Are Cardboard Boxes Safe and Effective?

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STATEMENT:  Dr. Rachel Moon, MD FAAP
Source: ASIP Listserv

January 30, 2017 – “We’ve gotten lots of inquiries about the baby boxes. Our understanding is that the state of New Jersey is working with the Baby Box company to try to distribute a baby box to all mothers of newborn infants in New Jersey.

Our understanding from our colleagues in New Jersey is that there is no research that will be happening as these boxes are given out. That is a real shame. We need to know what, if anything, about the boxes is effective, and what, if anything, is ineffective or even potentially a limitation to their use. The best type of study would be a randomized controlled trial, but even information about if the boxes are being used, how they are being used, and any impact on parent-reported sleep practices would be helpful. We need to have the research to guide our future efforts.  In this case, it appears that the enthusiasm and excitement (which is good) has outpaced the knowledge that we have.

There really is no evidence for these boxes. All industrialized countries have shown similar dramatic falls in infant mortality over the 20th century for numerous reasons, including improved nutrition, sanitation, immunizations, antibiotics, perinatology, and intensive care nurseries.  Please see graphs of the infant mortality rates in the 20th century in Finland and the U.S.

Finland has never studied the baby box, and although their infant mortality rate is lower than some other industrialized countries, there are many other reasons for their low infant mortality rates. For example, it is very possible that the Finnish boxes, because they are given as an incentive to get women into early prenatal care, are effective because of good prenatal care. Who knows? If that’s the case, then giving them to parents after the baby is born may have very little impact.

In the January 2017 issue of Pediatrics, a group from New Zealand has published their first report about the wahakura (a “safe sleep space” woven from flax consistent with indigenous culture), which showed that babies in wahakuras did not have more dangerous sleep situations than those in bassinets – and they breastfed more. New Zealand has some data to suggest that there are declining SUID rates in areas that have implemented wahakura and pepi-pods (a non-indigenous similar sleep space – looks like a Rubbermaid plastic under-bed storage container). However, there is an entire education program and community outreach program that accompanies these sleep spaces. So again, it is difficult to know what is making a difference.

Currently, the AAP Task Force on SIDS does not believe that there is yet enough evidence to say anything about the potential benefit or dangers of using wahakuras, pepi-pods, or baby boxes.” 

Rachel Y. Moon, M.D., FAAP
Division Head
General Pediatrics
Professor of Pediatrics
University of Virginia School of Medicine
Member of AAP Task Force on SIDS

Read additional quality and safety issues regarding cardboard boxes here:

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