Healing with laughter: the therapeutic power of laughter yoga in pediatric health – a systematic review

Abstract

Background

Laughter yoga is a non-pharmacological and non-invasive therapeutic approach that integrates voluntary laughter with controlled breathing exercises. This systematic review aimed to evaluate research investigating the impact of laughter yoga on children’s health outcomes.

Methods

This systematic review included studies with randomized controlled trial (RCT) and quasi-experimental designs, adhering to the PRISMA guidelines. This systematic review, conducted between December 18, 2023, and October 31, 2024, was guided by the PRISMA guidelines and a predefined protocol based on the PICOS-based protocol. Eligible studies included randomized controlled trials (RCTs) and quasi-experimental designs. A comprehensive literature search was conducted in Google Scholar, Medline/PubMed, Cochrane Library, Science Direct, CINAHL Complete, and OVID databases. Study selection was based on the PICOS framework, and methodological quality was assessed using the Joanna Briggs Institute-Meta Analysis Statistical Assessment and Review Instrument (JBI-MAStARI). Based on the inclusion criteria, six studies were incorporated into the review.

Results

The total sample across the included studies was 305 participants, with 66% of the studies involving at least 50 participants. Findings indicated that laughter yoga contributed to a reduction in anxiety and stress levels in children (p < 0.05), while no statistically significant effect was observed on depression scores (p > 0.05). Although no substantial improvement in self-esteem was reported, positive changes in self-concept were noted. Furthermore, laughter yoga was associated with an increase in salivary IgA levels (p < 0.01), whereas no significant influence on cortisol levels was found (p > 0.05). Additionally, the intervention was reported to alleviate pain, fatigue, and burnout while enhancing hope and overall happiness.

Conclusions

Study results showed that laughter yoga promoted the increase in happiness and self-concept in children and improved their ability to cope with stress. It also provided a physiological improvement by positively affecting pain and fatigue. In light of these results, it is recommended that laughter yoga be used more widely in children’s daily lives and clinical practices.

Introduction

Laughter is a reaction that exists in most moments of an individual’s life from birth to death and is used as a universal expression of emotional state [1]. It has many physical, psychological, and emotional effects on the individual. The physical effects include providing muscle activation, lowering blood pressure, and affecting the pain mechanism by increasing endorphin release [2]. Reducing stress and anxiety levels by increasing hormone release (adrenaline, noradrenaline, cortisol) is among its psychological effects [3]. Laughter is generally used to express happiness and humor to reflect the emotional state [4].

Laughter yoga is a non-invasive and non-pharmacological therapy method that combines spontaneous laughter and breathing exercises [1, 5]. It can be done in a group, accompanied by a trained and certified laughter yoga leader. Each session, which lasts at least 30–40 min, consists of four sections, and the program takes eight weeks. These components include hand-clapping and preparatory exercises, deep breathing techniques, children’s play activities, and structured laughter exercises [6]. Sessions are implemented by a yoga leader individually or in groups of 5–15 people [7]. Group sessions facilitate producing laughter as its contagious effect reaches more people [1, 8, 9]. Laughter yoga reduces stress, strengthens social harmony, and increases the quality of life in children and adult groups [10]. Yazdani et al. (2014) conducted a study with 38 nursing students and determined that students’ general health averages improved and their sleep disorders, anxiety, and depression levels decreased following laughter yoga [11]. Similarly, Geetha (2021) showed that laughter yoga reduced stress and improved coping skills in first-year nursing students [12].

Children can be easily affected by the people, objects, and events around them because their imaginations are wider and more developed than adults and they are constantly in pursuit of entertainment [13]. Due to their energetic nature, children are more easily affected by most events around them and design their environment in a way that they can adapt to with the help of play [14]. All these conditions make children ideal candidates for laughter yoga [9]. The purpose of laughter yoga used in children is to promote their physical and mental health by utilizing the benefits of laughter [15]. Laughter yoga has positive effects on children, such as improving mood, reducing stress and anxiety, strengthening social skills, and increasing self-esteem [16]. Incorporating laughter yoga into children’s daily lives can support their growth and development by creating a joyful and healthy environment. It also helps increase concentration and improve creativity, communication, and empathy among children [10, 17].

