Title: Abusive Head Trauma Prevention: The Role a Public Health System Can Play

Authors: Sue Ewy, MS, RN, PHN, and Shantel Wakley, BS
Minnesota Department of Health (MDH) and National Center on Shaken Baby Syndrome (NCSBS)

Background Evidence

What is shaken baby syndrome/abusive head trauma (SBS/AHT)? The Center for Disease Control and Prevention defines shaken baby syndrome as a preventable, severe form of physical child abuse resulting from violently shaking an infant by the shoulders, arms, or legs¹⁴. SBS/AHT may result from both shaking alone and shaking with impact so the term abusive head trauma (AHT) is used more inclusively.  

Abusive Head Trauma (AHT) is the leading cause of infant mortality due to physical abuse causing death in more than 25% of AHT cases¹. Approximately 1,200-1,400 clinically recognized cases occur each year in the United States¹⁵. Around 32-38 cases per 100,000 children less than 1-year-old suffer from AHT each year, and because 30-40% of cases are missed at medical institutions, the actual incidence is unknown despite these prior estimations¹⁶. Likely the known incidence is just the tip of the iceberg.

The evidence that shaking a baby is an extremely dangerous caregiving behavior is compelling and increasing. 

A study conducted by Dr. T. Berry Brazelton on healthy newborns in his Philadelphia practice found that all infants experience a normal phase of increased crying starting at 2 weeks, peaking at 2 months and decreasing in months 3-5². Many replications of Dr. Brazelton’s study found that regardless of whether the babies were born pre- or full-term and despite the vast differences in caregiving behaviors and even species, all the subjects studied showed an age-related crying or distress pattern. This led the NCSBS to hypothesize that this increased crying may be a trigger for AHT.

Two studies were then published showing the relationship between this crying curve and the age-related incidence of AHT^3,4. A study conducted on 273 hospitalized AHT cases in California from 1996 to 2000 showed that when plotting the number of cases by age the shape of the curve is very similar to the crying curve in Dr. Brazelton’s study.

To further support the evidence that normal crying and AHT are related they turned to publicly reported AHT cases. They graphed the 591 AHT cases by age regardless of their specified trigger, and the curve was virtually identical to the curve obtained in the California hospital study. Then they looked at the 166 cases that just mentioned frustration with crying as the specified trigger for shaking which was also virtually identical to the crying curve.

These studies found that the most common stimulus for AHT is an infant’s normal increased crying.

The knowledge that shaking a baby is an extremely dangerous caregiving behavior, increased infant crying is a normal part of child development all healthy infants experience, and this increase in inconsolable crying is the most common stimulus for AHT created a pathway for AHT prevention, and are the three lines of evidence the Period of PURPLE Crying program is based on.

The Period of PURPLE Crying

The Period of PURPLE Crying program is an effective, evidence-based prevention program that aims to support caregivers in their understanding of normal early increased infant crying and to reduce the incidence of AHT. Based on over 60 years of research on infant crying, the program teaches and reinforces messages like: 

• “Early increased crying is normal,” 
• “If the crying is too frustrating it is ok to walk away,” and
• “Never shake a baby.”

The PURPLE acronym was developed as a meaningful and memorable way for caregivers to recognize that these aspects of infant crying will happen and are completely normal in healthy infants. We then preface the acronym with the word “period” to remind parents/caregivers that this increase in crying does not go on forever, but only for a particular time period in the infant’s life and will come to an end.

Published Research

The delivery of this effective AHT prevention program has been studied for over 15 years and has shown the program to be highly effective at reducing cases as well as being cost effective. 

2007 – PURPLE Materials

In 2007, the Period of PURPLE Crying program materials were made public. 

2009 – Randomized Controlled Trials^6,7

Two years later, two parallel randomized controlled trials were published in both Canadian Medical Association Journal and in Pediatrics showing a change in knowledge and behavior related to the PURPLE program. 

2013 – Study in NC, USA⁸

In North Carolina in 2013, a study found that shaking as a form of discipline was reduced by 50% with PURPLE intervention. 

