What is PURPLE Crying in Babies?

This blog discusses PURPLE crying – where the term comes from, what it means, why it was created, and how it’s interchangeably used with another paediatric term to describe unsettled babies – colic.  In this article, I discuss the very confronting topics of shaken baby syndrome (SBS) and abusive head trauma (AHT). While these are exceptionally hard topics to talk about, as a community, the more we understand the risks of these serious topics and how to decrease them –  the better we’ll be as parents and the safer our babies will ultimately be.

What is PURPLE Crying? 

Purple crying, like colic, is a describing term. It’s not a disease.

In fact, it was originally designed to minimise shaken-baby syndrome, by normalising the period of unsettled behaviour and infant crying between 2 weeks and 4 months. 

It’s an acronym.

• Peak crying,
• Unexpected,
• Resistant to soothing,
• Pain-filled face,
• Long-lasting and occurring in the
• Evening.

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Who invented the term PURPLE Crying?

While a general medical term now, PURPLE Crying® is a registered trademark – the concept was developed by developmental paediatrician Prof Ronald Barr.  Barr is an Emeritus Professor of Pediatrics at the University of British Columbia. 

He was the Head of Developmental Neurosciences and Child Health Research at the Child and Family Research Institute (now British Columbia Children’s Hospital Research Institute) and is a member of the International Advisory Board of the National Center on Shaken Baby Syndrome. 

For over 30 years, he has researched infant crying and early infant behaviours and is considered a world expert on the subject. 

Barr categorised crying into three groups: 

1. fussing, 
2. crying, and 
3. inconsolable crying. 

The inconsolable crying where babies resist soothing, with a pain-like face is considered PURPLE crying.  The aim of normalising this type of crying is to stop parents from shaking their babies in frustration and exhaustion – shaken baby syndrome.

What is Shaken Baby Syndrome (SBS)?

Shaken baby syndrome (or abusive head trauma) is a dangerous form of child abuse. 

If your baby is continually sobbing or crying uncontrollably, it’s incredibly common for the parent to become upset, too. The correlation between highly unsettled babies and perinatal mental health problems is incredibly high.

If your baby is crying and won’t stop, you must never shake them or move them aggressively, as this is extremely dangerous for newborns. 

Why is this shaking a baby so dangerous for newborns? 

Your baby’s neck muscles are weak and their brains are very much still developing. Shaking a baby can cause their brain to move around in the skull, resulting in swelling and bleeding. This can lead to brain damage, blindness, or even death.

The rates of shaken baby syndrome are still too high:

While it’s hard to contemplate anyone hurting a baby intentionally, the incidence of Shaken Baby Syndrome or Abusive Head Trauma (AHT) in Australia is still too high.

This is a note from the from the Australia Family physician:

“Abusive head trauma of infants is a significant cause of morbidity and mortality. The incidence in Australia has been estimated at 29.6 cases of abusive head trauma for which hospital admission is required per 100 000 infants aged 0–24 months and under per year; more frequent than low speed runovers, drowning and childhood neoplasms.”

In the United States, between 1200–1400 children may be injured or killed by shaking every year – horrificly, it’s the leading cause of child abuse death in the US (1). 

Can Tossing My Baby in the Air or Rough Play Cause SBS?

Shaken baby syndrome is a form of child abuse that happens when an infant or small child is violently shaken to stop them crying –  that can put your baby’s life at risk.      

Shaken injuries are not caused by:

• Bouncing a baby on your knee.
• Tossing a baby in the air for fun.
• Jogging or bicycling with your baby.
• Falls off a couch or other furniture.
• Sudden stops in a car or driving over bumps.

Although the activities listed above can be dangerous and are not recommended, they will likely not cause the same degree of SBS injuries.

The #1 trigger for shaken baby syndrome is caregiver frustration with a baby’s crying

A baby crying uncontrollably is one of the hardest things in the world to listen to – there’s a reason they use infant’s crying sounds as a form of torture.     

The frustration and distress caused by this crying can be overwhelming for any parent.  

Add to this – exhaustion, confusion and conflicting advice – it can be an incredibly challenging time. Thus the implementation and education around PURPLE crying and thus the Period of Purple Crying (POPC) program was created.  

We need to ensure all parents in this situation are given all the support in the world to help them through this period and to know that shaking their baby is NEVER the correct response.   

Period of Purple Crying (POPC) Program 

What is a PURPLE crying period? The word period means the crying has a beginning and an end. 

The Period of PURPLE Crying® program is an evidence based approach to infant abusive head trauma prevention. 

It educates carers and service providers to understand the frustrating features of crying in normal infants, which can lead to shaking or abuse.

The program includes:

• An 11-page booklet, 
• 10-minute 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 

How widely used is the POPC Program used?

The program is implemented in over 800 hospitals and in the USA and in Canada, Japan and Australia

How effective is the POPC Program?

Overall, the POPC program has a mixed effect on patient outcomes – but no adverse outcomes.

POPC improves caregiver knowledge concerning infant crying but the POPC does not appear to affect caregiver frustration with crying.

