sharifi A, Motaghi M, Borji M, Moradi M. The Effect of Orange Essence Aromatherapy on Anxiety in School-Age Children with Diabetes. Biomed Pharmacol J 2017;10(1).
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The Effect of Orange Essence Aromatherapy on Anxiety in School-Age Children with Diabetes

Ali sharifi1, Minoo Motaghi2, Milad Borji3,4 and Mohsen Moradi5

1Nursing Department, Ilam University of Medical Sciences, Ilam, Iran.

2Nursing Department,Faculty of nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.

3M. Sc Student in Community Health Nursing, Young Researchers and Elite Club, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.

4Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran.

5Research Committee, Ilam University of Medical Sciences, Ilam, Iran.

Corresponding Author E-mail:



This study aimed to determine the effect of orange essence aromatherapy on anxiety in school-age children with diabetes, as anxiety reduction would be expected to have a positive impact on health in this population. This clinical trial enrolled 60 children with diabetes, who were randomized to either the experimental or the control group (30 in each group). For the children in the experimental group, two drops of orange essence were poured on to a strip of gauze inside an open box, which was then held at a 5-cm distance from the child’s nose. The children were then asked to breathe deeply for a span of 2 minutes. The control group received only routine care for diabetes. Data were collected using the Spielberger State-Trait Anxiety Inventory and the Revised Children’s Manifest Anxiety Scale. Data were analyzed using SPSS version 19 to perform descriptive and analytical statistical tests. No significant difference was observed between children's anxiety in the experimental and control groups (P>.05) prior to the use of orange essence aromatherapy. After the therapeutic intervention, the anxiety of the experimental group significantly decreased compared to that before the intervention (P<.05). Orange aromatherapy, which is non-pharmacological and non-invasive, may be a useful complementary medical treatment for the management of anxiety in children with diabetes.


Orange essence; anxiety; diabetes; child

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Diabetes is a health challenge that significantly affects patients’ QOL (1).Type 1 diabetes is a common metabolic disease in children (2). Currently, the reported prevalence of Type 1 diabetes in Iran is between 5% and 10%, and increasing by about 1% annually (3,4). Reflecting its severity, the World Health Organization has called diabetes “a silent epidemic” (5).

Patients with diabetes experience many complications that negatively affect quality of life (QOL), including psychological stress and anxiety (6,7), which are major causes of depression in this patient population.Diabetes canalso reduce concentration and lead to disorders related to decision-making skills. Psychological interventions are thus less effective than might be expected in this patient population (8). Anxiety in a broad sense refers to a vague feeling of fear and responses to internal and external stimuli that reflect cognitive, behavioral, emotional, and physical symptoms.Anxiety is experienced at some point in time by all people and is one of the most common psychological reactions to the beginning of stress (9). In children, anxiety can manifest in symptoms such as persistent inquietude (restlessness), sorrow, or unrealistic fears (10).Reducing anxiety in children who have experienced disease and hospitalization is very helpful for parents and their children (11).

Thephysiological symptoms of anxiety include changes in appetite, muscle tension, headache, lethargy, palpitations, weight change, and sleep disturbance. Anxiety also has emotional symptoms that include reduction in the power of concentration, forgetfulness, futile thoughts, worries, frustration, and irritability.Communicational outcomes of anxiety can include loneliness, having few friends, irritability, reluctance to talk, and lowered tolerance threshold to external stimuli (12).

Medications that reduce anxiety include benzodiazepines, which have often been prescribed by doctors but can lead to nausea, vomiting, and drug dependency (13). The use of non-pharmacological methods such asaromatherapy iscomplementary to pharmacological methods, holistically considering all of the health needs of the patient being treated. This type of treatment has been introduced as a part of holistic nursing (14). Use of aromatherapy has been growing in nursing care as a low-risk treatment that is easy to administer and also inexpensive (15). Also important is thatnurses can independently initiate this treatment(9).

Results of previous studies have shownthat aromatherapy works for skin wound healing and reduction of anxiety, pain, and fatigue (16). Fragrances such as lavender(17), orange (15,18,19), and rose (20) are among those used to reduce stress and anxiety.

