implementing the period of purple crying ® in community settings in north carolina a program of the...

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


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


Intracranial “Cascade” from ShakingIntracranial “Cascade” from Shaking


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


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 “Crying Curve”The “Crying Curve”(Brazelton, (Brazelton, PediatricsPediatrics 1962) 1962)

Less

Large differen

ces from

infant to infant

More


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


Assumption:Assumption:

““Colic”Colic” is an abnormality, is an abnormality,or “something wrong” with the infant.or “something wrong” with the infant.


““Peak Pattern” of Early Crying BehaviorPeak Pattern” of Early Crying Behavior(Hunziker & Barr, (Hunziker & Barr, PediatricsPediatrics 1986) 1986)


!Kung San Hunter Gatherers!Kung San Hunter Gatherers

(Photos by Marjorie Shostak)


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


HourlyHourly Cry/Fret DurationCry/Fret Duration in !Kung San in !Kung San InfantsInfants (Barr, Konner et al., (Barr, Konner et al., DMCNDMCN 1991) 1991)


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)


““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)


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)


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.


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 “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.


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


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)


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®


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 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


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


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


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.


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.

http://www.dontshake.org/

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.



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


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.


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.


For more information about the Period of PURPLE Crying Program

Contact:

Western Region

Julie Hansford, MSW

at the Center for Child and Family Health

[email protected]

Triangle Region

Susan McCraw, M.Ed.


[email protected]

Eastern Region

Katheryn Grubbs, MSW


[email protected]

Research Specialist

Nina Kane, MSW


[email protected]

Project Manager

Kelly Sullivan, Ph.D.


[email protected]

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.


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.


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)

implementing the period of purple crying ® in community settings in north carolina a program of the...

Documents

national center

registered trademark

shaken baby syndrome

north carolinaa program

north carolinafunded

large head

duke endowment

knownknown incidence