1. Implementing the Period of PURPLE Crying® in Community Settings in North Carolina
Need IPRC logo background clear
A Program of the National Center on Shaken Baby Syndrome, USA
Offered by Keeping Babies Safe in North Carolina
Funded by the CDC, the Duke Endowment, & the Doris Duke Charitable Foundation

2. 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.

3. Three Lines of Evidence of the Program
Crying
and Colic
Is Normal
Shaking Your
Baby
Is Dangerous
What we are going to talk about today is how the crying of normal newborn infants—can be used to prevent shaken baby syndrome. The story has three lines of evidence on which the program is based.[Click for yellow circle]. The first is, the increasing evidence that shaking a baby is an extremely dangerous care giving behavior. We have known this for a long time, and the evidence for this is increasing. We will talk briefly about that evidence.
[Click for green circle]. The second line of evidence is that, contrary to our past beliefs, increased crying often called colic in the first few months of life is a completely normal part of child development. Even though the evidence for this has been accumulated over the past 25 years, it is still not well known in pediatric textbooks or in much of the care giving advice literature. We will talk about some of the evidence for why this is true.
[Click for red square and connecting arrow]. The third line of evidence is the realization that early increased crying in normal infants is the most common stimulus for shaken baby syndrome. This connection is what makes it possible to use our new understanding of the normality of early increased crying to prevent shaken baby syndrome.
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 ( )

4. Factors Contributing to Injury
Shaken Baby Syndrome
What is Shaken Baby Syndrome? This is an animation of the way an infant’s head moves during a shaking event. [click animation]
You’ll notice it’s not just a back and forth motion. The baby’s head is moving in a figure 8 motion and this acceleration and deceleration contributes to the brain injury.
Some of the factors that contribute to a baby’s vulnerability are their weak neck muscles which offer very little resistance and their relatively large head size which can actually add momentum during the shaking. However, the most important factor is the person doing the shaking is so much more powerful than the baby and they are repeating this very violent act over and over.
Factors Contributing to Injury
Weak neck muscles,
Large head to body ratio,
Person doing the shaking is so much bigger
Violent, sustained force
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 ( )

5. Intracranial “Cascade” from Shaking
[Click on the animation] This animation gives you some idea of what goes on inside the head during the shaking. As you can see, some parts of the brain move in opposite directions to other parts of the brain, resulting in what are called “shearing forces” that damage the nerve cells in the brain.
As the shaking continues, some of the branches of the veins coming from the brain begin to break, resulting in blood being released near the surface, producing what is called a “subdural hematoma” (and sometimes a subarachnoid hematoma).
The damage to the brain cells initiates a whole cascade of chemical reactions that increase the damage, and produce (among other things) swelling of the brain (called “edema”). It is often the swelling of the brain that results in the most serious consequences.
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 ( )

6. Outcomes of Hospitalized Cases
19% - 40% die
Of those who survive: 65% - 80% have significant long term neurological and developmental abnormalities
Unfortunately, the outcomes for infants who are taken to hospitals are poor. In published studies as many as 19-40% of babies die as a result of shaking. Of those who survive, 65-80% have life long brain damage.
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 ( )

7. How Common is SBS? Actual incidence is not known
Known incidence is likely just the tip of the iceberg
Approx 1,300 US children a year experience severe or fatal head trauma
30-40% of cases are missed at medical institutions
[Review bullets.]
Also, one estimate for NC is that for every hospitalized case of SBS, 152 parents have indicated using shaking as a form of discipline.
And, infants may sustain more than one episode of shaking before receiving medical care.
Many victims are found to have both old and new injuries when they are brought to medical attention.
So, as you can see known cases of SBS are actually a fraction of the infants who are victims of Shaken Baby Syndrome
Now let’s look at the third line of evidence that demonstrates that crying and colicky infants are behaving normally when they cry, even though it is terribly frustrating to parents.
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 ( )