How strong is the evidence?

There is mixed research evidence

• At least one high-quality randomised controlled trial (RCT) showed the increase in behaviours associated with the prevention of shaking (2) 
• One Quasi-Experimental Design (QED) study on 5,961 parents in Japan projected a decrease in the rates of SBS (3) 
• An equal number of RCT/QED studies of similar size and quality show no observed effects 
• No RCT/QED studies show statistically-significant adverse effects.

So on balance, the intervention with new parents may have a positive outcome and won’t do any harm.  What I’d like to see is more resources available to support parents, helping them to understand the many drivers of highly unsettled behaviours – which is why I started my online programs.

Perinatal mental health prioritisation is key

I’m a proud Gidget Foundation and PANDA clinical ambassador – in my books and online programs, I raise awareness of the risks and symptoms of perinatal mental health. 

Having a highly unsettled baby is highly correlated with perinatal mental problems, making the 1 in 5 mothers and 1 in 10 father statistics skyrocket. If you have previously experienced challenges with mental health prior to having a baby, you are at even higher risk. 

Take a look at my Perinatal Mental Health blog and always remember if you need help, helo is available.

• PANDA (Perinatal anxiety and depression Australia) 1300 726 306
• The Gidget Foundation 1300 851 758

Is Purple Crying the same as Colic?

Purple crying, like colic, is a describing term. It’s not a disease.

It’s essentially just another way of saying colic, describing a period of highly unsettled behaviour from the first few weeks until around 4 months.

Both are more of an adjective – as opposed to providing helpful ways to actually alleviate a baby’s distress.

Like colic, it is definitely NOT a period to ‘suffer’ through and survive.

Yes most babies will grow out of it by the time they reach four months of age, but four months of highly unsettled behaviour and crying is not something you need to struggle through.

Find the cause, alleviate it – and enjoy the extra sleep!

 

Is COLIC an outdated term?

Most medical literature will say that colic is an outdated term, but if you look at the Google search results and the sheer volume of searches using the term ‘colic’ – you’ll see it’s a term very much still being used in the community.  Rather than say it’s outdated and doesn’t exist, I prefer to empower parents of highly unsettled babies with the knowledge and understanding that colic has causes and most importantly – colic has solutions.  

Common causes of crying: 

Yes all babies cry – yes a healthy baby cries – yes your baby’s crying can be normal – but almost all of the most common causes of colic are actually easily treated. 

My core concerns regarding the normalisation of PURPLE Crying and the dismissal of colic as a necessary phase, are that common non-pathological causes of crying can be so easily remedied. 

I think we do our babies a great disservice if we just throw a blanket on uncontrollable crying and label it as normal infant crying, because there’s so much we can do to help – if we understand our babies better. 

We can’t stop crying altogether but we can work to alleviate the common problems that drive highly unsettled behaviour.

Many of the common – easy to remedy – causes of crying are:

1. Excessive tiredness: always follow you baby’s correct awake windows and see my overview on tired signs below
2. Trapped wind from inadequate burping 
3. Intolerances to breastmilk or formula 
4. Lactose overload from too-frequent breastfeeding 

…and lots of other things… hunger, too hot, too cold, sleep environment not appropriate, undertired, not swaddled correctly, teething, over stimulated, itchy tags, eczema etc etc.  In my paediatric practice, these are many of the common reasons parents come to me with highly unsettled healthy babies – and with simple measures, we can alleviate nearly all of them.  

Give parents the information they need to better understand their babies and respond to their needs, this is the core to my philosophy.

 

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Distracting your baby vs uncovering what is driving their discomfort 

Many of the articles you’ll read on PURPLE crying and coping with PURPLE Crying will talk about ways to soothe and distract your crying baby, these include things like:

1. Skin-to-skin contact
2. Warm baths or running their head under warm water
3. Fresh air (let’s face it, that’s good for everyone!) 

My tips to soothe a crying baby are to return them to the feeling of being in the womb: 

• Swaddling, 
• Gentle Movement, 
• Patting & 
• White noise.  

…BUT babies drink more than milk, so if you’re not calm when you deliver these soothing therapies, then none of them will work.  Calming ourselves before we calm our babies is key to my approach. 

Lots more on this topic in my online baby sleep programs.

A final word…

There are some babies that I encounter in clinical practice – thankfully not many – but some who remain highly unsettled, despite the best efforts of parents and paediatricians. Some babies will remain unsettled, but before dismissing their discomfort as Purple Crying, or normalising their cries as a ‘period to survive’ – seek out possible causes, implement the solutions and at the very least try to alleviate the stress caused to babies and parents alike.

How to deal with colic or PURPLE Crying?

Download my free colic video. There’s a step-by-step guide to help you navigate what to do next.  My key advice is that this isn’t something you have to suffer through, but while you try to figure out what is driving the discomfort, make sure you ask for plenty of help and support.

For more information on all my tips and tricks to settle and soothe even the most unsettled babies – please see my sleep programs.