Under the influencers 

The brain is integrally dependent on oxygen. Within seconds to minutes, neurons deprived of oxygen suffer and die. In stroke patients, “time (to reperfusion) is brain,” with an estimated one million neuronal casualties per second. Without intervention, damage leads to permanent disability, vegetative states, coma—and in the worst extremes, brain death.  

I write this as a neurointensivist who cares for patients with devastating neurologic injuries and as a father. A recent TikTok challenge—the “Black Out” challenge promoting asphyxia resulted in the death of a young man named Mason. However, this trend predates TikTok. From 1995-2007 nearly 90 young people have died related to this trend, according to the CDC. Advocacy groups resulting from these tragedies estimate as of 2024, close to 200 people have died. But this probably underestimates the true impact; most are deemed suicides rather than accidental deaths.  

Once the domain of autoeroticism, this is now being promoted for its thrill and euphoria among our children, a vulnerable audience driven by an epidemic of external validation. Through challenges like consuming Tide pods, tablespoons of cinnamon, to spray paint torches and plastic bags over the head, influencers drive culture in an unfiltered and unencumbered way, amplified by artificial intelligence-based targeting algorithms to challenge their viewers to do ever more dangerous and extreme things in a desire to get likes, emojis, followers, and thumbs up. My daughters are part of this culture: this desire to “break the internet” and become the next viral sensation. In its most insidious form, popularity and fleeting fame consume the better judgement of our kids who disregard their own safety and common sense.   

When a trend goes viral it gains false legitimacy and grows legs. Children and many young adults lack the sophisticated executive functioning to determine how dangerous these outcomes can be. In an asphyxia challenge, participants are urged to put themselves in a vulnerable position on the brink of loss of consciousness. But once that threshold is passed, there is no self-correcting mechanism—you cannot undo what you’ve done because you’ve incapacitated yourself. You die. Or perhaps someone finds you when you have a few neurons left and are neurologically devastated, fully dependent on others. Even for the “winners” (those who only briefly lose consciousness and quickly recover) hypoxia causes structural neuronal changes, brain chemistry derangements, and cell death. This is the price of fame. 

We’ve regulated adversaries like big tobacco with their Joe Camel campaigns from influencing our children, yet the internet provides unfettered access to any influencer’s next great challenge in the name of freedom of speech and expression. Like parental concern for supervision on a playground and knowing who their children interact with, we should be equally concerned with who they “play” with on the internet.  

Clinicians should remind parents to be mindful of what their children are watching and to regulate this content, discuss the concept of viral challenges, and reinforce the values of safety and self-respect over fame and adoration.  

As a medical community, these principles are essential to the safety and survival of our children. The social media environment deserves more scrutiny and more protection against harm to young people. Perhaps more concerning is that the same unregulated, unsupervised platforms that require no peer review, no critical thinking, and upend centuries of medical practice based on the scientific method, are increasingly popular as “references” for our patients and trainees. Faster, easier and sexier than opening a book, Tiktok provides all the information you need to try something new—if only once. 

Author’s email: aschiav1@jhmi.edu

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.