Original Article
The impact of an educational intervention
on knowledge about infant crying and
abusive head trauma
Amy E Ornstein MDCM MSc1, Eleanor Fitzpatrick RN MN ENC(c)2, Jill Hatchette PhD3,
Christy G Woolcott PhD4, Linda Dodds PhD4
AE Ornstein, E Fitzpatrick, J Hatchette, CG Woolcott, L Dodds.
The impact of an educational intervention on knowledge about
infant crying and abusive head trauma. Paediatr Child Health
2016;21(2):74-78.
L’effet d’une intervention éducative sur les
connaissances relatives aux pleurs des nourrissons
et aux traumatismes crâniens non accidentels
BACKGROUND: Infants follow a predictable trajectory of increased
early crying. Frustration with crying is reported to be a trigger for abusive head trauma (AHT).
Objective: To evaluate the impact of postpartum delivery of the educational program, the Period of PURPLE Crying (PURPLE), in a group
of first-time mothers. The primary objective was to determine whether
there was a change in knowledge about infant crying and shaking after
exposure to PURPLE. Factors associated with change in knowledge
were also examined.
Method: A total of 93 participants were recruited over a four-month
period at a tertiary care hospital in Nova Scotia. Pre- and postintervention data were collected.
Results: Knowledge about infant crying increased significantly after
program delivery (P=0.001). Low baseline crying knowledge was a significant predictor of increased knowledge about infant crying (P≤0.01).
There was an insignificant decrease in shaking knowledge (P=0.5), which
may have been the consequence of high baseline knowledge.
Conclusion: An educational program for new parents appears to
be warranted, especially with respect to improving knowledge about
infant crying. This may have a positive benefit in AHT prevention.
Additional studies are required to evaluate the impact of the program
on other caregivers and on rates of AHT.
HISTORIQUE : Les nourrissons suivent une trajectoire prévisible
Key Words: Abusive head trauma; Child abuse prevention; Infant crying
W
hile less common than other forms of child abuse, such as
neglect and witnessing family violence, abusive head
trauma (AHT) can result in more severe outcomes; death occurs
in 12% to 36% of cases, and 13% to 60% of survivors experience
persistent motor, visual, cognitive and behavioural difficulties
(1-5). Incidence rates of AHT vary widely, and are reported to be
between 6.7 and 29 per 100,000 infants <1 year of age per year
(1,2-6,7), with a lower incidence in the second year of life (2,8).
Victims of AHT typically present with unexplained or inadequately explained cerebral dysfunction, intracranial hemorrhage,
retinal hemorrhage, and/or rib or other skeletal fractures (9-16).
In-hospital medical care and long-term care costs for survivors are
significant (17-20). Long-term costs of AHT have been estimated
to range from US$800,000 to US$20 million per child over a
lifetime (20,21).
d’augmentation des pleurs peu après la naissance. La frustration à
l’égard de ces pleurs est considérée comme un déclencheur des traumatismes crâniens non accidentels (TCNA).
OBJECTIF : Évaluer l’effet de la transmission d’un programme
d’éducation postnatale, la Period of PURPLE Crying (PURPLE), à un
groupe de mères d’un premier enfant. L’objectif primaire consistait à
déterminer si les connaissances relatives aux pleurs et aux secousses des
nourrissons changeaient après l’exposition à PURPLE. Les facteurs liés
aux changements de connaissances ont également été examinés.
MÉTHODOLOGIE : Les chercheurs ont recruté 93 participantes sur
une période de quatre mois dans un hôpital de soins tertiaires de la
Nouvelle-Écosse. Ils ont colligé les données avant et après l’intervention.
RÉSULTATS : Les connaissances sur les pleurs des nourrissons augmentaient de manière significative après la prestation du programme
(P=0,001). Le peu de connaissances sur les pleurs en début d’étude
était un prédicteur important d’augmentation des connaissances sur les
pleurs des nourrissons (P≤0,01). Il y avait une diminution non significative des connaissances sur les secousses (P=0,5), qui peut découler
des connaissances importantes avant l’intervention.
