary to me?
• 24:13
  What is that about? It's about a bunch of kids who go on this adventure and
• 24:17
  eventually save their family home.
• 24:19
  Nice. Okay, so it's called The Goonies. And then are you going on any fun trips
• 24:23
  or anything anytime soon? Yeah, yeah. We've got some trips planned this summer.
• 24:27
  I am definitely going to see my son in Connecticut.
• 24:30
  So that's one of the fun trips planned. He's doing an internship there. Correct. Nice.
• 24:36
  And it'll be hopefully cooler than it is in San Antonio right now.
• 24:40
  I think it is. Yeah. Yeah. And we also, as a family,
• 24:50
  cardiology, thank you so much for being here today on Pediatrics Now.
• 24:55
  Thanks, Holly. Don't forget to click on the link in this podcast for free credit
• 24:59
  that may include CME, MOC, or ethics credit, depending on our topic or podcast.
• 25:05
  Our sister podcast is Pediatrics Now for Parents. We'll have a shorter parent-friendly
• 25:10
  version that's meant to be one less thing you have to say in the exam room.
• 25:15
  The website for that is pediatricsnowforparents.com. Our website is pediatricsnowpodcast.com.
• 25:22
  Please send me your episode ideas and requests.
• 25:27
  Coming up next week, GLP-1s. You've heard a lot about it.
• 25:32
  Adolescents are taking it. There's a lot less bariatrics.