Di Rocco et al. Journal of Medical Case Reports 2011, 5:18 http://www.jmedicalcasereports.com/content/5/1/18 Page 5 of 6 Figure 5 Caffeine content of common commercial beverages as compared with FDA-approved safe content of up to 0.02% (6 mg/ounce). In our case series, both patients had essentially normal ECGs, ruling out endogenous cardiac causes for their arrhythmia, and both had admitted to consuming highly caffeinated drinks before atrial fibrillation developed. The patient in Case 1 admitted to consumption of a highly caffeinated beverage the day before his presenta- tion, which was likely metabolized by the time he received medical care; one could argue that he may have had a prolonged caffeine half-life because of his chronic caffeine use. He did complain of the same palpitations after energy-drink consumption earlier that week; per- haps his high caffeine intake led to intermittent atrial fibrillation, which was exacerbated by his vigorous ath- letic activity on the day of presentation. The patient in Case 2 had concurrent ingestion of alcohol with energy drinks and was also taking a base- line stimulant medication at the time of his presentation in atrial fibrillation. It is unclear how these other factors contributed to his arrhythmia; he certainly could have induced atrial fibrillation by alcohol intoxication, espe- cially as his arrhythmia resolved with fluid resuscitation alone. As he did receive medical care within the expected half-life of caffeine, the timeline would fit for atrial fibrillation influenced by caffeine intoxication; the combination of alcohol and caffeine intoxication could have certainly led to his arrhythmia. Conclusion With the increasing popularity of energy drinks in the pediatric and adolescent population, physicians should be aware of the arrhythmogenic potential associated with their consumption. It is important for pediatricians to understand the lack of regulation in the caffeine con- tent and other ingredients of these high-energy bev- erages and their complications, so that parents and children can be educated at well visits and sports physi- cals. We must inform the public on the potential health hazards related to excessive intake of caffeine-containing beverages by children and adolescents; the caffeine con- tent of energy drinks should be better regulated and reported on food labels; and the purchase of energy drinks by the young consumer should be more closely monitored. Given the possibility of cardiac arrhythmias and other untoward effects developing from caffeine use and abuse, further clinical trials reviewing the physiological effects and addictive potential for children and adoles- cents should be pursued, given the paucity of caffeine literature in this age group. Perhaps future studies could evaluate serum caffeine levels in pediatric patients who present with arrhythmias and concurrent caffeine con- sumption; this may be a useful measure to quantify into a risk model, should this correlation continue to be observed. Patient’s Perspective “One night...I felt dizzy and lightheaded. I realized that my heart was beating abnormally fast. My chest felt alien to me because my heart was beating with no set rhythm and was shifting around inside my rib cage. I thought I had somehow knocked my heart loose from its rightful place and now it was swinging about inside my body, beating erratically. I was admitted to the intensive care unit...I was amazed at the professional intensity with which the doctors and nurses performed their duties. The cardiologist told us it could be a fluke occurrence maybe caused by sugar or caffeine intake. I was put on a drug through my IV. The next morning... (my heart rate) had dropped to normal...I was instantly in a more affable mood...Some may say this was the spark that ignited a fire inside me to pursue a career in the medical field.” Consent Written informed consent has been obtained from the patient and parent of a patient who was a minor at the time for publication of this case report and accompany- ing images. Copies of the written consents are available for review by the Editor-in-Chief of this journal. Author details 1The Medical College of Wisconsin, Pediatric Hospital Medicine, Suite C560, CCC, P.O. Box 1997, Milwaukee, WI, 53201-1997, USA. 2Beth Israel Medical Center, 1st Ave at 16th Street, New York, NY, 10003, USA. 3Stony Brook University Department of Pediatric Cardiology, HSC T-11, 040, Stony Brook, NY, 11794-8111, USA. Authors’ contributions JRDR compiled, edited, and wrote the cases and also wrote the abstract, introduction, and discussion, and performed an updated review of the literature. AD initially summarized two cases, performed a literature review,