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Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials

An Erratum to this article was published on 10 March 2017


Children and/or their parents are in fear and anxiety when admitted to hospitals or undergo invasive surgeries or investigations. Clown therapy has been shown as an effective measure in reducing this hospital fear and anxiety. Hence, we carried out a systematic compilation of the existing evidence on the clinical utility of hospital clowns in pediatric population. Electronic databases were searched with an appropriate search strategy, and only randomized controlled trials comparing the effect of clown therapy with standard care in children were included. The key outcome measures were as follows: extent of anxiety and pain felt by children and extent of state and trait parental anxiety. Random effect model was applied when moderate to severe heterogeneity was observed. Forest plot, I2 statistics and risk of bias were evaluated using RevMan 5.3 software. A total of 19 studies were found eligible to be included in the systematic review and 16 for meta-analysis. The pooled SMD [95 % CI] for child anxiety score was −0.83 [−1.16, −0.51] favoring clown therapy. Similarly, a statistically significant reduction {SMD [95 % CI] −0.46 [−0.7, −0.21]} in the state anxiety was observed amongst parents.

Conclusion: We found that hospital clowns play a significant role in reducing stress and anxiety levels in children admitted to hospitals as well as their parents.

What is known:
• Trials with clown doctors in pediatric population have shown conflicting results in allaying anxiety amongst children undergoing either hospitalization or invasive procedures
What is new:
• This is the first systematic review and meta-analysis on hospital clowns
• We found out that hospital clowns reduce anxiety amongst children before undergoing either hospitalization or invasive procedures

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Confidence interval


Numerical rating scale


Relative risk


Standardized mean difference


Visual analogue scale


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We thank Prospero for registering this review protocol and Cochrane for utilizing RevMan 5.3 software in generating the pooled results and forest plot.

Authors’ contribution

KS—conceived the idea, analyzed the data, wrote the first draft of the manuscript, and approved the final draft. KS and GS—literature search, identified the studies, extracted the data, revised the draft of the manuscript, and approved the final draft of the manuscript.

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Corresponding author

Correspondence to Kannan Sridharan.

Ethics declarations


No fund was obtained for conducting this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Additional information

Revisions received: 29 June 2016; 2 August 2016

An erratum to this article is available at

Communicated by Jaan Toelen

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Sridharan, K., Sivaramakrishnan, G. Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 175, 1353–1360 (2016).

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  • Hospital clowns
  • Medical clowns
  • Children