8. The “Crying Curve” (Brazelton, Pediatrics 1962)
Large differences from infant to infant
More
Our understanding of the normality of early increased crying started with a study by T. Berry Brazelton, a well known pediatrician from Harvard University. This figure is from his very first published article back in 1962 which is known as the “normal crying curve.”
Dr. Brazelton asked mothers of all healthy newborns from his practice to take home diaries and record all of the fussing and crying that their infants did each day for three months.
Here is the data that was plotted and is known as the crying curve. There are two important things to notice.
The first is that there is a very clear increase, and then decrease, in the number of hours of crying and fussing, with the peak of that crying at about 6 weeks. As you can see, the onset is about 2 weeks, the peak is 2 months, and it decreases after that.
The second thing is that, just like height and weight, there is very large infant-to-infant variability in the amount of crying. Look at the median line. What is represented above and below represents about 50% of all the infants in the study. This means that 25% of these babies actually cried less [point to the space below the lower line] and 25% of normal babies cried more. [point to the space above the upper line]. This crying in the upper area is what many pediatricians and parents have traditionally thought of as colic. However, this increased crying is a period that all healthy babies go through.
Less
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 ( )

9. What is colic? Its defining features (Gormally & Barr, Ambulatory Child Health 1997)
Age-dependent crying pattern (peak during 2nd month);
These are due to changes in the amounts of crying that cluster during the evening
2. Associated behaviors (prolonged cry bouts, unsoothability, pain-like faces);
3. Unpredictable
In 1997, Gormally and Barr reviewed all the published literature on “colic” and they found that most people thought it came down to three things:
First, a crying curve just like in Brazelton’s study of normal infants;
Second, a number of behaviors associated with the crying included, 1) prolonged crying bouts, 2) bouts that are unsoothable, and 3) an expression that looks like the infant is in pain; and
Third, unpredictable, meaning crying that comes and goes, and is unrelated to dirty diapers, feeding, or anything else.
Although we could talk about all of these characteristics we are going to concentrate on the first of these: the age-dependent crying pattern (in red).
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 ( )

10. “Colic” is an abnormality, or “something wrong” with the infant.
Assumption:
“Colic” is an abnormality, or “something wrong” with the infant.
The assumption for years in almost all of the pediatric textbooks and parent advice literature has been that some infants “had” colic, and others didn’t, and those that “had” colic were abnormal or had something wrong with them.
What we will talk about here is that all normal infants have these crying characteristics, and that it has nothing to do with there being anything wrong with the infants, or their care givers.
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 ( )

11. “Peak Pattern” of Early Crying Behavior (Hunziker & Barr, Pediatrics 1986)
The first piece of evidence was a replication of Dr. Brazelton’s research almost 25 years later in Montreal, Canada by Dias, Hunziker and Barr. This research indicated the same crying patterns as the 1962 Crying Curve, despite an increase in the use of “snugglies” and the amount of carrying parents did. The infant to infant differences were also similar, with all infants showing a peak pattern regardless of whether they cried a lot or a little.
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 ( )

12. !Kung San Hunter Gatherers
Another important piece of evidence that this pattern was normal came from a unique observational study of a hunter gatherer tribe in Botswana called the !Kung San.
As you can see from these pictures, care giving among the !Kung San is quite different than in Western society. Among other things, the infants are constantly carried, and are constantly with their mothers.
By contrast, what we think of as normal care giving is usually quite different. In our society, infant’s are often separated from their care givers, and are often lying down in a crib.
(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 ( )

13. Care Giving Contexts
Let’s look at the differences between the !Kung and Western caregivers.
First, !Kung infants are in constant contact with their mothers, both because of being carried and because they sleep skin-to-skin with their mothers at night.
Second, carrying is constant because of the sling that mothers use, rather than in response to crying or for feeding;
Third, feeding is “continuous,” that is, they feed on average every 15 minutes for the first 2-3 years of life, in comparison to what we can call “pulse” feeding in the West;
Fourth, their posture is upright, both because of the sling, but also because they believe it is good for their development;
Fifth, their responsivness to infant crying is universal; they respond within 10 seconds 92% of the time to every fret and whimper, compared to what could be called “occasional non-response” in the West (the highest rate is about 25% of the time).
The !Kung San seem to do almost everything we know of that should be soothing to infants as part of their normal care giving. So the question is: do !Kung infants show the same crying curve that we see in infants in the West?
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 ( )

