Energy Drinks: The New Eye-Opener For Adolescents

doi:10.1016/j.cpem.2007.12.002

Clinical Pediatric Emergency Medicine

Volume 9, Issue 1, March 2008, Pages 35-42

https://doi.org/10.1016/j.cpem.2007.12.002 Get rights and content

The availability of caffeine-containing energy beverages, combined with aggressive marketing and “urban legend,” has promoted their widespread use, particularly among adolescents. The caffeine content of these products is presently unregulated. Rapid growth in the consumption of these supplements has resulted in increasing reports of caffeine poisoning. This article provides a review of caffeine's pharmacokinetics and describes the clinical manifestations and management of caffeine toxicity. Suggestions for future research are also offered.

Section snippets

Caffeine

The key ingredient in most energy drinks is caffeine, supplemented by a wide variety of amino acids, B vitamins, and herbal supplements [3]. Caffeine is found in a wide variety of beverages and pharmaceuticals, and has been called the most commonly used psychoactive substance in the world [4]. Major sources in the North American diet include coffee and tea for adults, and carbonated sodas, energy drinks, and chocolate for children and adolescents. A range of caffeine concentrations are found in

Guarana and Other Caffeine-Containing Ingredients

Guarana is derived from the seeds of Paullinia cupana, a South American plant known for its stimulant properties. Guarana contains large amounts of caffeine (4%-8%), theobromine, theophylline, and a high concentration of tannins [11]. Although caffeine concentration may vary widely in guarana preparations, 3 to 5 g of guarana provides approximately 250 mg of caffeine [12]. The effects of guarana ingestion are necessarily similar to caffeine; however, the duration of action may be much longer

Pharmacokinetics of Caffeine

Caffeine, or 1,3,7-trimethylxanthine, is rapidly and completely absorbed after oral ingestion, with nearly 100% bioavailability [34]. Ingested caffeine reaches peak plasma concentration within approximately 30 to 120 minutes, depending on gastric contents. Caffeine is 10% to 35% protein bound and is rapidly redistributed from blood to all tissues [35]. It readily crosses the blood-brain barrier and placenta, and can be found in breast milk 36, 37. Its volume of distribution is 0.61 L/kg [38].

Pharmacology

As a member of the methylxanthine family, caffeine is a structural analog of adenosine and a functional adenosine receptor antagonist [47]. Antagonism at presynaptic alpha-1 receptors leads to an increase in peripheral catecholamine release with subsequent activation of postsynaptic β-adrenergic receptors [48]. The resulting norepinephrine, dopamine, and serotonin release in the brain reverses the centrally mediated adenosine effects of sedation and anticonvulsant activity [6]. Caffeine also

Clinical Manifestations, Toxicity

In 2005, more than 4600 calls were made to the American Association of Poison Control Centers (Washington, DC) for questions regarding caffeine. Of those, 2600 involved patients younger than 19 years, and 2345 required treatment in a health care facility. There were no deaths attributed to caffeine in 2004 or 2005 50, 51. There are no available data on the proportion of these calls credited to energy drink use.

Most caffeine intoxications are mild; adverse effects, such as nausea and

Laboratory Findings

Hypokalemia is the sine qua non laboratory abnormality in caffeine intoxication. The presentation of vomiting, tachycardia, and hypokalemia should prompt a search for methylxanthine or other β-agonist exposure (ie, albuterol, clenbuterol). Hyperglycemia is common in caffeine toxicity, secondary to increased lipolysis, glycogenolysis, and gluconeogenesis [77]. Leukocytosis, mild metabolic acidosis, ketonuria, hypophosphatemia, and hypocalcemia have also been described [61].

Qualitative testing

Management

Treatment of patients with caffeine toxicity must begin with careful and immediate assessment of the patient's airway, breathing, and circulation. Intravenous access must be established and noninvasive monitoring devices used. Oxygen should be administered if necessary, and a fingerstick glucose level should be rapidly obtained. Serum electrolytes, including calcium and phosphorus, should be obtained. Serial electrocardiograms are indicated in any patient with palpitations, chest pain, or vital

Future Research

Several areas require investigation to further characterize the effects of long-term energy drink use in children and adolescents. One of the most worrisome is the combination of energy drinks with alcohol. Urban legend and pop culture have contributed to the mystique that energy drinks may prevent the depressant effects of intoxication when consumed with alcohol [99]. Instead, a recent study described no change in alcohol effects when combined with energy drinks [100]. The potential risk for

Summary

Clinicians should screen for energy drink use among their patients. Screening can identify symptoms related to toxicity and give patients greater understanding of the risks of high-dose and long-term energy drink use. When caffeine toxicity is suspected, immediate consultation with a regional poison control center or toxicologist is recommended. Clinicians should report all suspected cases of energy drink toxicity to a poison control center because the pooled data generated by poison control

Acknowledgments

The authors gratefully acknowledge the assistance of Dr Edward W. Boyer and Mr William B. Hendee in the preparation of the manuscript.