2015 – ER & Crying Complaints⁹

In 2015, PURPLE was found to decrease emergency department visits for complaint of crying unrelated to physical illness by 29% in BC, Canada. This reduction in emergency department visits led to a hospital cost savings of 18%. 

2018 – 8-Year Study¹⁰

One of the most important studies to support the program was published in 2018. An 8-year outcome of implementation study revealed the PURPLE program was associated with a 35% reduction in AHT in children under 2 years old. This study was published in the Child Abuse & Neglect Journal and was selected as the article of the year. 

2018 – Parents Use of the Program¹⁰

The same study also found that caregivers having physical materials at home with them to review is a critical component in AHT prevention. The study showed Mother’s use of the program materials more than doubled at home post discharge and 50% of fathers had read and view the materials by the 2-month mark when their infant crying was at its peak. 

2019 – Cost-Effectiveness¹¹

Following the above article, a cost-effectiveness study was published in 2019. This study found that every dollar spent on PURPLE had an associated $54 savings by society. This can be compared to Zero Tolerance where every $1 spent $25 is saved or Child Safety Seat Laws where every $1 spent $42 is saved. 

2021 – Hispanic Mothers¹²

In 2021, a study conducted on a population of Hispanic mothers found that their knowledge of normal infant crying patterns was improved through the delivery of PURPLE. 

2023 – Infant Physical Abuse¹³

The latest study featured was published in December 2023 and found that hospitalization rates for physical abuse in children under 2 years of age decreased by 30% in BC, after PURPLE was universally implemented.

Home Visiting & PURPLE

Home visiting programs that include the following components show positive impacts on their effectiveness:¹⁶

• Focus on improvement of parental expectations of the child and parenthood in general (p=0.016)
• Targeting parental responsiveness or sensitivity to a child’s needs (p<0.001)
• Video-based feedback (p=0.038)

The Period of PURPLE Crying program includes all three components.

Minnesota Family Home Visiting

The map shows the family home visiting programs who utilize the PURPLE materials when educating the families they serve throughout Minnesota.

Minnesota Department of Health's Family Home Visiting (FHV) section encourages local public health agencies who receive funding for family home visiting from MDH to incorporate the Period of PURPLE Crying program into the model that they provide.

The PURPLE program is embedded into the MN Maternal Early Childhood Sustained Home-Visiting (MECSH) model of FHV and is an approved Maternal, Infant, and Early Childhood Home Visiting evidence-based, FHV model. PURPLE materials are included in the "Crying and Settling" module within the MN MECSH curriculum. 

Program Delivery in Minnesota

The Period of PURPLE Crying program uses a three dose exposure approach to create a cultural change in the way society views normal infant crying.

MDH encourages all family home visiting grantees to incorporate the Period of PURPLE Crying program into the family home visiting that they provide.

MDH guidance suggests family home visiting grantees who implement the program provide both dose one and dose two to every family in the first few months after the birth of an infant. This ensures families receive the critical information before their infant's crying starts to naturally increase, and then a reinforcement of the information around the peak of their infant's crying.

. 

In the MN MECSH Model, home visitors are working toward providing dose one in week two and dose two in week eight of the curriculum to meet model fidelity. Family home visiting nurses have the capacity to deliver additional education at their discretion as appropriate through the infant's first year of life, reinforcing the key messages to any family. 

All MECSH home visitors are required, and supervisors are encouraged to complete the PURPLE Crying training from the NCSBS as well as refresh their training at least every two years. 

Local programs are encouraged to work with their local hospitals and medical clinics to coordinate public education and media campaigns.

Contact Information

If you are interested in learning more about the Period of PURPLE Crying program, or how your organization could implement it as your AHT prevention education contact the National Center on Shaken Baby Syndrome at PURPLE [AT] dontshake [DOT] org or call 801-447-9360 x 1

If you are interested in learning more about the Minnesota Department of Health’s efforts of delivering this program through their Family Home Visiting program contact the MDH at Health [DOT] HomeVisiting [AT] state [DOT] mn [DOT] us

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 (2004-2024).

