If all goes to plan, more than 300,000 infants in the United States will sleep in cardboard boxes before year’s end.
That’s according to a Los Angeles-based business called Baby Box Co., which is working with health organizations nationwide to give away thousands of boxes for parents to use as baby beds. It’s part of an educational model aimed at reducing sudden infant death syndrome, or SIDS, in the United States.
But that idea doesn’t rest well with prominent doctors, researchers and organizations focused on SIDS, who characterize the boxes as untested and unregulated for infants. Unanswered questions about the boxes abound, they say, and the product’s marketing overplays its similarities to the famed Finnish program that inspired it.
The Baby Box Co. says its box is as safe as any crib. Doctors and public health professionals who work with the company echo that view, saying its low cost and educational component make the product promising in states where it’s offered for free to expecting parents, including New Jersey, Ohio and—as of this week—Alabama.
About 3,500 die each year in the U.S. in sleep-related infant deaths, according to the American Academy of Pediatrics, whose Task Force on SIDS says enthusiasm about baby boxes has outpaced knowledge about them.
“I don’t think that we can be gung-ho, let’s do baby boxes,” said Dr. Rachel Moon, a University of Virginia pediatrician who chairs the task force. “Because the evidence just isn’t there.”
In Finland, every expectant mother receiving a prenatal checkup can get a box filled with baby necessities such as blankets and clothing free of charge. It began back in the 1930s, when almost one out of every 10 Finnish children died within their first year. Today, Finland has one of the lowest infant mortality rates in the world, a shift many link to the box.
The Baby Box Co. says it was “born from” this tradition, but it plays out differently in the U.S.: Parents complete a video-based course about safe sleep on Baby Box’s site before receiving their box in the mail or picking it up directly. It comes with diapers, wipes and a onesie. A sturdy mattress for sleeping. And while the box-as-bassinet concept plays prominently into Baby Box Co.’s marketing, it’s more of an afterthought in Finland.
“They’re saying this is just like the Finnish baby box. Well, yes, but actually no,” said Moon, the pediatrician. “The box may be the same, but they’re doing it in a totally different way.”
Anita Haataja, a senior researcher with Finland’s Social Insurance Institution, said a 2011 poll showed less than half of box recipients there—42%— ever used it as an infant sleep space. It’s what comes in the box that lures pregnant women to the prenatal checkups, she said, which over decades helped healthier childcare practices become the norm in Finland
Moon, the pediatrician, said several factors likely played a bigger role than the box in Finland’s success, including its universal health care, home visits with health professionals and generous parental leave policies—all of which have been shown to affect infant mortality. But Finland’s never studied their boxes, she said, so she can’t be sure.
Regardless, every industrialized nation saw dramatic falls in infant mortality over the 20th century, baby boxes or not, thanks to better nutrition, immunizations and antibiotics, Moon said.
Far more similar than America and Finland's health care systems are their baby boxes. More than 3,000 parents registered to receive the rectangular cartons in Alabama within its program’s first 24 hours, Baby Box Co. said. In New Jersey, some 17,000 boxes have shipped out since January. And unlike Finland, surveys show 73% of recipients use the boxes in place of a crib, the Baby Box Co. said.
That’s concerning to Dr. Thomas Hegyi, medical director of the SIDS Center of New Jersey. No studies have verified the boxes' safety for babies, he said. The company’s website says its boxes “meet or exceed all applicable tenets” of the Consumer Product Safety Commission. But as the National Institutes of Health notes, the commission has no mandatory safety standards for baby boxes.
“The Baby Box people say that this is the most wonderful thing because it has worked in Finland,” Hegyi said. “It’s nonsense.”
Among the questions he and Moon are asking: Does the box, more confined than slatted cribs, hold a baby’s exhaled C02 differently? Does the box’s cardboard bottom heat up when set on sun-drenched concrete, or grow weak if it touches water? (A photo on Baby Box Co.’s website shows a child sitting in a box near the ocean.)
“There is a perception out there that if people sell it, it must be safe,” Moon said, especially baby products. “There is no regulatory commission, anything, to look at this box and bless it.”
Baby Box Co. is trying to change that. While baby boxes aren’t subject to mandatory safety standards through the Consumer Product Safety Commission, it currently has a task force considering a standard for baby boxes in the U.S., with Baby Box Co. as consultants.
In the meantime, CEO Jennifer Clary said the boxes had been tested for bassinet standards, even though the product doesn't meet the technical definition of one.
“We do comply to the fullest extent that we can,” she said. “We’re the only infant sleep product that doesn’t have a single infant fatality.”
Dr. Kathryn M. McCans is a pediatrician and chair of New Jersey’s Child Fatality and Near Fatality Review Board, which used a grant to launch the state’s partnership with Baby Box Co. “I think it’s safe,” McCans said. “I think it’s equivalent to putting a baby in a basinet.”
McCans liked the Baby Box Co.’s program because it’s scalable, she said, letting her reach more families supplying cardboard boxes than she could portable cribs. That includes families without other sleep spaces who might otherwise bed share, a risk factor for SIDS.
Another question: Are the boxes big enough? At just under 27 inches in length, Hegyi and Moon question if infants could outgrow the box in under six months, the span during which SIDS is most likely to occur. Larger babies could be left without a sleep space, Hegyi said, and vulnerable to unsafe sleeping conditions.
McCann guessed that most children “will only last for the first three to six months” in the box, while Clary claimed company surveys showed babies in first-world countries outgrew the boxes in five or six months.
“It’s also not our responsibility to solve this unilaterally,” Clary said. “It’s a social issue.”
McCans brushed off qualms about the boxes’ lack of standards. Infants have died using standardized products recommended by the American Academy of Pediatrics such as the portable cribs, she said. And while McCans admitted that “there’s not the research” to verify the benefits of baby boxes, “there is no research or evidence that the boxes are harmful.”
Clary, the CEO, credits the boxes’ safety record thus far (the company formed in 2013) with its online educational components, which she considers the company’s core. McCan agreed.
“The program is not really about the box,” she said. The free box, she said, is just a means to bring young people into the online component, which offers states tailored syllabi. New Jersey's includes videos such as “Approximately how many babies die from SIDS in New Jersey each year?” (Answer: 60.)
But as long as baby boxes are holding babies, doctors like Hegyi will want to know more.
“I hope it comes out that it’s effective and safe. It’s easy to be supportive of this,” he said. “It’s harder to say: Wait a minute, where is the evidence?”