Ronald G. Barr

Effectiveness of Educational Materials Designed to Change Knowledge and Behaviors Regarding Crying and Shaken-Baby Syndrome in Mothers of Newborns: A Randomized, Controlled Trial

BACKGROUND. Infant crying is an important precipitant for shaken-infant syndrome. OBJECTIVE. To determine if parent education materials (The Period of PURPLE Crying [PURPLE]) change maternal knowledge and behavior relevant to infant shaking. METHODS. This study was a randomized, controlled trial conducted in prenatal classes, maternity wards, and pediatric practices. There were 1374 mothers of newborns randomly assigned to the PURPLE intervention and 1364 mothers to the control group. Primary outcomes were measured by telephone 2 months after delivery. These included 2 knowledge scales about crying and the dangers of shaking; 3 scales about behavioral responses to crying generally and to unsoothable crying, and caregiver self-talk in response to unsoothable crying; and 3 questions concerning the behaviors of sharing of information with others about crying, walking away if frustrated, and the dangers of shaking. RESULTS. The mean infant crying knowledge score was greater in the intervention group (69.5) compared with controls (63.3). Mean shaking knowledge was greater for intervention subjects (84.8) compared with controls (83.5). For reported maternal behavioral responses to crying generally, responses to unsoothable crying, and for self-talk responses, mean scores for intervention mothers were similar to those for controls. For the behaviors of information sharing, more intervention mothers reported sharing information about walking away if frustrated and the dangers of shaking, but there was little difference in sharing information about infant crying. Intervention mothers also reported increased infant distress. CONCLUSIONS. Use of the PURPLE education materials seem to lead to higher scores in knowledge about early infant crying and the dangers of shaking, and in sharing of information behaviors considered to be important for the prevention of shaking.

Do educational materials change knowledge and behaviour about crying and shaken baby syndrome? A randomized controlled trial

Background: Shaken baby syndrome often occurs after shaking in response to crying bouts. We questioned whether the use of the educational materials from the Period of PURPLE Crying program would change maternal knowledge and behaviour related to shaking. Methods: We performed a randomized controlled trial in which 1279 mothers received materials from the Period of PURPLE Crying program or control materials during a home visit by a nurse by 2 weeks after the birth of their child. At 5 weeks, the mothers completed a diary to record their behaviour and their infants behaviour. Two months after giving birth, the mothers completed a telephone survey to assess their knowledge and behaviour. Results: The mean score (range 0–100 points) for knowledge about infant crying was greater among mothers who received the PURPLE materials (63.8 points) than among mothers who received the control materials (58.4 points) (difference 5.4 points, 95% confidence interval [CI] 4.1 to 6.5 points). The mean scores were similar for both groups for shaking knowledge and reported maternal responses to crying, inconsolable crying and self-talk responses. Compared with mothers who received control materials, mothers who received the PURPLE materials reported sharing information about walking away if frustrated more often (51.5% v. 38.5%, difference 13.0%, 95% CI 6.9% to 19.2%), the dangers of shaking (49.3% v. 36.4%, difference 12.9%, 95% CI 6.8% to 19.0%), and infant crying (67.6% v. 60.0%, difference 7.6%, 95% CI 1.7% to 13.5%). Walking away during inconsolable crying was significantly higher among mothers who received the PURPLE materials than among those who received control materials (0.067 v. 0.039 events per day, rate ratio 1.7, 95% CI 1.1 to 2.6). Interpretation: The receipt of the Period of PURPLE Crying materials led to higher maternal scores for knowledge about infant crying and for some behaviours considered to be important for the prevention of shaking. (ClinicalTrials.gov trial register no. NCT00175422.)

