Medical Clowning: A Cost-Effective Way to Reduce Stress Among Children Undergoing Invasive Procedures

Background Distraction techniques like medical clowning and the use of soap bubbles can aid in reducing children's stress levels while undergoing invasive medical procedures. Such complementary therapies are not a common practice in Pakistan, and data exploring the potential benefits of complementary therapies are sparse. This study aimed to determine whether distractions like medical clowns and soap bubbles could reduce anxiety and pain perceived by children undergoing invasive medical procedures in a hospital in Pakistan. Material and methods We conducted a randomized controlled trial of 76 pediatric patients (aged six to 12 years) whose treatment required a peripheral intravenous (IV) catheter insertion at the pediatric ward of the Fauji Foundation Hospital in Rawalpindi, Pakistan, from March 2016 to June 2016. Peripheral IV catheter insertion was required for all patients as part of their treatments (no participants received IV catheter placement solely for this study). Our sample size was selected via random sampling, and we excluded patients whose parents or legal guardians did not consent for their inclusion. Study participants were randomly assigned to either a clown group (n=38) or a control group (n=38). The patients in the clown group underwent IV catheter placement while interacting with the medical student clown and soap bubbles in the presence of a parent. Patients in the control group underwent IV catheter placement with support provided only by the parent. We assessed the patient's distress and anxiety before, during, and after the procedure. We used the Observation Scale of Behavioral Distress (OSBD), before and after the procedure with the short version of self-reported Spielberger's State-Trait Anxiety Inventory-Children (STAI-C), the visual analog anxiety scale (VAS), and pain experienced with the Wong-Baker Faces pain scale (FPS) only after the procedure. Additionally, we collected demographic information. The hospital's ethical review committee approved our study design. Results Of the 76 study participants, 53.9% were male and 46.1% were female. Most patients lived in a rural setting (67%). Mean values of the FPS, OSBD, and STAI-C for the clown group (3.21, 6.23, and 8.52, respectively) were all lower than those for the control group (8.00, 18.02, and 15.29, respectively; p<.001); however, the difference was not statistically significant for children older than 10 years. After IV catheter placement, the mean VAS score for the clown group was also significantly lower than that for the control group (2.84 vs. 8.92, respectively; p<.001). Conclusion The use of distractions via medical clowns and soap bubbles was an effective nonpharmacological method of reducing anxiety and perceived pain in children undergoing invasive medical procedures. Therefore, proceduralists could use such techniques as powerful, noninvasive, and cost-effective complementary and alternative medicine tools in pediatric treatment settings in Pakistan. Further studies on the potential benefits of the aforementioned techniques are warranted.