This study aimed to systematically review research exploring the impact of laughter yoga on children’s health parameters. In this context, evidence-based care data were provided to nurses by analyzing studies on the effects of laughter yoga in children and assessing its effectiveness and reliability.

Methods

Study design

This systematic review included randomized controlled trials (RCTs) and quasi-experimental studies investigating the use of laughter yoga in children. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. PRISMA-P standards serve as evidence-based criteria commonly utilized in systematic reviews and meta-analyses [18] (Table 1). This review was not registered in PROSPERO, as the review process had already commenced before the decision to register was considered. However, all steps were conducted in line with PRISMA guidelines and a predefined protocol based on PICOS criteria.

Table 1.

Characteristics of studies based on PICOS

Author/year and country	Aim of the study	Data collection tools	Population	Intervention	Comparisons	Outcomes	Study designs
Kim et al. (2018)[15] South Korea	The study was to investigate the effect of laughter intervention on the physiological, physical and psychological responses of school-aged children with Atopic Dermatitis.	The 5-D Itch Scale Children’s Depression Inventory Normal Stress Scale	School-age children aged 6–12 with Atopic Dermatitis (n:45) Intervention Group (IG) (n:26) Control Group (CG) (n:19) Effect size 95% confidence interval.	In the experimental group, laughter yoga was performed face to face, once a week, and for four weeks. Laughter yoga was not implemented in the control group; routine lessons were continued.	The differences in S-IgA levels before and after the intervention are significant (p = 0.028). The difference in stress levels before and after the intervention is significant (p = 0.011).	While there was no significant difference in the Itch Scale results before and after laughter yoga intervention in the experimental group children, significant differences were reported in physiological responses. Depression in the experimental group had not differed significantly. However, it was determined that the stress levels of the children in the experimental group were significantly lower than the levels of those in the control group.	Quasi-Experimental
Öztürk & Açıkgöz (2021) [17] Türkiye	To examine the effect of laughter therapy on the happiness levels and self-esteem of 5th-grade students.	The School Children’s Happiness Inventory (SCHI) Coopersmith Self-Esteem Inventory (CSEI)	5th-grade secondary school students (n:61) IG (n:29) CG (n:32) Effect size 80% power and 95% confidence interval	In the experimental group, laughter yoga was performed face to face, twice a week, and for four weeks. Laughter yoga was not implemented in the control group; routine lessons were continued.	The pre-test and post-test results indicate that the average SCHI scores of students in both the control and experimental groups have increased. A significant increase was observed in the average SCHI scores of the experimental group compared to the control group (p < 0.05).	It was determined that laughter yoga increased the happiness level of students but had no effect on self- esteem.	Randomized Controlled
Kotekar & Shinde (2023) [9] Hong Kong	To investigate the effects of laughter therapy on the self-concept of adolescents with physical disabilities.	Self-Concept Inventory	Children aged 13-19 with mental and physical disabilities (n:60) IG (n:30) CG (n:30)	In the experimental group, laughter yoga was applied face-to-face, once a week, and for five weeks. No intervention was implemented in the control group.	The experimental group demonstrated a significantly better physical self-concept and moral self-concept compared to the control group (p < 0.05). The experimental group showed a significantly better social self-concept compared to the control group (p < 0.01).	It was reported that the self-concept of adolescents in the experimental group was significantly higher than that of the control group.	Randomized Controlled
Nirmala et al. (2023) [22] India	To examine the effects of digital storytelling and laughter therapy on pain, fatigue, and anxiety levels in children with hematologic cancer.	Wong-Baker Faces Pain Rating Scale (WBFPRS) Childhood Fatigue Scale (CFS) State-Trait Anxiety Inventory for Children State (STAIC-S)	Children aged 5-12 years diagnosed with hematological cancer (n:15) IG −1 (Digital storytelling DST) (n:5) IG −2 (Laughter Yoga) (n:5) CG (n:5)	In IG-1, digital storytelling was implemented for six days. In IG-2, it was implemented face to face in 30-minute sessions for six days. No intervention was implemented in the control group.	The DST had marked effect on level of pain and anxiety among children in IG-1. The Laughter therapy showed statistically significant changes in post test in level of pain and anxiety in children in IG-2.	It was reported that laughter yoga was effective in reducing pain and fatigue levels from severe to moderate and mild levels. The anxiety level of the laughter yoga group was significantly lower than that of the control group.	Randomized Controlled
Kuru Alıcı & Kalanlar (2024) [23] Türkiye	The study was to examine the effects of laughter yoga on hope and school burnout in middle school (eighth-grade) students.	Children's Hope Scale School Burnout Scale	8th- grade secondary school students (n:60) IG (n:30) CG (n:30) Effect size 95% power and 95% confidence interval	In the experimental group, laughter yoga was implemented face to face, twice a week, and for three weeks. It was not implemented in the control group; routine lessons were continued.	After laughter yoga, a statistically significant difference was observed between the intervention group and the control group in the mean scores on the School Burnout Scale (p <.05). There was a statistically significant difference between the intervention group and the control group in the mean scores on the Children's Hope Scale (p <.05).	It was stated that the burnout level of the laughter yoga group decreased and the hope level increased statistically significantly compared to the control group.	Randomized Controlled
Kalanlar & Kuru Alıcı (2024) [24] Türkiye	The study was to evaluate the effects of laughter yoga on exam anxiety and academic stress among 8th-grade students in Turkey.	Educational Stress Scale (ESS) Westside Test Anxiety Scale (WTAS)	8th-grade secondary school students (n:64) IG (n:32) CG (n:32) Effect size 95% power and 95% confidence interval	In the experimental group, laughter yoga was implemented face to face, twice a week, and for six weeks. Routine lessons continued with the students in the control group.	After laughter yoga, the intervention group showed a significant decrease in test anxiety (p < 0.005) and educational stress scores (p < 0.001) compared to the control group.	The study found that test anxiety and educational stress decreased in the laughter yoga group compared to the control group.	Randomized Controlled

