New Report Concludes No Evidence That Baby Boxes Are Safe or Effective in Reducing SIDS

A new report was released today in the Public Health Reports: SAGE Journals looking at the safety and efficacy of baby boxes.

Baby boxes are cardboard boxes that were first used in Finland for infants to sleep in during naps and at nighttime as part of an initiative to reduce the rate of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.  In 2017, baby boxes began being distributed in the U.S. through hospitals to mothers in lower socio-economic communities including in Alabama, New Jersey, Ohio and Texas. 

There is much debate and confusion around the use of baby boxes by families and health care providers. First Candle, along with many safe-sleep advocates, has remained concerned about the safety of these boxes and we are encouraged that this report carefully lays out the potential risks and the difference with the Finland program.    

As the report states, the distribution of baby boxes in Finland, which began in the 1930’s, was part of a health initiative focused on reducing rates of SIDS by increasing the number of women seeking prenatal care.  Receiving a baby box required a specified number of prenatal visits in order to receive a baby box.  This was followed by home visits once the baby was born.  A spokesperson for the Social Insurance Institution of Finland, Kela explained that the initiative aimed to increase prenatal care and included antipoverty actions which drove improvements in infant’s outcomes.  In other words, the baby box was not the solution, rather an incentive.

The report goes on to address each safety concern with the baby box:

New born baby in cardboard baby box.
Photo credit to WBUR

They’re not subject to standard safety certification by the Consumer Product Safety Commission.

Baby boxes do not meet the definition of a bassinette or crib and therefore aren’t covered under standard U.S. Safety Certifications.  Part of the certification is reporting adverse events.  Because accidents or deaths related to use of the baby box would not be reported to the CPSC, it would be difficult for families to monitor the safety of them. 

Ventilation

The height of the sides of the most commonly distributed baby box is 10 inches.  This height and the impermeability of cardboard raises concerns about the quality of air they are breathing.  Rebreathing expired air can result in potentially higher concentrations of carbon dioxide in the baby box which can post an increased risk of sleep-related death.  Additionally, poor ventilation can lead to the baby overheating which increases the risk of suffocation.

Cardboard Integrity

No empirical studies have been conducted looking at the likelihood of the cardboard base remaining dry and sanitary. Babies spit up and have wet diapers frequently and there is a great concern as to whether the box will maintain its structural integrity.  Because one of the touted benefits of the box is its portability there is a high likelihood that a parent will bring the box into the bathroom while showering causing the humidity to compromise the structural integrity as well.  The ability for the box to remain in tact becomes a serious safety concern.

Placement

Where a parent places the box is another tremendous concern.  Placing the baby box on a dresser or table raises potential hazards, including the box tipping over or falling.  Placing it on the floor poses the risk of pets, sibling or objects falling onto the baby.

The report concludes that without solid empirical studies done on the safety and use of the baby box dissemination of it to help reduce the rates of sleep-related infant deaths is premature.  

As the authors note however, if these boxes are being distributed by health care providers there is an assumption by the parents that the product is safe.  Currently, however, no evidence supports the safety of the baby box, the likelihood that the baby box will positively affect parenting practices or the creation of safe sleep spaces. 

The report concludes that until these concerns are resolved through rigorous research and evaluation, decisions by US public health departments to distribute baby boxes may be premature and should be carefully considered.

As per the American Academy of Pediatrics, the safest place for a baby to sleep is alone, on his/her back on a firm, flat mattress with nothing else in the area including pillows, blankets, stuffed animals, loose clothing or fluffy bumpers. 

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