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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Children Anxiety and Pain Scale
Numerical rating scale
Randomized controlled trials
Standardized mean difference
State-Trait Anxiety Inventory
Visual analog scale
Wong-Baker Faces Pain Rating Scale
Baker Faces Pain Rating Scale-Revised
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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
- Clown therapy
- Procedural pain