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Service Delivery Innovation Profile

Educational Materials Enhance the Ability of New Parents To Understand and Cope With Infant Crying


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Snapshot

Summary

The Period of PURPLE Crying program, distributed to new parents by clinicians and other service providers, consists of a video and booklet that help new parents and other caregivers understand and safely cope with infant crying, the most common trigger for shaken baby syndrome. The materials describe normal infant crying, explain the easy-to-remember acronym PURPLE (with each letter standing for various features of infant crying), suggest strategies for comforting a baby, acknowledge caregiver frustration when a baby cannot be soothed, explain the dangers of shaking the infant, and outline a positive approach for handling an inconsolable infant. Labor and delivery nurses or discharge nurses distribute these materials to new parents prior to discharge from the hospital or birthing center. Pediatricians, public health workers, adoption agencies, and other organizations interacting with new parents may also distribute these materials or reinforce their messages, which may be complemented by a public education campaign. Multiple studies show that the program increased mothers' knowledge about infant crying and shaken baby syndrome and the likelihood of such knowledge being shared with others and enhanced the ability of mothers to deal appropriately with distressed, crying babies.

Evidence Rating (What is this?)

Strong: The evidence consists of two randomized, controlled trials as well as unpublished data that evaluated key metrics of mothers' abilities to understand and cope with infant crying.
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Developing Organizations

National Center on Shaken Baby Syndrome
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Use By Other Organizations

The Period of PURPLE Crying materials have been distributed to parents and caregivers at more than 1,000 sites across the world.

Date First Implemented

2007
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Patient Population

Age > Infant (1-23 months); Newborn (0-1 month)end pp

Problem Addressed

Shaken baby syndrome (the intentional and violent shaking of a baby, with or without impact with a hard surface) is a tragic, preventable problem that often leads to serious injury or death.1 Typically caused by caregivers who are unable to manage their frustration with an infant’s inconsolable crying, shaken baby syndrome can be prevented by helping parents and caregivers understand and learn to cope with such behaviors. Many parents do not receive such support, however.
  • A leading cause of child mortality: Shaken baby syndrome occurs in an estimated 30 out of every 100,000 children under the age of one.2 Approximately 25 percent of all victims die as a result of their injuries, making it one of the leading causes of child abuse mortality in the United States.3,4 Among those who survive, approximately 80 percent suffer permanent disability such as severe brain damage, blindness, cerebral palsy, mental retardation, behavioral disorders, and impaired motor and cognitive skills.5
  • Unrealized potential of caregiver education: Shaken baby syndrome most commonly results from caregiver frustration with unpredictable, prolonged, and inconsolable infant crying.1 These caregivers generally do not understand that such crying is common in normal infants, and they remain unaware of strategies for coping with it. Educating them about normal infant crying, the dangers of shaking a child, and coping strategies can help address the problem, yet relatively few parents and caregivers receive such support.1

What They Did

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Description of the Innovative Activity

Labor and delivery nurses, discharge nurses, or health educators distribute the Period of PURPLE Crying program to new parents prior to discharge from the hospital or birthing center. The program offers an educational video and booklet for new parents and other caregivers to help them understand and cope with infant crying. The materials describe normal infant crying through an easy-to-remember acronym, suggest strategies for comforting a baby, explain the dangers of shaking, and suggest a positive approach to handling an inconsolable infant. Materials may also be distributed or reinforced by pediatricians, public health workers, adoption agencies, and other organizations interacting with new parents and may be complemented by a public education campaign. Key program elements include the following:
  • Educational materials: Information provided in November 2012 indicates that current materials include a full-color, 10-page booklet and DVD with 10- and 17-minute films (packaged together). The booklet and 10-minute film cover the following content:
    • Memorable acronym to explain infant crying: The materials explain the key features of infant crying through the acronym PURPLE, with each letter standing for a specific feature of infant crying:
      • Peaks: Crying peaks in the second month of life, usually coming to an end in the third or fourth month.
      • Unexpected: The crying can come and go for no apparent reason.
      • Resists soothing: No matter what caregivers try, the crying may continue.
      • Pain-like face: Infants may look like they are in pain, even if they are not.
      • Long lasting: Some infants cry for 3 to 5 hours a day or even more at the peak.
      • Evening: Most of the crying tends to cluster in the late afternoon or evening.
    • Emphasis on crying as normal and dangers of shaking: The materials emphasize that all babies go through a period of increased crying as a normal part of development, acknowledge caregiver frustration when a baby cannot be soothed, and explain the dangers of shaking a child.
    • Positive action steps when caring for crying baby: The materials also suggest positive strategies for comforting a baby, while acknowledging that they may not always work. Advice to parents includes the following:
      • Respond to a crying infant by increasing “carry, comfort, walk, and talk” responses.
      • If necessary, put the baby down in a safe place, walk away, calm down, and then check on the baby.
      • Never shake the baby.
    • Newly added 17-minute film: Information provided in November 2012 indicates that a film called "Crying, Soothing and Coping: Doing What Comes Naturally" was added to the DVD to provide additional evidence-informed strategies for soothing a crying infant and techniques for coping with soothing that does not work.
  • Three-pronged dissemination and support: States or communities have used any or all of a three-pronged strategy for disseminating and teaching the materials to parents, including using hospitals, birthing centers, and adoption agencies to distribute and teach them at birth or adoption; asking medical groups and other organizations that cater to new parents to distribute the materials or reinforce key messages; and using a public education campaign to raise awareness and highlight key messages.
    • Distribution at birth: Trained staff at hospitals and birthing centers distribute the DVD and booklet (packaged together) to all new parents using an established protocol. Information provided in November 2012 indicates that as part of the protocol, nurses and health educators first view a 27-minute online training presentation that explains the material and its evidence base and that emphasizes the importance of distribution to all new parents. The protocol offers various resources to use with new parents, including talking points, with 3- and 10-minute versions available depending on the organization's discharge processes, and a teach-back educational strategy that uses the program booklet to educate new parents and asks parents questions about the information to verify understanding. Once trained, the nurse or health educator distributes materials to all new parents, introduces the content, reviews the booklet (particularly the acronym PURPLE), and ideally plays the video for the parents. The nurse or educator also advises parents to share the materials with all the baby’s caregivers.
    • Distribution or reinforcement by other organizations: During their regular interactions with new parents, pediatricians, public health workers, and representatives of foster care agencies, home visitation programs, and adoption agencies ask if they have received the Period of PURPLE Crying materials. If so, they reinforce the key educational messages. If not, they give the materials to the parents and provide an overview of them.
    • Public education campaign: Some organizations have sponsored communitywide media campaigns to promote the sharing of program materials; these campaigns may include radio or television advertisements, social media, or participation in a yearly campaign, called CLICK for Babies, to collect purple-colored baby caps from knitters and crocheters across the country (updated November 2012).