References (104)

R. Ellison et al.
Current caffeine intake of young children: amount and sources
J Am Diet Assoc
(1995)
A.R. Henman
Guarana (Paullinia cupana var. sorbilis): ecological and social perspectives on an economic plant of the central Amazon basin
J Ethnopharmacol
(1982)
J.T. Brosnan et al.
The sulfur-containing amino acids: an overview
J Nutr
(2006)
P.P. Stapleton et al.
Taurine and human nutrition
Clin Nutr
(1997)
H. Dega et al.
Ginseng as a cause for Stevens-Johnson syndrome
Lancet
(1996)
V. Vuksan et al.
Herbal remedies in the management of diabetes: lessons learned from the study of ginseng
Nutr Metab Cardiovasc Dis
(2005)
W.A. Watson et al.
2004 Annual report of the American Association of Poison Control Centers toxic exposure surveillance system
Am J Emerg Med
(2005)
L.A. Reyner et al.
Efficacy of a ‘functional energy drink’ in counteracting driver sleepiness
Physiol Behav
(2002)
J.G. Millichap et al.
The diet factor in pediatric and adolescent migraine
Pediatr Neurol
(2003)
A. Chopra et al.
Resolution of caffeine-induced complex dysrhythmia with procainamide therapy
J Emerg Med
(1995)

S.J. Iyadurai et al.

New-onset seizures in adults: possible association with consumption of popular energy drinks

Epilepsy Behav

(2007)

G.W. Josephson et al.

Caffeine intoxication: a case of paroxysmal atrial tachycardia

JACEP

(1976)

J. Forman et al.

Myocardial infarction resulting from caffeine overdose in an anorectic woman

Ann Emerg Med

(1997)

K.D. Wrenn et al.

Rhabdomyolysis induced by a caffeine overdose

Ann Emerg Med

(1989)

C.C. Appel et al.

Caffeine-induced hypokalemic paralysis in pregnancy

Obstet Gynecol

(2001)

J. Golej et al.

Severe respiratory failure following charcoal application in a toddler

Resuscitation

(2001)

R.V. Nagesh et al.

Caffeine poisoning treated by hemoperfusion

Am J Kidney Dis

(1988)

K. Price et al.

Treatment of caffeine toxicity with esmolol

Ann Emerg Med

(1990)

V.E. Whitehurst et al.

Reversal of acute theophylline toxicity by calcium channel blockers in dogs and rats

Toxicology

(1996)

K.V. Blake et al.

Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline-induced seizures in mice

Ann Emerg Med

(1988)

A. Hoffman et al.

Effect of pretreatment with anticonvulsants on theophylline-induced seizures in the rat

J Crit Care

(1993)

G.A. Bernstein et al.

Caffeine withdrawal in normal school-age children

J Am Acad Child Adolesc Psychiatry

(1998)

N. Shute

Over the limit?. US News and World Report

Foxnews.com

Teens abusing energy boosting drinks, doctors fear

L. Dlugosz et al.

Reproductive effects of caffeine: a review and theoretical analysis

Epidemiol Rev

(1992)

R. Gilbert et al.

Caffeine content of beverages as consumer

Can Med Assoc J

(1976)

P. Nawrot et al.

Effects of caffeine on human health

Food Addit Contam

(2003)

N.L. Benowitz

Clinical pharmacology of caffeine

Annu Rev Med

(1990)

J.R. Hughes et al.

A systematic survey of caffeine intake in Vermont

Exp Clin Psychopharmacol

(1997)

Health Canada

It's your health: caffeine

R.R. McCusker et al.

Caffeine content of energy drinks, carbonated sodas, and other beverages

J Anal Toxicol

(2006)

Guarana. In: AltMedDex System [intranet database]. Greenwood Village CVG (Colo): Thomson Micromedex; 2007. Available...

Food Safety Promotion of Board

A review of the health effects of stimulant drinks: a final report from the Food Safety Promotion Board

C.F. Haskell et al.

