Implementing the Period of PURPLE Crying®
in Community Settings in North Carolina
A Program of the National Center on Shaken Baby Syndrome, USAOffered by Keeping Babies Safe in North Carolina
Funded by the CDC, the Duke Endowment, & the Doris Duke Charitable Foundation
What is the Period of PURPLE Crying®?
• An evidenced -based Shaken Baby Syndrome Program.
• Provides new information on infant crying
• Tested through 3 years of randomized controlled trials.
• Currently implemented in all North Carolina birthing hospitals.
• Has a three dose approach.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Three Lines of Evidence of the ProgramThree Lines of Evidence of the Program
Shaking Your Baby
IsIs DangerousDangerous
Cryingand ColicIs NormalIs Normal
The most common stimulus
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Shaken Baby SyndromeShaken Baby Syndrome
• Weak neck muscles,Weak neck muscles,• Large head to body ratio, Large head to body ratio,
• Person doing the shaking is so much biggerPerson doing the shaking is so much bigger• Violent,Violent, s sustainedustained forceforce
Factors Contributing to InjuryFactors Contributing to Injury
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2007)
Intracranial “Cascade” from ShakingIntracranial “Cascade” from Shaking
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Outcomes of Hospitalized CasesOutcomes of Hospitalized Cases
• 19% - 40% die19% - 40% die
• Of those who survive: 65% - 80% have Of those who survive: 65% - 80% have significant long term neurological and significant long term neurological and developmental abnormalitiesdevelopmental abnormalities
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
How Common is SBS?How Common is SBS?
• Actual incidence is not knownActual incidence is not known
• Known incidence is likely just the tip of the Known incidence is likely just the tip of the icebergiceberg
• Approx 1,300 US children a year Approx 1,300 US children a year experience severe or fatal head traumaexperience severe or fatal head trauma
• 30-40% of cases are missed at medical 30-40% of cases are missed at medical institutionsinstitutions
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
The “Crying Curve”The “Crying Curve”(Brazelton, (Brazelton, PediatricsPediatrics 1962) 1962)
Less
Large differen
ces from
infant to infant
More
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
What is colic? Its defining featuresWhat is colic? Its defining features(Gormally & Barr, (Gormally & Barr, Ambulatory Child HealthAmbulatory Child Health 1997) 1997)
1.1. Age-dependent crying pattern (peak Age-dependent crying pattern (peak during 2during 2ndnd month) month);;
These are due to changes in the amounts of These are due to changes in the amounts of crying that cluster during the eveningcrying that cluster during the evening
2. Associated behaviors (prolonged cry 2. Associated behaviors (prolonged cry bouts, unsoothability, pain-like faces);bouts, unsoothability, pain-like faces);
3. Unpredictable3. Unpredictable
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Assumption:Assumption:
““Colic”Colic” is an abnormality, is an abnormality,or “something wrong” with the infant.or “something wrong” with the infant.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
““Peak Pattern” of Early Crying BehaviorPeak Pattern” of Early Crying Behavior(Hunziker & Barr, (Hunziker & Barr, PediatricsPediatrics 1986) 1986)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
!Kung San Hunter Gatherers!Kung San Hunter Gatherers
(Photos by Marjorie Shostak)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Care Giving ContextsCare Giving Contexts
!Kung San Western Contact Constant Intermittent
Carry Constant Response to cry
Feeding “Continuous” “Pulse”
Posture Upright Supine
Responsivity Universal Occ. Non-response
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
HourlyHourly Cry/Fret DurationCry/Fret Duration in !Kung San in !Kung San InfantsInfants (Barr, Konner et al., (Barr, Konner et al., DMCNDMCN 1991) 1991)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Parental Responses to Infant Chimp Parental Responses to Infant Chimp DistressDistress (Bard, In Barr et al. (eds.) 2000)(Bard, In Barr et al. (eds.) 2000)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
““Distress Curves” Distress Curves” In other mammalian speciesIn other mammalian species
• Guinea pig pups (Pettijohn, 1979)