Context of the Innovation

Established in 1990 as a nonprofit organization, the National Center on Shaken Baby Syndrome is the only organization in the world dedicated solely to the prevention of shaken baby syndrome. The impetus for the Period of PURPLE Crying program came from the center’s advisory board, which charged staff with developing an evidence-based program to address the problem. The program was designed by Ronald Barr, MDCM, a developmental pediatrician and leading researcher on infant crying, and Marilyn Barr, BIS, founder and director of the center.

Did It Work?

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Results

Multiple studies show that the program increases mothers' knowledge about infant crying and shaken baby syndrome and the likelihood of such knowledge being shared with others and enhances the ability of mothers to deal appropriately with distressed babies.
  • Increased knowledge of infant crying: Information provided in November 2012 indicates that mothers exposed to program materials scored higher on a test measuring knowledge of infant crying than did mothers who did not participate (69.5 versus 63.3 percent in one study, 63.8 versus 58.4 percent in a second study, and 56.1 versus 53.1 percent in a third study).1,2,6 In all three studies, participating mothers also scored higher on knowledge about the dangers of shaking, although this finding was statistically significant only in the second study.2
  • Increased likelihood to share knowledge with other caregivers: Participating mothers were more likely to share information with other caregivers than nonparticipants, including descriptions of infant crying (67.6 versus 60.0 percent), advice about walking away if frustrated (51.5 versus 38.5 percent), and the dangers of shaking (49.3 versus 36.4 percent).2 In another study, there was an 18.3 percent increase in sharing information with other caregivers on walking away if frustrated by inconsolable crying.6
  • Improved coping strategies: Participating mothers were 1.7 times more likely to walk away from an inconsolable infant when frustrated than those who did not participate.2 In another study, participating mothers were 4.8 times more likely to walk away from an inconsolable infant when frustrated.6 One study also found that participating mothers had 8.6 more minutes per day of contact with their baby when distressed.1 However, the studies have found no significant difference between participating and nonparticipating mothers with respect to the number of times a distressed infant was picked up.1,2
  • Similar findings in vulnerable populations: Unpublished data on use of program materials with high-risk, first-time mothers found similar results, with the program improving their knowledge about infant crying and their behavioral responses to it and increasing the likelihood of sharing information with other caregivers.7

Evidence Rating (What is this?)

Strong: The evidence consists of two randomized, controlled trials as well as unpublished data that evaluated key metrics of mothers' abilities to understand and cope with infant crying.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Reviewing relevant research: The staff conducted an extensive literature review to identify the most salient content to include in the program. Dr. Barr created the concept of the Period of PURPLE Crying and the acronym PURPLE based on this research.
  • Creating video and booklet: Ronald and Marilyn Barr worked with center staff (including the marketing director and graphics design personnel) to create the video and booklet. They focused on making the materials understandable, educational, and attractive to parents (they wrote them at a third-grade level and in a culturally competent manner) and economical for providers.
  • Conducting randomized, controlled trials (RCTs) and focus groups: The center conducted two RCTs—one in Seattle and one in British Columbia. At the same time, the center held 38 focus groups with parents to obtain feedback about the materials.
  • Revising materials: Based on information gathered during the focus groups and the clinical trials, the organization revised and shortened the video and booklet.
  • Launching program to the public: In 2007, center staff contacted administrators and maternity nurses at hospitals and birthing centers in Utah to solicit interest in the program and eventually expanded it to other states and Canada.
  • Translating into other languages: The materials have been translated into 10 languages; with each new translation, the center holds focus groups with parents to ensure accuracy and applicability.
  • Ongoing enhancement: The 10-minute film was updated with new b-roll in October 2012 to reflect changes in public health safety standards and best practices.

