- Peter S Blair Professor of Epidemiology and Statistics 1,
- Anna Pease Senior Research Associate 1,
- Francine Bates Managing Director 2,  Helen Ball Professor of Anthropology 3,
- John MD Thompson Associate Professor, Epidemiologist and Statistician 4,
- Fern R Hauck [1
- Rachel Moon Professor of Pediatrics 5,
- Betty McEntire CEO and Executive Director 6,
- Anat Shatz Managing Director 7 ,
- Marta Cohen Specialist for Pediatric Pathologists 8,
- Trina C. Salm Ward Lecturer in Social Work 9,
- Peter Fleming Professor of Infant Health and Developmental Physiology 1  1 Bristol Medical School, Unive Rsity of Bristol, St Michael's Hospital, Bristol BS2 8EG, United Kingdom
2 Lullaby Trust, London, UK
3 Durham University, Durham, United Kingdom
4 University of Auckland, Auckland, New Zealand
5 University of Virginia, Charlottesville, VA, USA
6 American SIDS Institute, Naples, FL, USA
7 Israeli Foundation for the Study and Prevention of Infantile Death, Jerusalem, Israel
8 Sheffield Children's Hospital NHS Trust, Sheffield, UK
9 University of Wisconsin, Milwaukee, WI, USA
The successful reduction of child mortality (sudden infant death or sudden infant death syndrome) in England and Wales from nearly 1,600 deaths in 1988 to less than 200 in 2015 is based on evidence-based research. 1 Results from the case study Control studies at international level form the basis for infant sleep recommendations. We are therefore concerned that cardboard boxes are being promoted for sleeping as a safe alternative to the more traditional baby cribs, bassinets or Moses baskets without any observational data.23 The cardboard box is based on a Finnish tradition of giving pregnant women a box of free infant care items – including a mattress that fits as a temporary sleeping environment for infants into the bottom of the box – as an incentive to enter early in pregnancy care. It was part of efforts to reduce health inequalities and recognize the hardships of the Finnish people after World War II. Any government or charitable organization willing to provide a box of free childcare products should be applauded, but we have three concerns: the lack of evidence that the cardboard baby box can be safely used (and no evidence, that SIDS reduces), the lack of safety standards, and the promotion of the cardboard box could undermine the current security news.
Lack of Observational Data
Use of the cardboard box in Finland since the 1930s and the relatively low SIDS rate in this country are no evidence that boxing SIDS reduce. The prices in neighboring countries such as Sweden and Denmark are equally low, although they traditionally do not offer crates. The few case-control studies567 conducted in Finland do not mention the case and attribute the lower mortality rates mostly to "a reasonably high standard of living, good maternal education, well-organized primary health services for mothers and children, and rapid progress in obstetric and neonatal care equally available and regionalised. "6 There is little published evidence on how often these boxes are used in Finland for infant sleep and whether this is largely restricted to daytime sleep.
Often, SIDS deaths occur unnoticed, encouraging parents to sleep in the same room as infants at night, and sleeping in the same room for at least the first six months to sleep there.8 Baby beds are important (with their staffs and raised surface) and baskets or Moses baskets (low weight) sides) allow infants to be easily seen by parents and can also facilitate airflow, while the cardboard box (with its higher opaque sides) non-carers can only see the child when
Any future observational study dealing with the safety of cardboard cages needs to be controlled so that the findings can be compared to normal practice and can be equipped with sufficiently large numbers to quantify adverse events.
The cardboard baby box has other potential problems. Some of the boxes have lids, are potentially flammable (especially if they are not laminated), and when placed on a floor are prone to drafts, pets, and young siblings. If the box is placed at a height, it can fall down and be a tempting sleeping place for pets. There is no data on the durability of the box (especially if it gets wet or dirty). In terms of size, the majority of babies at the age of 3 months will outgrow the cardboard box, while most baby cribs and cradles can be used for up to 5 months. 9 British and EU safety standards for children's furniture exist only for traditional children's beds. Cribs and Bassinets; There is currently no specific standard for using a cardboard box as a sleeping place for a baby, although this is currently being investigated.10 Mattresses must comply with British standards 7177 and 1877 and the filling must comply with British fire safety regulations; this must be clearly labeled.10
Further evidence-based interventions
The cardboard baby box is not to be confused with the wahakura (a Māori woven flat basket) or the pepi-pod a (plastic box with low, ventilated sides) ), both of which are intended to be taken to the parental bed to give babies their own separate sleeping space. These devices are currently being studied in New Zealand to avoid potentially dangerous situations in bed (when parents smoke or drink alcohol); first findings are very encouraging.1112131415 The baby box made of cardboard is not intended for use in the parents' bed and therefore offers no better alternative to bed sharing than the basket, bassinet or Moseskorb.
Post-perinatal mortality in New Zealand fell by 30% between 2009 and 2015, 16 but we do not know whether this was due to the use of Wahakura or Pepi-pod, or to the specific advice that comes with the intervention the increased awareness of the child safety. We support any initiative that raises awareness of SIDS, including appropriate SIDS risk-reduction advice distributed with cardboard boxes. However, this notice may be undermined if the messages indicated are incorrect or mixed with non-evidence-based messages about the intervention itself. Parents can not afford the pedagogical aspect if the cardboard box's driving force is not a public health initiative but a commercial marketing strategy whose motives could include collecting data for profiling or direct marketing.
Conclusions  The dramatic decline in SIDS rates is the result of evidence from observational studies. Population-wide initiatives should meet high standards of safety and efficacy and be subjected to rigorous evaluation prior to implementation, as the potential for unintentional and unintentional damage is much greater than for those targeting a selected population. Without evidence, the baby box made of cardboard should not be offered as a comparable alternative to baby cots, baskets or Moses baskets, but only as a temporary substitute, if nothing else is available – if the device complies with recognized safety standards. We encourage rigorously controlled studies to better understand how families use the cardboard box and its safety implications.