Variations in Heritability of Cortisol Reactivity to Stress as a Function of Early Familial Adversity Among 19-Month-Old Twins

CONTEXTnCortisol reactivity is a marker of vulnerability for a variety of stress-related diseases that likely arise from the contributions of both genetic and environmental sources of influence. However, little is known about gene-environment interplay in early cortisol reactivity.nnnOBJECTIVESnTo examine the genetic and environmental contributions to early cortisol reactivity in a population-based sample of 19-month-old twins and to determine whether these contributions vary as a function of early familial adversity.nnnDESIGNnA variant of the twin method, with genetic and environment contributions to cortisol reactivity estimated as a function of familial adversity. Familial adversity was defined as the presence of 7 risk factors during perinatal and postnatal development (eg, at 6 and 19 months of age): maternal smoking during pregnancy, low birth weight, low family income, low maternal educational level, single parenthood, young motherhood, and maternal hostile or reactive behaviors. Twins exposed to 4 or more risk factors at either time were considered as having been exposed to high (vs low) familial adversity (23.4% of the sample).nnnSETTINGnCentre de Recherche Fernand-Seguin at the Hôpital Louis-Hyppolite Lafontaine, Montréal, Quebec. Patients Participants were families of twins from the Québec Newborn Twin Study recruited between April 1, 1995, and December 31, 1998, in the greater Montréal area. A total of 346 twins, 130 monozygotic and 216 dizygotic, were included in the study.nnnMAIN OUTCOME MEASURESnSalivary cortisol samples were collected before and after the participating twins had been exposed to unfamiliar situations; change in cortisol over time was used as a measure of cortisol reactivity.nnnRESULTSnDistinct patterns of genetic and environmental contributions to cortisol reactivity were evidenced as a function of familial adversity, suggesting a possible gene-environment interplay. In low-familial adversity settings that characterized most families, both genetic and unique but not shared environmental factors accounted for individual differences in cortisol reactivity, with shared genes explaining the similarity observed within twin pairs. By contrast, in conditions of high familial adversity, both shared and unique environmental factors, but not genetic factors, accounted for the variance in cortisol reactivity.nnnCONCLUSIONnThis pattern of differing genetic and environmental contributions according to familial adversity suggests that, early in life, high familial adversity may have a programming developmental effect on cortisol reactivity.

Influence of supine sleep positioning on early motor milestone acquisition.

This study aimed to determine whether supine sleep-positioned infants have delayed motor skills at age 4 and 6 months, and if delays are associated with decreased exposure to prone position. One 4 and one 6-month-old sample of healthy infants born at term were recruited. Motor assessments included the Peabody Developmental Motor Scale (PDMS) and Alberta Infant Motor Scale (AIMS). Parents completed an infant behavior diary for 3 consecutive days. Seventy-one 4-month-old infants were assessed (38 males; mean age 4.4 mo, standard deviation [SD] 0.2). Mean motor scores were close to normative standards (AIMS 47.7, SD 19.6; PDMS gross motor quotient [GMQ] 96.3, SD 6.5; PDMS fine motor quotient [FMQ] 99.2, SD 4.8). No infant scored below cut-off values used to identify motor delay. Milestones less likely to be achieved included extended arm support in prone, hands to feet in supine, and sitting with arm support. Exposure to tummy time while awake was correlated with AIMS scores (r = 0.38, p < 0.01). F i fty 6-month-old infants were assessed (21 males; mean age 6.4 mo, SD 0.4). Mean scores were shifted down for all scales, and as much as 1 SD for PDMS (AIMS 44.5, SD 21.6; PDMS GMQ 85.7, SD 7.6; PDMS FMQ 88.9, SD 9.0). Only 22% of 6-month-olds could sit without arm support versus 50% expected in a normative sample. Remarkably, 22% of our sample exhibited gross motor delays (quotient <78). Tummy time (awake) was significantly associated with the AIMS (r = 0.64) and PDMS GMQ (r = 0.55) and FMQ (r = 0.33) quotients, even after adjusting for confounders. Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning. This has important implications for interpreting motor assessments of infants at risk and for preventing inappropriate referrals.

Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers

Head trauma from abuse, including shaken baby syndrome, is a devastating and potentially lethal form of infant physical abuse first recognized in the early 1970s. What has been less recognized is the role of the early increase in crying in otherwise normal infants in the first few months of life as a trigger for the abuse. In part, this is because infant crying, especially prolonged unsoothable crying, has been interpreted clinically as something wrong with the infant, the infant’s caregiver, or the interactions between them. Here, we review an alternative developmental interpretation, namely, that the early increase in crying is a typical behavioral development in normal infants and usually does not reflect anything wrong or abnormal. We also review evidence indicating that this normal crying pattern is the most common trigger for abusive head trauma (AHT). Together, these findings point to a conceptualization of AHT as the consequence of a failure in an otherwise common, iterative, and developmentally normal infant–caregiver interaction. They also imply that there is a window of opportunity for prevention of AHT, and potentially other forms of infant abuse, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. If effective, there may be important implications for prevention of infant abuse nationally and internationally.

Inconsolable Infant Crying and Maternal Postpartum Depressive Symptoms

OBJECTIVE: To quantify the extent to which maternal report of inconsolable infant crying, rather than colic (defined by Wessel’s criteria of daily duration of fussing and crying >3 hours), is associated with maternal postpartum depressive symptoms. METHODS: Participants were 587 mothers who were recruited shortly before or after delivery and followed longitudinally. At 5 to 6 weeks postpartum, mothers recorded the duration and mode (fussing, crying, or inconsolable crying) of their infant’s distress by using the Baby’s Day Diary. The Edinburgh Postnatal Depression Scale (EPDS) was administered at enrollment and at 8 weeks postpartum. Using regression models that included baseline EPDS scores and multiple confounders, we examined associations of colic and inconsolable crying with later maternal EPDS scores at 8 weeks postpartum. RESULTS: Sixty mothers (10%) met the EPDS threshold for “possible depression” (score ≥9) at 8 weeks postpartum. For mothers reporting >20 minutes of inconsolable crying per day, the adjusted odds ratio for an EPDS score ≥9 was 4.0 (95% confidence interval: 2.0–8.1), whereas the adjusted odds ratio for possible depression in mothers whose infants had colic was 2.0 (95% confidence interval: 1.1–3.7). These associations persisted after adjusting for baseline depression symptoms. CONCLUSIONS: Maternal report of inconsolable infant crying may have a stronger association with postpartum depressive symptoms than infant colic. Asking a mother about her ability to soothe her infant may be more relevant for potential intervention than questions about crying and fussing duration alone.

Daytime Cortisol Secretion in 6-Month-Old Twins: Genetic and Environmental Contributions as a Function of Early Familial Adversity

BACKGROUNDnDysregulation of daytime cortisol activity has been associated with stress-related pathologies. Research suggests that early environmental adversity might shape cortisol activity. However, little is known about the genetic and environmental contributions to early cortisol and how this varies as a function of environmental circumstances. The goals of the study were to estimate the genetic and environmental contributions to daytime cortisol secretion in infant twins and to investigate whether these contributions varied as a function of familial adversity (FA).nnnMETHODSnParticipants were 517 6-month-old twins. Salivary cortisol was collected when the infants woke up at home and in the morning, upon arrival at the laboratory. Familial adversity was defined by seven perinatal and postnatal risk factors: maternal smoking during pregnancy, low birth weight, low family income, low maternal education, single parenthood, young motherhood, and maternal hostile/reactive behaviors. Genetic and environment contributions to cortisol activity were estimated for high (three risk factors or more: 21.3% of the sample) versus low FA.nnnRESULTSnGenetic factors accounted for cortisol levels in different ways: a moderate main effect of genes was found for home-based awakening cortisol, whereas the contribution of genes to morning cortisol was conditional to FA. Genetic factors accounted for most of the variance in morning cortisol in high family adversity but not in low family adversity.nnnCONCLUSIONSnEarly FA modulates the heritability of morning cortisol in infants. The results are consistent with the diathesis-stress model, with genetic factors more likely to be expressed in adverse settings.

