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

Abstract 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