IG Intervention Group, CG Control Group

Study questions

This systematic review aimed to address the following research questions:

• - What types of studies have explored the effects of laughter yoga on children?

• - Does laughter yoga provide physical and psychological benefits for children?

• - Can the findings of these studies be effectively applied in real-world practice?

Search strategy and study selection

The study search and selection process followed the methodology described in the systematic review framework by Eriksen and Frandsen (2018) [19] A total of six databases were systematically searched: Google Scholar, Medline/PubMed, Cochrane Library, Science Direct, CINAHL Complete, and OVID. To ensure comprehensive literature retrieval, Medical Subject Headings (MeSH) were used to identify relevant keywords. A structured search strategy was applied, incorporating various spelling and phrasing combinations of the terms “Laughter Therapy” and “Laughter Yoga”: (“Laughter Yoga” [Title/Abstract]) OR (“Laughter Therapy” [Title/Abstract])) OR (“Yoga, Laughter” [Title/Abstract])) OR (“Laughter Therapy, Laughter Yoga” [Title/Abstract]).

The search encompassed titles, abstracts, and full-text articles, ensuring a broad and inclusive screening approach. Two independent researchers (RCÇ, ŞD) conducted the initial screening process. When the title and abstract lacked sufficient details for eligibility assessment, full-text versions were obtained. All full-text articles were subsequently reviewed and reassessed by all reviewers independently. Additionally, reference lists of the included articles were examined to identify further relevant studies. The systematic search process was conducted between December 18, 2023, and October 31, 2024.

Inclusion criteria were defined according to the PICOS [P: (Participants), I: (Interventions), C: (Comparators), O: (Outcomes), S: (Study designs)] framework (Fig. 1). [19].

Fig. 1.

