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Clown therapy for procedural pain in children: a systematic review and meta-analysis

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Abstract

Among the distraction techniques used for the non-pharmacological management of acute pediatric pain, one of the most performed is clown therapy. Despite the presence in the literature of some systematic reviews that evaluate its effectiveness, none of them examines its outcomes on procedural pain which has therefore been investigated in this study. The literature search for randomized controlled trials (RCTs) was performed on the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus over a time frame ranging from each database setup date to 31 July 2021. The primary outcome was the procedural pain of children. We used the Cochrane Risk of Bias tool to assess the risk of bias of the included studies. Six RCTs were selected for this review, which included a total of 517 pediatric subjects. Children undergoing clown therapy during the venipuncture or peripheral vein cannulation procedure reported less pain than those exposed to the standard of care (SMD =  −0.55; 95% CI: −1.23, 0.13) but the result was not found to be statistically significant. School-aged children and adolescent reported significantly less pain (SMD =  −0.51; 95% CI: −0.92, −0.09). Compared to the standard of care, children’s anxiety was significantly lower with clown therapy (SMD =  −0.97; 95% CI: −1.38, −0.56).

Conclusion: Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution.

What is Known:

• Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain.

• Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates.

What is New:

• Clown therapy seems effective in reducing procedural pain and anxiety in children.

• The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom.

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Availability of data and material

Additional data may be available upon request to the corresponding author.

Code availability

No custom code was developed for the present study. All software employed are open source.

Abbreviations

CAPS:

Children Anxiety and Pain Scale

CI:

Confidence interval

NRS:

Numerical rating scale

RCTs:

Randomized controlled trials

RR:

Relative risk

SMD:

Standardized mean difference

STAI:

State-Trait Anxiety Inventory

VAS:

Visual analog scale

WBFPRS:

Wong-Baker Faces Pain Rating Scale

WBFPRS-R:

Baker Faces Pain Rating Scale-Revised

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Author notes

  1. Viviana Fusetti and Luca Re contributed equally.

Authors and Affiliations

  1. Pain Therapy and Rehabilitation Unit, Palliative Care, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy

    Viviana Fusetti, Alessandra Pigni, Antonino Tallarita & Augusto Tommaso Caraceni

  2. Bachelor School of Nursing, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Luca Re, Silvia Cilluffo & Maura Lusignani

  3. Università Degli Studi Di Milano, Milan, Italy

    Luca Re, Silvia Cilluffo, Augusto Tommaso Caraceni & Maura Lusignani

  4. Università Degli Studi di Roma, Tor Vergata, Roma, Italy

    Viviana Fusetti

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Contributions

All authors contributed to the study’s conception and design. Material preparation, data collection, and analysis were performed by Luca Re and Viviana Fusetti. The first draft of the manuscript was written by Luca Re and Viviana Fusetti, and was later revised by Alessandra Pigni, Antonino Tallarita, Silvia Ciluffo, Augusto Caraceni, and Maura Lusignani. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Viviana Fusetti.

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Fusetti, V., Re, L., Pigni, A. et al. Clown therapy for procedural pain in children: a systematic review and meta-analysis. Eur J Pediatr 181, 2215–2225 (2022). https://doi.org/10.1007/s00431-022-04440-9

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