A subcategory of sour orange grown in different parts of Iran is currently medically used to either treat or palliate the symptoms of liver disorders, colds, postmenopausal symptoms, digestive disorders, skin rashes, and rheumatism (18). Given the prevalence of anxiety in schoolchildren with diabetes andthe role of orangeessence aromatherapy in reducing anxiety in patients,this research aimsto determine the effect of orange essence aromaon the anxiety ofschool-agechildrenwith diabetesin Ilam, Iran.

Materials and Methods

60 school-age children in Ilam, Iran who had diabetes were randomized 1:1 to an experimental or a control group (n=30 for each group).Inclusion criteria were: having type 1 diabetes, aged 6 to 12 years, living in Ilam, and provided informed consent to participate in the study. Exclusion criteria included non-interest in enrolling, existence of any health or other crisis during the intervention, presence of asthma and allergies, known psychiatricdisorders, sensory and motor disorders, gaining more than 6 points in the polygraph testthat is obtained as part of the Children’s Manifest Anxiety Scale, scores of >40 on the Spielberger State-Trait Anxiety Inventory, or taking anxiety-lowering medications <1 month before or during the intervention.

The aim of the study was first explained to parents and their children. Aromatherapy began after both the children and parents provided informed consent. Data were collected using the SpielbergerState-Trait Anxiety Inventoryand the RevisedChildren’s Manifest Anxiety Scale, and children were excluded from the trial at this point as described above with respect to these test scores.Rash and smell tests were then performed in the children who did not meet any of the exclusion criteria. For the skin allergy test,0.2milliliter of cardamom solution covered with hypoallergenic adhesive was placed undereach child’s arm.During the next evening, children with allergic symptoms on this skin test (redness, itching, or swelling at the placement site) were excluded (21,22). For the olfactory test, the ability to detect the smell oforangesolutionwas considered present when children expressed that they were able to perceive a pleasant aroma(21).

After exclusion of the patientswho scored high on tests for characteristics of anxietyor who had respiratory or skin allergies,children were interviewed to complete the anxious-behavior questionnaire.This questionnaire has37 questionsthatinvestigate the manifestations of anxietyin three distinct areas (physiological, social, and the tendency to worry). Twenty-eight of the 37 questions are related tothese 3 areas(score 0-28), with9 questions related to the polygraph scale (score 0-9). Each question is a yes (score, 1) or no (score, 0) question, with lower scores suggesting lower levels of anxiety. A low polygraph score implies greater levels of sincerity in a child’s responses to the questions.Samples were excluded from the study with polygraph scores of >6 (12,23).The study of Taghavi et al. (24) proved the reliability of this questionnaire.

Children were allocated to the control and experimental groups using an A/B envelope system, in which the names for each group were written down on a piece of paper inside an envelope. Children chose one of these envelopes every day. For the experimental group, aromatherapy was conducted 3 times a week using orange essence (Saturday, Monday, and Wednesday) before bed time for two weeks. The control group continued with their current care. For children in the experimental group, two drops of orange essence were poured on one strip of gauze inside an open box, which was then held at a distance of 5 cm from each child’s nose.Children were asked to breathe deeply for a period of 2 minutes (25). The anxiety questionnaire was filled out before and afterthe intervention for children in both study groups. The researcher’s phone number was provided to children so they could call if they had any questions.

The study design was approved by the Ethics Committee at the University of Medical Sciences. Ethical considerations in this study included random assignment of experimental and control groups, obtaining the informed consent of parents and children, no cost to the patient,and explanation of the nature of the research to patients. The study complied with the guidelines put forth by the Declaration of Helsinki and the Belmont Report. Descriptive and analytical statistics tests were analyzed using SPSS Version 21 . In all cases, the P value was considered significant at<0.05.


Table 1: Demographic profile table-school age children with diabetes before and after the intervention.