PICOS criteria used in this systematic review

Assessment of risk of bias and methodological quality

To minimize potential bias, two independent researchers (RCC, SD) conducted the literature search, study identification, data extraction, and quality assessment based on the predefined inclusion criteria.The Cochrane Collaboration’s Risk of Bias Tool [20] was used to evaluate the risk of bias, with assessments performed independently by the first and second researchers. A final consensus was reached in a joint session that included a third researcher (Table 2). Studies with a low risk of bias are considered reliable, while studies with an unclear risk raise concerns about result validity. Conversely, studies with a high risk of bias are more likely to have unreliable findings. In addition to bias assessment, methodological quality was evaluated based on: Sample size, use of power analysis, appropriateness of statistical tests (e.g., control for assumptions, multiple testing corrections), selective outcome reporting (ensuring all evaluated outcomes are reported with statistical details such as p-values).

Table 2.

Risk of bias of the ıncluded trials [20]

Studies	Selection bias		Performance bias	Detection bias	Attrition bias	Reporting bias	Other bias
	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Anything else ideally prespecified
Öztürk & Açıkgöz (2021) [17]	Low	High	High	Unclear	Unclear	Low	Low
Kotekar & Shinde (2023) [9]	Low	High	High	High	Unclear	Low	Low
Nirmala et al. (2023) [22]	Low	High	High	High	Unclear	Low	Low
Kuru Alıcı & Kalanlar (2024) [23]	Low	Low	High	Low	Low	Unclear	Low
Kalanlar & Kuru Alıcı (2024) [24]	Low	Low	Low	Low	Low	Low	Low

Study selection process

A total of 541 studies were accessed as a result of an electronic search with keywords from Google Scholar (n = 353), Medline/PubMed (n = 10), Cochrane Library (n = 29), Science Direct (n = 13), CINAHL Complete (n = 88), and OVID (n = 48). After removing duplicates and excluding studies that did not meet the inclusion criteria (e.g., irrelevant titles/abstracts or unsuitable content), a total of 6 studies were included in the systematic review (Fig. 2).

Fig. 2.

PRISMA flow diagram

The methodological quality of the research articles included in this systematic review was evaluated using the 13-item quality assessment tool (JBI Critical Appraisal Checklist for Randomized Controlled Trials), developed by the Joanna Briggs Institute (JBI) for assessing randomized controlled trials [21]. Quality assessments were conducted independently by the first (RCC) and second (SD) researchers, and any discrepancies were resolved in a consensus session with the third researcher. The results of the quality assessment for each included study are presented in Table 2 under the “Critical Appraisal Tool” section.

Data analysis

The review protocol was predefined based on the PICOS framework to ensure a systematic and structured approach. To maintain consistency and reliability in data evaluation, the researchers developed a data summary table, which facilitated a comprehensive comparison of the included studies. Each study was systematically assessed based on several key parameters, including author(s), publication year, and country, the study aim, the data collection tools used, the study population, the intervention applied, the comparisons made, the outcomes measured, and the study design. The evaluation of the studies was conducted using this structured data table (Table 1). Given the limited number of studies included in this systematic review and the heterogeneity among them, a meta-analysis could not be performed. Instead, the findings from the studies were synthesized qualitatively and presented in narrative form to provide a comprehensive understanding of the effects of laughter yoga on children’s health.

Ethical considerations

The studies included in this systematic review posed no risk of harm to the researchers, and no financial support was received for conducting the review. The PICOS framework was used to define the inclusion and exclusion criteria, while the PRISMA model guided the evaluation and synthesis of the studies.The methodological quality of the included studies was assessed using the 13-item JBI Critical Appraisal Checklist for Randomized Controlled Trials, developed by the Joanna Briggs Institute [21]. Additionally, the risk of bias was evaluated with the Cochrane Collaboration’s Risk of Bias Tool [20] to ensure the reliability of the findings.

Results

Study characteristics

Of the studies 83% were carried out in 2021 and the following years. The studies had been carried out in South Korea [15], Türkiye [17, 22, 23], Hong Kong [9], and India [24].

The studies included in the systematic review had been designed in randomized controlled (n: 5) [9, 17, 22–24] and quasi-experimental type (n:1) [15]. The quasi-experimental study was conducted using a pre-test and post-test design [15]. In randomized controlled studies (n: 5), children had been assigned to the experimental and control groups by using the randomization method [9, 17, 22–24]. It was found that only two of the reviewed studies used computer-generated allocation as the method of randomization [22, 23], while the remaining studies did not clearly specify the method used [9, 17, 24]. Randomized controlled trials examined the effects of laughter yoga on children’s stress, anxiety, self-concept, self-esteem, happiness, cortisol levels, pain, fatigue, hope and burnout levels. A quasi-experimental study examined the effects of laughter yoga on children’s levels of depression, stress and itching (Table 1).

