A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department

The Effects of Hospital-Based School Lessons on Children's Emotions, Distress and Pain

Lessons conducted in hospitals ensure school continuity for hospitalized children unable to attend regular school. Hospital-based school (HS) provides a tailored experience that ensures normality for children through education. The objective of this study is to evaluate the effects of the proposed lessons in reducing negative emotions, distress, and pain in children, as well as fostering positive affects. The study was conducted with 32 hospitalized children, aged 8-12 years, in the Onco-Hematology and Pediatric Unit of Meyer Children's Hospital IRCCS (Florence, Italy). Positive and negative emotions were measured using the Positive and Negative Affect Scale for Children; distress was measured using the Physiological Hyperarousal for Children; pain was measured using the Visual Analogue Scale for children. Variables were assessed before (T0) and after (T1) lessons, for three times; for each variable, collected data were averaged at both T0 and T1. Statistical analyses showed a significant increase in positive emotions in hospitalized children and a significant decrease in negative emotions, distress, and pain; nevertheless, only for pain the significant correlation between its scores before and after the HS lessons indicated that the detected change occurred for all participants in much the same way. These preliminary results suggest that HS lessons can promote hospitalized children's well-being, at least as far as pain reduction is concerned.

Medical clowning in hospitalized children: a meta-analysis

BACKGROUND

Medical clowning has been proven effective in reducing pain, anxiety, and stress in many sporadic, usually small-scale studies. Our meta-analysis aims to evaluate the efficiency of medical clowns in reducing pain and anxiety in hospitalized pediatric patients and their parents in different medical fields.

METHODS

A thorough literature search was conducted from different databases, and only randomized controlled trials (RCTs) were included with children aged 0 to 18 years old. A total of 18 studies were included, and statistical analysis was performed on the combined data.

RESULTS

A total of 912 children (14 studies) showed significantly reduced anxiety when procedures were performed with a medical clown compared with the controls (- 0.76 on anxiety score, P < 0.001). Preoperative anxiety was lower in 512 children (nine studies) with clown interventions than in the controls (- 0.78, P < 0.001). The pain scale was completed by 338 participants (six studies), indicating a trend toward reduced pain during procedures performed while the clown was acting compared to controls (- 0.49, P = 0.06). In addition, medical clown significantly (- 0.52, P = 0.001) reduced parental anxiety in 489 participants in ten studies; in six of the ten studies, with a total of 380 participants, medical clown significantly reduced parental preoperative anxiety (P = 0.02).

CONCLUSION

Medical clowns have substantial positive and beneficial effects on reducing stress and anxiety in children and their families in various circumstances in pediatrics.

Effect of soap bubbles technique, coughing and distraction cards on reducing pain and anxiety during phlebotomy in children

This study aims to compare three techniques (soap bubbles, distraction cards, coughing) to reduce pain and anxiety in children during phlebotomy and collection with the use of a control group. Pain levels of children were assessed with the Wong-Baker FACES Pain Rating Scale and anxiety levels of children were assessed with the Children's Fear Scale. This randomized controlled study involved intervention groups and a control group. The population of this study consisted of 120 Turkish children (30 subjects in each of the four groups soap bubbles technique, distraction cards, coughing, and control groups) between the ages of 6 and 12. The study found that pain and anxiety levels of the children in intervention groups were lower than those of the children in the control group during phlebotomy procedure and this difference was statistically significant (P < .05). No difference was found among the three techniques (Soap bubbles, distraction cards, and coughing) to reduce pain and anxiety in children during the phlebotomy procedure (P > .05). Soap bubbles, distraction cards and coughing techniques were found to reduce pain and anxiety in children during phlebotomy. Nurses can play an effective role in reducing pain and anxiety by using these techniques.

Motivations and Personal Traits Can Predict Self-Efficacy of the Clown Therapist: A Descriptive Study

The individual and collective perception of self-efficacy in clown therapists is fundamental in order to be able to be active, restrained, energetic and defocused, if necessary, without being overwhelmed by any problems patients might have. The present study evaluated both the incidence of motivational and dispositional functions on the level of perceived self-efficacy with a sample of 259 Italian clown therapists who were administered The Volunteer Self-Efficacy Scale, the Volunteer Process Model and the Italy Personality Inventory. The significance of a hierarchical linear regression model of perceived self-efficacy was tested. The results showed that the value orientation of the operators mainly influenced the level of perceived self-efficacy, that is, the search for actions with a high social meaning, rather than the orientation towards situations and experiences that allow one to expand one's knowledge and promote one's own person. Profiles with higher perceived self-efficacy were associated with the trait of dynamism and conscientiousness, while a person's vulnerability was found to be a significant negative predictor of self-efficacy. An additional significant predictor was the experience of the clown therapist. The results of the study also showed a positive and functional role of the synergy conferred by teamwork. The group mitigates the emotional difficulties of the individual and supports him/her by orienting him/her technically and compensating for any inexperience in the field of animation in sensitive contexts, such as hospital wards with serious and vulnerable patients, such as children.

