Utilizing complementary therapy to enhance quality of life and reduce stress and fatigue in pediatric cancer patients

Table 2 Protocol intervention hospital clowns as a complementary therapy for management psychological stress and cancer-related fatigue and enhancing the quality of life

Item	Description
Ref.	Lopes-Júnior et al[26]
Objective	To assess the effect of a hospital clown intervention on the levels of stress and CRF in pediatric cancer patients receiving chemotherapy by measuring the levels of salivary cortisol and salivary alpha amylase
Sample	16 children and adolescents (6-14 years old, mean ± SD: 11.40 ± 3.44) with cancer receiving a hospital clown intervention
Protocol of intervention	The participants served as their own controls before and post-intervention over a 3-day period. Each patient received 1 session of the HC and provided eight saliva samples (4 samples at pre-intervention and 4 samples at post-intervention). All saliva samples were collected each day at the same time for all patients to maintain comparability among participants and to avoid that differences would be a result of normal daily oscillations in biomarkers. Data were collected at + 1, + 4, + 9, and + 13 hours after awakening (8:30 am), i.e., at 9:30 am, 12:30 pm, 5:30 pm, and 9:30 pm, respectively. The 8 points chosen for saliva collection were based on international recommendations for children and adolescents, to allow a better characterization of the biomarker circadian rhythms. In order to minimize external influences of measurements, at all sample collection time points, pediatric cancer inpatients had no invasive procedures or any other acute stresses in the last hour before sample collection and underwent preparation for saliva collection - which consisted of not ingesting any food or drinks 1 hour before the procedure and not brushing the teeth or using mouthwash before collection. After preparation had been completed, participants were requested to refrain from swallowing briefly (for 30 seconds) and then “drooling” the saliva from the mouth directly into the collection device
Outcome measure	CRF and psychological stress. Children: PedsQL MFS (CRF scale-cancer module) and ESI (stress scale). Parents: PedsQL MFS
Main results	Participants mean age was 11.4 ± 3.4 years old. 50% were white, and 68.7% had completed primary school. Regarding the neoplasms, 6 was osteosarcoma, 4 ALL and 4 lymphoma. Most (81.3%) were primary neoplasm, and among the 16 patients, 68.7% had metastases. Also, 56.3% were using corticosteroids during the chemotherapy protocol. In comparison with baseline measurements, the total stress and CRF levels improved at the post-hospital clown intervention (P = 0.003 and P = 0.04, respectively). Salivary cortisol showed a significant decrease after clown intervention at the collection time points + 1, + 9, and + 13 hours (P < 0.05), but not α-amylase. The total ESI stress scores from the pediatric patients correlated positively with AUC for cortisol at pre-intervention (r = 0.35, P = 0.03). Decreased stress scoring after the clown intervention correlated positively with decreased levels of cortisol (r = 0.02, P = 0.04). Contrary, the total ESI stress scores from the patients correlated negatively with AUC for α-amylase at pre-intervention (r = -0.57, P = 0.02), but not at the post-intervention. These findings suggest that the hospital clowns as a complementary therapy may improve stress and CRF

CRF: Cancer-related fatigue; HC: Hospital clowns; PedsQL: Pediatric quality of life; MFS: Multidimensional fatigue scale; ESI: Escala de stress infantil (child stress scale); ALL: Acute lymphocytic leukemia; AUC: Area under curve.