• Rat pups (Hofer et al., 1999)
• Chimpanzees (Bard, 2000)
• Free-living rhesus macaque monkeys (Barr et al., 2005)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Age-related Crying Patterns in Age-related Crying Patterns in Preterm InfantsPreterm Infants
(Barr, Chen, et al., (Barr, Chen, et al., DMCN DMCN 1996)1996)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
In SummaryIn Summary
“Colic” is a manifestation of normal behavioral development
“Colic” is the upper end of a continuum of crying behavior in normal infants (like height: some infants are taller and some are shorter)
“Colic” is not an indication of disease in the infant.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Crying as the Stimulus for Crying as the Stimulus for Shaken Baby SyndromeShaken Baby Syndrome
Crying as a stimulus
to shakingNormalcy of Normalcy of Increased Increased
Inconsolable Inconsolable CryingCrying
DangerDanger of of
shaking shaking an infantan infant
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
The “Crying Curve”The “Crying Curve” (Brazelton, (Brazelton, PediatricsPediatrics 1962) 1962)
Hypothesis:: IF crying was a significant stimulus for SBS,
THEN the pattern of age-related incidence of SBS should be
similar to the age-related properties of the crying curve.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Age-specific Incidence ofAge-specific Incidence of Hospitalized Hospitalized Cases of SBS Cases of SBS
(Barr, Trent et al., (Barr, Trent et al., Child Abuse & NeglectChild Abuse & Neglect 2006) 2006)
0
5
10
15
20
25
30
35
40
45
50
0 8 16 24 32 40 48 56 64 72 80
Age (weeks)
No
. of
ca
se
s
1 year
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
NCSBS Age-specific Incidence of 591/166NCSBS Age-specific Incidence of 591/166Publicly-reportedPublicly-reported Cases of SBSCases of SBS
(Lee, Barr et al., (Lee, Barr et al., JDBPJDBP 2007) 2007)
0
20
40
60
80
100
120
0-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 33-36 37-40 41-44 45-48 49-52 53-56 57-60 61-64 65-68 69-72 73-76 77-80
Baby's Age (weeks)
No
. o
f C
ases
Crying Stimuli (n=166) All Stimuli (n=591)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Prevention:Prevention:
Prevention Prevention ??
Crying as Crying as Stimulus Stimulus to SBSto SBS
Dangers Dangers of of
ShakingShaking
Normalcy Normalcy of Early of Early CryingCrying
??
The Period of PURPLE CryingThe Period of PURPLE Crying®
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Crying as a “Window of Opportunity” Crying as a “Window of Opportunity” to Prevent SBSto Prevent SBS
• An opportunity to teach caregivers and all members of society about the normality of early increased crying;
• An opportunity to see SBS as the only negative clinical consequence of early increased crying;
• Tells us when the teaching must occur to be effective.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
The Period of PURPLE CryingThe Period of PURPLE Crying®
PP Peak of CryingPeak of Crying
UU UnexpectedUnexpected
R R Resists SoothingResists Soothing
PP Pain-like FacePain-like Face
LL Long LastingLong Lasting
EE EveningEvening
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Important Action Steps When Infant Important Action Steps When Infant Crying Is FrustratingCrying Is Frustrating
• Comfort, Carry, Walk and Talk with your baby
• If it’s too frustrating it is OK to walk away
• NEVER shake or hurt a baby, AND remember…
• If you have concerns, have your doctor examine your baby
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Making Making PURPLEPURPLE Widely Acceptable Widely Acceptable
• Educational, and Educational, and attractive to parents to parents of newborns on the of newborns on the first day of lifefirst day of life
• Grade 3 level Grade 3 level language language
• Valuable for all parentsValuable for all parents• EconomicalEconomical
• Clear, memorable, Clear, memorable, salient, meaningful, salient, meaningful, attractive, attractive, positive messagemessage
• MulticulturalMulticultural• Acceptable to Public Acceptable to Public
Health NursesHealth Nurses (no bottles, blankets, or (no bottles, blankets, or bumper pads)bumper pads)
• Each parent receives a copy to review and to review and to share with others
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Program HypothesisProgram Hypothesis
1. the meaning of increased crying in early infancy, and
2. the danger of shaking as a response to the frustration with that crying.