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.

Managing acute pain in children presenting to the emergency department without opioids

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

Effectiveness of clown intervention for pain relief in children: A systematic review and meta-analysis

BACKGROUND

Pain is common in children receiving medical procedures, and there is a lack of adequate awareness and management. In addition, children who undergo medical procedures involving pain may also experience stress, crying and prolonged hospitalisation. Clown intervention is a promising nonpharmacological intervention. However, studies on the effectiveness of clown intervention in pain management have reported conflicting findings.

OBJECTIVE

To evaluate the effectiveness of clown intervention in relieving pain in children, as well as its effects on cortisol levels, crying duration and length of hospital stay.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

PubMed, Web of Science (SCI), Embase, PsycINFO, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Weipu (VIP), Wanfang Data and SinoMed were systematically searched from inception date to December 31, 2020.

REVIEW METHODS

Two reviewers independently used the Cochrane risk of bias tool to assess the risk of bias of the included studies. Meta-analysis was conducted when data were available, otherwise, a narrative description was provided. Data were analysed using Review Manager 5.3. The review process is reported according to PRISMA.

RESULTS

Nine studies including 852 children met the inclusion criteria. The results showed that compared with standard care, clown intervention was beneficial for relieving pain. Further subgroup analysis showed that it was more effective with children aged 2-7 years. The duration of crying after the procedure and the length of stay were shortened, but there was no significant difference in cortisol levels.

CONCLUSION

Clown intervention may be a promising way to relieve acute pain in children, especially those aged 2-7 years. It also seems to shorten the duration of crying and the length of hospital stays, but the effect on cortisol levels is still uncertain. More high-quality randomised controlled trials are needed to confirm these results and take into account different age groups, cultural backgrounds and specific populations.

The effectiveness of a medical clowning program on improving emotional status among hospitalized children undergoing cancer treatment: A quasi-experimental study

PURPOSE

To examine the effectiveness of one-time medical clowning on improving short-term positive emotions among hospitalized children undergoing cancer treatment, and to analyze whether age moderates this effect.

DESIGN

In this quasi-experimental research study, we recruited a pooled sample of 96 children who were undergoing cancer treatment in pediatric oncology/hematology wards at three university-affiliated medical centers in Taiwan from June 2018 through April 2020.

METHODS

Children's demographic characteristics, symptom distress, quality of life, and pretest emotional status were collected at T1. At T2, we collected only posttest emotional status. We adapted generalized estimating equation models to evaluate the effectiveness of medical clowning on enhancing positive emotions.

FINDINGS

Changes in the probabilities of positive emotion were significantly different across groups (51.84% for the experimental group, 15.76% for the control group; Δ = 36.08, p = 0.001), and the change was more than two times larger for the experimental group (effect ratio = 3.28, p < 0.05) than for the control group. When evaluating the moderating effect of age on the intervention, none of the coefficients reached the significant (p < 0.05) levels, suggesting that age may not moderate the intervention effect.

CONCLUSION

This study demonstrates the core value of medical clowning in child-friendly health care. Our findings clearly support the benefit of the one-time medical clowning program on enhancing short-term emotional well-being across age groups of children. Medical clowning programs should be strongly encouraged and supported in pediatric oncology wards.

CLINICAL RELEVANCE

Medical clowning programs should be widely and continuously implemented in pediatric oncology wards as a routine clinical practice for enhancing emotional well-being among children receiving cancer treatment. Nurses need to be aware of medical clowning's equal effectiveness across age groups, not only or better for younger children.

Reducing Pediatric Patient Anxiety: Implementing a Nonpharmacologic Intervention to Aid Patients Undergoing Radiation Therapy

Pharmacologic interventions are often used to assist with immobilization and decrease anxiety in pediatric patients undergoing radiation therapy. For these patients, distraction can be an alternative to using pharmacologic measures to address anxiety. As a distraction technique, this pilot project placed pediatric patients aged 3 to 6 years in a remote-controlled ride-on car (RC-ROC) to enter and exit the radiation therapy treatment room. Evaluation of the effectiveness of this distraction technique included patient propofol dosing, time sedated, and time in the treatment room, as well as staff satisfaction with the technique.

Effectiveness of hospital clowns for symptom management in paediatrics: systematic review of randomised and non-randomised controlled trials

OBJECTIVE

To evaluate evidence from randomised controlled trials and non-randomised controlled trials on the effectiveness of hospital clowns for a range of symptom clusters in children and adolescents admitted to hospital with acute and chronic conditions.

DESIGN

Systematic review of randomised and non-randomised controlled trials.

