Skip to main content

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


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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

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.



Children Anxiety and Pain Scale


Confidence interval


Numerical rating scale


Randomized controlled trials


Relative risk


Standardized mean difference


State-Trait Anxiety Inventory


Visual analog scale


Wong-Baker Faces Pain Rating Scale


Baker Faces Pain Rating Scale-Revised


  1. Pisani MA, Ely EW (2006) Monitoring and treatment of pain, anxiety, and delirium in the ICU. Clinical critical care medicine. Mosby Inc., Maryland Heights, pp 51–59

    Chapter  Google Scholar 

  2. Fein JA, Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine, American Academy of Pediatrics (2012) Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics.

    Article  PubMed  Google Scholar 

  3. Pancekauskaitė G, Jankauskaitė L (2018) Paediatric pain medicine: pain differences, recognition and coping acute procedural pain in paediatric emergency room. Medicina.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S (2019) Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Paediatr Child Health.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ali S, Chambers A, Johnson DW, Newton AS, Vandermeer B, Williamson J, Curtis SJ (2014) Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians. CJEM.

    Article  PubMed  Google Scholar 

  6. Krauss BS, Calligaris L, Green SM, Barbi E (2016) Current concepts in management of pain in children in the emergency department. Lancet.

    Article  PubMed  Google Scholar 

  7. Ali S, McGrath T, Drendel AL, Amy LDO (2016) An evidence-based approach to minimizing acute procedural pain in the emergency department and beyond. Pediatr Emerg Care.

    Article  PubMed  Google Scholar 

  8. Cooke MW (2013) UK Ambulance Service Clinical Practice Guidelines 2006. Accessed 28 July 2021

  9. Dionigi A (2017) Clowning as a complementary approach for reducing iatrogenic effects in pediatrics. AMA Journal of Ethics.

  10. Manyande A, Cyna AM, Yip P, Chooi C, Middleton P (2015) Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev.

  11. Messina M , Molinaro F, Meucci D, Angotti R, Giuntini L, Cerchia E, Bulotta AL, Brandigi E (2014) Preoperative distraction in children: hand-held videogames vs clown therapy. Pediatr Med Chir.

  12. Chen E, Joseph MH, Zeltzer LK (2000) Behavioral and cognitive interventions in the treatment of pain in children. Ped Clin North Am.

    Article  Google Scholar 

  13. Berk LS, Tan SA, Fry WF, Napier BJ, Lee JW, Hubbard RW, Lewis JE, Eby WC (1989) Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci.

    Article  PubMed  Google Scholar 

  14. Vagnoli L, Caprilli S, Robiglio A, Messeri A (2005) Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics.

  15. Vagnoli L, Caprilli S, Messeri A (2010) Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Pediatric Anesthesia.

  16. Dionigi A, Sangiorgi D, Flangini R (2013) Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol.

  17. Lopes-Júnior LC, Pereira-da-Silva G, Silveira DS, Veronez LC, Santos JC, Alonso JB, Lima RA (2018) The effect of clown intervention on self-report and biomarker measures of stress and fatigue in pediatric osteosarcoma inpatients: a pilot study. Integrative Cancer Therapies.

  18. Lopes-Junior LC, Silveira DS, Olson K, Bomfim EO, Veronez LC, Santos JC, Lima RA (2020) Clown intervention on psychological stress and fatigue in pediatric patients with cancer undergoing chemotherapy. Cancer Nursing.

  19. Ortiz MI, López-Zarco M, Edna JAB (2012) Procedural pain and anxiety in paediatric patients in a Mexican emergency department. J Adv Nurs.

  20. Könsgen N, Polus S, Rombey T, Pieper D (2019) Clowning in children undergoing potentially anxiety-provoking procedures: a systematic review and meta-analysis. Syst Rev.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lopes-Júnior LC, Bomfim E, Olson K, Neves ET, Calheiros Silveira DS, Rodrigues Nunes MD, Nascimento LC, Pereira-da-Silva G, Garcia Lima RA (2020) Effectiveness of hospital clowns for symptom management in paediatrics: systematic review of randomised and non-randomised controlled trials. BMJ.