14. Hourly Cry/Fret Duration in. Kung San Infants (Barr, Konner et al
Hourly Cry/Fret Duration in !Kung San Infants (Barr, Konner et al., DMCN 1991)
This figure show the amounts of crying and fretting per hour in !Kung San infants at different ages. [Click to bring up circle.]
As you can see, the !Kung have the very same pattern of increased, and then decreased, crying as we see in Western infants in the first 3-4 months of life.
They also have the same degree of variability from infant to infant.
This was a strong indication that this pattern of early crying was not due to differences in care giving, nor was it due to something abnormal or wrong in the infants, but rather that it was part of a very basic normal behavioral pattern in young infants in the first few months of life. One important note however, is that while the number of crying bouts for these infants was the same, the length of crying bouts were shorter so we can say that carrying an infant more may decrease the length of crying bouts.
[Speaker Note: If someone asks about the peak occurring during the 3rd month this is almost certainly a consequence of the small sample size, and not a substantial difference. If we plotted just crying (as opposed to crying and fretting), the peak occurs in the second month.]
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 ( )

15. Parental Responses to Infant Chimp Distress (Bard, In Barr et al. (eds
Another important observation that indicates the normality of this curve came from studies on non-human mammals. This study reported that infant chimpanzees also have a similar distress curve in infancy.
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 ( )

16. “Distress Curves” In 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)
In fact, all non-human breast-feeding species studied to date, have a similar distress curve. This includes guinea pig pups, rat pups, chimpanzees, and free-living rhesus macaques (monkeys).
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 ( )

17. Age-related Crying Patterns in Preterm Infants (Barr, Chen, et al
Age-related Crying Patterns in Preterm Infants (Barr, Chen, et al., DMCN 1996)
A study that provides another piece to the puzzle examines the crying behaviour of preterm infants. In 1996, Dr. Barr found that premature infants also go through exactly the same crying curve over the same length of time.
However, the interesting part is that their curve starts at 2 weeks corrected age.
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 ( )

18. In 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.
Putting all the evidence together, we can summarize it as indicated on this slide; namely, that…[read the slide].
NOTE: I usually add that the phrase “….or psychopathology in the caregiver(s)” refers to the literature concerning whether post partum depression results in colic, or colic contributes to post partum depression. The evidence points to the latter, rather than the former.
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 ( )

19. Crying as the Stimulus for Shaken Baby Syndrome
Danger of shaking an infant
Crying as a
stimulus
to shaking
Normalcy of Increased Inconsolable Crying
We have learned that shaking a baby is very dangerous, and that increased crying in the first 5 months of life is normal. Now we will show evidence that this increased crying is the stimulus to 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 ( )

20. The “Crying Curve” (Brazelton, Pediatrics 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.
In addition to the anecdotal evidence from parents about how truly frustrating this early infant crying can be, Barr and Trent wanted to find more convincing evidence of the important of early crying for shaken baby syndrome.
[Click for yellow hypothesis box]. They hypothesized that if crying was a stimulus for shaking a baby then the pattern of SBS cases sorted by age should be similar to Brazeltons’ original 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 ( )

21. Age-specific Incidence of Hospitalized Cases of SBS (Barr, Trent et al
Age-specific Incidence of Hospitalized Cases of SBS (Barr, Trent et al., Child Abuse & Neglect 2006)
1 year
And, as you can see here, this is exactly what they found. These are findings from the State of California Public Health Service of all hospitalized shaken baby cases in the State of California in 2006.
You can see that the number of cases by age is very similar to the crying curve. In fact the majority of cases are under 6 months of age.
This is pretty strong evidence that the two are related however, there was no direct information from this data set that crying actually was the stimulus for the 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 ( )