To make a long term sustained reduction in the number of cases of Shaken Baby Syndrome*, there will need to be a cultural change in the way society understands:
*The goal in NC is to reduce the incidence of Shaken Baby Syndrome by 50%
PURPLE Implementation
Dose One: Maternity nurses provide crying education and the PURPLE materials to all new parents.
Dose Two: Public Health and medical offices remind parents to review the program and review key points.
Dose 2.5: Community groups reinforce the message.
Dose Three: Public Education Campaign.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
Implementing NC HospitalsAs of 4/7/09
Some hospitals began implementing as early at April 2007 while others have just begun
Map Key
White counties do not have hospitals appropriate for Dose 1
Hospital not implementing
[Show clips of the PURPLE DVD]
Why Reinforce the PURPLE Crying Message?
• PURPLE Crying begins to increase at 2 weeks of age, after parents have left the hospital.
• With the excitement of birth, parents might not fully recall everything they learn in the hospital.
• In order for the PURPLE Program to be most effective, we believe parents need to receive the information more than once from those people they trust.
How Dose 2 Partners Can Help to Reinforce
the Period of PURPLE Crying®
Messages
Who are the Dose 2 and 2.5 Partners?
• Medical offices who serve families.
• Public Health offices who give immunizations.
• Home visitor programs.
• Prenatal programs
• Emergency Room services.
• Day care and Community Groups serving families.
Training for Partners on the Period of PURPLE Crying Program®
1. To understand the research, the rationale of the program, and the messages, professionals should complete training session on the program.
2. Training is offered through web-based (www.dontshake.org) or in person PURPLE Crying training.
Primary Care Providers/Sick and Well Baby Checks
(Pediatricians, Family Physicians, Health Dept primary care, Community Health Centers)
At the well baby check, in their first weeks of life, primary care providers are an ideal source of universal reinforcement of the PURPLE Crying Program messages.
Medical and Health DepartmentReinforcement and Reminder Card
• Used to remind parents they should have received the program in the hospital. From the maternity nurse.
• Ask parents if they saw the DVD or read the booklet.
• Encourage parents to go home and review the PURPLE materials.
• The reminder card does not replace the review of the tested materials. Parents need to review the materials they got at the hospital.
• Use the card to reinforce the PURPLE messages the parent got from the program given at the hospital.
• Parents should be reminded about the PURPLE messages each visit in the first few months, if possible.
• Optimal if nurse provides the card, but front desk staff are acceptable. Parents can ask doctor questions about it.
• If parents are already acquainted with the program they do not need to take the card.
Reinforcement and Reminder Card(Available in English and Spanish)
front back
Additional Ways to Reinforce PURPLE Crying Program at Your Office
1. Hang PURPLE Reminder poster(s) in exam rooms.
2. Keep small supply of PURPLE Packages of materials (free of charge) to provide to caregivers with BABIES ≤ 5 MONTHS of age who say they did not receive a copy at the hospital.
3. If possible, have DVD playing in waiting room.
Poster Options(Available free in English, Spanish, bilingual)
Adoption Agencies and Foster Parents
• Professionals in these agencies should be trained to give the program to the foster parents and adoptive parents.
• Same education parents receive at the hospital.
• Scripts, presentation and materials should be used for these parents.
• Foster parents and adoptive parents should receive a set of the PURPLE program materials to keep and review.
Home Visiting(MCC, CSC, NFP, CHN, PAT, etc.)
• Use the opportunity to reinforce the PURPLE Crying Program messages.
• Meaningful to caregivers because the baby is somewhat older and the caregivers are likely to have a more personal relationship with this provider.
• Depending upon the program’s interest and resources, a range of activities are available to reinforce PURPLE Crying Program.
Protocol to Reinforce PURPLE Crying During a Home Visit
1. Ask the parent if the received the PURPLE Materials at the hospital after the birth of their baby. (Show them a package to remind them).
2. If the parent did not receive the materials have some packages on hand to give to them. (Keep a few on hand for this purpose).
3. Review the materials with the parent including going over the booklet and the DVD.
4. Answer any questions the parent may have about the program messages.
Home Visiting Form
PRENATAL Programs Protocol
1) Use 3 minute or 10 minute script to discuss crying. (Visuals are available.)