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  Google Scholar 

  23. Ucun Y, Küçük L (2020) Terapötik Palyaço Müdahalesinin Çocukların Ruh Sağlığına Etkisi: Sistematik Derleme. Jaren.

    Article  Google Scholar 

  24. Higgins JP, Altman DG, Gøtzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Cohen J (1998) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates, Hillsdale

    Google Scholar 

  26. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Calderón MA, Boyle RJ, Penagos M, Sheikh A (2011) Immunotherapy: the meta-analyses. What have we learned? Immunol Allergy Clin North Am.

  28. Sterne JA, Egger M (2001) Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol.

    Article  PubMed  Google Scholar 

  29. Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics.

  30. Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Bmj.

  31. Begg CB, Mazumdar M (1994) Operating characteristics of a rank correlation test for publication bias. Biometrics.

    Article  PubMed  Google Scholar 

  32. Rosenthal R (1979) The file drawer problem and tolerance for null results. Psychol Bull.

    Article  Google Scholar 

  33. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Guyatt GH (2011) GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol.

  35. Meiri N, Ankri A, Hamad-Saied M, Konopnicki M, Pillar G (2016) The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2–10 years old undergoing venous blood drawing-a randomized controlled study. Eur J Pediatr.

    Article  Google Scholar 

  36. Rimon A, Shalom S, Wolyniez I, Gruber A, Schachter-Davidov A, Glatstein M (2016) Medical clowns and cortisol levels in children undergoing venipuncture in the emergency department: a pilot study. IMAJ 18(11):680–683

    PubMed  Google Scholar 

  37. Wolyniez I, Rimon A, Scolnik D, Gruber A, Tavor O, Haviv E, Glatstein M (2013) The effect of a medical clown on pain during intravenous access in the pediatric emergency department: a randomized prospective pilot study. Clin Ped.

    Article  Google Scholar 

  38. Felluga M, Rabach I, Minute M, Montico M, Giorgi R, Lonciari I, Taddio A, Barbi E (2016) A quasi randomized-controlled trial to evaluate the effectiveness of clown therapy on children’s anxiety and pain levels in emergency department. Eur J Pediatr.

    Article  Google Scholar 

  39. Kristensen HN, Lundbye-Christensen S, Haslund-Thomsen H, Graven-Nielsen T, Sørensen EE (2018) Acute procedural pain in children. Clin J Pain.

    Article  PubMed  Google Scholar 

  40. Kurudirek F, Arikan D, Sarialioğlu A (2021) Effects of therapeutic clowning on pain and anxiety during venous blood sampling in Turkey: randomised controlled trial. J Spec Pediatr Nurs.

    Article  PubMed  Google Scholar 

  41. Pérez-Aranda A, Hofmann J, Feliu-Soler A, Ramírez-Maestre C, Andrés-Rodríguez L, Ruch W, Luciano JV (2019) Laughing away the pain: a narrative review of humour, sense of humour and pain. Eur J Pain.

    Article  PubMed  Google Scholar 

  42. Koller D, Gryski C (2008) The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. Evidence-based complementary and alternative medicine.

    Article  PubMed  Google Scholar 

  43. Battrick C, Glasper EA, Prudhoe G, Weaver K (2007) Clown humour: the perceptions of doctors, nurses, parents and children. Journal of Children’s and Young People’s Nursing.

  44. Venrooij LT, Barnhoorn PC (2017) Hospital clowning: a paediatrician’s view. Eur J Pediatr.

    Article  Google Scholar 

  45. Kristensen HN, Sørensen EE, Stinson J, Thomsen HH (2019) “WE do it together!” An ethnographic study of the alliance between child and hospital clown during venipunctures. Journal of Pediatric Nursing.

Download references

Author information

Authors and Affiliations



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.

Corresponding author

Correspondence to Viviana Fusetti.

Ethics declarations

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Communicated by Piet Leroy

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Clown therapy
  • Procedural pain
  • Children