A double-blind, placebo-controlled, multi-dose evaluation of the acute behavioural effects of guarana in humans

J Psychopharmacol

(2007)

W.C. Heird

Taurine in neonatal nutrition—revisited

Arch Dis Child Fetal Neonatal Ed

(2004)

M.L. MacDonald et al.

Nutrition of the domestic cat, a mammalian carnivore

Annu Rev Nutr

(1984)

J.T. Coon et al.

Panax ginseng: a systematic review of adverse effects and drug interactions

Drug Saf

(2002)

E. Ernst

The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava

Ann Intern Med

(2002)

C.A. Ries et al.

Agranulocytosis caused by Chinese herbal medicines. Dangers of medications containing aminopyrine and phenylbutazone

JAMA

(1975)

K. Janetzky et al.

Probable interaction between warfarin and ginseng

Am J Health Syst Pharm

(1997)

R.K. Siegel

Ginseng abuse syndrome. Problems with the panacea

JAMA

(1979)

S. Braganza et al.

Riding high on energy drinks. Modern medicine

P.E. Lheureux et al.

Science review: carnitine in the treatment of valproic acid-induced toxicity—what is the evidence?

Crit Care

(2005)

S. Russell

Carnitine as an antidote for acute valproate toxicity in children

Curr Opin Pediatr

(2007)

Carnitor

Carnitor (levocarnitine) tablets and oral solution, and Carnitor SF sugar-free oral solution package insert

M. Soop et al.

Influence of carnitine supplementation on muscle substrate and carnitine metabolism during exercise

J Appl Physiol

(1988)

J. Decombaz et al.

Muscle carnitine after strenuous endurance exercise

J Appl Physiol

(1992)

E. Brass

Supplemental carnitine and exercise

Am J Clin Nutr

(2000)

Bodybuilding.com

l-Carnitine information and product listing: an amino acid that helps with fat loss

M.J. Arnaud

The pharmacology of caffeine

Prog Drug Res

(1987)

