Social media has revolutionized the way we share information, both for better and for worse. Over the past decade, there has been a surge in Internet challenges that pose significant risks to children. From the infamous cinnamon challenge in 2012 to the Tide Pod challenge in 2016 and the nutmeg challenge in 2020, these viral trends have resulted in severe harm to young individuals. They have spread like wildfire through various platforms such as YouTube, Facebook, and, more recently, TikTok.

TikTok, a social media platform that allows users to view and share short videos tailored to their interests, has gained immense popularity since its launch in 2017. With over 1 billion users worldwide, it has become a center for entertainment and even public health messaging. However, just like any other social media platform, TikTok is not immune to misinformation. What is particularly concerning is that 32.5% of TikTok users are teenagers, who are impressionable and likely to engage in various challenges they come across on the platform.

One such challenge that gained traction on TikTok was the “Benadryl challenge.” In August 2020, Johnson & Johnson, the makers of Benadryl, issued a warning after a 15-year-old girl died from ingesting a large amount of diphenhydramine, the active ingredient in Benadryl. This challenge encouraged users to consume excessive amounts of diphenhydramine to experience a high and document their reactions. Subsequently, numerous cases of diphenhydramine poisoning emerged, prompting the US Food and Drug Administration to issue a warning in September 2020.

Diphenhydramine toxicity and treatment

Diphenhydramine, a first-generation antihistamine, has been around since 1946. It works by blocking histamine and muscarinic receptors in the body. The antimuscarinic effects of diphenhydramine contribute to its potential for abuse. In fact, the abuse of antimuscarinic agents, including diphenhydramine, has been documented for centuries. The recent shift, however, is towards self-harm, with a significant increase in reported cases among individuals aged 10 to 25 in the United States since 2011.

The symptoms of diphenhydramine toxicity are primarily due to its antagonism of muscarinic receptors. This can lead to a range of effects, including increased heart rate, dry mouth, dilated pupils, urinary retention, flushed skin, and delirium. Not all patients will exhibit the full spectrum of symptoms, but many will experience delirium and dilated pupils without an increased heart rate. Sedation and an increased risk of seizures are also common due to the antihistaminic effects of diphenhydramine. Moreover, the drug can block sodium and potassium channels in the heart, potentially causing dangerous heart rhythm abnormalities.

Treatment for diphenhydramine toxicity is mainly supportive. Agitation and seizures are typically managed with benzodiazepines. In cases where patients have QRS segment prolongation on an electrocardiogram, sodium bicarbonate may be administered to counteract the effects of diphenhydramine on the heart. Physostigmine, a reversible inhibitor of acetylcholinesterase, can be used to relieve delirium and agitation by increasing the amount of acetylcholine in the brain. However, the use of physostigmine varies among healthcare providers depending on their comfort and regional practices. Monitoring the heart, respiratory system, and urinary function is crucial during treatment, and creating a calm environment can help reduce agitation. Most patients will recover within 24 hours.

Conclusion

It is imperative for pediatricians to be aware of and discuss the risks associated with challenges like the TikTok Benadryl challenge. This dangerous trend has already resulted in death and significant morbidity. Early recognition of signs and symptoms of diphenhydramine toxicity, along with proper supportive management using benzodiazepines, sodium bicarbonate, and, if necessary, physostigmine, is crucial for positive outcomes. For assistance, healthcare professionals can reach out to their local poison centers by calling 800-222-1222.

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