DATA SOURCES

Medline, ISI of Knowledge, Cochrane Central Register of Controlled Trials, Science Direct, Scopus, American Psychological Association PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature.

STUDY SELECTION

Randomised and non-randomised controlled trials were peer reviewed using the following eligibility criteria: children and adolescents who were admitted to hospital for acute conditions or chronic disorders, studies comparing use of hospital clowns with standard care, and studies evaluating the effect of hospital clowns on symptom management of inpatient children and adolescents as a primary outcome.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently screened studies, extracted data, and appraised the risk of bias. Methodological appraisal was assessed by two investigators independently using the Jadad scale, the revised Cochrane risk-of-bias tool for randomised controlled trials (RoB 2), and the risk of bias in non-randomised studies (ROBINS-I) tool for non-randomised controlled trials.

RESULTS

24 studies (n=1612) met the inclusion criteria for data extraction and analysis. Most studies were randomised controlled trials (n=13). Anxiety was the most frequently analysed symptom (n=13), followed by pain (n=9), psychological and emotional responses and perceived wellbeing (n=4), stress (n=4), cancer related fatigue (n=3), and crying (n=2). Five studies used biomarkers, mainly cortisol, to assess stress or fatigue outcome following hospital clowns. Most of the randomised controlled trials (n=11; 85%) were rated as showing some concerns, and two trials were rated with a high risk of bias. Most non-randomised controlled trials (n=6; 55%) were rated with a moderate risk of bias according to ROBINS-I tool. Studies showed that children and adolescents who were in the presence of hospital clowns, either with or without a parent present, reported significantly less anxiety during a range of medical procedures, as well as improved psychological adjustment (P<0.05). Three studies that evaluated chronic conditions showed favourable results for the intervention of hospital clowns with significant reduction in stress, fatigue, pain, and distress (P<0.05).

CONCLUSIONS

These findings suggest that the presence of hospital clowns during medical procedures, induction of anaesthesia in the preoperative room, and as part of routine care for chronic conditions might be a beneficial strategy to manage some symptom clusters. Furthermore, hospital clowns might help improve psychological wellbeing in admitted children and adolescents with acute and chronic disorders, compared with those who received only standard care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107099.

Effects of Therapeutic Clowning on Pain and Anxiety During Intrathecal Chemotherapy in Turkey

PURPOSE

The aim of the present study was to explore the effect of therapeutic clowning on pain and anxiety during intrathecal chemotherapy.

DESIGN & METHODS

The study was conducted using a quasi-experimental method with a pretest-posttest control group design. The study sample was composed of children between 7 and 12 years old (N = 78) who had been diagnosed with acute myeloid leukaemia and acute lymphoblastic leukaemia and were undergoing intrathecal chemotherapy in a hospital in Turkey. The study was conducted with children who received services at this hospital. The results were obtained from 74 children (i.e. 36 in the control group, 38 in the clown group). The data were collected with a questionnaire developed by the researchers, the Visual Analogue Scale (VAS) and the Faces Pain Rating Scale (FACES). VAS and FACES were used to measure pain and anxiety levels. Therapeutic clowning was applied to children in the intervention group. Analyses included percentage distributions, mean, chi-square, t-test, variance, and correlation analysis.

RESULTS

Results showed that children in the clown group had significantly lower pain and anxiety than children in the control group (p < .001).

CONCLUSIONS

According to the results, therapeutic clowning was effective in relieving the pain and anxiety of children between the ages of 7 and 12 years who undergone intrathecal chemotherapy.

PRACTICE IMPLICATIONS

Due to its positive effects, therapeutic clowning could be explore for use in other areas of paediatric nursing for the children between the ages of 7 and 12 years as a complementary treatment.

The Efficacy of Distraction Cards and Kaleidoscope for Reducing Pain During Phlebotomy: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to determine the efficacy of distraction cards and a kaleidoscope in reducing pain during phlebotomy procedures among children aged 6 to 12.

DESIGN

This randomized controlled study involved intervention groups and a control group.

METHODS

Data were obtained by the use of an information form and the visual analog scale. Data were analyzed with descriptive statistics as well as Kruskal-Wallis, Wilcoxon, and post hoc tests.

FINDINGS

During the phlebotomy, children in the control group experienced more pain than children in the distraction cards group and kaleidoscope group (P < .001). There was no significant difference between pain scores of the two intervention groups (P > .05). Both methods were found to be effective in reducing pain.

CONCLUSIONS

It may be helpful to inform children and parents about the process before procedural interventions. Nurses would likely benefit from education on the use of distraction cards and kaleidoscope to be used during procedural interventions.