The Period of PURPLE Crying can only be delivered to families as the App+Booklet package. Altering the program materials, referring parents to our website page intended for providers, only showing the videos to families without providing the App+Booklet package, or adding any of the PURPLE information onto websites, flyers, handouts, or other resources created is a violation of the program Fidelity and Copyright.

References

1. 1. Narang, S. K., Fingarson, A. D., Lukefahr, J. M., & COUNCIL ON CHILD ABUSE AND NEGLECT (2020). Abusive Head Trauma in Infants and Children. Pediatrics, 145(4), 1-7.
2. 2. Brazelton, T.B. (1962, April). Crying in Infancy. Pediatrics, 29(4), 579-88.
3. 3. Lee, C., Barr, R. G., Catherine, N., & Wicks, A. (2007, August). Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? Journal of Developmental & Behavioral Pediatrics, 28(4), 288-93.
4. 4. Barr, R.G., Trent, R.B., & Cross, J. (2006, January). Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse & Neglect, 30(1), 7-16.
5. 5. Stirling, J., Gavril, A., Brennan, B., Sege, R. D., Dubowitz, H., & American Academy of Pediatrics, Council on Child Abuse and Neglect. (2024). The pediatrician’s role in preventing child maltreatment: Clinical report. Pediatrics, 154(2), e2024067608.
6. 6. Barr, R. G., Barr, M., Fujiwara, T., Conway, J., Catherine, N., & Brant, R. (2009). Do educational materials change knowledge and behaviour about crying and shaken baby syndrome? A randomized controlled trial. Canadian Medical Association Journal, 180(7), 727-733.
7. 7. Barr, R. G., Rivara, F. P., Barr, M., Cummings, P., Taylor, J., Lengua, L. J., & Meredith-Benitz, E. (2009). Effectiveness of Educational Materials Designed to Change Knowledge and Behaviors Regarding Crying and Shaken-Baby Syndrome in Mothers of Newborns: A Randomized, Controlled Trial. Pediatrics, 123(3), 972-980.
8. 8. Reese, L. S., Heiden, E. O., Kim, K. Q., & Yang, J. (2014). Evaluation of Period of PURPLE Crying, an Abusive Head Trauma Prevention Program. JOGNN, 752-761.
9. 9. Barr, R. G., Rajabali, F., Aragon, M., Colbourne, M., & Brant, R. (2015). Education About Crying in Normal Infants is Associated with a Reduction in Pediatric Emergency Room Visits for Crying Complaints. Journal of Developmental & Behavioral Pediatrics, 36(4), 252-257. 
10. 10. Barr, R.G., Barr, M., Rajabali, F., Humphreys, C., Pike, I., Brant, R., Singahl, A. (2018, October). Eight-year outcome of implementation of abusive head trauma prevention. Child Abuse & Neglect, 84, 106-14.
11. 11. Beaulieu, E., Rajabali, F., Zheng, A., Pike, I. (2019). The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of PURPLE Crying.
12. 12. Jalloul, R.J., Vigil, A., Chen, H.Y., et al. (2021). Effectiveness of Educational Materials Designed to Improve Knowledge Regarding Crying and Shaken Baby Syndrome in Moths of Hispanic Population. Hispanic Health Care International. 2022;20(3):179-183.
13. 13. Sadler, K., Rajabali, F., Zheng, A., et al. (2023). Impact of a Parent Education Program Delivered by Nurses and Health Care Providers in Reducing Infant Physical Abuse Hospitalization Rates in British Columbia, Canada. Canadian Journal of Nursing Research. 2023;0(0). 
14. 14. (2010, March). Shaken Baby Syndrome Tip Sheet. Retrieved from CDC: CDC_5965_DS1.
15. 15. Keenen, H. T., Runyan, D.K., Marshall, S .W., Nocera, M. A., Merten, D. F., & Sinal, S. H. (2003). A Population-Based Study of Inflicted Traumatic Brain Injury in Young Children. Journal of the American Medical Association, 290(5), 621-26. 
16. 16. Jenny, C., Hymel, K. P., Titzen, A., Reinart, S. E., & Hay, T. C. (1999). Analysis of missed cases of abusive head trauma. Journal of the American Medical Association, 281(7), 621-626.