The Period of PURPLE Crying Program

About the program

The Period of PURPLE Crying program is designed to increase knowledge and change behaviors related to crying and the dangers of shaking infants. It is used to educate parents about normal infant crying, strategies to use when infants cry and the dangers of shaking in an effort to decrease abusive head trauma.

The letters in the word “PURPLE” each stand for a property of crying in normal infants that is frustrating to caregivers:

• P for peak pattern of crying
• U for unexpected crying
• R for crying that is resistant to soothing
• P for showing a pain-like face when they cry
• L for long lasting cries
• E for evening clustering of crying.

The program consists of educational materials that are distributed and explained to parents by healthcare professionals. These include a booklet, DVD, and an app. The materials suggest three steps when caring for a crying infant:

1. increase “carry, comfort, walk and talk” responses
2. if the crying is too frustrating, it’s OK to walk away, put the baby down in a safe place, calm yourself and then return to check on the baby
3. never shake or hurt a baby.

Who does it work for?

The POPC program is designed for parents of newborn infants.

The program has been evaluated in Japan (Fujiwara et al. 2012).

A randomised control trial was conducted with 201 people in Japan (105 in the intervention group and 96 in the control group). Majority of mothers were 30-34 years old (39%). For 46% of mothers this was their first baby. Mother’s were eligible for the study if they had an uneventful pregnancy and gave birth to a healthy baby.

The POPC program has not been evaluated in Australia or with Aboriginal Australians.    

What outcomes does it contribute to?

The program had a mixed effect on parenting knowledge. Parents who participated in the program are more likely to know details about infant crying (e.g. it increases in the first few weeks of life and reaches a peak in the first 2-3 months). However, the program did not impact parent’s knowledge on shaking babies.

No effect:

Parenting stress: the program shows no effects in rates of frustration of parents with infant crying.

Positive parenting behaviour (Shaken Baby Syndrome): the program shows no effects on responses to general crying and unsoothable crying, and caregiver self-talk responses to unsoothable crying.

Negative Outcomes:

No negative outcomes were found.

How effective is it?

Overall, the POPC program has a mixed effect on client outcomes.

How strong is the evidence?

Mixed research evidence (with no adverse outcomes):

• At least one high-quality randomised controlled trial (RCT)/quasi-experimental design (QED) study reports statistically significant positive effects for at least one outcome, AND
• An equal number or more RCT/QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
• No RCT/QED studies show statistically significant adverse effects.

How is it implemented?

The POPC program is implemented using an 11-page booklet, DVD and/or app. These are explained to new parents by a healthcare professional at a one-off discussion before their infants are two weeks of age. The materials describe what shaken baby syndrome is, the frustration of crying infants and the dangers of shaking. They also emphasise telling other caregivers about the program. They key steps are outlined:

1. increase “carry, comfort, walk and talk” responses
2. if the crying is too frustrating, it’s OK to walk away, put the baby down in a safe place, calm yourself and then return to check on the baby
3. never shake or hurt a baby.

The hospital or clinic administering the POPC must purchase the booklets which contain a code to watch the video. The full program is available at three levels:

• education using the booklet and video given sometime before two weeks of age
• reinforcement by primary care providers
• a public health campaign

How much does it cost?

Information about the cost of the POPC program can be found on the website at:

https://store.dontshake.org/category-s/108.htm

The booklet and DVD cost USD$2.30 per copy, while the booklet and app package is USD$2.00 per copy.

What else should I consider?

Materials have been created in multiple languages and are intended to be distributed before infants are 2 weeks old.

Cultural differences in response to infants crying should be considered when implementing the POPC program. Studies in Japan show that there are differences in risk factors for shaken baby syndrome than in western society, such as two infant age peaks, and having even one sibling (Fujiwara, Okuyama, & Miyasaka, 2008; Fujiwara, Okuyama, Tsui, & Koenen, 2008). There may need to be adaptation of the materials if implemented within CALD or Indigenous communities (Fujiwara et al. 2012).

Where does the evidence come from?

One RCT conducted in Japan with 201 participants (Fujiwara et al. 2012).

Further resources

POPC program website: http://purplecrying.info

Fujiwara et al. (2012), 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 & Neglect, Vol. 36, No. 9, pp. 613-620.