Use of Audiobooks as an Environmental Distractor to Decrease State Anxiety in Children Waiting in the Pediatric Emergency Department: A Pilot and Feasibility Study

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED. Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre-post intervention changes in fear and state anxiety. Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's d _z = 0.22-0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content "a lot" as well as enjoyed listening to the audiobook "a lot." Without prompting, 15% of participants requested to listen to an additional audiobook. Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

Children Listening to Music or Watching Cartoons During ER Procedures: A RCT

OBJECTIVE

This study aims to determine if listening to music and watching cartoons are effective to distract children from pain and distress during procedures in the emergency room (ER).

METHODS

This study is a single-center, 3-armed, superiority randomized controlled trial comparing listening to music, watching cartoons, and standard care during ER procedures in children aged 3-13 years. The primary outcome was pain measured from video footage with the Alder Hey Triage Pain Score (AHTPS). Children older than 4 years self-reported pain with the Faces Pain Scale-Revised (FPS-R). The secondary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). Another indicator of distress was heart rate.

RESULTS

Data of 191 participants were analyzed for the 3 groups: music (n = 75), cartoon (n = 62), and control (n = 54). The median age was 7.3 years (4.9-9.7). In multivariable analysis, pain assessed with the AHTPS was significantly lower (B = -1.173, 95% confidence interval -1.953, -0.394, p = .003) in the music group than in the control groups. Across the 3 groups, 108 children self-reported pain with the FPS-R after the procedure. The scores were lowest in the music group, but the differences between groups were not significant (p = .077). OSBD-r distress scores assigned during the procedures were not significantly different between the 3 groups (p = .55). Heart rate directly after the procedure was not statistically significantly different between the 3 groups (p = .83).

CONCLUSIONS

Listening to recorded music is a beneficial distraction for children experiencing pain during ER procedures, whereas watching cartoons did not seem to reduce pain or distress.

Acute Procedural Pain in Children: Intervention With the Hospital Clown

INTRODUCTION

Hospitalized children often describe needle-related procedures as the worst pain possible and such procedures may be emotionally traumatic. The use of hospital clowns (HCs) related to painful medical procedures in children may offer pain relief, but this has not been systematically evaluated. The objective of this study was to assess the effect of a therapeutic clown in comparison with standard care on the experience of pain in children receiving venipuncture.

MATERIALS AND METHODS

A sample of 116 children aged 4 to 15 years consecutively admitted to the hospital was allocated to either the experimental (presence of HC) or control group (standard care) before venipuncture. Self-reported pain after the procedure was assessed using the Faces Pain Scale combined with a 0 to 10 Numerical Rating Scale. Separate analysis was conducted in age groups from 4 to 6 (N=37) and 7 to 15 (N=74) years.

RESULTS

Without the clown present, the mean pain score (2.7±2.8) was not significantly different between the 2 age groups. Children aged 7 to 15 years had lower pain scores when the clown was present compared with the control group (P=0.025). Children aged 4 to 6 years had higher pain scores with the clown present, although the difference was not statistically significant (P=0.054). Children with pain (N=49) or previous experiences with venipuncture (N=56) did not score pain significantly differently.

DISCUSSION

Assessing the pain experience of children receiving venipuncture with the presence of an HC indicates a pain relieving effect for children older than 6 years. However, future studies should carefully study the effects on younger children where mixed effects may be present.

An ongoing WE: A focused ethnographic study of the relationship between child and hospital clown during recurrent pain‐related procedures and conditions

Aim

This study explored the interaction between child and hospital clown during recurrent hospitalizations for repeated pain‐related procedures and conditions.

Background

Despite improvements in the management of pain in hospitalized children, procedural pain in particular is a common experience for hospitalized children, and they continue to report undertreated pain. Hospital clowns are widely used as a nonpharmacological intervention in hospitalized children. Little research has examined the influence of hospital clowns during recurrent hospitalizations on repeated painful procedures.

Design and methods

Ethnographic fieldwork using focused ethnography was conducted. Data were collected during October–December 2017 using participant observation and informal interviews with children at one pediatric unit at a Danish university hospital. Data include 61 interactions between children aged 4–14 years and hospital clowns. The participants comprised 13 children undergoing recurrent hospitalizations. The data were coded using thematic analysis, and the research team verified the resulting themes.

Results

The overarching theme was defined as An ongoing WE, based on two identified themes, that is, Stronger in a WE and Hope in the WE. The WE was characterized by a responsive interaction between the child and clown, which evolved over the course of an ongoing relationship.

Conclusion

This study demonstrates how an ongoing WE was constructed with children during repeated painful procedures and conditions. Specifically, the study emphasizes the importance of developing a trusting relationship on the child's terms. Children seemed to experience enhanced coping with painful procedures during the recurring hospital clown encounters, thus reinforcing their competence and hope for coping with future painful procedures. These findings may improve psychosocial care for hospitalized children undergoing repeated painful procedures and conditions and may facilitate multidisciplinary initiatives, such as nurses’ advocacy for the inclusion of hospital clowns during recurrent hospitalizations for repeated painful procedures to ensure optimal pain management.