In all studies included in the systematic review, the sample groups (n: 305) were school- age children. Laughter yoga sessions were held face to face in all experimental groups. The sessions were implemented in 6-day [24], 3-week [23], 4- week [10, 15], 5-week [9] and 6- week [22] programs. In 50% of the studies in which the number of sessions was stated, a total of two sessions of laughter yoga had been performed [22, 23], while it had been implemented as four sessions [15] and eight sessions [17] in the remaining groups. The sessions had taken about 30 to 50 min on average (Table 1).

Effects on laughter yoga on health parameters

While 50% of the studies included in the systematic review examined the effects of laughter yoga on children’s stress, depression and anxiety levels, 33% addressed the effects on self-concept. These studies show a reduction in anxiety symptoms and a significant decrease in stress levels in children. However, no significant change was found in depression scores. In addition, in studies conducted with students, a decrease in educational stress and test anxiety and an increase in happiness levels were observed. In one study on self-esteem, no significant difference was found, but in another study, positive improvements in self-concept were noted.

Findings on physiological effects suggest that laughter yoga increases salivary IgA levels, but does not significantly change cortisol levels. Furthermore, laughter yoga intervention has been reported to reduce pain and fatigue, increase hope and reduce burnout in children with cancer (Table 1).

Quality assessment and risk of bias

In the quasi-experimental study included in this systematic review (n = 1) [15], the effects of laughter yoga were clearly defined. Outcome measurements were conducted multiple times, both before and after the intervention, ensuring a robust follow-up process. The collected data were analyzed reliably, enhancing the study’s validity. Among the six included studies, five employed randomization methods to allocate participants into treatment groups. The baseline characteristics of the treatment groups were comparable, reducing potential confounding effects. Participants were randomly assigned using blinding techniques, ensuring that biases related to allocation were minimized. Apart from the laughter yoga intervention, all other procedures were administered uniformly across the treatment groups, maintaining internal validity. The follow-up processes were successfully completed, and participants were analyzed according to their original group assignments (intention-to-treat analysis). Outcomes were measured consistently across treatment groups, and reliable evaluation methods were used. Moreover, appropriate statistical analyses were applied, and the study designs were deemed methodologically sound.

Among the randomized controlled trials (RCTs) included, one study [23] fully met al.l quality assessment criteria (Table 3).

Table 3.

Assessment of the methodological quality of randomized controlled studies

	Öztürk & Açıkgöz (2021) [17]	Kotekar & Shinde (2023) [9]	Nirmala et al. (2023) [22]	Kuru Alıcı & Kalanlar (2024) [23]	Kalanlar & Kuru Alıcı (2024) [24]
1. Was true randomization used for assignment of participants to treatment groups?	🗸	🗸	🗸	🗸	🗸
2.Was allocation to treatment groups concealed?	X	X	X	🗸	🗸
3.Were treatment groups similar at the baseline?	🗸	🗸	🗸	🗸	🗸
4.Were participants blind to treatment assignment?	🗸	🗸	🗸	🗸	🗸
5.Were those delivering treatment blind to treatment assignment?	X	X	X	🗸	X
6.Were outcomes assessors blind to treatment assignment?	X	X	X	🗸	🗸
7.Were treatment groups treated identically other than the intervention of interest?	🗸	🗸	🗸	🗸	🗸
8.Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analysed?	🗸	🗸	🗸	🗸	🗸
9.Were participants analysed in the groups to which they were randomized?	🗸	🗸	🗸	🗸	🗸
10.Were outcomes measured in the same way for treatment groups?	🗸	🗸	🗸	🗸	🗸
11.Were outcomes measured in a reliable way?	🗸	🗸	🗸	🗸	🗸
12.Was appropriate statistical analysis used?	🗸	🗸	🗸	🗸	🗸
13.Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?	🗸	🗸	🗸	🗸	🗸
Overall appraisal	Include: 10	Include:10	Include: 10	Include: 13	Include: 12

Reference: The Joanna Briggs Institute (2020). Checklist for Randomized Controlled Trials [21] https://jbi.global/sites/default/files/2019-05/JBI_RCTs_Appraisal_tool2017_0.pdf

Adverse events

No adverse events related to laughter yoga were reported in any of the included studies.

