Education Program Takes Aim at Shaken Baby Syndrome

Diana Phillips

December 18, 2014

A multicomponent educational intervention is useful and effective for teaching mothers soothing/coping techniques as well as about the dangers of shaking an infant, a study has shown.

Called the Period of PURPLE Crying program, the intervention was designed to educate infant caregivers about the risks for pediatric abusive head trauma (AHT), a form of inflicted brain injury resulting from violent shaking or blunt impact. The acronym PURPLE describes specific characteristics of an infant's crying: Peaks in crying that are Unexplained; Resists soothing; accompanied by a Pain-like face; Long-lasting, and occurring in the Evening and late afternoon.

Previous randomized controlled trials showed that the program, which includes an educational intervention with a trained healthcare professional, program brochure, 10-minute DVD, refrigerator magnet, bib, and caregiver checklist, is effective in "relatively resource-rich settings." However, the program has not previously been evaluated in the community setting, Laura Schwab Reese, a doctoral candidate at the Injury Prevention Research Center at the University of Iowa in Iowa City, and colleagues report in an article published online August 18 and in the November/December 2014 issue of the Journal of Obstetric, Gynecologic & Neonatal Nursing.

The investigators evaluated the efficacy of the program as implemented in five birthing hospitals in a city in the Midwest, measuring the effect of the program on mothers' knowledge of the dangers of infant shaking and coping/soothing tools. The hospitals were selected and enrolled from a stratified sample pool of 12 facilities and had annual birth rates ranging from 600 to 3500 infants. Participants included new mothers who gave birth in one of the enrolled hospitals between March 15 and August 10, 2011, who received the intervention, as well as the trained nurses who delivered it, the authors explain.

To evaluate the implementation, the mothers and nurse educators completed a survey at the end of each in-person education session rating how well the session was delivered and the perceived usefulness. For the outcome evaluation, the researchers contacted participants by telephone 2 months after discharge, when infant crying and the incidence of AHT peaks, to measure their knowledge of the dangers of shaking and coping and soothing techniques.

Of 211 mothers who completed the baseline survey, 160 (76%) rated the intervention a 9 or 10 on a scale of 1 to 10, where 10 is "very useful," the authors report. "Only 9% (19/211) of the mothers rated the education session a 7 or less," they write. Many of the mothers commented that they appreciated the opportunity to openly discuss the issues addressed in the intervention.

With respect to nurse feedback, there was a high degree of agreement between mother's and nurse's ratings of the program across attitudes (83.9%), knowledge of normal crying (83.4%), knowledge of the dangers of shaking (81.5%), and knowledge of techniques for soothing (80.0%), the authors observe. "However, mother and nurse responses only matched 69.6% of the time regarding intent to share, with nurses rating their perception of mothers' intent to share the program with other caregivers higher than mothers' self-reported intent."

In the outcome evaluation, more than half (54.4%) of the mothers correctly answered all nine questions about the dangers of shaking an infant, and more than half (57.4%) correctly answered the six questions about normal infant crying.

In terms of knowledge deficits, 23.5% of mothers responded incorrectly to the statement, "Infants go through a stage around two months where they may cry for up to 5 hours a day"; 22.1% responded incorrectly to the statement, "A good parent should be able to soothe his or her crying infant"; and 17.7% incorrectly responded to the statement, "When an infant cries, it is always a sign that something is wrong." The authors note that the correct answers, respectively, are True, False, and False.

Additional findings include:

  • 95.6% of mothers correctly answered all three items on the shaking subscale,

  • 51.5% were able to recall one or more techniques to soothe their infants' crying,

  • 58.8% of mothers reported trying at least one soothing technique,

  • 38.2% were able to recall at least one coping technique, and

  • 26.5% reported trying one or more coping technique.

Only 41% of mothers reported sharing information about the dangers of shaking with other caregivers of their child, the authors write. The most common reasons for not sharing were the perception of little risk because the infant was being cared for by family or a qualified day care provider (39%), that the parents were the infants' only caregivers (22%), or that mothers did not think about sharing or gave no reason (22%).

In subgroup analysis, college education was significantly associated with a perfect score on overall knowledge and on knowledge of normal infant crying. "In addition, higher education was associated with increased ability to recall one or more techniques for coping with crying," the authors write.

The study findings suggest the Period of PURPLE Crying was well delivered and well received in the community setting, the authors write. Given that pediatric AHT is a leading cause of death in children younger than 1 year of age, with mortality rates ranging from 15% to 38%, "[t]hese findings support the importance of future broad dissemination and implementation of Period of PURPLE Crying to prevent [AHT]," they conclude.

The authors have disclosed no relevant financial relationships.

J Obstet Gynecol Neonatal Nurs. 2014;43:752-761. Abstract


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