Clowning in children undergoing potentially anxiety-provoking procedures: a systematic review and meta-analysis

BACKGROUND

The operation areas of clowns in the medical context are multifaceted. Clowning in children undergoing surgery has been shown to be able to lessen children's anxiety. Hence, our aim was to assess the effectiveness of clowning on anxiety in children undergoing potentially anxiety-provoking procedures.

METHODS

We searched MEDLINE, CENTRAL, and EMBASE for randomized controlled trials (RCTs) in December 2018. The primary outcome was children's anxiety. We used the Cochrane risk of bias tool to assess risk of bias of the included studies.

RESULTS

We found eleven RCTs including 733 children. Their risk of bias was relatively high. Children undergoing clowning were significantly less anxious in preoperative time compared to parental presence or no intervention (mean difference (MD) - 7.16; 95% CI - 10.58, - 3.75) and in operation, induction, or patient room (MD - 20.45; 95% CI - 35.54, - 5.37), but not during mask application or physician examination (MD 2.33; 95% CI - 4.82, 9.48). Compared with midazolam, children's anxiety was significantly lower in preoperative time (MD - 7.60; 95% CI - 11.73, - 3.47), but not in the induction room (MD - 9.63; 95% CI - 21.04, 1.77).

CONCLUSIONS

Clowning seems to lower children's anxiety, but because of the increased risk of bias of included studies and the very low quality of evidence, these results should be considered with caution.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016039045.

"WE do it together!" An Ethnographic Study of the Alliance Between Child and Hospital Clown During Venipunctures

PURPOSE

Hospital clowns are widely used as a means of non-pharmacological intervention in the treatment of hospitalized children. However, little research has examined the impact of clowns on common painful needle-related procedures. This study explored children's pain experience and their ability to cope during a venipuncture while interacting with a clown in the acute admission unit.

DESIGN AND METHODS

An ethnographic fieldwork study was conducted. Data were collected over a 10-month period through participant observation and informal interviews, supplemented by video recordings. The participants comprised 38 acutely admitted children aged 4 to 15 years undergoing a venipuncture in the presence of a hospital clown. Analysis was structured in three stages: before venipuncture; during venipuncture; and after venipuncture.

RESULTS

The development of a responsive interaction between child and clown, identified as a WE, was found to be beneficial to the child during venipuncture procedure. The WE was characterized by three themes "How do WE do this together?"; "WE are together"; and "I/WE did it!"

CONCLUSIONS

The study emphasizes the importance of a WE established between child and hospital clown from the first encounter until a final evaluation. This WE was verbalized repeatedly by the clown and the child and was essential in shaping a tailored approach which met the needs of each child. This approach seemed to strengthen the child's competence in pain management and ability to cope, thus building competence for future venipunctures.

PRACTICE IMPLICATIONS

Establishing a WE might advance the psychosocial care of hospitalized children undergoing acute painful procedures.

Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: A pilot study

BACKGROUND

Hospitals can cause anxiety, pain, and fear in children perceiving medical procedures as intrusive and painful. Among the nonpharmacological strategies, distraction techniques have proved to be effective in the management of pain and distress.

METHODS

The aim of the present study is to assess the effectiveness of soap bubbles as a distraction technique for the management of anxiety, fear, and pain in children waiting for a medical examination at the paediatric emergency room. We employed a parallel trial design with a sample consisting of 74 children (M = 9.30; SD = 1.10; 50% female) randomly assigned to either a control or experimental group. The children in the experimental group underwent the soap bubble protocol while waiting for a medical examination at the paediatric emergency room. Anxiety, fear, and pain were assessed by self-report administered to the children before the triage and the application of the soap bubbles (baseline), after the application of the soap bubbles (T1), and after the medical examination (T2).

RESULTS

The children in the experimental group showed a significant reduction of perceived pain while waiting for the medical examination (T1), whereas no difference was found after the medical examination (T2). Furthermore, the children in the experimental group showed a significant reduction in fear (T1 and T2), whereas no difference was found in the anxiety scores measured by the Child Anxiety.

CONCLUSION

The use of soap bubbles is a good distraction technique in the reduction of fear and the perception of pain in children awaiting a medical examination at the paediatric emergency room.

Do clowns attenuate pain and anxiety undergoing botulinum toxin injections in children?

OBJECTIVE

Botulinum toxin injection (BTI) is the primary treatment for spasticity in children. Anxiety and pain are important concerns to address to attenuate the discomfort of BTI. The aim of this study was to compare the effectiveness of medical clowns and usual distractions, both added to nitrous oxide (N₂O) and analgesic cream, on pain and anxiety during BTI sessions in children.

