Consumer Education Considerations in Aromatherapy – Part One: Child Safety Lids

Standard

Online databases of injuries or adverse reactions from essential oils include 251 reports since 2013. American Association of Poison Control Centers report 51,279 incidents of poisoning by essential oils, including one death between 2011 and 2015 (at the date of posting , 2016 data is not available online). There is much debate within the aromatherapy community regarding: pregnancy safety, which oils are safe for children, and specific percentages for dilution. After assessment of the risks, the three main dangers seen in the data are not those but: neat usage of oils (dosage), ingestion, and accidental poisoning of children. New buyers of aromatherapy products, including single bottles of essential oils, need to be taught how to use and store them, safely. The referral to and role of the aromatherapist is often as safety consultant as noted by Jean Valnet, “I must at this stage make it clear that this in no way claims to replace the difficult art of the therapist ‘All is poison, nothing is poison’ said Paracelsus, and in reality the dosage is all-important, for natural essences used carelessly are just as likely to be toxic” (Valnet, 11) Any consumer education program needs to include aromatherapists and be: communicated in language consumers understand, in a format with which they are comfortable and familiar, and including learning tools they need to accomplish that. Consideration of industry use of child-resistant tops, as well as, evaluating new labeling standards might primarily address consumer learning and ultimately reduce essential oil injuries. The goal of this series of posts is to explore risk mitigation for essential oils.

Essential oil safety, a topic of much debate, floods social media, small blogs, and trade journals.  Yet, there are few hard metrics regarding the scope of the problem. Further complicating establishing the extent of the issue, there is limited information regarding how the risks one takes with essential oils compares with those allopathic remedies with similar goals for use (ie: Peppermint (mentha x piperita)/ Eucalyptus (eucalyptus Radiata) blend versus Children’s Mucinex in a 3 year old). Effective consumer education is needed. However, without a clearly articulated problem statement, succinct guidelines built on consensus, and a systematic means of communication with the end consumer there is limited probability of the development of broad safety standards . There are three types of resources on adverse reactions and injuries used in this paper: historical, trade, and institutional data.

Historical Data

Essential Oil Safety Second Edition by Tisserand and Young contains historical data on injuries. For each oil with the textbook, literature on adverse reactions that could be found in public records are listed. Injuries and deaths contain nearly a century of data.

Trade Data

There are two data points within the Aromatherapy Trade for reporting harm. Tisserand Institute Adverse Reaction Database and Atlantic Institute of Aromatherapy Injury Report.

Tisserand Institute Adverse Reaction Database is run by aromatherapist and safety expert, Robert Tisserand. It is less than a year old. Atlantic Institute of Aromatherapy Injury Report is run by aromatherapist and educator, Sylla Shephard-Hangar and is three years old. Both are online forms. Both are self-reported.  Neither was controlled for duplicate data in the other.

Tisserand Institute Adverse Reaction Database (ARD), “… is a collection of self-reported adverse reactions to essential oils. Each report has been verified by personal contact and further questioning and is accompanied by images where possible. The ARD was created to underline the potential dangers that do exist when essential oils are used inappropriately. It should be emphasized that most people never have an adverse reaction to essential oils. However, inappropriate use does increase risk.” (Tisserand, 2016)

The database currently contains 38 incidents including: two anaphylaxis, 21 undiluted use, two minimal dilution, three at 50% dilution. 70% of injuries were dermal with no or limited dilution. (See note at end of paper regarding current data)

Atlantic Institute of Aromatherapy Injury Report contains 213 incidents since its inception. In 2016 there were 83 reports. Of those: 46 reported undiluted use, 33 involved ingestion, there were 11 migraines, and one incident which included a subsequent heart attack

Institutional Data

“The American Association of Poison Control Centers (AAPCC) supports the nation’s 55 poison centers in their efforts to prevent and treat poison exposures. Data is uploaded to their National Poison Data System every 8 minutes. The AAPCC works with America’s 55 poison centers to track poisonings and their sources, including household products, food and beverages, chemicals in the workplace and home, environmental toxins, drugs and medicine, and animal and insect bites and stings.” The 2016 report was not available at the time of writing. Incidents are not coded in the document according to topical, internal, or inhalation except when death occurs. However, cross-referencing the information with news sources, shows that incidents have doubled since 2011 and that accidental ingestion by children is the most common form of poisoning, although improper topical application was common as well. (AP Press, 2016), (FOX13 Salt Lake City, 2016) Although some of the calls to local Poison Control resulted in emergency room visits, ER data is kept by state and no national database was found to retrieve data. Going through each state’s database was too large of a task for the scope of this project.

