They've been touted as a safe alternative to bassinets, cots and moses baskets. But now a team of international experts has warned that cardboard baby boxes shouldn't be promoted as a safe sleeping space in the absence of rigorous testing.
"Results from case-control studies internationally form the basis for infant sleep recommendations," writes Peter Blair, professor of epidemiology and statistics at Bristol Medical School, and 11 other experts in the British Medical Journal." We are, therefore, concerned that cardboard boxes are being promoted for infant sleep, as a safe alternative to the more traditional cots, bassinets, or Moses baskets, without any observational evidence in place."
The boxes are promoted as the perfect baby shower gift and usually contain a selection of essentials such as clothes, nappies and wipes.
Concerns about the promotion of a cardboard baby box as a place for infants to sleep: They're being promoted without any evidence in place, warn experts https://t.co/AjQcjHS1Vw pic.twitter.com/UPufr038bS— The BMJ (@bmj_latest) October 21, 2018
Cardboard baby boxes originated in Finland as part of a program launched in 1930 where all mums were given a box. But while they've been widely lauded and credited with decreasing the number of deaths from SIDS, experts say there are a number of issues with the boxes.
"Any government or charity that is willing to provide a box full of free unbranded infant care items should be applauded," they write.
"But we have three concerns: the scarcity of observational evidence that the cardboard baby box can be used safely (and no evidence that it reduces SIDS), the lack of safety standard regulations in place, and that promotion of the cardboard baby box could serve to undermine current safety messages."
According to the expert team, Finland's low rates of SUDI can't necessarily be attributed to the cardboard baby boxes. Additionally, there's a need for observational controlled studies.
"The few case-control studies conducted in Finland do not mention the box and largely attribute the lower mortality rates to 'a reasonably high standard of living, good educational level of mothers, well organised primary maternal and child health services, and the rapid advances in obstetric and neonatal care equally available and regionalised,'" they write.
The authors note that along with lack of evidence, some of the boxes come with lids, are potentially flammable and "susceptible to low level draughts, domestic pets, and young siblings," if placed on the floor. In addition, "Cots (with their bars and raised surface) and bassinets or Moses baskets (with low sides) allow infants to be easily seen by parents and may also facilitate air flow, whereas the cardboard box (with its higher opaque sides) does not—carers can see the infant only if they are looking from directly over the box."
Currently, there's also no data on how durable the boxes are, particularly if wet or dirty - an issue particularly relevant for our Australian climate.
As a result, their recommendations are clear. "Without supporting evidence, the cardboard baby box should not be promoted as a comparable alternative to cots, bassinets, or Moses baskets, but as only a temporary substitute if nothing else is available—if the device meets accepted safety standards.," they write.
"We encourage rigorous controlled studies to better understand how families use the cardboard baby box and its safety implications."
The authors note that while any initiative that raises awareness of SIDS, "including appropriate SIDS risk reduction advice distributed with cardboard baby boxes," is something to be supported, there's a strong caveat.
"This advice can be undermined if the messages given are incorrect or mixed with non-evidence based messages about the intervention itself," the experts write. "Parents may not buy into the educational aspect if the driving force of the cardboard baby box is not a governmental public health initiative but a commercial marketing strategy, the motives of which might include capturing data for profiling or direct marketing."
Last year Red Nose issued a statement in response to the baby boxes appearing for sale in Australia. The boxes are promoted as
"Red Nose advises that the low rates of sudden unexpected death in infancy (SUDI) in Finland are not due to the 'baby box' alone, but are underpinned by the increased health care mothers and babies receive through earlier engagement in antenatal care and the information provided to them for safe infant sleeping. All other Scandinavian countries also have very low rates of SUDI, despite parents not being supplied with a 'baby box'."
The National Scientific Advisory Group advised parents to also be aware of the following issues:
- Baby box products that are made from cardboard may not be suitable for all Australian climates. Such factors as humidity and dampness may make the box soft and likely to become less rigid and maybe even break when carried.
- Anything that makes it hard to see the baby in a safe sleeping product (eg. high box sides) should be avoided.
- Products that sit on the floor may increase the risk of pets sleeping in them or the danger of being tripped over.
- The baby box supplier should provide evidence that the mattress used meets the voluntary standard for cot mattresses.
- Babies who can sit up and pull themselves to standing should not be left in baby box unobserved
- While all cots and portable cots sold in Australia must meet ACCC mandatory safety standards, there is no such standard for "baby boxes".
For more information on safe sleeping for babies, visit Red Nose