Book/journal summary critique

Pediatric Perspectives

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Lori Williams is Clinical Nurse Specialist, Pediatric Universal Care Unit and Float Team, American Family Children’s Hospital, University of Wisconsin Hospitals and Clinics, 1675 Highland Avenue, Room 7404, Madison, WI 53792 ([email protected]).

The author declares no conflicts of interest.

DOI: https://doi.org/10.4037/aacnacc2020931

The use of integrative and complementary practices for health care has increased in the United States during the past decade.1-4 One complemen- tary practice that has become more popular is aromatherapy, the use of con- centrated essential oils extracted from aromatic plant materials (eg, flowers, herbs, leaves, bark, wood, roots, seeds, and peels) to treat illness as well as enhance psychological and physical well-being.2,5,6 The term aromatherapy was initially used by the French chemist Gattefossé in 1936; however, the use of distilled plant materials can be traced back to medieval Persia.6,7 In Notes on Nursing, Florence Nightingale8 described the use of aromatherapy to promote health and healing during the Crimean War.9

Although relatively new to the United States, aromatherapy is used by nurses all over the world10 and has been part of holistic nursing practice in the United Kingdom, Australia, Canada, Germany, and Switzerland for the past 15 years.3,5 The Royal College of Nursing in the United Kingdom accepts aromatherapy, with the exception of internal ingestion, as part of nursing care.10 In the United States, oils currently available for medicinal use are deemed safe by the US Food and Drug Administration,6 and aromatherapy has been recognized by most state boards of nursing as a legitimate part of the provision of holistic nursing.3

Aromatherapy is used by nurses to enhance comfort, promote relaxation, reduce stress and anxiety, improve mood and coping, increase sense of well- being, promote sleep, relieve pain, and minimize postoperative nausea and vomiting, although its mechanism of action is unclear.2,3,5,11 Little evidence supports the clinical use of aromatherapy beyond enhancing relaxation.12 Few empirical studies demonstrate the safety and efficacy or guide practice regard- ing the use of essential oils in humans.12 The pain-relieving aspects of essential oils have not been demonstrated.12

There are very few published trials on the use of aromatherapy as a medical intervention, and the data regarding its effects on health lack scientific rigor.2,12 Available studies are too small, have varied methods of oil application and dose, lack blinding, and have incorrect or absent statistical analysis, making it diffi- cult to determine applicability of the findings in a clinical scenario.5,12 For exam- ple, the use of massage to deliver oils makes it difficult to determine if observed effects are from the oil or the massage. A patient’s psychological association of a smell may also play a role. It remains unclear if aromatherapy use has a transient or sustained effect.2 Additionally, it remains unclear if there is a

Is Aromatherapy a Critical Care Intervention? Lori Williams, DNP, RN, RNC-NIC, CCRN, NNP-BC

Lori Williams, DNP, RN, RNC-NIC, CCRN, NNP-BC

Department Editor

AACN Advanced Critical Care Volume 31, Number 2, pp. 198-202

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cumulative effect after multiple uses.5 The variance in results may be because of the particular essential oil used or the symptom targeted, as each oil has differing effects based on its chemical properties.5 The effects of aromatherapy are difficult to measure and are likely to be small.2 However, aromather- apy is becoming increasingly popular and more prevalent in society1,2,13 and is also the fastest growing type of complementary ther- apy among nurses in the United States.3,10

This column presents current knowledge about the use of aromatherapy in the acute care setting, particularly for children. Advanced practice nurses may be asked by parents or nurses to consider aromatherapy use as an adjunct when traditional therapies are not desired or are not achieving the desired effect. Advanced practice nurses may also be asked to participate in protocol develop- ment to ensure safe administration in the acute care setting.

Selecting an Essential Oil When clinicians use essential oils, they should

be clear about the purpose and intended thera- peutic outcome, since the chemistry of each oil determines its therapeutic properties. Table 1 explores some of the more commonly used essential oils and their therapeutic qualities. The goal for clinicians using integrative ther- apies should be symptom relief not cure.5 Oils should be chosen on the basis of the patient’s preference and treatment goals and should be administered in a way to minimize the risk of inducing side effects.