22. NCSBS Age-specific Incidence of 591/166 Publicly-reported Cases of SBS (Lee, Barr et al., JDBP 2007)
To further support that crying and shaking are related, this direct information was available in the “SBS Victim Data Base” kept by the National Center on Shaken Baby Syndrome. This database is made up of publicly-reported cases of shaken baby syndrome, and because they are mostly news stories they can often contain information about the stimulus to the shaking.
When Lee, Barr, and their colleagues graphed the shaken baby cases by age [Click to show “all stimuli” curve], regardless of the specified trigger, you can see the shape of the curve is virtually identical to the curve obtained in the California hospital study that was on the previous slide.
Then, when they looked at just cases that mentioned crying was the specified trigger for shaking as the reason for shaking [click to bring up the red indicator of the “crying stimuli” curve], it can be clearly seen that the curve has exactly the same shape as the overall curve. And, of course, both curves are similar to the crying curve.
This study provides even more direct, and convergent, evidence that crying is an important, and probably, the most important, stimulus for shaken baby syndrome.
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 ( )

23. The Period of PURPLE Crying®
Prevention:
The Period of PURPLE Crying®
Dangers of Shaking
Prevention ? ?
Crying as Stimulus to SBS
Normalcy of Early Crying
So, now we turn to what to do about this. If our knowledge of the dangers of shaking (yellow circle) and the normalcy of increased crying in early infancy (green box) come together because crying is the most frequent and important stimulus of shaken baby syndrome (red box) [Click for Prevention box], does this provide us with an opportunity for prevention?
We think it does, and this is where the prevention program developed by the National Center on Shaken Baby Syndrome—called The Period of PURPLE Crying—comes in. It takes all of this evidence and puts it into a parent education package that addresses the crying, the shaking, and the timing of this normal development in the lives of infants to prevent shaken baby syndrome from happening.
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 ( )

24. Crying as a “Window of Opportunity” to 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.
This new knowledge about crying can work because it provides a “window of opportunity to teach caregivers and all members of society about the normality of early increased crying; An opportunity to point out that SBS is the only negative clinical consequence of early increased crying; and;
It clearly tells us that we need to teach before two weeks of age if it is to be effective.
NOTE: It may not be known to your audience that shaken baby syndrome is the only negative clinical consequence for the baby of early increased crying. However, there is a whole line of research about long term follow up of infants with colic. The results are clear that there is no long term negative consequence to the infant, regardless of the outcome looked at. This includes no increased incidence of allergies, recurrent abdominal pain, or “difficult infant” temperament.
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 ( )

25. The Period of PURPLE Crying®
P Peak of Crying
U Unexpected
R Resists Soothing
P Pain-like Face
L Long Lasting
E Evening
So, the challenge has been to incorporate these important lines of evidence into a set of prevention materials. [Click to show pictures] And this has resulted in the program called the Period of PURPLE Crying, and [click] the reason that it is called this is that the letters in the word “PURPLE” each stand for one of the six properties, or features, of crying in normal infants that contribute to the frustration and anger that care givers experience.
The first P stands for the peak pattern of crying where the amount of crying goes up and up peaking at the second month of life, and then it usually begins to decline until about 3-5 months of age;
U stands for Unexpected, referring to the fact that these crying bouts begin or end completely unpredictably and for no apparent reason.
They are not related to dirty diapers, feeding, or anything else that is going on in the environment of the infant;
The R stands for resistance to soothing, when nothing that you do can calm the baby down;
The second P is for the “pain-like face” when the infant looks like it is in pain, even when it is not, which adds to the anxiety and frustration on the part of the care giver;
The L stands for the fact that these bouts are long lasting, averaging about 35 minutes/bout during these first weeks and months of life but can go as long as 5 hours or more;
And the E stands for the fact that they tend to cluster in the late afternoon and evening hours, often when the care givers themselves are most tired and frustrated.
The other important word in the name is “Period.” This reminds care givers that the crying problems do not go on for ever, but only for a particular period in their infant’s life.
The purpose of the PURPLE acronym is to provide a quick, memorable and easy way for them to “recognize” and acknowledge that these crying characteristics can happen.
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 ( )