Summary

  2012 2013 2014 2015
Notation Essential oils made the list of the top 25 substances with the most increased injury reporting. Essential oils made the list of the top 25 substances with the most increase of serious exposures. Essential oils made the list of the top 25 substances with the most increase of serious exposures One death
Incidents 10,729 11,032 13,069 16449
Children ~ 7913    (74%) 7875   (72%) 9258   (71%) 12,027   (73%)
Major Outcomes 8 11 4 10
Page references 25, 211 26, 194 29, 128 141

One death is listed due to essential oils. Upon further investigation, it is unclear if this actually was cinnamon essential oil that was ingested or the herb. The report states the child was eating cinnamon rather than drinking. The description sounds more like the culinary spice. The incident reports states. “Acute cinnamon ingestion and aspiration: probably responsible. Scenario/Substances: A 4 y/o male was eating cinnamon, coughed, choked, and presented to the ED in cardiac arrest. Clinical Course: The patient was unable to be resuscitated and died in the ED. Autopsy Findings: Cause of death: cinnamon aspiration. Manner of death: accidental. “ The author will report this as a death by essential oils in alignment with the AAPCC report.

Risk Assessment

According to the National Association of Holistic Aromatherapy: “Safety involves a state of being free from risk or occurrence of injury, harm, or danger.” (NAHA) Even situations one might assume is risk free like drinking a cup of coffee (Center for Justice and Democracy) most or walking on the street (Coscarelli, 2014) would be hard pressed to say that something is of no risk or occurrence of injury, harm or danger. Safety standards might be better described as mitigating risk rather than free from risk.

Risk assessment is varied. According to the US Government, “A risk assessment is the process of identifying potential hazards … and analyzing methods of response if exposure occurs.” (US Department of Homeland Security, 2016). Pros and cons are weighed often with corporations, organizations and individuals accepting certain calculated risks. Ultimately, they look at how the benefits might outweigh the potential risks or that contain the least amount of risk. A hazard is weighed, the specific vulnerability assessed and finally the impact analyzed.

But the definition of safety from some aromatherapy resources sets up a mindset that zero risk is not only possible but the goal of aromatherapists. It is this author’s humble opinion that is not realistic and sets up an unattainable standard. Clearly some people are willing to take risks while others will not. Customers are willing to take risks. After all, in spite of many warnings, including the eyebrow raising warning to “Seek immediate medical help if you experience an erection lasting more than 4 hours.”, had roughly $2 billion in sales in 2016. Often, aromatherapists suggest natural supplements in lieu of essential oils to mitigate risk. However, poisoning due to vitamins and mineral supplements far surpass the number of poisonings due to essential oils.

Comparison

  2014 2015
Vitamin Supplements 65,733 (159) 66,384 (164)
Mineral Supplements 29,377 (95) 29,067 (160)
Essential Oil 13,069 16,449

Ultimately, that is the topic this series of posts hopes to address: What educational vehicles might be effective for an aromatherapist to use to reasonably assist in risk assessment for end consumers? Safety should not be proprietary but a goal. Many consumer education models might embrace a calculated risk and educated choice rather than seek to remove all risk.

Aromatherapist as Consumer Educator

Aromatherapy training for many people comes with the expectation that there will be a financial return on investment for their education. For some that might be a new career in aromatherapy and for others, like massage therapists or doulas, just adding another component to their current practice. This training should set an aromatherapist’s skills aside from those of the general practitioner. According to Shirley Price “Aromatherapy is a treatment designed to help by the correct use and application of essential oils obtained from plants”. Emphasis added on the word correct. (Price, 7) Unlike a new user of essential oils, an aromatherapist should have the ability to increase effective use of oils and mitigate their risk. What that looks like and how that can be communicated to the end consumer can be a topic of debate.  There are few items on a store shelf from a chain saw to Tylenol that would require the buyer to buy books, seek training, or need a trade professional to safely use.  Yet, that is the situation for many buying essential oils at a local market.

At this time, it appears that the main vehicles for safety education in this trade are Google and Facebook. Unfortunately, what is safe is not necessarily agreed upon and contentious. There is no consensus and as an outsider, it appears that it would be difficult gain accord amongst thought leaders in the community. “Aromatherapy is complex in many ways …. The oils used, although simple in that each is the pure, natural product of a single plant, are complex potent substances that need to be used with care, knowledge and experience”. (Lawless, 14).

For many, referral rather than educational empowerment is the answer to tough usage situations. “The art of the disclaimer reached new levels of perfection. A particularly pointless example, repeated in book after book, was the admonition that essential oils should only be ingested under the supervision of a licensed physician – when all the authors were keenly aware that there were only a handful of conventional physicians who knew anything about essential oils:.  (Schnaubelt, 73) This author would add that the same conundrum is apparent when the words “licensed physician” are replaced with “aromatherapist trained in aromatic medicine”, the numbers are few and “Yellow Pages” absent. The role of the aromatherapist, though, need not just be as in person consultant but perhaps as writer of health education policy, tools, and resources. The communication of safety factors for the use of items that affect one’s wellness fall under the realm of health education.  Educators need to meet the consumer where they are at. They are online, on their mobile devices and with their aromatherapy products.