METHODS

The primary outcome was pain evaluated by the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Secondary criteria were pain rated on a Visual Analog Scale (VAS) by the child and parent, anxiety rated on a VAS before and during BTIs by the child and parent(s), rating of the success of the sessions on a 4-point Likert scale by the physician and parent(s), and rating of the benefits of the distraction by the parent(s). Non-parametric tests were used for between-group comparisons.

RESULTS

Baseline group characteristics of the clown and control groups did not differ. During 88 BTI sessions (40 with clown distraction and 48 with control distraction) in 59 children (35 boys; 52 with cerebral palsy, 12 with moderate to severe cognitive disorders), median maximal FLACC score was 2.5 (interquartile range [IQR]: 1-4) in the clown group and 3 (IQR: 1-4.3) in the control group. VAS self-reported pain score was 2.5 (IQR: 0-5) and 3 (IQR: 1-6.3) in the clown and control groups (P=0.56), and VAS proxy-reported pain score was 2.5 (IQR: 0.3-3.4) and 3 (IQR: 1-4.5) (P=0.25). After BTI sessions, the 2 groups did not differ in VAS self- and proxy-reported anxiety (P=0.83 and P=0.81). Physician and parent ratings of the success of sessions were similar between the groups (P=0.89 and P=0.11). Parent ratings of the perceived benefits of distraction were higher in the clown than control group (P=0.004).

CONCLUSIONS

Although clown distraction was particularly appreciated by parents, it did not significantly reduce pain or anxiety in children as compared with usual distraction.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03149263.

Feeling happy and carefree: a qualitative study on the experiences of parents, medical clowns and healthcare professionals with medical clowns

Purpose: To explore the effect of medical clowns and its relevant actors and conditions.

Method: Semi-structured interviews were conducted with fourteen parents who had experiences with medical clowns in the Netherlands. Four focus groups were held with seven medical clowns and 25 healthcare professionals. The interviews and focus groups were audio-recorded and transcribed verbatim. Content analysis was used to analyse the data.

Results: Concerning the clown effect, we distinguished the following themes: happiness, distraction, carefree feeling and activation. This effect depended upon clown characteristics (appearance, tailoring, low-key play, making an effort); child characteristics (age, autonomy, fear, living cut off from society, communication); parent characteristics (autonomy, attitude); healthcare professional characteristics (attitude, communication); and organizational conditions (timing and planning, collaboration, accessibility, awareness).

Conclusion: This study shows that medical clowns are of value for children with serious illnesses or mental disabilities in several care settings. An asset of medical clowns is that they tailor their play to the child and situation.Support of and communication with parents and healthcare professionals is critical. The proposed model of the clown effect can help shape future research. The results can help medical clown organizations to enhance their services and optimize clown encounters.

Needle-related pain and distress management during needle-related procedures in children with and without intellectual disability

Children with intellectual disability frequently undergo needle-related procedures for diagnosis or treatment. Nevertheless, only a few studies deal with pain and distress management during the procedure in this population of children. This study aimed to investigate the number of anxiety and pain management techniques performed during needle procedure in children with intellectual disability (cases) compared to a population of children without intellectual disability (controls). This multicenter cohort study was performed from July 2016 to January 2018 in the pediatric ward of four urban hospitals in Italy. Eligible subjects were children with and without intellectual disability, from 4 to 17 years old, who needed venipuncture or intravenous cannulation for diagnosis or treatment. Use of topical anesthesia, distraction techniques, and physical or verbal comfort during procedures were recorded. Pain and anxiety scores were also recorded. Forty-seven cases and 94 controls were recruited. Three pain- and anxiety-relieving techniques were performed during the procedure in 12 (25%) cases and in 10 controls (11%); two techniques were performed in 23 (50%) cases and in 26 (28%) controls; 12 (25%) cases and 52 (55%) controls received only one.Conclusion: In this series, children with intellectual disability received significantly more relieving techniques, but experienced more pain and anxiety when compared to children without intellectual disability. What is Known: • Children with intellectual disability experience more episodes of pain than cognitively healthy ones, and almost 10% of these episodes are due to medical procedures. What is New: • Children with intellectual disability despite receiving more relieving techniques during a needle-related procedure experienced more pain and anxiety when compared to healthy children.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Laughing away the pain: A narrative review of humour, sense of humour and pain

BACKGROUND AND OBJECTIVE

The link between humour and sense of humour with pain has been a topic of research for decades. The purpose of the present article was to review the different studies that have been conducted to date on the association between humour and sense of humour with pain.

DATABASES AND DATA TREATMENT

The literature search was conducted using the PubMed, Science Direct and ProQuest databases. Forty-one studies were reviewed, and the results are summarized and structured into three sections: experimental pain, chronic pain and pain in children.