2) Inform parents that they will receive their own copy of PURPLE.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
3 Minute Script
Educate parents of newborns about: Normal infant crying; Receiving a DVD/booklet about normal infant
crying and that it will be important to review it; Having their infant checked by a health
professional if the crying becomes a concern; The dangers of shaking, and; The importance of sharing this information with
others. Designed for a one-on-one setting.
10 Minute Script
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
Educate parents of newborns about: Normal infant crying; Receiving a DVD/booklet about normal infant
crying and that it will be important to review it; Having their infant checked by a health
professional if the crying becomes a concern; Crying research; The PURPLE acronym; Stressors that can add to the frustration; The dangers of shaking, and; The importance of sharing this information with
others. Designed for a classroom setting.
POSTNATAL Protocol(Community programs, emergency rooms,
family support programs)
If you are providing support post-natally and parents received PURPLE:
1) Use the 3 minute or the 10 minute script to reinforce the crying education. Visuals are available.
2) Encourage parents to view the received materials.
3) Address concerns.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
POSTNATAL Protocol (Continued)
If you are providing support postnatally and parents did not receive PURPLE:
1) Use the 3 minute or the 10 minute script to discuss crying.
2) Encourage parents to view your program’s office copy of the DVD and booklet – OR
3) Address concerns.
4) Encourage parents to visit the NC PURPLE.org website to order a set of
materials.
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2009)
For more information about the Period of PURPLE Crying Program
Contact:
Western Region
Julie Hansford, MSW
at the Center for Child and Family Health
Triangle Region
Susan McCraw, M.Ed.
at the Center for Child and Family Health
Eastern Region
Katheryn Grubbs, MSW
at the Center for Child and Family Health
Research Specialist
Nina Kane, MSW
at the Center for Child and Family Health
Project Manager
Kelly Sullivan, Ph.D.
at the Center for Child and Family Health
Shaken Baby Syndrome incidence reduction: hospital-based program
Dias MS, Smith K, deGuehery K, Mazur P, Li V, Shaffer ML. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics. 2005;115(4):e3470-3477.
Evidence that shaking is dangerous
Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. Br Med J. 1971;2:430-31.
Conway EE Jr. Nonaccidental head injury in infants: the shaken baby syndrome revisited. Pediatric Annals. 1998;27(10):677-90.
King WJ, MacKay M, Sirnick A. Canadian Shaken Baby Study Group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. Canadian Medical Association. 2003;168(2):155-59.
ReferencesReferences
Evidence that crying is normal (continued)
Pettijohn TF. Attachment and separation distress in the infant guinea pig. Developmental Psychobiology. 1979;12(1):73-81.
Hofer MA, Masmela JR, Brunelli SA. Behavioral mechanisms for active maternal potentiation of isolation calling in rat pups. Behavioral Neuroscience. 1999;113(1):51-61.
Barr RG, Warfield JJ, Catherine NLA. 2005. Is there an ‘early distress peak’ in free ranging rhesus macaque monkeys? Paper presented at: the Biennial Meeting of the Society for Research in Child Development; April 07-10, 2005: Atlanta, GA.
Barr RG, Chen S, Hopkins B, Westra T. Crying patterns in preterm infants. Dev Med Child Neurol. 1996;38(4):345-55.
ReferencesReferences
Evidence for crying as a stimulus to shaking
Barr RG, Trent RB, Cross J. Age-related incidence curve of hospitalized shaken baby syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse and Neglect. 2006;30(1):7-16.
Lee CK, Barr RG, Catherine N, Wicks A. Age-related incidence of publicly-reported shaken baby syndrome cases: is crying a trigger for shaking? Journal of Developmental and Behavioral Pediatrics. 2007;28:288-93.
ReferencesReferences
The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
What is the scope of this project?• Funded through September 2012 to provide
education about infant crying and the dangers of shaking to the caregivers of every baby born in NC
• To be effective, caregivers need to receive the education in three ways
1. Every NC hospital that delivers babies provides the “first dose” of the education to caregivers (initiative began in September, 2007)
2. Caregivers receive the “second dose” of the education at their sick and well baby checks in the first month of life and through various programs that serve infants and their families (initiative began in April 2009)
3. “Third dose” consists of a statewide media campaign designed to create a cultural change in the understanding of infant crying (currently in development)