Variable Group Pvalue
  Experimental Group Control Group
Gender 0.79
Male 18(60) 17(56.7)
Female 12(40) 13(43.3)
Type of insulin 0.12
70/30 13(43.3) 11(36.7)
Nph & reg 17(56.7) 19(63.3)
Number of insulin injections 0.88
2 times 11(36.7) 12(40)
3 times 8(26.7) 7(23.3)
More than 3 times 11(36.7) 11(36.7) 1
Age 9.53±1.75 9.10±1.66 0.33
Duration of diabetes 3.50±1.81 3.87±1.52 0.4

In Table 2, the means and standard deviations are shown for physiological and social anxiety and for tendency to worry before and after the experiment. Statistical tests showed that the differences between the experimental and control groups were not significant before the experiment (P>.05). After the intervention, the experimental group showed a significant degree of improvement in these three areas (P<.05).

Table 2: Comparison of the mean and standard deviations of anxiety before and after the intervention

Outcome Measure   Experimental Group Control Group
Group Mean(SD) P value Mean(SD) P value
Physiological anxiety Before 6.10(2.36) 0.53 5.63(2.22) 0.44
After 5.10(3.56) 5.57(2.02)
Tendency to worry Before 5.43(2.43) 0 5.87(1.75) 0.43
After 3.00(2.16) 5.93(1.55)
Social anxiety Before 5.47(2.27) 0.02 5.43(1.75) 0.94
After 4.00(2.71) 5.40(1.77)
Anxiety (total) Before 17.00(4.37) 0 16.93(3.91) 0.95
After 12.10(5.54) 16.90(3.67)


This study aimed to determine the effect of orange essence aromatherapy on anxiety in children with type 1 diabetes.The findings of this study showed that aromatherapy with orange essencereduces anxiety in children with type 1 diabetes.Aromatherapy affects children (and adults) in two physiological and psychological ways.Several studies have shown that vegetable oils contain chemical components that havemany effectson mind and feeling (26).Aromatherapy enters the body through the skin or through inhalation(stimulating the olfactory receivers).This allows transmission of messages by the olfactory nerve above the nose to the olfactory bulb, which is adjacent to the limbic system, and leads to an impact on memory, emotions, spirit, and feelings/emotions (27,28).

The findings of this study showed that children’s anxiety significantly decreased in the experimental group after aromatherapy with orange essence. Kanani et al. studied the effects of aromatherapy with orange essenceon the anxiety of patients undergoing hemodialysis; they used a paper tissue wetted with a drop of orange essence for 15 to 20 minutes, three times a week for 4 weeks as aromatherapy.The results showed that after aromatherapy,the manifest and hidden anxiety levels of patients weresignificantly reduced(15).In astudy by Lehrner et al. that compared the impact of aromatherapy with orange or lavender and music therapy on anxiety in patients having dental work found that use of orange essence led to significantly lower levels of anxiety (29),consistent with the results of the present study.

In the study of Rannani et al, orange essence was given as aromatherapy to children with leukemia at frequencies of 3 days per week and 3 times per week, with results show ingthat aromatherapy improved sleep quality in these patients (25).In astudy by Rashidi-Fakkari et al, that aimed to determine the influence of aromatherapy with orange essence on the severity of pain innulliparous women, patients were divided into three groups.Geranium essencewas given to the first intervention group (A), orangeessence was given to the second intervention group(B), and distilled water was provided to the control group.The results showed that pain intensity was significantly reduced in the experimental group receiving orange essence as aromatherapy, but no significant difference was observed between the geranium essence and control groups (30).

One of the strengths of this study is that it addresses a topic that our knowledge has not been previously addressed; specifically, the effect of orange essence aromatherapy on anxiety reduction in children with type 1 diabetes. Among the weaknesses and limitations of this study,it can be pointed out that aromatherapy is not performed by the researcher in actual practice. Rather, training is given to parents and children, who must then use aromatherapy at home. The researchers in this study carried out follow up by phone. Also in this study, a questionnaire was used to assess anxiety; clinical examinations have not been used.


Due to the positive effects of aromatherapy on anxiety in school-age children with diabetes, this complementary treating method, which is a non-pharmacologicaland non-invasive alternative,should be performed to reduce anxiety in children with diabetes as appropriate.

Conflict of Interest

There is no conflict of interest between authors


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