Resources Used and Skills Needed

  • Staffing: Adopting the program requires no new staff, as existing staff incorporate it into their daily routines.
  • Costs: The cost of program materials varies based on quantity ordered, with each DVD/booklet combination costing $3.50 for orders of 100 to 499, $2.50 for orders of 500 to 999, and $2.00 for orders of 1,000 or more. Military organizations and statewide programs qualify for the $2.00 price regardless of quantity ordered. To encourage distribution, the center does not accept orders of less than 100.
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Funding Sources

National Center on Shaken Baby Syndrome
The Period of PURPLE Crying program is funded through the support of a variety of public and private organizations and foundations. The Doris Duke Charitable Foundation and the George and Dolores Dore Eccles Foundation funded the trial in Seattle, WA, while the Canadian Ministry for Child and Family Development funded the trial in British Columbia, Canada.end fs

Tools and Other Resources

The Period of PURPLE Crying program materials are available at: http://www.dontshake.org/sbs.php?topNavID=4&subNavID=32&navID=664.

Adoption Considerations

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Getting Started with This Innovation

  • Plan implementation carefully: The program rollout should be planned carefully to ensure that all relevant staff receive training and that each family gets a copy of the materials and related education and support.
  • Get multiple stakeholders involved: Those adopting the program should introduce it to a wide variety of community stakeholders (e.g., law enforcement, public health providers, local health associations) to facilitate widespread dissemination of the message. In addition, providers within the hospital setting—such as social workers and emergency department clinicians—should be educated about program content to increase the likelihood that they will share salient messages with parents.
  • Build program into existing processes: Each implementation site has different funding sources, policies, and procedures and therefore must integrate the program into its own culture and processes.

Sustaining This Innovation

  • Seek sources of ongoing funding: To facilitate reorders, program material costs should be incorporated into the adopting organization's operating budget.
  • Reengage with nurses and other providers: Regularly touch base with maternity nurses and other key providers to ensure they remain enthusiastic about sharing program content.
  • Survey parents and share data: Periodically survey parents about the value of the program and share feedback with providers and administrators to help sustain support for the program.

Use By Other Organizations

The Period of PURPLE Crying materials have been distributed to parents and caregivers at more than 1,000 sites across the world.

More Information

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Contact the Innovator

Julie Price
Director, International Prevention
National Center on Shaken Baby Syndrome
1433 North Highway 89, Suite 110
Farmington, UT 84025
Phone: (801) 447-9360
E-mail: jprice@dontshake.org

Innovator Disclosures

In addition to the external funders listed in the Funding Sources section, Ms. Price reported that the National Center on Shaken Baby Syndrome has received funding from several organizations to cover her travel expenses for speaking engagements and prevention planning meetings.

References/Related Articles

Information about the Period of PURPLE Crying program is available at: http://www.dontshake.org/purpleprogram.

Information for parents about the Period of PURPLE Crying program is available at: http://www.purplecrying.info/.

Information about the National Center on Shaken Baby Syndrome is available at: http://www.dontshake.org.

Barr RG, Rivara FP, Barr M, et al. 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. 2009;123(3):972-80. [PubMed]

Barr RG, Barr M, Fujiwara T, et al. Do educational materials change knowledge and behavior about crying and shaken baby syndrome? a randomized controlled trial. CMAJ. 2009;180(7):727-33. [PubMed]

Footnotes

1 Barr RG, Rivara FP, Barr M, et al. 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. 2009;123(3):972-80. [PubMed]
2 Barr RG, Barr M, Fujiwara T, et al. Do educational materials change knowledge and behavior about crying and shaken baby syndrome? a randomized controlled trial. CMAJ. 2009;180(7):727-33. [PubMed]
3 King WJ, MacKay M, Sirnick A, Canadian Shaken Baby Study Group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ. 2003;168(2):155-9. [PubMed]
4 Starling SP, Holden JR, Jenny C. Abusive head trauma: the relationship of perpetrators to their victims. Pediatrics. 1995;95(2):259-62. [PubMed]
5 National Center on Shaken Baby Syndrome [Web site]. Statistics available at:http://www.dontshake.org/sbs.php?topNavID=2&subNavID=10.
6 Fujiwara T, Yamada F, Okuyama M, et al. Effectiveness of educational materials designed to change knowledge and behavior about crying and shaken baby syndrome: a replication of a randomized controlled trial in Japan. Child Abuse Negl. 2012;36(9):613–20. [PubMed]
7 Connecticut 2010. Period of PURPLE Crying effective in changing knowledge and behavior in a home visiting program supporting high risk first time mothers. Available at: http://dontshake.org/pdf/DrBradshawHomeVisitPURPLE.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.). (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.)
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 12, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.