Discussion

This section aims to examine the types and characteristics of studies investigating the effects of laughter yoga on children’s health, with a particular focus on its impact on physical, psychological, and social well-being. It will explore the effects of laughter yoga on stress, anxiety, self-concept, happiness, pain, fatigue, and physiological parameters in children, while also evaluating the methodological approaches employed and the practical implications of these findings in educational and healthcare settings.

Types and characteristics of studies examining the effects of laughter yoga on children

This systematic review aimed to analyze studies investigating the effects of laughter yoga on children’s health. A review of the existing literature revealed that no previous systematic review had specifically examined laughter yoga in children. Therefore, this study was conducted to fill this gap and contribute to the existing body of knowledge. In this systematic review, six studies focusing on school-age children were analyzed, and the effects of laughter yoga on children’s well-being were systematically examined.

Laughter yoga can be applied not only to children but also to adolescents, adults, and older people, covering a wide age range [1, 17]. There are some studies in the literature on the examination of the effects of laughter yoga in different age groups. For example, Geetha (2021) applied laughter yoga to first-year nursing students [12], while El Sayed et al. (2024) applied it to older individuals aged ≥ 60 [25]. Studies in this systematic review focused on school-age children [9, 15, 17, 22–24]. Focusing on different age groups in studies was found to be effective in examining the age-related effects of laughter yoga.

The first study on the examination of the effects of laughter yoga on health parameters in children was conducted in 2018, and it has become more popular since 2023. More than half of the studies were conducted in Türkiye. The most frequently used scales in the studies were those designed to measure stress/anxiety levels [15, 22, 24], and those designed to evaluate physiological parameters were the least frequently used ones [15].

It was observed that all studies included experimental and control groups and the subjects had been assigned to the groups by using the randomization method. When the methodological quality of the studies was evaluated according to the Joanna Briggs Institute-Meta analysis Statistic Assessment and Review Instrument, it was determined that their quality was at an adequate level. It can be said that the evidence level of the studies was high in terms of research design and methodological quality.

Physical, psychological, and social effects of laughter yoga on children

Laughter yoga is recognized as a valuable nursing intervention and complementary therapy due to its numerous advantages. It is cost-effective, requires no special equipment, can be performed in any setting at any time, is easily accessible, and is widely accepted [5, 26]. Given these benefits, laughter yoga has been increasingly integrated into nursing and healthcare practices. The primary goal of laughter yoga in children is to enhance both physical and mental health by harnessing the therapeutic benefits of laughter [9, 15, 17].

Laughter yoga has physiological, psychological, and social effects on children. These effects contribute to the physical and mental development and strengthening of social skills of children in the development and growth age [15–17]. It was observed that mostly mental health parameters were measured in the studies evaluated in this systematic review, while there were fewer studies on parameters affecting physical health. However, there was no research on spiritual health parameters. There were some studies in the literature on the examination of the effects of laughter yoga on salivary cortisol levels [1], changes in stress levels, coping skills [27], and happiness levels [28]. Similarly, it was observed in the studies within the scope of this systematic review that children’s depression, stress, and anxiety levels, self-concept, happiness levels, salivary IgA and cortisol levels, pain and fatigue changes were examined following laughter yoga intervention [9, 15, 17, 22–24]. It is thought that it is useful to examine the different effects of laughter yoga as it can be easily applied without requiring any tools.