CONCLUSION : Un programme d’éducation pour les nouveaux
parents semble justifié, particulièrement pour accroître les connaissances sur les pleurs des nourrissons. Il pourrait contribuer à prévenir
les TCNA. Il faudra réaliser d’autres études pour évaluer l’effet du
programme auprès d’autres personnes qui s’occupent de nourrissons et
sur le taux de TCNA.
It has been suggested that the most salient infant characteristic
contributing to AHT risk is inconsolable crying (22,23). Many
AHT prevention programs address caregiver knowledge of normal
crying patterns, skills (eg, how to soothe a crying infant), appropriate coping responses (eg, walking away from a crying infant when
frustrated) and protective factors (eg, having a predefined action
plan). One such program is Period of PURPLE Crying (PURPLE),
which was developed based on knowledge about normal infant
crying and its association with AHT (24).
Improved knowledge about early infant crying has been
reported in several populations after receipt of the PURPLE
materials (25-27), although factors responsible for change have
not yet been described. Our objectives were to quantify the change
in knowledge of first-time mothers about infant crying and infant
shaking after receiving the PURPLE program materials, and to
identify factors associated with any change in knowledge.
1Department
of Pediatrics, Dalhousie University and IWK Health Centre; 2Department of Emergency Medicine, IWK Health Centre; 3IWK Health
Centre Research Services and Adjunct Faculty Community Health and Epidemiology, Dalhousie University; 4Perinatal Epidemiology Research Unit,
Departments of Obstetrics & Gynecology and Pediatrics, Dalhousie University, Halifax, Nova Scotia
Correspondence: Amy E Ornstein, 5850 University Avenue, Halifax, Nova Scotia B3J 3G9. Telephone 902-470-8222,
e-mail [email protected]
Accepted for publication September 6, 2015
74
©2016 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 21 No 2 March 2016
Education intervention on infant crying and shaking
Methods
During their postpartum admission, mothers who delivered a term
infant were invited to participate. Women who could not converse in English, did not have a telephone or whose infant was
admitted to the neonatal intensive care unit were excluded. All
women provided informed written consent. The present study was
approved by the IWK Health Centre Research Ethics Board
(Halifax, Nova Scotia).
All mothers received the PURPLE materials while in hospital.
Program materials included a 10-min DVD and an 11-page information booklet, which mothers were encouraged to watch and
read. PURPLE materials highlight the features of normal infant
crying and teach that babies should never be shaken. The behavioural component of the program describes action steps that guide
caregivers on how to respond to crying. Additional details about
the program are available at http://purplecrying.info. Before their
receipt of the PURPLE materials, a preintervention questionnaire
was administered through an in-person interview. A follow-up
postintervention questionnaire was administered via telephone
approximately six weeks after discharge. Each survey required
approximately 10 min to complete.
Demographic information, pregnancy and obstetric factors, and
knowledge regarding infant crying and shaking were collected at
pre-intervention, in the postintervention follow-up or at both
points of contact.
Knowledge of infant crying and shaking were measured using
previously published scales that were created for research exploring this topic (25,26), and were designed by experts in the field
and pilot tested with subjects before use. The Knowledge of Infant
Crying Scale consists of eight items that include statements about
the characteristics of normal infant crying such as frequency,
onset and duration, and how to safely respond to this behaviour.
Responses are measured on a four-point (0 to 3) Likert scale, with
participants indicating their degree of agreement with statements
(strongly disagree to strongly agree). Five items are true statements
about crying and stronger agreement with these statements indicates
greater knowledge. Three of eight items are incorrect statements
about crying and stronger disagreement indicates greater knowledge.
The maximum score possible for this scale is 24, which was transformed to a 100-point scale for ease of interpretation.
The Shaking Knowledge Scale consists of five items and includes
statements about the consequences of shaking a baby and the
responsibility of caregivers for sharing this information with all
other caregivers. Similarly, responses are measured on a four-point
(0 to 3) Likert scale, with participants indicating their degree of
agreement with statements. Four items are true statements about
shaking and stronger agreement with these statements indicates
greater knowledge. One of the five items is an incorrect statement
about shaking and stronger disagreement indicates greater knowledge. The maximum score possible for the Infant Shaking
Knowledge Scale is 15, which was transformed to a 100-point scale.