RESULTS

For experimental pain, the findings support the idea that humorous distractions, such as watching a comedy clip, increase pain tolerance, although most of the studies indicate that other non-humorous distractions produce similar effects. Regarding chronic pain, humour has been studied as a way of coping with pain and the emotional distress produced by chronic pain conditions. The results of correlational studies show significant associations between the use of humour and main variables such as anxiety and catastrophizing. Finally, concerning pain in children, similar findings to those described for the previous sections have been reported, with a notable presence of studies on clinic clown interventions, which promote emotional well-being among children and their parents, although their effectiveness in pain reduction is controversial.

CONCLUSIONS

The study of the link between humour and pain is still on an early stage, and overcoming the limitations of previous studies is required to strengthen the promising results that have been observed up to date.

SIGNIFICANCE

This review summarizes all main findings regarding humour, sense of humour and pain up until the first half of 2018 and offers a list of aspects to be considered in further studies regarding the link of humour and pain to contribute to a more systematic research.

A cross-cultural perspective of medical clowning: comparison of its effectiveness in reducing pain and anxiety among hospitalized Bedouin and Jewish Israeli children

PURPOSE

Medical clowning has proven effective for reducing pain, anxiety, and stress, however, its differential effects on children from different cultures have not yet been researched. This study evaluated the effects of medical-clowning intervention on anxiety and pain among Jewish and Bedouin children, and anxiety among their parents, in southern Israel.

PATIENTS AND METHODS

The study was conducted in hospital pediatric departments and employed a pre-post design involving quantitative and qualitative methods. The study included 89 children whose ages ranged from 7.5 to 12 years (39 Jewish and 50 Bedouin) and 69 parents (19 Jewish and 50 Bedouin). Questionnaires assessing pain, anxiety, and demographics were used at the pre-intervention stage and pain, anxiety, and enjoyment of different aspects of the intervention were evaluated following the intervention. The intervention stage lasted for 8-10 minutes and included the use of word play, body language, and making faces, as well as the use of props brought by the clown. Semi-structured interviews were also conducted at the post-intervention stage.

RESULTS

The intervention reduced pain and anxiety among both groups of children and reduced anxiety among both groups of parents. However, anxiety levels were reduced more significantly among Bedouin children. The nonverbal components of the clowns' humor were most central, but it was the verbal components that mediated the reduction in anxiety among the Bedouin children.

CONCLUSION

This study underscored the effectiveness and importance of medical clowning in reducing pain and anxiety among children in different cultural contexts. Moreover, the issue of culturally appropriate humor was underscored and implications for intercultural clown training are discussed.

Is there a role for clowns in paediatric intensive care units?

Hospital clowning is a programme in healthcare facilities involving visits from specially trained actors. In the paediatric intensive care unit (PICU), clowning may appear inappropriate and less intuitive. The patient could appear too ill and/or sedated, the environment too crowded or chaotic and the parents too stressed. Relying on our experience with professionally trained clowns both in France and Canada, the purpose of this article is to offer a model for hospital clowning and to suggest standards of practice for the implementation of clowning in PICUs. In this work, we provide a framework for the implementation of clown care in the PICU, to overcome the challenges related to the complex technical environment, the patient's critical illness and the high parental stress levels. Regardless of the specifics of the PICU, our experience suggests that professional clown activity is feasible, safe and can offer multiple benefits to the child, his/her parents and to hospital personnel. Due to the specific challenges in the PICU, clowns must be educated and prepared to work in this highly specialised environment. We stress that prior to clowning in a PICU, professional performers must be highly trained, experienced, abide by a code of ethics and be fully accepted by the treating healthcare team.

Acute pain management: acetaminophen and ibuprofen are often under-dosed

Most children with pain are managed by either acetaminophen or ibuprofen. However, no study has so far investigated if children are prescribed adequate doses of acetaminophen or ibuprofen in emergency department. Aim of this retrospective study was to investigate the prevalence of under-dosage of these drugs in children presenting with pain in emergency department. Children initially prescribed with acetaminophen or ibuprofen for pain management were included. The χ ² automatic interaction detection method was used considering the percentage variation from the minimum of the appropriate dose as dependent variable while prescribed drug, age, gender, body weight, type of hospital (pediatric or general), and availability of internal guidelines on pediatric pain management in the emergency department as independent variables. Data on 1471 children managed for pain were available. Under-dosage was prescribed in 893 subjects (61%), of whom 577 were prescribed acetaminophen and 316 ibuprofen. The use of acetaminophen suppositories, body weight <12 kg or >40 kg, and the use of oral ibuprofen identified clusters of children associated with under-dosage prescription.