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Single Dose of an Energy Dietary Supplement with a Small Amount of Caffeine Prevents an Increase of a Low Frequency Resting State EEG in Possible Mental Fatigue
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Due to the increasing needs to enhance our cognitive performance, and decrease fatigue with increasing number of tasks in our everyday life, it’s interesting to study whether a small amount of active substance present in dietary supplements, is enough to impact cognition. We investigated an acute effect of an energy dietary supplement containing low amount of caffeine (55 mg) and other stimulatory ingredients by means of a resting state EEG in a double blind, placebo controlled study (N = 47, 27 women). The use of a nonparametric cluster-based permutation analysis allowed us to observed a significant group × block interaction effect after 90 minutes post-ingestion (P = 0.022 cluster corrected) in the ‘eyes closed’ condition, i.e. an increase in normalized rsEEG power in the placebo group, which was abolished in the study group. This difference corresponded to a broad spatio-spectral cluster between around 6.5 Hz and 10.5 Hz (i.e. high theta and low alpha band) maximal over centro-temporo-parieto-occipital scalp areas. Similar trend but without significant effect was found in the ‘eyes open’ condition. Our results suggest that low caffeine content dietary supplementation acts as a reversal of the fatigue-related brain activity in the neural networks active in the resting state. These findings not only may help to clarify previous nonconclusive findings, but more importantly, show that an ingestion of caffeinated stimulants before neurocognitive examinations, both in research and diagnostics, should be taken into account, as they may influence cognition, even in small doses and when the effects are absent in the behavioral measures.
A case of refractory ventricular fibrillation after caffeine poisoning successfully treated by supportive care
2022, Toxicology Reports
Caffeine (1,3,7-trimethylxantine), a structural analog of adenosine, is widely used as a central nervous system stimulant in beverages and drugs. Caffeine overdose induces hypokalemia, fatal ventricular fibrillation, and cardiac arrest, resulting in death. We describe a case of caffeine overdose that presented with refractory ventricular fibrillation that was treated with supportive care because invasive care for severely ill patients was limited due to the COVID-19 pandemic. A 20-year-old woman with no underlying medical history ingested 90,200-mg caffeine tablets (total dose 18 g) in a suicide attempt. She was transported to the emergency department 45 min after ingestion with dizziness, palpitations, nausea, and vomiting. She developed cardiac arrest 80 min after ingesting the caffeine, with refractory ventricular tachycardia that recurred for about 2.5 h. Advanced life support including defibrillation was started immediately and we gave intravenous Intralipid emulsion, potassium chloride, amiodarone, and esmolol, without hemodialysis or extracorporeal membrane oxygenation (ECMO). The ventricular fibrillation was stopped 4 h after ingestion. As supportive care, mechanical ventilation, sedatives, and neuromuscular blockade were continued until 12 h after ingestion. Although she suffered from prolonged, refractory ventricular tachycardia, she recovered without complications. This case report describes the clinical course of severe caffeine intoxication without an active elimination method, such as hemodialysis or ECMO and explores the treatment of caffeine intoxication with a literature review.
Prevalence and associated factors to energy drinks consumption among teenagers in the province of Barcelona (Spain)
2021, Gaceta Sanitaria
Analizar la prevalencia del consumo de bebidas energéticas en estudiantes de cuarto curso de Educación Secundaria Obligatoria de la provincia de Barcelona, y su asociación con características sociodemográficas y hábitos de salud.
Estudio transversal que incluyó 8078 alumnos de centros educativos, seleccionados aleatoriamente, de 41 municipios de la provincia de Barcelona. Utilizando la Encuesta sobre hábitos relacionados con la salud se recogieron características sociodemográficas y de salud. Variables analizadas: consumo de bebidas energéticas, características sociodemográficas, hábitos de salud y prácticas de riesgo. Se realizó un análisis descriptivo y bivariado. Para analizar los factores asociados al consumo de estas bebidas se utilizaron modelos de regresión logística, ajustados por sexo y edad, considerando significativo un valor de p < 0,05.
El 30,9% había consumido bebidas energéticas en la última semana. Según el modelo, el consumo fue mayor en los varones (odds ratio [OR]: 3,29; intervalo de confianza del 95% [IC95%]: 2,82-3,83), migrantes de primera generación (OR: 2,46; IC95%: 2,01-3,03) e hijos de padres sin estudios (OR: 3,15; IC95% 2,08-4,77). No desayunar (OR: 1,53; IC95%: 1,17-2,00), la práctica deportiva (OR: 1,40; IC95%: 1,11-1,75), el consumo habitual de alcohol (OR: 1,51; IC95%: 1,19-1,91) y tabaco (OR: 1,79; IC95%: 1,33-2,41), y un peor rendimiento escolar (OR: 2,21; IC95%: 1,47-3,32) resultaron factores de riesgo.
El uso de bebidas energéticas es frecuente en la población adolescente, con un patrón de consumo que varía según las características sociodemográficas, destacando el papel del sexo y los hábitos de riesgo para la salud. Una mayor evidencia sobre el consumo y sus factores de riesgo permitirá desarrollar estrategias preventivas eficaces.
To analyse the prevalence of energy drinks consumption among 4 th year high school students in the province of Barcelona (Spain), and its association to sociodemographic characteristics and health related habits.
Cross-sectional study including 8078 students from randomly selected high schools in 41 municipalities. Sociodemographic and health characteristics were collected from the Questionnaire on health related habits. Studied variables: energy drinks consumption, sociodemographic characteristics, health related habits and risk behaviours. Descriptive and bivariate analyses were performed. To analyse the factors associated with energy drinks consumption, logistic regression models were used, adjusting by sex and age and considering significance at p-value < 0.05.
30.9% of the sample consumed energy drinks during the last week. According to the model, consumption was higher among men (odds ratio [OR]: 3.29; 95% confidence interval [95%CI]: 2.82-3.83), first generation migrants (OR: 2.46; 95%CI: 2.01-3.03), and children of parents without studies (OR: 3.15; 95%CI: 2.08-4.77). Not having breakfast (OR: 1.53; 95%CI: 1.17-2.00), practising sport (OR: 1.40; 95%CI: 1.11-1.75), regular alcohol (OR: 1.51; 95%CI: 1.19-1.91) and tobacco (OR: 1.79; 95%CI: 1.33-2.41) consumption, and a worse school performance (OR: 2.21; 95%CI: 1.47-3.32), were also risk factors for energy drinks use.
