KY: Shaken Baby SyndromePage 10 of 13

8. Interventions and Prevention of SBS/AHT

The first thing to know is that crying in a young baby is often normal; it’s part of their neurological development. As pediatricians, we teach parents that if you know the baby has been fed, is not sick, is clean, and is not injured or hurt, then it’s okay to put the baby down if the baby is crying because that baby is simply at the time of the day where they cry a lot.

I don’t know any baby who ever cried themselves to death, but I do know of too many cases where parents got frustrated by the baby crying and we ended up in a really quite terrible situation. We always want parents to have a support system. If you are the primary caregiver and you’ve reached your end, it’s always appropriate to say to a partner, grandparent, a support person, or somebody you trust, “Can you take over because I’ve had enough of the crying baby?” And it’s also perfectly fine to take a crying baby and put them in a nice safe sleep environment like a crib and walk away and calm yourself down, do something that relaxes you and rejuvenates you so you don’t get frustrated with this crying baby.

Cindy Christian, MD
NICHD, 2013

Shaking most often occurs in response to a baby crying or other factors that can trigger the person caring for the baby to become frustrated or angry. Family members, friends, and healthcare providers can help parents understand that it’s okay for a baby to cry, especially from 2 to 8 weeks of age. The problem is not the crying, it’s how a caregiver responds to it.

Giving parents and caregivers tools that help them cope with frustration while caring for a baby are important components of any SBS prevention program. Health professionals play a key role in reinforcing prevention by helping parents and caregivers understand the dangers of violently shaking a baby, the risk factors and the triggers for it, and ways to lessen the load on stressed-out parents and caregivers, all of which may help to reduce the number of cases of SBS.

Behavioral strategies such as graduated extinction (where the parent returns to check on their crying child at increasing time intervals with brief parental reassurance) and positive bedtime routines have been shown to be effective strategies for managing sleep problems in children aged 6 months or older (Cook et al., 2012). A program that provides parents with information about normal sleep and cry patterns and ways to reduce stimulation and provide a predictable environment in the first few months of life may be able to prevent both infant sleeping and crying problems.

Shaken Baby Syndrome Prevention Programs

Many prevention and education programs strive to raise awareness about SBS, educate parents and other caregivers about the serious effects of SBS-related injuries, and inform them about infant crying behavior and safe ways to reduce and prevent SBS injuries. Examples of common prevention strategies include:

  • Coordinated hospital-based primary prevention programs targeting parents of newborns.
  • Home visits for new parents
  • Anticipatory guidance at well-baby visits in pediatric practice or health clinics.
  • School prevention programs for junior high and high school students providing them with an understanding of child maltreatment issues, anger management techniques, and child care skills.

The Period of PURPLE Crying

Established in 1990, the National Center on Shaken Baby Syndrome is the only organization in the world dedicated solely to the prevention of shaken baby syndrome. The center has developed a number of educational tools and programs, including the popular and effective Period of PURPLE Crying (PURPLE) program. The program was designed by Ronald Barr, a developmental pediatrician and leading researcher on infant crying, and Marilyn Barr, founder and director of the center.

The Period of PURPLE Crying program is a public health education approach to SBS/AHT that recognizes excessive crying as a normal part of child development. It stresses that infants go through a normal period of crying that comes and goes unexpectedly, starting at about 2 weeks of age and peaking at 2 to 3 months of age. Numerous research studies from throughout the world have shown that parents who received training and materials through the PURPLE program are more knowledgeable about infant crying and are more likely to share their knowledge with other caregivers (Jenny, 2009).

A chart explaining the Period of PURPLE Crying program.

As illustrated above, each of the letters in PURPLE stand for a property of crying in healthy infants that can frustrate parents and caregivers:

  • P = peak pattern, in which crying increases at about 2 weeks, peaks in the second to third month, and then declines
  • U = unexpected bouts of prolonged crying that come and go
  • R = resistance to soothing
  • P = pain-like look on the child’s face when they are crying
  • L = long crying bouts—up to 35 or 40 minutes per bout
  • E = bouts of crying tend to occur in the late afternoon and evening although they can happen at any time of the day

The PURPLE program also emphasizes three main points:

  • Parents are encouraged to use typical calming responses (carry, comfort, walk, talk) with their infants.
  • If the crying is too frustrating, it is okay put the baby down in a safe place, walk away, calm yourself, and then return to check on the baby.
  • Never shake a baby. (Barr et al., 2009)

Labor and delivery nurses, discharge nurses, and health educators can distribute the Period of PURPLE Crying program materials to new parents prior to the baby’s discharge from the hospital or birthing center. Program materials include an educational video and booklet for new parents and other caregivers to help them understand and cope with infant crying. The materials provide 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 (AHRQ Healthcare, 2013).

The National Center on Shaken Baby Syndrome also offers a school-based program for junior and senior high school students, which teaches students about the medical aspects of shaking injuries, combined with basic anger management and childcare skills. Teaching students how frustration can lead to shaking emphasizes the importance of appropriate coping skills.

There are also programs targeting males, especially new fathers, with information and resources for providing safe and nurturing care for their new infants and safe strategies for coping with frustration caused by crying babies. Other programs emphasize professional education and trainings for doctors, nurses, therapists, social workers, and others providing family services.

The Period of PURPLE Crying

  • It is part of the infant’s normal development and occurs in all babies.
  • It differs from colic, which is an abnormality that occurs in some, but not all, babies.
  • It differs from crying associated with illness, which may be related to an acute episode of illness with other symptoms such as diarrhea.

Getting the Prevention Message Out

States or communities have used any one or all elements of a three-pronged strategy for disseminating and teaching the materials to parents. The strategy encourages hospitals, birthing centers, and adoption agencies to distribute materials and provide education about SBS/AHT to parents and caregivers at birth or adoption. Medical groups and other organizations that cater to new parents are encouraged to distribute the materials and reinforce key messages about prevention. Finally, state and communities are encouraged to use a public education campaign to raise awareness and highlight key messages (AHQR, 2013).

Distribution at Birth

Trained staff at hospitals and birthing centers are encouraged to distribute the DVD called “Crying, Soothing and Coping: Doing What Comes Naturally” and a full-color, 10-page booklet (packaged together) to all new parents, using an established protocol. 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 (AHQR, 2013).

The protocol offers various resources to use with new parents. These include 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 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.

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 are encouraged to ask parents and caregivers 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 Campaigns

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 (AHRQ, 2013). Click here for more information about the CLICK for Babies program.

Key Points for Medical Providers

  • Remind parents and caregivers that crying is normal for babies.
  • Infant crying normally increases at 2 to 3 weeks of age, peaks around 6 to 8 weeks of age, and tapers off when the baby is 3 to 4 months old.
  • During medical visits, ask parents how they are coping with parenthood and their feelings of stress.
  • Remind parents that they may experience a sudden decrease in sleep, but that things will get better.
  • Encourage parents to check for signs of illness, fever, unusual behavior, or discomfort.
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