Infants communicate through crying. It is a normal, developmental stage that all infants go through, especially in the first four to five months of life. The crying typically increases at around two weeks of age, peaks at two to three months and declines by five months. Some infants cry as long as five hours a day or more while others cry for only 20 minutes or less each day. This is still normal.

Crying, especially inconsolable crying, is the most common trigger for shaking and physical abuse.  Research has shown that all normal infants have inconsolable crying in the first few months. Some have much more than others, with infants in approximately the top 20% considered to experience colic. Parents can reduce most crying bouts but when it comes to inconsolable crying, there is little they can do to reduce it which can be frustrating.

The Period of PURPLE Crying program takes advantage of this critical connection between normal crying and shaking to educate parents and the general public both about normal crying behavior and the dangers of shaking. PURPLE is an evidence-based shaken baby syndrome/abusive head trauma (SBS/AHT) prevention program that has been available provincially since 2009. The program has two aims:

1. Support parents and caregivers in their understanding of early increased infant crying; and
2. Reduce the incidence of SBS/AHT in British Columbia.

Implementation

Crying education and program materials are delivered to parents of BC’s nearly 43,000 annual births via three doses or exposures:

1. Maternity Nurses and Midwives;
2. Public Health Nurses; and a
3. Public Education Campaign. 

The Period of PURPLE Crying provides educational information about the properties of normal infant crying that are uniformly frustrating to caregivers, and appropriate action steps that caregivers need to know. Inconsolable infant crying is the number one trigger that precedes a shaking event.

The letters in the word PURPLE describe the properties of normal infant crying that are frustrating:

The behavioural component, “three action steps” guides caregivers on how to respond to crying in order to reduce crying as much as possible and to prevent shaking and abuse. These action steps are:

The program materials include either:

DVD + Booklet Package

1. Available in 11 languages: English, French (Quebecois), Punjabi, Cantonese, Korean, Japanese, Vietnamese, Spanish (Mexican), Portuguese (Brazilian), Somali and Arabic (soon to be in Hebrew)
2. Full colour 10-page booklet
3. Parent Reminder Card
4. DVD including:
   • 10-minute PURPLE Crying video
   • 17-minute Crying, Soothing, Coping: Doing What Comes Naturally video

Web and Mobile Application + Booklet Package

1. Available in 3 languages: English, Spanish and French (Quebecois)
2. Full colour 10-page booklet
3. Parent Reminder Card
4. Web and mobile application including:
   • 10-minute PURPLE Crying video
   • 17-minute Crying, Soothing, Coping: Doing What Comes Naturally video
   • 10-page e-booklet

Prior to discharge from the hospital, families receive crying education from a maternity nurse and resources to take home (DVD/booklet package or App/booklet package).  Within two weeks of being at home, families receive reinforcement of the program messages from a public health nurse during the new baby follow up phone call or home visit.  Several midwifery clinics and Aboriginal health centres also provide the crying education and materials to families. 

Evaluation

The BC Period of PURPLE Crying program is currently being evaluated through quality improvement process measures as well as active and passive surveillance.

Quality improvement measures include:

• public health nurse administrative forms (February 2009 to September 2011);
• maternity nurse surveys (September 2009 to March 2014);
• parent surveys when their infants are 2-4 months of age (January 2010 and ongoing);
• public health nurse surveys (October 2012 and ongoing)

For active and passive surveillance, incidence rates of SBS and other forms of physical abuse in 0-2 year olds are collected from the Neurosurgery Department at BC Children’s Hospital (completed), Child Protective Services, the BC Coroners Office and Canadian Institute for Health Information.  The SBS and physical abuse rates are compared pre-/post- PURPLE program implementation.