Energy drinks consumption is a prevalent habit among adolescents. Its pattern varies depending on sociodemographic characteristics, with gender playing a relevant role. Health related habits and risk behaviours have been associated too to energy drinks use. Further evidence regarding consumption and its risk factors will allow the development of effective preventive strategies.
Consider Going Decaf: An Intentional Caffeine Overdose in the Emergency Department
2020, Journal of Emergency Medicine
Caffeine (1,3,7-trimethylxanthine) is a naturally occurring compound found in plants and is the most utilized drug in the world. An estimated 89% of U.S. citizens and 80% of people worldwide consume caffeine on a regular basis. The prevalence of caffeine supplementation by individuals has been increasing in body-weight regulation (e.g., weight loss, body building). When used in excessive amounts it can precipitate serious health consequences, including death. Given this, and the ease of accessibility, caffeine has been seen in intentional overdose. However, suicide attempts via caffeine overdose are rare. In 2017, the American Association of Poison Control Centers reported 3765 cases of caffeine overdose, of which 650 were intentional and none resulted in death from caffeine alone. An ingestion of 5 g (80–100 mg/kg) is likely to prove fatal.
We present the case of a suicide attempt via caffeine with a reported 20-g overdose, which would be an estimated blood caffeine level of 427.1 mg/L. The patient was given activated charcoal and treated for symptomatic tachycardia and diaphoresis. He was ultimately evaluated by Psychiatry and was discharged home with no adverse outcomes from his intentional overdose. We also examine the physiology of the potential adverse effects of caffeine use and the current literature related to caffeine overdoses.
Caffeine is consumed by billions of individuals globally. It is rarely associated with death, but can cause a variety of adverse effects including tachydysrhythmias, hypokalemia, seizures, and rhabdomyolysis. Caffeine overdoses should be treated immediately with activated charcoal if within the appropriate timeframe of 1–2 h post-ingestion, and special attention should be given to the cardiovascular effects of caffeine, as tachydysrhythmias may prove fatal.
Caffeinated energy drink consumption and predictors of use among secondary school students over time in the COMPASS cohort study
2019, Preventive Medicine Reports
Citation Excerpt :
Caffeinated energy drinks (CEDs) commonly contain a moderate to high level of caffeine, stimulating herbal supplements, and sugar or sugar derivatives (McCusker et al., 2006; Health Canada, 2015a). Evidence suggests that within the CED market, nearly half of consumers are 25 years of age or younger (Pomeranz et al., 2013; Babu et al., 2008; Clauson et al., 2008). While Health Canada recommends limiting daily caffeine intake among adolescents to ≤2.5 mg/kg body weight, it has been reported that the typical CED available in the Canadian market contains between 80 and 180 mg of caffeine (Health Canada, 2013; Health Canada, 2015b).
Consumption of caffeinated energy drinks (CED) by youth is a public health priority, given the lack of regulation and evidence for both short and long-term health effects of CED use. Considering the potential risks associated with excessive caffeine consumption, this paper examined CED consumption and predictors of CED use over time in a large sample of Canadian secondary school students participating in the COMPASS study.
Using linked longitudinal data (n = 4949) from the first three years of the COMPASS study (2012/13 to 2014/15), three logistic Generalized Estimated Equation models were performed to examine predictors of weekday CED use, weekend CED use, and weekly CED use.
The prevalence of weekly CED use remained fairly consistent across the three years of follow-up; 12.5% in year-1, 11.3% in year-2, and 11.4% in year-3. Smokers and marijuana users at follow-up were all at greater odds of weekday or weekly CED use, regardless of baseline use. Binge drinkers at baseline were at greater odds for weekday or weekly CED use, but not if they started binge drinking after their baseline year. Marijuana users at follow-up were all at greater odds of weekend CED use, regardless of baseline marijuana use.
>1 in 10 youth reported consuming CEDs one or more times per week, where specific subpopulations of youth, such as marijuana users, appear to be more frequent CED users. Although CED use remained relatively constant over the three-year period examined, prevalence of CED use remains problematic among secondary school students.
Energy drink consumption among German adolescents: Prevalence, correlates, and predictors of initiation
2019, Appetite
Citation Excerpt :
Energy drinks (ED) are beverages that contain high levels of caffeine in combination with other ingredients such as amino acids, sugars or sweeteners, guarana, taurine, ginseng, l-carnitine, herbal supplements, and B vitamins (Babu, Church, & Lewander, 2008; McCusker, Goldberger, & Cone, 2006; Reissig, Strain, & Griffiths, 2009; Seifert, Schaechter, Hershorin, & Lipshultz, 2011).
Energy drinks (EDs) have become popular worldwide. Despite growing concerns about negative health effects of ED, they are increasingly popular among adolescents, yet little is known about the context and patterns of ED use in adolescents.
This study examined the prevalence and correlates of ED use as well as initiation rates and predictors among German adolescents over a one-year period.
A school-based longitudinal study of 6902 adolescents ages 9–19 years was conducted in 44 schools in six Federal states of Germany in 2016–2018. Demographics, ED use, drug use behavior, advertising exposure, intrapersonal, interpersonal, and community factors were assessed.
Lifetime ED use was reported by 61.7% of the participants, while 21.4% reported past 30-day use. In two multilevel models, lifetime and past 30-day ED use were positively associated with male sex, older age, drug use, poor dietary habits, higher BMI, sensation seeking, worse school performance, and more frequent ad exposure (p < .01). One quarter of the non-users initiated ED use in 12 months. ED initiation was positively associated with male sex (AOR, 1.50 [95% CI, 1.11–2.03]), greater sensation seeking traits (AOR, 1.25 [95% CI, 1.08–1.43]), more frequent ED ad exposure (AOR, 1.31 [95% CI, 1.12–1.53]), and curiosity about trying EDs (AOR, 2.31 [95% CI, 1.74–3.07]), while inversely associated with better school performance (AOR, 0.84, [95% CI, 0.73–0.97]) and attending a gymnasium-type school (AOR, 0.69 [95% CI, 0.50–0.96]).
ED consumption is common among German adolescents. The association between EDs and negative health and lifestyle outcomes and risky behaviors is concerning. Parents, school officials, and healthcare providers should be aware of signs and consequences of excessive ED consumption and limit their use by adolescents. Adopting policies that limit the direct marketing to minors under the age of 18 years can be also beneficial in curbing this epidemic.