The Preparation for Infant Crying Scale captures the degree of
preparedness of mothers for infant crying before delivery. This
scale has been used in previous research examining this topic (28)
and consists of five questions, including: number of hours devoted
to learning about infant crying before delivery; perceived amount
of learning about infant crying before delivery; sources of information about infant crying; utility of information sources; and perceived utility of information about infant crying. Information
about perceived confidence and future concern about infant crying
was collected using the Confidence and Future Concern Scale created to capture how confident first-time mothers are with managing infant crying. This scale has been used in previous research
Paediatr Child Health Vol 21 No 2 March 2016
exploring this topic (28), with an additional question added about
a participant’s previous knowledge of PURPLE.
Statistical analyses
To quantify the change in knowledge, the difference between
baseline and post-intervention score was calculated for knowledge about infant crying and shaking. The statistical significance of the change in knowledge scores was assessed using
paired t tests, first within the entire sample and then within
strata of baseline knowledge (ie, high or low). A cut-off score for
low baseline knowledge of both crying (raw score = 62.5) and
shaking (raw score = 80) was established by inspection of the
distribution of scores for the entire sample on each scale, and
determined based on approximating 70% of the sample to be in
the low knowledge group and 30% in the high knowledge group.
This approach ensured that an adequate number of participants
were in each group and that the knowledge scores in each group
were sufficiently distinct.
The factors that were assessed as predictors of change in knowledge (increased versus no change or decrease) included maternal
age, maternal education, household income, planned pregnancy,
infant sex, time devoted to learning and amount learned about
crying before delivery, confidence with managing a crying infant,
anticipation of crying as an issue, previous knowledge of PURPLE,
baseline crying and shaking knowledge, and location where the
book was read and DVD was viewed. Factors associated with a
change in knowledge in univariate analyses using Fisher’s exact
test with P≤0.5 were entered in a backward stepwise logistic regression model to identify those that were independent predictors of a
change in knowledge. OR and 95% CI were calculated for variables that remained within the final model based on a likelihood
ratio statistic of P<0.05.
A sample size of 91 participants was determined using the
formula provided by Cohen (29) with power set at 0.80 and α set
at 0.05 to detect a medium effect size when using a multiple
regression analysis with approximately five variables. All analyses were performed using SPSS version 20 (IBM Corporation,
USA). In cases in which participants failed to answer one question (n=5 infant crying knowledge scale on prequestionnaire;
n=9 on infant crying knowledge scale post-test questionnaire),
responses were assigned based on the mode response choice for
that participant.
Results
A total of 125 first-time mothers consented to participate and
completed the baseline questionnaire; of these, 97 (77.6%) also
completed the postquestionnaire after discharge from hospital.
One mother who had a high proportion of data missing and three
mothers who did not receive the PURPLE materials were excluded,
leaving 93 participants for analysis. The postquestionnaire was
completed an average of 5.7 weeks (range 4.7 to 9.6 weeks) after
discharge from hospital.
Of 93 participants, approximately 95% were between 20 and
39 years of age. More than one-half of the mothers had an undergraduate or college degree and reported an annual household
income >$60,000. Fifty-seven (61.3%) mothers reported that the
pregnancy was planned and fifty-eight (62.4%) reported that caregiving would be shared equally between parents.
