Effects of a clown's presence on pain and anxiety during botulinum toxin injections in children with motor disabilities

Abstract : Introduction/Background : Botulinum toxin injections (BTI) in children often involve several sites of injections and repetitions of the procedure. Reducing pain and anxiety during this procedure is a high priority but remains a challenge. The aims of this study were to evaluate the effectiveness of medical clown presence on pain and anxiety during BTI with premedication (Nitrous Oxyde, EMLA) compared to usual distraction procedures. Material and method : Children with motor disabilities, mostly cerebral palsy (1–18 years old) were recruited from the pediatric rehabilitation department of the Brest University Hospital. Children were randomized into the usual distraction group (music, movies…) or the clown distraction group. Pain was evaluated using the Face Legs Activity Cry Consolability (FLACC) scale by an independent observer and using the visual analogic scale (VAS) by the child and his parents. Anxiety before and during the BTI was evaluated using a VAS by the child and his parents. Proceeding of BTI was evaluated by the physician and child's parent, and benefit of distraction was evaluated by child's parent using a 4 point Likert scale. Results : Eighty-seven children were included [55 males, mean age = 8.2 years (SD 3.6)]; 40 children in the clown group and 47 in the usual distraction. The two groups were comparable on the main sample characteristics and in term of procedures. There were no significant differences between groups on the FLACC and VAS anxiety and pain. Both distractions were considered beneficial by the parents but the result was significantly higher in the clown group (P = 0.002). No differences were found between groups for the different subgroups. Conclusion : The clown presence during BTI does not seem to reduce significantly pain or anxiety in children/parents compared to usual distraction. However the presence of the clowns likely improves the level of distraction as evaluated by the parents which is a key result for such a repetitive procedure.