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

Ding Y, Yin H, Wang S, Meng Q, Yan M, Zhang Y, Chen L. J Clin Nurs. 2022 Jan 5. doi: 10.1111/jocn.16195. Epub ahead of print. PMID: 34985166.


Take-Home Message

Clown intervention (humor-based distraction; e.g., singing) decreases acute pain and hospital stays in children 2 to 7 years old.


Pain is a common symptom among patients who undergo medical procedures. Nonpharmacological interventions to mitigate pain, especially in children, are of particular interest to clinicians. Clown interventions, which provide humor-based distractions (e.g., magic, songs, games, dances) to improve a pediatric patient’s mood and pain, are becoming more widespread despite inconsistent evidence that it reduces pain.

Study Goal

Ding and colleagues completed a systematic review and meta-analysis to evaluate the effectiveness of clown intervention in reducing pain, cortisol levels, crying duration, and length of hospital stays among children.


The researchers completed a comprehensive literature search. Keywords used for the literature search were, “child”, “pediatrics”, “kids”, “infant”, “adolescent, clown”, “clown intervention”, “hospital clown”, “medical clown”, and “pain”. The researchers assessed 34 articles for eligibility. They included an article if it met 4 inclusion criteria: (1) randomized controlled trial study design, (2) included children 0 to 17 years old, (3) compared a clown intervention to standard care, and (4) used a standard pain scale as the primary outcome measure. A total of 9 articles were included in the final systematic review. Two independent reviewers then completed the “risk of bias” tool from the Cochrane Handbook and extracted data. 


Overall, the risk of bias analysis revealed 5 studies had a low risk of bias, while the risk of bias was unclear in 4 studies. All of the studies were performed in Israel (6 studies), China (2 studies), or Italy (1 study). The clown intervention typically involved children receiving surgery (3 studies) or intravenous cannulation/venipuncture (3 studies). The authors found that the clown intervention reduced pain in patients in 5 out of 9 studies. However, when they looked closer, they noticed that a clown intervention was beneficial among children 2 to 7 years old (2 studies) but not among patients over 7 years old (2 studies). The clown intervention also decreased hospital stays (1 study) and may reduce crying times (2 studies). However, the clown intervention had no impact on serum cortisol levels (2 studies).


The authors demonstrated that clown interventions might be beneficial, especially among younger kids; however, few high-quality studies are available. It would be interesting to know how clown interventions work among children in the United States, especially when they need to be seen for a musculoskeletal injury (e.g., fracture).  

Clinical Implications

Sports medicine clinicians who see younger patients may want to explore the feasibility of a clown intervention in their practice since it is low risk and may have some benefits. Alternatively, it may even be worth considering what other humor-based distractions could be offered to pediatric patients.  

Questions for Discussion

Have you or do you use clown interventions in your clinical practice? If so, what strategies have you used, and have you found them to be particularly beneficial?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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