ISPID statement on the promotion of the cardboard 'Baby Box'
ISPID Board, May 2018
Any government or charity that is willing to provide a cardboard box full of free unbranded infant care items to mothers of new-born infants should be applauded. However, if the cardboard box is being recommended for infant sleep then the advice that goes with this needs to be carefully considered.
We are concerned that infants are being encouraged to sleep in cardboard boxes with little evidence that this is either safe or appropriate. The 'Baby Box' is based on a Finnish tradition of presenting mothers of new-born infants with a cardboard box full of free infant care items including a mattress that fits into the bottom of the box as a makeshift infant sleeping environment. There is no published evidence that the 'Baby Box' reduces the SIDS rate and little information on how these boxes are used. Any tenuous claims that the box may save lives appear to be two-fold; firstly the observation that the SIDS rate in Finland is relatively low and secondly that the 'Baby Box' provides a safer alternative to hazardous bed-sharing. However the SIDS rates in neighbouring countries, such as Sweden, are equally low , despite not traditionally providing boxes. Further, safer alternatives to hazardous bed-sharing, such as cots (cribs) and bassinets, are already available. Commonly, SIDS deaths occur unobserved and so we encourage parents to sleep in the same room as the infant at night and be in the same room for day-time sleep . Importantly both the cot (with its bars) and the bassinet (with its low sides) are designed so the infant can be easily seen by the parent, whilst the cardboard box (with its higher sides) is not. Placing a young infant into a cardboard box means that carers can only see the infant if they 'hover' directly over the box.
There are potentially other issues especially in terms of how the 'Baby Box' may be used. Some of the cardboard boxes come with their own lids, are potentially flammable (especially if not laminated) and may be a tempting sleeping space for some domestic pets. There are also no data about the durability of the cardboard box (especially if it becomes wet or dirty) and concern about the size; the majority of babies will reach a length equal to or longer than the cardboard box by 2½ to 3 months of age. We question why commercial companies are becoming interested in giving away 'Baby Boxes'.
The 'Baby Box' is not to be confused with the Wahakura (Maori woven flax basket) or the Pepi-pod (plastic box with low sides), both of which are designed to be brought into the parental bed to give infants their own unique sleeping space. These devices are currently being studied in New Zealand, and initial findings are extremely encouraging [3-7]. The 'Baby Box' is not designed to be brought into the parental bed.
The dramatic fall in SIDS rates has been borne on the back of evidence from observational studies. Without the evidence in place such devices as the 'Baby Box' should not be promoted as an alternative to cots, bassinets etc. but rather an alternative if nothing else is available (and only then if the device passes accepted safety standards). We encourage rigorous studies to better understand how families use the 'Baby Box' and the safety implications.
- Vege A, Rognum TO. Use of new Nordic criteria for classification of SIDS to re‐evaluate diagnoses of sudden unexpected infant death in the Nordic countries. Acta Paediatr 1997; 86 (4): 391-396.
- Blair PS, Platt MW, Smith IJ, Fleming PJ; SESDI SUDI Research Group. Sudden Infant Death Syndrome and the time of death: factors associated with night-time and day-time deaths. Int J Epidemiol 2006; 35 (6): 1563-1569.
- Baddock SA, Tipene-Leach D, Williams SM, Tangiora A, Jones R, Iosua E, Macleod EC, Taylor BJ. Wahakura Versus Bassinet for Safe Infant Sleep: A Randomized Trial. Pediatrics 2017; 139 (2) pii: e2016016.
- Abel S, Stockdale-Frost A, Rolls R, Tipene-Leach D. The wahakura: a qualitative study of the flax bassinet as a sleep location for New Zealand Māori infants. N Z Med J 2015; 128 (1413): 12-19.
- Tipene-Leach D, Baddock S, Williams S, Jones R, Tangiora A, Abel S, Taylor B. Methodology and recruitment for a randomised controlled trial to evaluate the safety of wahakurafor infant bedsharing. BMC Pediatr 2014; 14: 240.
- Tipene-Leach D, Baddock SA, Williams SM, Tangiora A, Jones R, McElnay C, Taylor BJ. The Pēpi-Pod study: Overnight video, oximetry and thermal environment while using an in-bed sleep device for sudden unexpected death in infancy prevention. J Paediatr Child Health 2018. doi:10.1111/jpc.13845
- McIntosh C, Trenholme A, Stewart J, Vogel A. Evaluation of a sudden unexpected death in infancy intervention programme aimed at improving parental awareness of risk factors and protective infant care practices. J Paediatr Child Health 2018; 54 (4): 377-382.
Previous ISPID statements are available here.