According to some studies in the literature, laughter yoga reduces stress in nursing students [12, 29] and also positively affects depression and anxiety levels [11]. The studies examined within the scope of the review also showed that laughter yoga was effective in reducing stress, anxiety, and exam anxiety levels, in parallel with the studies in the literature [15, 22, 24]. However, unlike the literature, it was not found to be effective in changing the level of depression [15]. Depression is less common in childhood compared to adults, which can be associated with the finding that laughter yoga did not affect the depression level of children. However, it protects and improves psychological health, which shows that it can be used as an effective treatment method.

Different results were obtained regarding the effect of laughter yoga on self-concept. While one study showed that laughter yoga caused an increase in self-concept levels (Kotekar & Shinde, 2023), according to another study, it had no effect [17]. There was no study in the literature on the examination of the effect of laughter yoga on self-concept in an adult group. Self-concept is shaped in childhood, which shows why it was studied especially in this age group.

Laughter yoga supports children’s growth and development by creating a joyful and healthy environment and gives them a hopeful perspective [1, 23]. It can improve happiness levels in cancer patients and individuals struggling with addiction [28, 30]. The results of the studies included in the review similarly showed that laughter yoga increased the happiness level of children [17]. As a non-invasive method, laughter yoga alone may be effective in increasing the level of happiness in individuals. In one of the studies in this systematic review, laughter yoga was found to increase the hope level of children [23]; however, there was no study in the literature on its effect on the hope levels of adult groups. This suggests that the study was conducted in the child age group considering that the level of hope could be shaped more easily in childhood than in adulthood.

Regular implementation of laughter yoga in children has been shown to support emotional healing and mitigate burnout by enhancing energy levels [23]. In a study involving nurses caring for patients with COVID-19, laughter yoga was identified as an effective intervention for reducing burnout levels [6]. Similarly, another study conducted with nurses working in a Psychiatric Mental Health and Addiction Treatment Hospital demonstrated a statistically significant decrease in burnout following laughter yoga sessions [31]. One study included in the review, in parallel with the literature, showed that laughter yoga reduced the burnout levels of 8th-grade secondary school students and could be used as an effective method. The interpretation of these findings is that laughter yoga can be used as an effective method in burnout management in all age groups.

Practical implications and applicability of study results

The examination of the studies indicated that laughter yoga affected children’s salivary IgA levels, pain levels, and fatigue status but did not change salivary cortisol levels [15, 24]. Unlike other studies examined, the results of the study by [10] with first-year nursing students and the study by Meier et al. (2021) with healthy individuals indicated that laughter yoga reduced cortisol levels [32]. Özer & Ateş (2021) and Namazinia (2023) also revealed that laughter yoga was effective in coping with pain and fatigue in individuals receiving chemotherapy and hemodialysis treatment. Cortisol levels vary depending on stress levels [26, 33]. Children’s stress levels are lower than adults, and this is thought to be the reason why laughter yoga did not affect children’s cortisol levels. Laughter yoga intervention does not require physical effort, so it can be used in cases of pain and fatigue.

Laughter yoga is a low-cost, non-invasive intervention that can be applied in various settings, including schools, hospitals, and homes. The evidence presented in the reviewed studies, combined with its accessibility and safety profile, indicates that laughter yoga can be integrated into healthcare practices and educational settings to support children’s emotional, psychological, and even physiological well-being.

Implications for nurse educators and future research

Current research on laughter yoga suggests its effectiveness in improving children’s well-being; however, further high-quality studies with larger sample sizes are needed to establish its definitive efficacy and reliability. Given that laughter yoga is a non-invasive, cost-effective, and evidence-based approach, educators may consider incorporating it into classroom settings as part of daily activities or stress management strategies.

Despite the existing body of literature, there remains a need for randomized controlled trials (RCTs) to provide robust evidence regarding the impact of laughter yoga on children. Additionally, qualitative studies exploring children’s perspectives, experiences, and attitudes toward laughter yoga would offer valuable insights into its acceptability and perceived benefits.

