Traumatic Head Injury due to Child Maltreatment


All babies cry, but some cry more than others. Crying, a normal part of infant development, can be stressful and frustrating for any caregiver.

Frustration over normal infant crying is the cause of Traumatic Head Injury due to Child Maltreatment in over 90% of cases.


The Public Health Agency of Canada’s Joint Statement on Shaken Baby Syndrome (SBS) originally published in 2001 was recently revised to reflect developments in knowledge, understanding and practice with and between sectors including implementing updated terminology and approach to Traumatic Head Injury due to Child Maltreatment (THI-CM) in Canada. The term THI-CM is believed to reflect current language used by health professionals and aids to separate the diagnosis (traumatic head injury) from opinion on the cause of injury (child maltreatment).

Definition: THI-CM is defined broadly to include traumatic injury to the head (skull and/or brain and/or intracranial structures), which may also be accompanied by injury to the face, scalp, eye, neck or spine, as a result of the external application of force from child maltreatment.

This update requires collaboration in BC to ensure that terminology changes are aligned. BCIRPU and the Prevent Shaken Baby Syndrome BC program will continue to work with all our partners as we proceed to adapt the use of THI-CM as the preferred term in Canada for research, public health, policy, and prevention initiatives.

Assault is a leading cause of intentional death and injury in infants under the age of two. THI-CM are the signs and symptoms resulting from the violent shaking of an infant or small child. THI is the leading cause of death and injury in infants under the age of one.

Infants communicate through crying. It is a normal, developmental stage that all infants go through, especially in the first four to five months of life. The crying typically increases at around two weeks of age, peaks at two to three months, and declines by five months. Some infants cry as long as five hours a day or more, while others cry for only 20 minutes or less each day. This is still normal. Normal infant crying is the main stimulus in over 90% of THI-CM cases.

The Period of PURPLE Crying® Program

Each of the letters of the word PURPLE refers to one of the six characteristics of infant crying:

  for   Peak of Crying—Crying peaks during the second month, decreasing after that;

U   for  Unexpected—Crying comes and goes unexpectedly, for no apparent reason;

R   for  Resists Soothing—Crying continues despite all soothing efforts by caregivers;

P   for   Pain-like Face—Infants look like they are in pain, even when they are not;

L   for   Long Lasting—Crying can go on for 30-40 minutes, and longer;

E   for   Evening Crying—Crying occurs more in the late afternoon and evening.

Each year, Period of PURPLE Crying® Program education and materials are made available to 45,000 new BC parents.


If you’re feeling frustrated by your child’s crying, try the following steps:

  • Carry, comfort, walk, and talk with the infant: Increase contact with your child, reduce some of the fussing, and attend to their needs.
  • If the crying is too frustrating, it is okay to walk away: Put your child down in a safe place and take a few minutes to calm down and then go back and check on them again.
  • Never shake or hurt an infant: There is never a circumstance when it is okay to shake or hurt an infant, no matter how much they’re crying.

Prevent Shaken Baby Syndrome BC, a program of BC Children’s Hospital, has delivered the Period of PURPLE Crying® Program to parents across the province since 2009. The program is a THI-CM/infant abuse prevention education program that educates caregivers in their understanding of early increased crying in infants and improves awareness around the dangers of shaking infants.

The Period of PURPLE Crying® program is delivered to approximately 45,000 new parents/caregivers at all maternity hospitals and public health units/community health centres in BC each year. Program materials are available either as a booklet/phone app package, or a booklet/DVD package in 11 languages. The program is regularly evaluated, and has been associated with a 35% reduction in the number of children under two admitted to BC hospitals with shaking-related injuries.1


The PURPLE program utilizes a 3-dose strategy to introduce, reinforce and promote messages:

  1. Introduce: Maternity nurses provide crying and shaking education and PURPLE resources prior to discharge.
  2. Reinforce: Public health nurses reinforce the education and supply resources to any parents who did not receive them during well-baby telephone calls, home visits, and first immunization check-ups.
  3. Promote: Increasing public awareness and knowledge on infant crying is undertaken through targeted public awareness campaigns, including: community service outreach initiatives and social media campaigns.

Service providers who support parent/caregivers and newborns—such as childcare providers, foster care workers, family practice physicians, pediatricians and non-government organizations—also receive program messages.

Training and resources are provided to ensure that parents and caregivers get consistent messaging and resources wherever they go for help and support.



Cost of Traumatic Head Injury due to Child Maltreatment.2

This study estimated the lifetime costs to society of incidental THI-CM events and compared the benefits and associated costs of THI-CM before and after the implementation of the PURPLE program.  An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of THI-CM events according to their severity (least severe, severe, and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health service perspectives using decision tree models.


1. Barr, R. G., Barr, M., Rajabali, F., Humphreys, C., Pike, I., Brant, R., … & Singhal, A. (2018). Eight-year outcome of implementation of abusive head trauma prevention. Child abuse & neglect84, 106-114. Available from:

2. Beaulieu, E., Rajabali, F., Zheng, A., & Pike, I. (2019). The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada. Child abuse & neglect, 97, 104133.