Baby in a box? What you need to know about safe infant sleep

Every day, 10 babies in the United States die from unsafe sleep. That’s more than the number of children who die from cancer. It is a staggering number, and one that is much higher than I ever though it would be. While it is unlikely that we’ll ever be able to get this number to zero, we do know a tremendous amount about how to protect babies from sleep-related death.

As a pediatrician and a parent to three kids, I know firsthand how hard sleep can be for parents of infants. Some babies sleep wonderfully from the beginning, but most wake more often, or take much more effort to get to sleep, than most parents ever imagined. Infant sleep is a huge deal, and everyone searches for the magic answer. We know that the safest thing to do is to have infants sleep:

  • On their back, not their side or their tummy
  • Alone, with no blankets, bumpers, bears or anything else
  • In their own space (for example, in a bassinet or crib)

The U.S. National Institute of Child Health and Human Development’s “Back to Sleep” (now “Safe to Sleep”) message has resulted in a significant decrease in deaths from Sudden Infant Death Syndrome (SIDS), resulting in half as many tragedies. What has not changed as significantly are sleep-related deaths from strangulation and suffocation related to objects in sleep spaces, or from sleeping in unsafe places and positions.

A safe place for a baby to sleep is a flat surface, on an approved, firm mattress, in an approved sleep product. In the U.S., these products are all approved by the Consumer Product Safety Commission (CPSC), based on careful testing and monitoring. A crib, bassinet or play yard (for example a Pack ’N Play) with the original, approved mattress is the only safe place for a baby to sleep through his or her first year of life.

Unfortunately, a quick Google search about infant sleep will yield a number of products that have not been evaluated or approved by the CPSC as safe. These include baby boxes, angled sleep spaces and “breathable” mattresses. All of these products have several things in common:

  • They all market a solution to sleep problems that families face
  • They all claim to have been tested for safety
  • Almost none of them have actually undergone assessment by the CPSC, and therefore are not to be trusted!

At first blush, these products may seem like a good idea, but they are really preying on the anxiety and exhaustion of parents and caregivers. Let’s look at the baby boxes as an example.

In Finland, the Finnish government has distributed sleeping boxes to all families with newborns. This was done as a public health measure to ensure all babies had a safe place to sleep.

In the past few years, American companies have begun manufacturing and aggressively marketing similar boxes. I remember thinking that it felt like a disruptive idea, and a potentially easy, low-cost approach to dealing with our epidemic. I had many questions about how they would work, what they were made of, and how we knew they would be safe for babies in this country.

I now think differently. We are not Finland. They are a country of 5.5 million people, a country with universal health care, including prenatal care, early-infancy home visiting support programs and a much more homogenous populace, both in terms of economic and racial/ethnic characteristics. It’s not safe to assume that what works in Finland will work in the U.S.

Simply put, I am scared of baby boxes. I’m scared because I have no idea how safe they are, specifically how they compare to other established sleep spaces. To date, there are no standards that apply to the boxes; they are being marketed with no peer reviewed information about their safety, and no assurances that they are not harmful. If I cannot be certain, I am not willing to take risks with something so potentially devastating.

Right now, there are thousands of boxes being given to families of newborns across the United States, free of charge. This is because the for-profit companies that make them are giving them to hospitals to establish a market. We do not allow formula companies or drug manufacturers to do that, so why are we OK with the box makers? Companies are giving away a product that has no established safety standards, when we have plenty of alternatives that are safe and proven.

The boxes are made of cardboard, and come with a mattress. In using them, the infant simply sleeps in the box as they would a crib or bassinet (both of which must meet strict CPSC standards). Where does one put a box with a baby in it? On the floor? On a bed, table, couch? I am not sure any of those places are ideal. What happens if the box gets wet? Babies spit up and leak out of diapers, after all. What happens when a baby can roll to their side or tummy? This occurs between 3-6 months, which is also the highest risk period for SIDS.

A bassinet that meets CPSC standards can be purchased for a price similar to the cost of the boxes. They also can be used until the baby can roll, and they have a proven safety record when used correctly. Portable play yards are only slightly more expensive than the commercial boxes, meet stringent CPSC standards, and can be used for babies for well beyond a year or two of life.

As a pediatrician, my job is to do what’s best for kids. I do that through application of the best available science, and partnership with parents and caregivers. The science tells me that unsafe sleep is among the leading causes of death for babies, and we know the safest ways for infants to sleep are alone, on their back, in a safe place. Until I have science that shows that the boxes are a safe place, I would urge parents and caregivers to use what we know to be safe. It is simply not worth the risk.

The OHSU Doernbecher Tom Sargent Safety Center partners with the Cribs for Kids program, an evidence-based non-profit that helps distribute CPSC-certified play-yards for sleep at cost. We ensure that every sleep space that we distribute comes with face-to-face education about proper use and safe sleep. We hope to be able to reach a broader cross section of the Portland community, and will be working with community-based groups with moms in need to get the safe sleep message out there, and cribs into the homes of families that have no safe place for their babies to sleep. If you need help, let us know. If you have questions or concerns, please feel free to contact us.

Ten babies a day. How can we do anything other than what we know to be the safest?

Ben Hoffman, M.D. 
Medical Director, OHSU Doernbecher Tom Sargent Safety Center
Professor of Pediatrics
OHSU Doernbecher Children’s Hospital