Oils are typically chosen for their perceived benefits and low risk of interactions with med- ications.4 The most common choices are lav- ender, peppermint, ginger root, sweet orange, rosemary, eucalyptus, mandarin, and Roman chamomile.4,6 Uses may include to decrease

postoperative nausea and vomiting, to decrease use of rescue antiemetics, as an adjuvant to reduce pain, to promote sleep or perceived sleep quality, and to promote a general sense of well-being. Aromatherapy is starting to be combined with guided imagery to reduce fear and anxiety in children4 and has been shown to have an effect when combined with con- ventional treatment in children.17-19

The patient’s history of use of essential oils should be assessed to determine if there are any contraindications to their use. Although essential oils are natural, that does not mean that they are safe to use in all patients or in medically fragile populations.4 Most profes- sional aromatherapists avoid the use of essen- tial oils around newborns and would not advocate use among the neonatal intensive care unit population.4 Contraindications may include age less than 3 years, pregnancy, history of bronchial hyperactivity (asthma), or hypersensitivity leading to migraines.16

It is recommended that use of essential oils in nursing practice be guided by stan- dards and guidelines and by clinicians who have been trained in the use of essential oils.12 RJ Buckle Associates endorses 2 training programs for health professionals: the Clinical Aromatherapy for Health Profes- sionals certification course and the Integra- tive Aromatherapy Certificate.20 Several organizations (eg, the Alliance of Interna- tional Aromatherapists, the National Associa- tion for Holistic Aromatherapy, and the American Holistic Nurses Association) can provide guidance when nurses are learning about the use of essential oils.

Dosing and Administration Development of hospital-based protocols

may be advisable to ensure consistent and safe use of aromatherapy. Safe administration

Abbreviation: PONV, postoperative nausea and vomiting. a Data were derived from Buckle,3 McDowell,9 Maddock-Jennings and Wilkinson,12 Lillehei and Halcon,14 and Lua and Zukaria.15 b Peppermint is not recommended for children younger than 3 years of age.16

Essential Oil Analgesic Anti-

inflammatory Anti-

spasmodic Calming Sedative Well-being PONV Ginger x x x x x Red Mandarin

x x x x x

Lavender x x x x x x Peppermintb x x x x x x x Rose x x x x x x

Table 1: Common Essential Oils and Indications for Usea

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includes consideration of the need for informed consent, staff training, or certification; deter- mination of which oils to use; cost; application method; education of patients; safe storage and disposal; minimization of infection con- trol concerns; whether administration will be by physician order or nursing intervention; documentation of administration; and avail- ability of safety data sheets.4 Supervision of administration in child patients by nurses and parents is essential.

Patient education is critically important. The patient, or parents/caregivers, must under- stand the potential benefits versus risks of aromatherapy use and agree to accept them. Some hospitals require written authorization, whereas others only require verbal agreement.4 It is not necessary to obtain an order from a provider to institute aromatherapy.21

There are many modes of aromatherapy administration (Table 2). The cognitive and developmental needs of the child must be

kept in mind when determining a mode of administration. When clinicians use aroma- therapy, they must consider the fact that many hospitals have fragrance-free policies in place.4 Employees with fragrance sensitivi- ties may claim a workplace disability under the Americans with Disabilities Act if they develop symptoms such as breathing problems, skin rashes, nausea/vomiting, lightheadedness/ dizziness, or headache when exposed to scents.22 The US Equal Employment Opportunity Com- mission oversees complaints by workers; there have been several lawsuits related to reac- tions to aromatherapy in the work setting resulting in multimillion-dollar settlements for some workers.23

Although administration via diffuser is pop- ular in the home, diffuser use is not recom- mended in hospitals and may be prohibited to limit unintended exposure of others. Dif- fuser use can affect respiratory passages, caus- ing irritation of mucous membranes, cough,

Method Technique Advantages Disadvantages

Active diffusion

Ultrasonic diffuser; vibrations agitate water and oil to create a fine mist

Nebulizing type does not use water.

Anyone in room may be affected. Allergies/sensitivities can be triggered. Water reservoir can be a breeding ground

for bacteria and fungi. Risk for electrical shock Tripping hazard from cord

Passive/ warming diffusion

Small electrical heater warms a device; warmth volatizes the oil, carrying it into the air

Scent production limited Risk for electrical shock Tripping hazard from cord

Specimen cup

Oil-soaked cotton ball or gauze square stored inside the cup; Patient inhales oil vapors at will

Inexpensive Readily available Single-patient use Kept at bedside Vapors localized to

patient’s immediate area

Patients with impaired cognitive or motor ability may not be able to open and close the cup.