26. Important Action Steps When Infant Crying 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 ( )

27. Making PURPLE Widely Acceptable
Educational, and attractive to parents of newborns on the first day of life
Grade 3 level language
Valuable for all parents
Economical
Clear, memorable, salient, meaningful, attractive, positive message
Multicultural
Acceptable to Public Health Nurses (no bottles, blankets, or bumper pads)
In order to make the booklet and DVD as acceptable and as accessible as possible, so that it can achieve acceptance and wide distribution to mothers, fathers, caregivers and the general public, it incorporates a number of important features:
It’s educational, and attractive to parents of newborns on the first day of life (in comparison to other more dramatic and sometimes aversive or shocking type videos on SBS);
It has a clear, memorable, meaningful, and positive message;
It uses Grade 3 level language;
It’s available in many languages;
It is valuable information for all parents;
It is acceptable to Public Health Nurses,(no bumper pads, toys in cribs or formula);
It is economical [depending on the audience, you can say that it is available for as little as $2 per couple if bought in large quantities]; and
A key point of the program is that each parent receives a copy of their own to review when they need it, and to share with other, temporary, care givers.
Each parent receives a copy 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 ( )

28. Program Hypothesis
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 meaning of increased crying in early infancy, and
the danger of shaking as a response to the frustration with that crying.
The hypothesis of the PURPLE program is that, in order to achieve a long term sustained reduction in shaken baby syndrome, we need to create a cultural change in the way society understands both (1) the meaning of increased crying in early infancy, and (2) the danger of shaking as a response to the frustration with that crying.
This hypothesis emphasizes that it is not just parents, but everyone [including the neighbor next door who pounds on the wall and says “shut that baby up”] who needs to know about this. It also emphasizes that just warning about the danger of shaking is not enough; rather, society needs to understand the connection with crying, as well as shaking as a response to the frustration with that crying.
So what does The Period of PURPLE Crying teach parents…. [next slide]
*The goal in NC is to reduce the incidence of Shaken Baby Syndrome by 50%
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 ( )

29. 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.
All families of newborns throughout BC will receive education on normal infant crying as well as one copy of the Period of PURPLE Crying DVD and booklet from Maternity Nurses and Midwives.
Public Health Nurses will provide a second exposure to the education and if parents were missed, they will provide one copy of the DVD and booklet.
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 ( )

30. Implementing NC Hospitals As of 4/7/09
Map Key
White counties do not have hospitals appropriate for Dose 1
Hospital not implementing
Some hospitals began implementing as early at April 2007 while others have just begun

31. [Show clips of the PURPLE DVD]

32. 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.

33. How Dose 2 Partners Can Help to Reinforce the Period of PURPLE Crying® Messages

34. 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.

35. Training for Partners on the Period of PURPLE Crying Program®
To understand the research, the rationale of the program, and the messages, professionals should complete training session on the program.
Training is offered through web-based ( or in person PURPLE Crying training.
Remind that poster is free, maybe 2 slides

36. 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.
“activities” vs. “resources”

37. Medical and Health Department Reinforcement 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.

38. Reinforcement and Reminder Card (Available in English and Spanish)
front
back

39. Additional Ways to Reinforce PURPLE Crying Program at Your Office
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.
Remind that poster is free, maybe 2 slides

40. Poster Options (Available free in English, Spanish, bilingual)

41. 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.
Maybe describe their role/goal. Similar to hospital teaching
Because of their unique access to parents, we’re asking you to meet a higher standard of practice

42. 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.
Maybe describe their role/goal. Similar to hospital teaching
Because of their unique access to parents, we’re asking you to meet a higher standard of practice

43. Protocol to Reinforce PURPLE Crying During a Home Visit
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).
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).
Review the materials with the parent including going over the booklet and the DVD.
Answer any questions the parent may have about the program messages.

