DOI: 10.1542/peds.2012-3418; originally published online April 22, 2013;
Pediatrics
Amelia Grant-Alfieri, Judy Schaechter and Steven E. Lipshultz
''Cinnamon Challenge''Ingesting and Aspirating Dry Cinnamon by Children and Adolescents: The
located on the World Wide Web at:The online version of this article, along with updated information and services, is
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
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Ingesting and Aspirating Dry Cinnamon by Childrenand Adolescents: The
“
Cinnamon Challenge
”
The
“
Cinnamon Challenge
”
entails swallowing a tablespoon of groundcinnamon in 60 seconds without drinking
fl
uids. However, as stated onwww.cinnamonchallenge.com, this challenge is practically impossible,decidedly unpleasant, and potentially harmful. The site warns:
“
Do notattempt the cinnamon challenge without talking to a doctor. Obviously they [sic] are going to tell you not to do it. [It] can be dangerous andshouldn
’
t be taken lightly. You never want to purposely or mistakenlyinhale any substances such as cinnamon. It
’
s going to burn, you aregoing to cough, and regret you tried.
”
1
Videos of people attempting the Cinnamon Challenge have become anInternet sensation. Typically, a video reveals a group of adolescentswatching as someone taking the challenge begins coughing andchoking when the spice triggers a severe gag re
fl
ex in response toa caustic sensation in the mouth and throat. As of August 10, 2012, there were 51100 YouTube clips depicting the Cinnamon Challenge.One video was viewed
.
19 million times, predominantly by 13- to 24-year-olds, ages similar to people taking the Cinnamon Challenge andassociated with the greatest need for conformity.These videos have raised concerns of choking, aspiration, and pul-monary damage. In most cases, the effects are temporary, yet theCinnamon Challenge has led to dozens of calls to poison centers,emergency department visits, and even hospitalizations for adoles-cents requiring ventilator support for collapsed lungs.
2
RESULTS FROM PRECLINICAL STUDIES
Cinnamon is a caustic powder composed of cellulose
fi
bers, which arebioresistant and biopersistent; they neither dissolve nor biodegrade in the lungs. We found no studies of cinnamon inhalation in humans, but 1study of rats examined the pulmonary effects of a single intratrachealdose of 2 mg of cellulose in 2 test groups (particle sizes, 7.6 and 4.2
m
m).
3
Mild multifocal granulomatous in
fl
ammation was observed 2 to30 days after exposure. More serious consequences, such as granulo-mata, interstitial
fi
brosis, alveolar histiocytosis, alveolar lipoproteinosis,and alveolar cell hyperplasia, occurred 3 to 6 months later, and gran-uloma and thickened interalveolar septa with worsened in
fl
ammationand
fi
brotic lesions were apparent 1 year later.In a second study, rats receiving single intratracheal doses of 15 mg(particle size
,
7
m
m) of cinnamon dust and cellulose dust had
AUTHORS:
Amelia Grant-Al
fi
eri,
a
,
b
Judy Schaechter, MD,MBA,
c
,
d
,
e
and Steven E. Lipshultz, MD
a
,
b
,
d
,
e
,
f
a
Division of Pediatric Clinical Research,
b
Program in Pediatric Integrative Medicine,
c
Division of Adolescent Medicine,
d
Department of Pediatrics, University of Miami Leonard M. Miller School of Medicine, Miami, Florida;
e
Holtz Children
’
s Hospital of the Jackson Health System, Miami, Florida; and
f
Batchelor Children
’
s Research Institute, Miami, Florida
KEY WORDS
cinnamon, particulate inhalation, pediatrics, respiratory effectswww.pediatrics.org/cgi/doi/10.1542/peds.2012-3418doi:10.1542/peds.2012-3418Accepted for publication Feb 25, 2013Address correspondence to Steven E. Lipshultz, MD, Departmentof Pediatrics (D820), Leonard M. Miller School of Medicine,University of Miami, PO Box 016820, Miami, FL 33101. E-mail:slipshultz@med.miami.eduPEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:
The authors have indicated they have no
fi
nancial relationships relevant to this article to disclose.
FUNDING:
Supported in part by the US Department of Healthand Human Services Health Resources and ServicesAdministration (HRSA-C76HF15614-10679, Pediatric IntegrativeMedicine Research Center), the National Center for ToxicologicalResearch (NCTR-E0728711), the L. Coulter Foundation (Division of Pediatric Clinical Research), and the Batchelor Foundation(Batchelor Children
’
s Research Institute). This work wassupported by the National Institutes of Health, Bethesda, MD(HL111459, HL109090, HL078522, HL053392, HL079233, HL087000,HL095127, HD060325, NR012885, CA127642, CA068484, HD052104).Funded by National Institutes of Health.PEDIATRICS Volume 131, Number 5, May 2013
833
PEDIATRICS
PERSPECTIVES
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evidence of damaged lung elasticity andalveobronchiolitis at days 1 and 7 andevidence of
fi
brotic changes at 1 month.
2
Thus, cellulose is not inert and is in fact the component of cinnamon responsiblefor inducing pulmonary
fi
brosis.