Change in knowledge scores is reported in Table 1. The mean
(±SD) baseline score for crying knowledge was 62.0±10.6. An
overall increase in crying knowledge was observed (mean
3.5 [95% CI 1.5 to 5.5]; P<0.01). Women with low baseline knowledge of infant crying had a greater increase in crying knowledge
75
Ornstein et al
Table 2
Univariate associations between factors and change in
crying and shaking knowledge
Table 1
Change in crying and shaking knowledge from pre- to
postintervention overall and stratified according to
baseline knowledge
Knowledge on
100-point scale
n
Change in knowledge (95% CI)
Crying knowledge Shaking knowledge
P
Crying
Overall
% with
increase
46
47
48
66
0.10
26
30
0.82
16
57
18
63
56
55
0.91
25
30
25
0.95
55
28
10
56
54
70
0.71
31
21
30
0.70
57
36
56
58
1.00
21
39
0.10
47
60
0.68
46
54
Female
Time spent learning about crying before baseline, h
30
26
0.82
0.16
14
38
26
0.14
43
65
61
38
0.25
29
23
30
31
0.94
1
20
40
32
100
60
50
62
0.63
100
20
22
37
0.16
54
39
57
56
1.00
33
21
0.24
1
19
34
39
100
58
47
64
0.36
100
16
26
33
0.23
57
36
72
33
<0.01
38
19
0.06
71
22
61
45
0.23
25
36
0.42
57
36
53
64
0.39
26
31
0.81
93
3.5±9.7 (1.5 to 5.5)
<0.01
Low <62.5
57
6.2±8.4 (3.4 to 8.4)
<0.01
High >62.5
36
−0.8±10.2 (−4.3 to 2.6)
0.64
Shaking
≥30
≤29
Maternal education
Postgraduate degree
Undergraduate/college
93
−0.7±10.0 (−2.8 to 1.3)
0.5
Baseline
% with
increase
P*
≤Grade 12
Annual household income, $
Low <80.0
45
1.6±10.2 (−1.4 to 4.7)
0.29
≥60,000
High >80.0
48
−3.0±9.3 (−5.6 to −0.2)
0.04
20,000–59,999
Data presented as mean ± SD unless otherwise indicated
than women with high baseline knowledge (mean 6.2 [95% CI
3.4 to 8.4] versus −0.8 [95% CI −4.3 to 2.6]). For change in crying
knowledge, the calculated Cohen’s effect size of the intervention
was 0.33.
The mean baseline score for shaking knowledge was 84.0±7.7.
An insignificant decrease in knowledge of shaking was observed
(mean −0.7 [95% CI −2.8 to 1.3]; P=0.5).
Predictors of change in crying knowledge (increased versus
no change or decrease) are shown in Table 2. Variables that were
identified as candidate predictors of change in knowledge with
P<0.5 in univariate analyses were: maternal age; time devoted to
learning about crying before baseline; amount learned about crying
before baseline; anticipation of crying as an issue; low baseline crying knowledge; watched PURPLE program DVD in hospital; and
read PURPLE program booklet in hospital. However, only baseline
level of crying knowledge remained in the model as a significant
predictor of change in knowledge of crying (P<0.01) (Table 3).
Mothers with low baseline knowledge were at significantly greater
odds for a knowledge increase than mothers with high baseline
knowledge (OR 5.13 [95% CI 2.10 to 12.6]; P≤0.01).
In a similar analysis performed to identify predictors of change
in shaking knowledge, candidate predictors identified in univariate analyses were: planned pregnancy; time devoted to learning
about crying before baseline; perceived confidence level before
baseline; previous knowledge of PURPLE; anticipation of crying as
an issue; low baseline shaking knowledge; and watched DVD in
hospital (Table 2). Factors identified as independent predictors of
increased shaking knowledge with multiple logistic regression
were: planned pregnancy; length of time learning about infant crying before baseline; perceived level of confidence for dealing with
a crying infant at baseline; and previous knowledge of PURPLE
(Table 3). Mothers whose pregnancy was unplanned were at nearly
four times the odds of an increase in shaking knowledge than
mothers with a planned pregnancy (OR 3.98 [95% CI 1.36 to
11.6]; P=0.01) and mothers who had heard of PURPLE at baseline
had almost three times the odds for an increase in shaking knowledge than mothers who had not (OR 2.71 [95% CI 0.92 to 7.95];
P=0.07). Mothers who had spent little time (ie, <1 h) or a significant amount of time (ie, >10 h) learning about infant crying were
at lower odds than mothers who had spent between 1 h and 9 h,
for an increase in shaking knowledge (P=0.04). Additionally, for
each increase in the category of confidence for dealing with a crying infant, the odds of an increase in shaking knowledge increased
(OR 1.86 [95% CI 0.90 to 3.84]; P=0.09).
76
P*
Maternal age, years
Baseline
Overall
n
Factor
<20,000
Planned pregnancy
Yes
No
Infant sex
Male
23
37
34
0–<1
1–9
≥10
68
62
44
Amount learned about crying before baseline
7
26
44
16
None at all
Very little
Fair amount
Large amount
Perceived confidence at baseline
Not confident
Somewhat
Adequately
Very
Previous knowledge of PURPLE
Yes
No
Anticipation crying issue
Very likely
Likely
Maybe
Not at all
Baseline crying/shaking knowledge
Low
High
Watched DVD in hospital
Yes
No
Read book in hospital
Yes
No
*From Fisher’s exact test (two-sided) and inclusion in logistic regression if P<0.5
for crying or shaking. PURPLE Period of PURPLE Crying program
Discussion
AHT can result in significant morbidity and mortality. Educating
caregivers about crying, a predictable behaviour of infants, may be
an upstream preventive intervention.