Container can easily be misplaced. Device might be accessed by smaller

children visiting the patient.

Personal inhaler or “aroma- sticks”

Method of passive diffu- sion; plastic device encloses an oil-soaked fabric core. Patient inhales oil vapors from the device.

Very low cost Lasts days to weeks

Easily misplaced Requires manual dexterity to use Cannot be used by patients who are

sedated, have cognitive impairment, or have limited use of hands

Aromapatch Designed to adhere to skin, gown, or clothing; small reservoir contains several drops of oil; applied near face or upper chest

Small Single use Oils remain in the reservoir

and do not come into contact with skin

Easy to apply Easy to remove Not easily misplaced

Skin irritation from adhesive Higher cost

Table 2: Common Methods of Aromatherapy Administration

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and wheezing for the patient and anyone else in the room. Water in the diffuser chamber can contribute to hospital-acquired infections because of bacterial growth in the water if diffusers are not cleaned properly.4

The most common methods of administra- tion in the hospital are active and passive inha- lation. For active inhalation, 1 to 3 drops of oil are placed on a tissue, cotton ball, or gauze, which is held near the nose for 5 to 10 minutes. The patient may breathe in as much of the scent as desired, then the scent is removed. For passive inhalation, a drop of oil is placed on the patient’s sheet or pillow- case near the head. When essential oils are administered via inhalation, the scent of the oil travels through the olfactory bulb to the limbic system, where the aroma is processed.5

Safety Precautions, Storage, and Disposal

Aromatherapy is thought to be safe and effective with few side effects; however, oils should be kept out of the reach of children. Direct contact near or in the eyes should be avoided, as oils can cause irritation.10 Those administering aromatherapy with essential oils should be cautious about touching or rubbing their eyes because oils can linger on the hands even after washing with soap and water.10 In the event of eye contact, eyes should be irrigated as quickly as possible with milk or a carrier oil (eg, olive, nut, coconut, or vegetable oil) to dilute the essen- tial oil. Eyes should then be rinsed with copi- ous amounts of water or saline solution for the next 1 to 2 hours to minimize chemical burn.10,24 If a skin reaction occurs, dilute the oil on the affected area with a carrier oil, then wash with nonperfumed soap.10 If an oil is taken internally, vomiting should not be induced. The nearest poison control cen- ter should be contacted while the patient is encouraged to drink whole or 2% milk.10 The essential oil bottle should be retained for identification.

Essential oils should be stored in a cool, dark location with the cap tightly closed, because oils are sensitive to changes in tem- perature and light.4 Citrus oils are particu- larly prone to oxidation, so they should be kept in a cool dark place such as a refrigera- tor that is not used for patient food or drink.4 Essential oils should be kept locked in the

inpatient pediatric setting with safety data sheets easily accessible.4

Bottles should be labeled with the date of opening. If stored properly, oils should last up to 1 year after opening. Oils should be disposed of via the regular waste or a sink drain if the bottle has been opened but not labeled, if the cap has been off for an unde- termined length of time, or if the product has been open longer than a year.

It is important to minimize the potential for infection when using aromatherapy. In 2016, an outbreak of drug-resistant Pseudo- monas aeruginosa in an Australian surgical intensive care unit was linked to a bottle of essential oil that had been shared between 7 patients.25 As hospitals have moved to single- patient-use products, there have been no fur- ther reports of infection.

Conclusion At this time, available studies support aro-

matherapy use for the few patients in whom it has been studied. Data do not support use as the sole treatment for any symptom in chil- dren for which it may currently be used. As a treatment, aromatherapy is low cost and has minimal side effects. The popularity of this complementary therapy needs to be balanced with the potential risk of allergies, adverse effects, safety concerns such as the potential for infection or accidental ingestion, and inap- propriate use by uninformed administrators. Larger randomized controlled trials are needed to guide evidence-based administration and achieve optimal outcomes for this therapy.

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10. Buckle J. Aromatherapy. In: Dossey BM, Keegan L, Barrere CC, Helming MA, Shields DA, Avino KM, eds. Holistic Nursing: A Handbook for Practice. 7th ed. Burl- ington, MA: Jones & Bartlett Learning; 2016:345-363.

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