CONCLUSION

Prescription of acetaminophen and ibuprofen was frequently under-dosed. The use of suppositories, lower and higher body weight, and the use of ibuprofen were associated with under-dosage. Under-dosing may reflect prescription of anti-pyretic doses.

CLINICAL TRIAL REGISTRATION

Agenzia Italiana del Farmaco-Observational Study Register (RSO). Registration code: PIERRE/1 What is Known: • Pain is frequent in children presented to emergency department. • International recommendations on pain management are often not implemented. What is New: • Acetaminophen and ibuprofen were frequently underdosed in children prescribed for pain in the Italian emergency departments. • Under-dosage may be related to the habit of using acetaminophen and ibuprofen in the recommended range for fever treatment.

Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections- A quasi-randomized controlled crossover study

Objective

We investigated the impact of clown-care on pain in 45 children with cerebral palsy who underwent recurrent Botulinum-toxin injections (age 7.04± 4.68 years). Participants were randomized to receive either clown (n = 20) or standard (n = 25) -care.

Methods

Pain Visual-Analogue-Scale (range 1–5) was reported before and after procedures. Pain assessment was lower for children undergoing Botulinum-toxin injections with clown-care (2.89± 1.36) compared to standard-care (3.85± 1.39; p = 0.036) even though pain anticipated prior to procedures was similar (~3).

Findings

Children who underwent the first procedure with clown-care reported lower pain even after they crossed-over to the following procedure which was standard (p = 0.048). Carryover effect was more prominent in injection-naïve children (p = 0.019) and during multiple procedures (p = 0.009). Prior pain experience correlated with pain in subsequent procedures only when first experience was standard-care (p = 0.001).

Conclusions

Clown-care alleviated pain sensation during Botulinum-toxin injections and initial clown-care experience reduced pain during subsequent injections even though clowns were not present.

Trial registration

clinicaltrials.gov ID # NCT01377883.

Hospital clowning: a paediatrician's view

This study investigates the current position of hospital clowns from the perspective of paediatricians and paediatric residents. A total of 14 attending paediatricians and paediatric residents participated in two focus group sessions. Data were analysed using Atlas.ti 5.0. In general, physicians reported positive experiences regarding the interaction between hospital clowns and paediatric patients on the ward. Physicians were more interested in research on children's perception of hospital clowns than in research on the clinical efficacy of hospital clowning. No direct collaboration between physicians and hospital clowns was reported. However, physicians proposed conditions which may streamline their encounters with hospital clowns such as clear communication prior to hospital clown visits, and the condition that visits do not impede medical interventions.

CONCLUSION

Overall, paediatricians and paediatric residents view the positive impact on paediatric patients as the most important aspect of hospital clown visits, rather than the clinical efficacy of hospital clowning. In light of the growing number of hospital clowns worldwide, this article provides recommendations for arranging their encounters with paediatricians and paediatric residents to maintain optimal health care. What is known: • Previous studies show a clinically significant pain- and anxiety-reducing effect of hospital clowning in paediatric patients admitted to hospitals or undergoing (invasive) medical procedures. • In general, paediatricians have positive ideas about hospital clowns, aside from personal prejudices. What is new: • This novel study gives deeper insight into day-to-day interaction between paediatricians and hospital clowns on the ward. • This study provides recommendations for clinical practice to arrange encounters between physicians and hospital clowns during hospital clown visits.

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

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, I(2) 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.

Strategies for diversity: medical clowns in dementia care - an ethnographic study

BACKGROUND

As nursing homes become increasingly diverse, dementia care needs a wider range of culturally responsive strategies for individual and collective social interactions. While previous studies conclude that medical clowns have positive effects on verbal and non verbal social interactions, research is lacking from the perspective of residents' cultural background. The aim of this study was to identify interaction strategies employed by medical clowns in culturally diverse dementia care settings.

METHOD

An ethnographic approach was used and data were collected through observation of interactions between medical clowns and residents with dementia in two nursing homes during a ten week period.

RESULTS

The observations showed that the medical clowns interacted with residents by being tuned in and attentive to the residents as individuals with a unique life-history, confirming each person´s sense of self. The clowns used sensory triggers, encouragement and confirmation in culturally responsive ways to bond socially with the residents in their personal spaces. The clowns involved objects in the daily environment that were meaningful for the residents, and paid attention to significant places and habits in the past. The clowns further contributed to joint interaction in the common spaces in the nursing homes, using music and drama.

CONCLUSION

The strategies employed by medical clowns in activities with older people with dementia appear to support social interaction. The medical clowns used the social and material environment in culturally responsive ways to strengthen individuals' sense of self, while contributing to a sense of togetherness and interaction among residents in the common spaces. Findings suggest that both verbal and non-verbal cultural content affected social interaction. The non-demanding encouraging way the clowns tuned in to the residents as individuals could help nurses and staff members improve ways of communication in social activities inside the nursing home.