4
In rats receiving a single intratrachealdose (15 mg; particle size
,
5
m
m) of cellulose dust, alveobronchiolitis andgranulation developed 1 month afterexposure.
5
Three months after exposure,granulation in the alveolar and bron-chial lining indicated
fi
brotic changes.These results con
fi
rm that high cellulosecontent can trigger a hypersensitive air-way and irritate mucous membranes.
CLINICAL EFFECTS OF CINNAMON
The temporary responses to cinnamonare common to several substances andprobably do not increase the risk of long-term damage. Reports of causticand allergic responses to cinnamon-containing household food or personalhygieneproductsarerare,andcinnamon-
fl
avored cereals and toast are usuallybenign. However, attempts to swallowa large quantity of dry cinnamon carrya real risk of aspiration. At least 30participants nationwide have requiredmedical attention.
6
Cinnamon inhala- tion can cause pulmonary in
fl
amma- tion, predisposing airways to epitheliallesions and scarring. Aspirated pow-der entering the upper airways cancause in
fl
ammation and, in more severecases, aspiration pneumonia. Thus, theCinnamon Challenge may pose greaterand unnecessary health risks for personsallergic to cinnamon or with broncho-pulmonary diseases, including asthma.In humans, the
fi
bers and other com-ponents of cinnamon can also causeallergic andirritant reactions, includingacute symptoms and temporary, if notpermanent, lung function changes.As an allergen, cinnamon may also trigger a hypersensitivity-inducedasthma attack. Although asthma isfairly controllable, it can be fatal if theairways swell and close, suffocating the patient.In 2011, the US American Association of Poison Control Centers received 51calls related to the Cinnamon Chal-lenge.
6
For the
fi
rst 6 months of 2012, there were 178 such calls, or
∼
0.03%of the 600000 total calls received in this period. Of these 178 calls, 122(69%) were classi
fi
ed as intentionalmisuse or abuse (consistent with theCinnamon Challenge), and
∼
30 (17%)required medical attention. The surgein calls during 2012 coincided with theincreased number of Cinnamon Chal-lenge videos on YouTube.
2
According to the Florida Poison In-formation Center
–
Miami, between July2011 and June 2012, there were 26calls regarding cinnamon exposurein individuals ranging from age 1.5 to83 years. Most patients had only minorconsequences that resolved after di-lution, irrigation, and washing the af-fected area, and most did not requirefollow-up. Of the 5 cases that did in-volve follow-up, symptoms resolvedin 1 to 2.5 hours. Of the overall 26cases, 13 (all youths aged 8
–
18 years)involved the Cinnamon Challenge. Of these 13 cases, 2 had
“
potentially toxic
”
exposures. Common symptomsincluded coughing and burning of themouth, nose, and throat. More serioussymptoms included extensive cough-ing, vomiting, nosebleed, and chest tightness. With only 1 exception (eme-sis), possible aspiration and pulmonarysymptoms were limited to adolescents,all of whom had ingested dry powderfrom the Cinnamon Challenge. Although the known health risks of the challengeare relatively low, they are unnecessaryand avoidable.The Cinnamon Challenge is a behavioralphenomenon, a popular dare fueled bypeer pressure that, along with com-petition, often instigates risk-takingbehaviors among adolescents. In fact, the large Internet presence and peerpressure are what have increased thepopularity of the Cinnamon Challenge.The total number of Google hits on this topic rose from 0.2 million in 2009 to 0.9million in 2010; to 2 million in 2011; and to 2.4 million in the
fi
rst half of 2012.Claiming an immense increase inpopularity from 2001 to 2007, the Cin-namon Challenge Web site in January2012 boasted 70000 Twitter mentionsdaily.
7
Its presence on social mediasites has been augmented with postingsby celebrities and even governmentof
fi
cials posting their own CinnamonChallenge videos.Given the allure of social media, peerpressure, and a trendy new fad, pedia- tricians and parents have a
“
challenge
”
of their own in counseling tweens and teens regarding the sensibilities of thechoices they make and the potentialhealth risks of this dare. Counseling canmodify risk behaviors related to peerpressure, such as preventing tobaccoand alcohol use, pregnancy, and expo-sure to sexually transmitted diseases.Parents should be reminded that theiradvice matters in countering peer pres-sure. Furthermore, schools and pedia- tricians should be encouraged to discusswith children the Cinnamon Challengeand its possible harmful effects, espe-cially with children having cinnamonhypersensitivity, asthma, pulmonary cys- tic
fi
brosis, or chronic lung disease.Although we cannot make a strongstatement on documented pulmonarysequelae in humans, it is prudent towarn that the Cinnamon Challenge hasa high likelihood to be damaging to thelungs. These discussions can also helpchildren learn to weigh the risks andrewards of yielding to peer pressurewhen considering senseless and riskybehaviors.
ACKNOWLEDGMENTS
We thank Richard S. Weisman, PharmD,Andrew A. Colin, MD, and Vivian Franco,MPH, for assistance with the prepara- tion of the manuscript.
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GRANT-ALFIERI et al
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