Child-resistant Lids Addressing Child Accidental Poisonings

The majority of essential oil injuries reported to Poison Control are accidental exposure to children, that is 37,073 injuries to children 12 and under. The most simple method available to address this is already familiar to consumers – child-resistant lids.  When child-resistant lids were introduced in 1967, they reduced child poisoning by 91%. (Mancini, 2014). Currently the only essential oil required by the Poison Packaging Prevention Act of 1970 to use a child-resistant cap, is wintergreen (gaultheria procumbens) if containing more than 5% methyl salicate. The only company, that I know, which offers child-resistant lids on all of their oils is Florihana. However, Robert Tisserand has a list of 46 more toxic oils that he suggest use child-resistant caps, including wintergreen. (Tisserand, 651-65) It is perhaps obvious to most consumers that anything with a child-resistant cap needs extra care. Without language, just in packaging, a safety message is communicated. The ultimate questions here are, if assessing the risk that 72.5% of all poisonings were children and the majority of those due to accidental ingestion: 1. Could this help prevent it? 2. Would the industry be willing to consider it? 3. Would companies with dissenting safety opinions find this to be a workable safety standard to adopt?

CONCLUSION AND DISCUSSION:

Industry Packaging Recommendations to Prevent and Reduce Injuries

The original vision for this paper was to look at mobile Apps as a viable means of consumer education. Self-serving I admit. However, upon delving into the data regarding injuries, adverse reactions and poisonings; the difference between a 1% and 2% dilution in lavender in a nine- year old, whether blue chamomile theoretically could interact with Welbutrin, and if it was unethical to recommend ginger to a woman with severe morning sickness seemed to lessen in their importance in addressing safety. Malcolm Gladwell in Blink (Gladwell, audiobook disc 5) explains that simplicity and frugality in decision making are often essential to finding what is most important and upon which to focus. What, when looking at the information from American Association of Poison Control Centers, is apparent in the blink of an eye? 72% of injuries, that is 37,073 injuries are to children and overwhelmingly accidental. That is what is apparent in the blink of an eye. In the big picture from that point of view, child poisonings, is the most important item. Upon a second blink utilizing the trade data, dermal reactions are the next most important.

Kurt Schnaubelt wrote, “Developing a sense for the real side effects of essential oils is something every lay individual with a modicum of common sense will easily accomplish” (Schnaubelt, 76) Buyers of essential oils need to be given the opportunity and information to use common sense and Facebook and Google should not be the easiest resources to which to turn. Consumer education programs need a clearly articulated problem statement, succinct guidelines built on consensus, and a systematic means of communication with the end consumer.

Data from trade resources and National Poison Control document well over 50,000 injuries in the past six years. 72% of injuries, that is 37,073 injuries are to children and overwhelmingly accidental. This is the problem. I would argue that the fact that an oil has a child-resistant lid on it inherently communicates that it is to be handled with care.

Child-resistant caps might address the problem and meet recommendations to effectively communicate with the essential oil consumer. In order to prevent and reduce injuries and adverse effects, perhaps the essential oil industry and aromatherapy trade might find a few items of consensus and focus directly on those few items, such as risk mitigating packaging. This might be a means to create critical mass and foster future discussions throughout the industry on other safety issues.

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Bio: Nancy, a formally trained aromatherapist, holds two masters in education and developed the national gluten-free curriculum GREAT as the director of education for the health non-profit Beyond Celiac. Nancy lives with celiac disease and lupus and incorporates a strict gluten-free diet and essential oils into her wellness choices. She can be contacted at:  Nancy@TheBardsApothecary.com and http://www.TheBardsApothecary.com. Nancy created The Bards App (available for both iphone and Android) as an accessible and affodable educational tool for the end consumer.

NOTE: Since this post was written, on 12/11/17 Robert Tisserand Essential Training Facebook Page posted the following: “One year ago, the Tisserand Institute launched its Safety Pages, together with a detailed Adverse Reaction Database. The database now has 60 cases, many accompanied by photos. Most of these are skin reactions, but we are now vetting some cases of inhalation.
The reports are verified with the person who filed them, and commented on by Robert Tisserand, who offers insights into why the reaction happened, and what lessons can be learned.
Please bear in mind this database is not meant to scare you off using aromatherapy, but rather to point to potential dangers. Perhaps the main take-away is that virtually any essential oil can cause an adverse skin reaction, and the concentration makes a difference – undiluted application carries a higher risk. Most users will never experience such reactions, but we are advocating for safe use – minimizing risk without taking away benefits.”