Paediatr Child Health Vol 21 No 2 March 2016
Education intervention on infant crying and shaking
In a sample of 93 first-time mothers after exposure to the
PURPLE program materials, there was a statistically significant
improvement in knowledge about early infant crying. For change
in crying knowledge, the calculated Cohen’s effect size was similar
to that reported in previous evaluations (25-27).
To date, PURPLE has been delivered and evaluated in a limited number of settings. In British Columbia, all new parents
receive program materials either in hospital before discharge
from the birth admission or at an early postpartum contact with
public health or a home nurse visitor. Results of two large scale
randomized controlled trials have demonstrated that mothers
who received program materials scored higher on crying knowledge scales, and were more likely than controls to share advice
and information with others about walking away if frustrated by
inconsolable crying. Participants were also more aware of the
dangers of shaking (25-26). In Nova Scotia, program delivery
was previously evaluated in an emergency department setting
(personal communication with authors). This study was the first
reported to have used a pre-post intervention study design in the
evaluation of PURPLE.
Likely due to high baseline knowledge levels about infant shaking, a change in shaking knowledge was not demonstrated in the
entire sample. However, in mothers with low baseline shaking
knowledge, there was an insignificant increase in knowledge about
shaking. The greatest improvement in knowledge was observed in
those who had low baseline levels of knowledge for both crying
and shaking, and suggests that those who were in the greatest need
for education became more knowledgeable after exposure to the
program materials. A planned pregnancy, previous knowledge of
PURPLE, having spent between 1 h and 9 h learning about infant
crying at baseline and increased confidence for managing a crying
infant resulted in greater odds of a positive change in shaking
knowledge postintervention. These characteristics may also
describe a caregiver who is more motivated and receptive to learning about their new infant.
We observed that the average baseline knowledge scores for
infant shaking were greater than those for infant crying, a finding
that is consistent with other studies and is likely a result of educational campaigns about shaken baby syndrome over the past decade (30,31). This trend toward greater knowledge about the harms
of shaking than about normal infant crying suggests that those
who already have significant knowledge about a topic (ie, high
baseline knowledge) do not have the same room for improvement
in their knowledge scores, which may explain why we did not
observe a statistically significant change in shaking knowledge postintervention. Given that previous knowledge of PURPLE was associated
with an improvement in shaking knowledge, the introduction of the
materials at any point before delivery, such as during prenatal classes,
may be important as a means to maximize knowledge gain.
Overall, these results support PURPLE as an effective tool to
improve knowledge about infant crying and, especially, in those
with low baseline knowledge. If a caregiver is prepared with strategies for coping with early infant crying and understands that it is
a normal phase of infant development, they may be less inclined to
interpret their infant’s persistent crying negatively, such as a reflection of their parenting efficacy, or that the baby is being difficult
on purpose or does not like them. These findings are significant
because of the reported association between infant crying as a trigger
for infant abuse and, specifically, shaking injury.
Strengths and limitations
Prospective data collection and repeated measures for data collection
were strengths of the present study. The prepost intervention design
Paediatr Child Health Vol 21 No 2 March 2016
Table 3
Factors independently predictive of improvement in crying
and shaking knowledge
Factor
Level
OR (95% CI)
P
Low
High*
5.13 (2.10–12.6)
1.00
<0.01
Yes*
No
1.00
3.98 (1.36–11.6)
0.01
Time spent learning about
infant crying before
baseline
No time to <1 h
1–9 h*
>10 h
0.18 (0.04–0.80)
1.00
0.27 (0.08–0.95)
0.04
Perceived confidence for
dealing with a crying
infant at baseline
Per increase in
Likert unit
1.86 (0.90–3.84)
0.09
No*
Yes
1.00
2.71 (0.92–7.95)
0.07
Improved crying knowledge
Baseline level of crying
knowledge
Improved shaking knowledge
Planned pregnancy
Previous knowledge of
PURPLE
*Referent category. PURPLE Period of PURPLE Crying program
enabled consideration of the effect of our intervention and permitted
examination of factors predictive of change in knowledge. To date,
the educational effect of PURPLE has been evaluated in several randomized controlled trials (25-27); however, the effect of baseline
characteristics, including knowledge regarding program effectiveness,
was not described. The knowledge and response scales we used were
based on previously published measurement tools (25,26) designed
for the purpose of studying and evaluating the program.