44. Home Visiting Form

45. PRENATAL Programs Protocol
Use 3 minute or 10 minute script to discuss crying. (Visuals are available.)
Inform parents that they will receive their own copy of PURPLE.
Information on the Period of PURPLE Crying may be given when convenient for both parents and personnel. If you are providing support prenatally, it is important to remember that it may be the first time parents are hearing about the program.
When discussing PURPLE, we request using either the 3 minute or the 10 minute script. You may use visuals such as the normal crying curve and/or the PURPLE acronym which are included in your implementation package.
Please inform parents that they will receive their own copy of PURPLE from a maternity nurse or midwife immediately after giving birth.
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 ( )

46. 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.
The 3 minute script educates parents of newborns about:
Normal infant crying - its increase, peak and decline;
Receiving a DVD/booklet about normal infant crying, from a maternity nurse or midwife, 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.
This script is designed for a one-on-one setting such as a home visit.
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 ( ) 46

47. 10 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;
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.
The 10 minute script educates parents of newborns about the same important issues as the 3 minute script, but in more detail.
In addition to discussing infant crying, the dangers of shaking and the importance of sharing this information with others, the 10 minute script also covers crying research, the PURPLE acronym as well as other stressors that can add to the parents’ frustration.
This script is designed for a classroom setting such as a prenatal or a parenting class.
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 ( )

48. POSTNATAL Protocol (Community programs, emergency rooms, family support programs)
If you are providing support post-natally and parents received PURPLE:
Use the 3 minute or the 10 minute script to reinforce the crying education. Visuals are available.
Encourage parents to view the received materials.
Address concerns.
If you are providing support postnatally, it is ideal to provide PURPLE information when the infant is around two weeks of age (when the crying generally starts).
If parents received PURPLE, we request:
Using either the 3 minute or the 10 minute script to reinforce the crying education. You may also use visuals to enhance your teaching;
Encouraging parents to view the DVD and booklet, and;
Addressing any 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 ( )

49. POSTNATAL Protocol (Continued)
If you are providing support postnatally and parents did not receive PURPLE:
Use the 3 minute or the 10 minute script to discuss crying.
Encourage parents to view your program’s office copy of the DVD and booklet – OR
Address concerns.
Encourage parents to visit the
NC PURPLE.org website to order a set of materials.
If you are providing support postnatally and parents did not receive PURPLE, we request:
Using either the 3 minute or the 10 minute script to discuss crying;
Encouraging parents to view your office copy of the DVD and booklet, or;
Encouraging parents to visit their nearest health unit or speak with their midwife to view the materials, and;
Addressing any concerns.
Your office copy will include a booklet in English and a DVD which may be viewed in 9 different languages (English, French, Spanish, Punjabi, Portuguese, Cantonese, Korean, Vietnamese and Japanese) plus closed-captioning.
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 ( )

50. 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.
Eastern Region
Katheryn Grubbs, MSW
Research Specialist
Nina Kane, MSW
at the Center for Child and Family Health
Project Manager
Kelly Sullivan, Ph.D.

51. References
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):e
Evidence that shaking is dangerous
Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. Br Med J. 1971;2:
Conway EE Jr. Nonaccidental head injury in infants: the shaken baby syndrome revisited. Pediatric Annals. 1998;27(10):
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):

52. References 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 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):

53. References 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:

54. 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 ( )

55. 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
Every NC hospital that delivers babies provides the “first dose” of the education to caregivers (initiative began in September, 2007)
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)
“Third dose” consists of a statewide media campaign designed to create a cultural change in the understanding of infant crying (currently in development)