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Energy Drinks: The New Eye-Opener For Adolescents

Section snippets

Caffeine

Guarana and Other Caffeine-Containing Ingredients

Pharmacokinetics of Caffeine

Pharmacology

Clinical Manifestations, Toxicity

Laboratory Findings

Management

Future Research

Summary

Acknowledgments

J Am Diet Assoc

J Ethnopharmacol

J Nutr

Clin Nutr

Lancet

Nutr Metab Cardiovasc Dis

Am J Emerg Med

Physiol Behav

Pediatr Neurol

J Emerg Med

Epilepsy Behav

JACEP

Ann Emerg Med

Ann Emerg Med

Obstet Gynecol

Resuscitation

Am J Kidney Dis

Ann Emerg Med

Toxicology

Ann Emerg Med

J Crit Care

J Am Acad Child Adolesc Psychiatry

Over the limit?. US News and World Report

Teens abusing energy boosting drinks, doctors fear

Reproductive effects of caffeine: a review and theoretical analysis

Epidemiol Rev

Caffeine content of beverages as consumer

Can Med Assoc J

Effects of caffeine on human health

Food Addit Contam

Clinical pharmacology of caffeine

Annu Rev Med

A systematic survey of caffeine intake in Vermont

Exp Clin Psychopharmacol

It's your health: caffeine

Caffeine content of energy drinks, carbonated sodas, and other beverages

J Anal Toxicol

A review of the health effects of stimulant drinks: a final report from the Food Safety Promotion Board

A double-blind, placebo-controlled, multi-dose evaluation of the acute behavioural effects of guarana in humans

J Psychopharmacol

Taurine in neonatal nutrition—revisited

Arch Dis Child Fetal Neonatal Ed

Nutrition of the domestic cat, a mammalian carnivore

Annu Rev Nutr

Panax ginseng: a systematic review of adverse effects and drug interactions

Drug Saf

The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava

Ann Intern Med

Agranulocytosis caused by Chinese herbal medicines. Dangers of medications containing aminopyrine and phenylbutazone

JAMA

Probable interaction between warfarin and ginseng

Am J Health Syst Pharm

Ginseng abuse syndrome. Problems with the panacea

JAMA

Riding high on energy drinks. Modern medicine

Science review: carnitine in the treatment of valproic acid-induced toxicity—what is the evidence?

Crit Care

Carnitine as an antidote for acute valproate toxicity in children

Curr Opin Pediatr

Carnitor (levocarnitine) tablets and oral solution, and Carnitor SF sugar-free oral solution package insert

Influence of carnitine supplementation on muscle substrate and carnitine metabolism during exercise

J Appl Physiol

Muscle carnitine after strenuous endurance exercise

J Appl Physiol

Supplemental carnitine and exercise

Am J Clin Nutr

l-Carnitine information and product listing: an amino acid that helps with fat loss

The pharmacology of caffeine