Infant Distress at Five Weeks of Age and Caregiver Frustration

OBJECTIVEnTo investigate the differential association of three modes (fussing, crying, unsoothable crying) and three properties (duration/day, frequency/day, maximum bout length) of infant distress with daily caregiver frustration.nnnSTUDY DESIGNnReplicated cross-sectional studies were completed in Vancouver, British Columbia (n = 1065) and Seattle, Washington (n = 1857). Infant fussing, crying, and unsoothable crying and caregiver frustration were measured daily for 4 days at 5 weeks of age by the Babys Day Diary. Generalized estimating equation models were used to predict caregiver frustration from nine measurements of distress.nnnRESULTSnIn Vancouver, measurements of distress significantly associated with caregiver frustration in decreasing order of magnitude were as follow: (1) maximum bout length of unsoothable crying; (2) duration/day of crying; and (3) frequency of unsoothable crying and duration/day of fussing. In Seattle, associated measurements of distress were: (1) maximum bout length of unsoothable crying; (2) maximum bout length and duration/day of crying, frequency of unsoothable crying, and duration/day of fussing; and (3) frequency/day of crying.nnnCONCLUSIONSnDaily caregiver frustration is associated differentially with different modes and properties of infant distress. Specifically, maximum bout length of unsoothable crying was most strongly related in both sites. Additionally, frequency/day of unsoothable crying and duration/day of crying and of fussing were significantly associated at both sites.

National, Regional, and State Abusive Head Trauma: Application of the CDC Algorithm

OBJECTIVE: To examine national, regional, and state abusive head trauma (AHT) trends using child hospital discharge data by applying a new coding algorithm developed by the Centers for Disease Control and Prevention (CDC). METHODS: Data from 4 waves of the Kids’ Inpatient Database and annual discharge data from North Carolina were used to determine trends in AHT incidence among children <1 year of age between 2000 and 2009. National, regional, and state incidence rates were calculated. Poisson regression analyses were used to examine national, regional, and state AHT trends. RESULTS: The CDC narrow and broad algorithms identified 5437 and 6317 cases, respectively, in the 4 years of KID weighted data. This yielded average annual incidences of 33.4 and 38.8 cases per 100u2009000 children <1 year of age. There was no statistically significant change in national rates. There were variations by region of the country, with significantly different trends in the Midwest and West. State data for North Carolina showed wide annual variation in rates, with no significant trend. CONCLUSIONS: The new coding algorithm resulted in the highest AHT rates reported to date. At the same time, we found large but statistically insignificant annual variations in AHT rates in 1 large state. This suggests that caution should be used in interpreting AHT trends and attributing changes in rates as being caused by changes in policies, programs, or the economy.

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☆

OBJECTIVESnInfant crying is particularly frustrating to caregivers in the first few months of life and the most common trigger for shaking and abuse. The effectiveness of the Period of PURPLE Crying prevention materials (DVD and booklet) designed to increase knowledge and change behaviors related to crying and the dangers of shaking was reported in North America. The aim of this study was to replicate the effectiveness of the PURPLE materials with mothers of newborns in Japan.nnnMETHODSnIn a randomized controlled trial, 201 parents received either PURPLE materials or analogous control materials on infant safety via mail within 2 weeks of birth. At 6 weeks, mothers completed a 4-day behavioral diary. At 2 months, participants completed a predefined 20-min structured telephone survey by an independent firm to assess knowledge and behavior.nnnRESULTSnScores on crying knowledge scales (out of 100) were significantly higher in the intervention than control groups (56.1 vs. 53.1; difference=3.0, 95% confidence interval [CI]: 1.0-4.9, p<0.005). Percentage of sharing of advice to walk away if frustrated by crying was significantly higher in the intervention than control groups (22.4% vs. 4.1%; difference=18%, 95% CI: 7.4-29.1). Walking away during unsoothable crying was significantly higher in the intervention group than controls (0.085 vs. 0.017 events per day, rate ratio=4.8, 95% CI: 1.1-21.2) by diary. Self-talk behavior scale (out of 100) tended to significance in the intervention group (16.6 vs. 8.9, difference=7.7, 95% CI: -1.0 to 16.4, p<0.1).nnnCONCLUSIONSnCrying knowledge, sharing of walk away information with others and walk away behavior when crying was unsoothable were higher for those who received intervention than control materials. The Period of PURPLE Crying materials may be useful in Japan as well as in North America for informing caregivers about the properties of infant crying and changing some behaviors related to infant crying and shaking. (UMIN Clinical Trials Registry register no. UMIN000001711.).