Limitations of our study include its relatively short time frame,
adoption of a convenience sample and the application of exclusion
criteria which restricted population characteristics (eg, non-English
speaking mothers). In addition, we did not have a comparison group
that did not undergo the intervention. Longer follow-up could have
offered a perspective on knowledge retention of participants and use
of appropriate responses to infant crying. Research assistants
approached most first-time mothers, with 41.4% of eligible mothers
during the study period recruited to participate. It is possible that
there were differences between those who were not approached,
those who did not consent to participate and our participants. The
inclusion of fathers and male caregivers in future studies should be
considered for a more complete program evaluation.
Conclusions
PURPLE was designed as a universal intervention, appropriate in
style and content for delivery to anyone involved in caring for an
infant. We observed different effects of the intervention based on
maternal characteristics. Favourable outcomes were demonstrated
with a measured change in the knowledge of mothers about early
infant crying. As a next step, evaluation of how these findings may
relate to a reduction in the number of AHT cases is important.
Currently, large-scale longitudinal population studies are underway to investigate this question in both British Columbia and
North Carolina (USA). Results of these studies should be generalizable to other jurisdictions. Other important outcomes related to
infant crying may include visits to the emergency department,
calls to health help lines or hospital admissions for crying, and
incidence of other forms of infant abuse such as bruising or fractures without associated brain injury. These outcomes may provide
evidence of program success.
In the interim, acceptance of crying as a normal newborn
behaviour requires that knowledge and anticipatory guidance are
provided to caregivers to ensure that it is managed in the most
effective and safe way.
77
Ornstein et al
Acknowledgement: The IWK Health Centre provided funding
through a Category A grant.
DISCLOSURE: The authors have no other finanical relationships or
conflicts of interest to declare.
REFERENCES
1.Barlow K, Thompson E, Johnson D, Minns RA.
The neurological outcome of non-accidental head injury.
Pediatr Rehabil 2004;7:195-203.
2.Bennett S, Ward M, Moreau K, et al. Head injury secondary to
suspected child maltreatment: Results of a prospective Canadian
national surveillance program. Child Abuse Negl 2011;35:930-6.
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;168:155-9.
4.Ewing-Cobbs L, Prasad MR, Kramer L, et al. Late intellectual and
academic outcomes following traumatic brain injury sustained
during early childhood. J Neurosurg 2006;105(Suppl 4):287-96.
5.Stipanicic A, Nolin P, Fortin G, Gobeil MF. Comparative study of
the cognitive sequelae of school-aged victims of shaken baby
syndrome. Child Abuse Negl 2008;32:415-28.
6.Ellingson KD, Leventhal JM, Weiss HB. Using hospital discharge
data to track inflicted traumatic brain injury. Am J Prev Med
2008;34(Suppl 4):S157-S162.
7.Kaltner M, Kenardy J, Le Brocque R, Page A. Infant abusive head
trauma incidence in Queensland, Australia. Inj Prev
2013;19:139-42
8. Fujiwara T, Barr RG, Brant RF, Rajabali F, Pike I. Using International
Classification of Diseases, 10th edition, codes to estimate abusive head
trauma in children. Am J Prev Med 2012;43:215-20.
9.Chiesa A, Duhaime AC. Abusive head trauma.
Pediatr Clin North Am 2009;56:317-31.
10. Christian CW, Block R; Committee on Child Abuse and Neglect,
American Academy of Pediatrics. Abusive head trauma in infants
and children. Pediatrics 2009;123:1409-11.
11. Canadian Associated of Chiefs of Police; Canadian Institute of
Child Health; Canadian Paediatric Society; et al. Joint statement
on Shaken Baby Syndrome. Paediatr Child Health 2001;6:663-77.