Resources for series of posts

American Association of Poison Control Centers National Poison Data System Annual Report 2012 Retrieved from: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2012_NPDS_Annual_Report.pdf

American Association of Poison Control Centers National Poison Data System Annual Report 2013 Retrieved from: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2013_NPDS_Annual_Report.pdf

American Association of Poison Control Centers National Poison Data System Annual Report 2014 Retrieved from: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2014_AAPCC_NPDS_Annual_Report.pdf

American Association of Poison Control Centers National Poison Data System Annual Report 2015 Retrieved from: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2015_AAPCC_NPDS_Annual_Report_33rd_PDF.pdf

American Herbal Products Association: Trade Requirement and Guidance Policy for Labeling of Undiluted Essential Oils Used Topically and Offered for Retail Sale. Retrieved from: http://www.ahpa.org/Portals/0/PDFs/Policies/Guidance-Policies/AHPA_Labeling_Undiluted_Essential_Oils_Topical.pdf?ver=2016-04-26-145908-950

AP Press. (2016) Tennessee Poison Control Center warns of toxicity of essential oils.

Retrieved from: http://wate.com/2016/05/11/tennessee-poison-control-center-warns-of-toxicity-of-essential-oils/

Atlantic Institute of Aromatherapy Injury Report. Retrieved from: http://aromatherapyunited.org/injury-reports/injury-reports-2016/

Baker, N. (2015) The Bards App. Retrieved from: http://www.thebardsapothecary.com/the-bards-app.html

Center for Justice and Democracy. McDonalds’ Hot Coffee Case – Read the Facts NOT the Fiction. Retrieved from: McDonalds’ Hot Coffee Case – Read the Facts NOT the Fiction

Coscarelli, J. (2014) New York Magazine. Falling Air Condition Hits Woman in Head, Reigniting Every New Yorker’s Mostly Irrational Fear. http://nymag.com/daily/intelligencer/2014/09/nyc-fear-falling-air-conditioners.html

doTERRA (2014) Approved Claims List. Retrieved from: https://doterra.com/US/en/flyers-approved-claims-list

FOX13 News Salt Lake City. (2016). Retrieved from: http://fox13now.com/2016/12/26/poison-control-calls-related-to-essential-oils-doubled-since-2011/

Gladwell, M.(2005) Blink. New Your, NY. Little, Brown and Company. Audiobook.

Gladwell, M. (2002) The Tipping Point. New York, NY. Little, Brown and Company.

Lawless, J.  (1997) The Complete Illustrated Guide to Aromatherapy. Barnes and Noble.

Mancini, M. (2014). The Surprising Origins of Child Proof Lids. http://mentalfloss.com/article/54410/surprising-origins-child-proof-lids

National Association for Holistic Aromatherapy. Safety Information.
Retrieved from https://www.naha.org/explore-aromatherapy/safety/

Price, S. (1987) Practical aromatherapy: How to use essential oils to restore vitality. London, UK. Harper Collins Hammersmith.

Schnaubelt, K. (2011) The Healing Intelligence of Essential Oils
Rochester, VT, Healing Arts Press

Shutes, J. & C. Skipper. (2015). French Aromatherapy Certification Course. School for Aromatic Studies.

Tisserand Institute Adverse Reaction Database (ARD) Retrieved from http://tisserandinstitute.org/safety/adverse-reaction-database/#introduction/

Tisserand Institute (2015)  Are Eucalyptus and Peppermint Safe for Young Children? Retrieved from: http://tisserandinstitute.org/learn-more/kids-inhalation-safety/

Tisserand, R. & Young, R. (2014) Essential Oil Safety Second Edition, 147-163
New York, NY, Churchill Livingston Elsevier

Thompson, C. (2012) Aromatherapy Certification 101.  Essence of Thyme. British Columbia, Canada.

Thompson, C. (2012) Aromatherapy Certification 201. Essence of Thyme. British Columbia, Canada.

US Department of Homeland Security. Ready. Risk Assessment. Retrieved from https://www.ready.gov/risk-assessment

United State Consumer Product Commission. (2013) Poison Prevention Packaging Act Business Guidance. Retrieved from: https://www.cpsc.gov/Business–Manufacturing/Business-Education/Business-Guidance/PPPA

Valnet, J MD (1990) The Practice of Aromatherapy Rochester, VT Healing Arts, Press.

Woodward, V.A. (1991) The Complete Book of Essential Oils and Aromatherapy. Novato, CA. New World Library.

 

 

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