The reviewed studies exhibited variability in the frequency and duration of laughter yoga sessions, making it necessary to conduct further research to determine the optimal session structure for maximizing benefits. Furthermore, differences in implementation methods highlight the need for standardized protocols to ensure a consistent and reproducible approach to laughter yoga interventions. Establishing uniform guidelines would improve the reliability and validity of future studies and facilitate their replication. To promote the widespread adoption of laughter yoga among children, several strategies could be implemented. These include developing structured training programs led by experts in the field, encouraging family and teacher involvement, integrating technology-assisted interventions, conducting longitudinal studies, and organizing community-based programs. Such initiatives would contribute to enhancing the accessibility, effectiveness, and sustainability of laughter yoga as a therapeutic and educational tool for children’s physical, emotional, and social well-being.

Limitations

One of the primary limitations of this study is that, despite employing comprehensive search strategies with keywords specifically defining laughter yoga across widely used academic databases, some relevant studies may not have been accessed. Additionally, the review included only experimental and quasi-experimental studies published in English, which may have led to the exclusion of valuable research published in other languages. Future systematic reviews should consider removing language restrictions to enhance the generalizability and inclusivity of findings. This systematic review was not registered in a prospective registry such as PROSPERO, due to the retrospective initiation of the review. Although pre-registration enhances transparency, adherence to PRISMA guidelines and application of a predefined PICOS framework helped maintain methodological rigor.

This systematic review has several additional limitations. The limited number of studies investigating the effects of laughter yoga on children’s physical and psychological health presents a challenge in conducting more comprehensive research in this field. Furthermore, variations in measurement tools and evaluated parameters across the included studies create difficulties in directly comparing their findings. Additionally, the literature search period from December 2023 to October 2024 reflects the relatively recent emergence of laughter yoga research for children and the limited number of studies in this field. The increase in studies published after 2018 made this timeframe sufficient to ensure adequate coverage.

Another constraint is the heterogeneity of study results, which prevented the conduct of a meta-analysis; therefore, no meta-analytic results could be presented. Additionally, some randomized controlled trials (RCTs) lacked detailed methodological information, further limiting the depth of this review’s analysis. To the best of our knowledge, this study represents the first systematic review examining the impact of laughter yoga on children’s health. By conducting a comprehensive review of the existing literature across multiple databases, this research provides a critical evaluation of the topic and aims to serve as a foundation for future studies in this field.

Conclusion and recommendations

The findings of the reviewed studies indicate that laughter yoga positively contributes to children’s happiness and hope levels, enhances their self-concept, and reduces stress, anxiety, and test-related anxiety. Additionally, it provides physiological health benefits by influencing salivary IgA levels, pain perception, and fatigue status. While the psychological effects of laughter yoga were widely examined across the included studies, there was a notable scarcity of research investigating its physical and spiritual effects. Furthermore, no study specifically explored the impact of laughter yoga on spirituality. Given that humans are biopsychosocial beings, future research should broaden the scope of investigation to assess its effects on diverse health parameters. Laughter yoga, as a nursing intervention, has been demonstrated to be a low-cost, non-invasive, simple, effective, and evidence-based practice that nurses can independently apply to improve various health outcomes in children.

Integrating the positive health effects of laughter yoga into daily routines can play a vital role in supporting children’s emotional and mental well-being. The implementation of laughter yoga in clinical settings can provide an innovative approach to addressing various health concerns. It is essential to raise awareness among healthcare professionals and parents about the benefits of laughter yoga and encourage its integration into everyday life. Promoting the adoption of this practice will facilitate the use of laughter yoga as an effective tool for enhancing children’s physical, mental, and social health.

Authors’ contributions

R.C.Ç.: Conception, literature review and design, acquisition of data, analysis and interpretation of data, drafting and writing the manuscript; Ş.D: Conception, literature review and design, acquisition of data, analysis and interpretation of data, drafting and writing the manuscript; Ö.E.: Conception, literature review and design, acquisition of data, analysis and interpretation of data.

Funding

Not applicable.

Data availability

The data used in this study are available from the authors. Additionally, all studies included in this systematic review are available in the electronic databases and can be accessed. Data are available from the authors upon reasonable request and with the permission of the authors.

Declarations

There is no risk of harm to researchers in the studies included in the systematic review, and no financial support has been received for the review. PICOS was used for inclusion and exclusion criteria and PRISMA models were used for evaluation and synthesis. The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias Tool.

Ethics approval and consent to participate 

Not Applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.