12. American Academy of Pediatrics Committee on Child Abuse and
Neglect. Shaken baby syndrome: Inflicted cerebral trauma.
Pediatrics 1993;92:872-5.
13. American Academy of Pediatrics Committee on Child Abuse and
Neglect. Shaken baby syndrome: Rotational cranial injuriestechnical report. Pediatrics 2001;108:206-10.
14. Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA;
National Association of Medical Examiners Ad Hoc Committee on
Shaken Baby Syndrome. Position paper on fatal abusive head
injuries in infants and young children. Am J Forensic Med Pathol
2001;22:112-22.
78
15. Sieswerda-Hoogendoorn T, Boos S, Spivack B, Bilo RA, van Rijn RR.
Educational paper: Abusive head trauma part I. Clinical aspects.
Eur J Pediatr 2012;171:415-23.
16. Canadian Paediatric Society. Multidisciplinary guidelines on the
identification, investigation and management of suspected abusive
head trauma. Ottawa: Canadian Paediatric Society, 2007.
17. Ettaro L, Berger RP, Songer T. Abusive head trauma in young
children: Characteristics and medical charges in a hospitalized
population. Child Abuse Negl 2004;28:1099-111.
18. Libby AM, Sills MR, Thurston NK, Orton HD. Costs of childhood
physical abuse: Comparing inflicted and unintentional traumatic
brain injuries. Pediatrics 2003;112:58-65.
19. Ornstein A, Dipenta JC. Abusive head trauma in infants and why we
CAN afford to prevent it. Paediatr Child Health 2011;16:e9-10.
20. Murdoch H. Care for brain-damaged infant costs $20 million. 2009
<www.stuff.co.nz/the-press/news/2779678/Care-for-brain-damagedinfant-costs-20m> (Accessed June 11, 2013).
21. Friedman J, Reed P, Sharplin P, Kelly P. Primary prevention of
pediatric abusive head trauma: A cost audit and cost-utility analysis.
Child Abuse Negl 2012;36:760-70.
22. Barr RG. The normal crying curve: what do we really know?
Dev Med Child Neurol 1990;32:356-62.
23. Barr RG, Trent RB, Cross J. Age-related incidence curve of
hospitalized Shaken Baby Syndrome cases: Convergent evidence for
crying as a trigger to shaking. Child Abuse Negl 2006;30:7-16.
24. National Center on Shaken Baby Syndrome.The Period of PURPLE
Crying Infant Abuse Prevention Program: Guidebook for
Implementation and Management. Farmington: National Center
on Shaken Baby Syndrome, 2013.
25. Barr RG, Barr M, Fujiwara T, Conway J, Catherine N, Brant R.
Do educational materials change knowledge and behaviour about
crying and shaken baby syndrome? A randomized controlled trial.
CMAJ 2009;180:727-33.
26. Barr RG, Rivara FP, Barr M, et al. Effectiveness of educational
materials designed to change knowledge and behaviours regarding
crying and shaken-baby syndrome in mothers of newborns: A
randomized, controlled trial. Pediatrics 2009;123:972-80.
27. Fujiwara T, Yamada F, Okuyama M, Kamimaki I, Shikoro N, Barr R.
Effectiveness of educational materials designed to change
knowledge and behaviour about crying and shaken baby syndrome:
A replication of a randomized controlled trial in Japan.
Child Abuse Negl 2012;36:613.
28. Ornstein A, Abeysekera J, O'Connell C. Asessing the need for
perinatal preparation about infant crying: a step towards child
abuse prevention. Canadian Paediatric Society 87th Annual
Conference. Vancouver, British Columbia, June 22-16, 2010.
29. Cohen J. A power primer. Psychol Bull 1992;112:155.
30. Dias MS, Smith K, DeGuehery K, Mazur P, Li V, Shaffer ML.
Preventing abusive head trauma among infants and young children:
A hospital-based, parent education program. Pediatrics
2005;115:e470-7.
31. Deyo G, Skybo T, Carroll A. Secondary analysis of the “Love Me...
Never Shake Me” SBS education program. Child Abuse Negl
2008;32:1017-25.
Paediatr Child Health Vol 21 No 2 March 2016