Effect of Clown Therapy on Symptoms and Emotions of Children with Neoplastic Disease: A Systematic Review with Meta-Analysis

INTRODUCTION: Clown therapy is a widely used nonpharmacological intervention for the control and management of symptoms and emotions in pediatric settings. There are some studies evaluating the effect of the intervention on children with neoplastic disease, but a systematic review summarizing the overall benefit is lacking. OBJECTIVE: To evaluate the effect of clown therapy on the symptoms and emotions of children with neoplastic pathology. METHODS: Studies (randomized or quasi-randomized parallel-group controlled trials) were searched from biomedical databases, web resources, and trial registries. The intervention was compared with standard care; primary outcomes were pain and anxiety, and secondary outcomes were fear, stress, fatigue, depression, distress, and mood. Risk of bias was assessed with RoB 2, and the overall effect size was calculated with variable effects meta-analysis. The summary of results was illustrated in accordance with the GRADE method. RESULTS: Five quasi-randomized parallel-group trials with a high risk of bias were included (N = 376, mean age: 6.9-10.9 years). Children who received clown therapy manifested a reduction in anxiety (N = 181; SMD = -2.17 [95% CI: -4.20, -0.14], p < 0.05) and fatigue (N = 176; SMD = -2.03 [95% CI: -5.39, 1.32], p > 0.05). The certainty/quality of evidence is very low. CONCLUSIONS: Clown therapy seems more effective than standard care in reducing anxiety and fatigue in children with neoplastic disease. However, more studies are needed to confirm the results, as the very low certainty/quality of evidence currently does not justify routine implementation of the intervention in pediatric oncology.