Abusive head trauma (AHT) in infants often is triggered by caregiver frustration in response to persistent crying, which is a normal part of infant development.
Given the significant morbidity and mortality associated with AHT, pediatricians should take a comprehensive approach to reduce the risk of AHT and promote child safety. This approach should include interventions that address infant crying and its effect on caregivers.
One such intervention is an evidence-based program created in 2007 called the Period of PURPLE Crying. It aims to reduce AHT by educating caregivers about normal infant crying, strategies for soothing and the risks of shaking. PURPLE stands for:
- Peak of crying (crying may peak in the second month of life),
- Unexpected (crying can come and go, and the reason is unclear),
- Resists soothing (baby won’t stop crying despite use of soothing strategies),
- Pain-like face (babies look like they are in pain even when they are not),
- Long lasting (baby may cry for five hours a day or more)
- Evening (baby may cry more in the late afternoon or evening).
The program equips parents with calming techniques such as skin-to-skin contact, singing, warm baths, going outside for a walk and checking to see if the baby is hungry, tired or needs changing.
Strategies that focus on the caregiver’s well-being can further reduce the risk of AHT. Caregivers who respond to every cry while struggling with sleep deprivation can feel overwhelmed and exhausted. It is important to reassure them that it’s OK to place their baby in a safe space, like a crib or bassinet, and take a break, breathe deeply and collect themselves when feeling overwhelmed. Remind them to check on the baby every 10-15 minutes. This respite can prevent frustration from escalating.
While family support can be beneficial, not all caregivers have that privilege. It is essential for pediatricians to let caregivers know that help is available and normalize the process of seeking help. Childhelp, a national child abuse prevention organization, has a 24/7 helpline (1-800-4-A-CHILD) that supports parents who are having difficulty managing their child’s crying. Similarly, the National Maternal Mental Health Hotline (1-833-TLC-MAMA) and Postpartum Support International (1-800-944-4773) offer helplines for new and expectant parents struggling with postpartum depression, anxiety or stress.
Importantly, caregivers should feel empowered to seek medical advice and reassurance from their child’s pediatrician, especially when they are still learning their child’s temperament and needs. Pediatricians also should be a resource for caregivers struggling with their own psychosocial, mental health and emotional needs.
Initiating an open line of communication with caregivers during the first newborn visit or earlier is important to assess and build rapport with the family. Social determinants of health and caregiver well-being should be discussed to identify potential stressors that may increase the risk for AHT. It also is beneficial to identify and acknowledge protective factors, such as safe, stable, nurturing relationships.
Furthermore, pediatricians should consider discussing AHT and other forms of physical abuse. Such transparency can strengthen the pediatrician-caregiver relationship and ensure a mutual interest in the child’s safety.
Dr. Doswell and Dr. Jouk are members of the AAP Council on Child Abuse and Neglect.
