Can an NHS ‘cardboard box’ really prevent cot death?

Will putting babies to sleep in a simple cardboard box reduce the risk of cot death – which kills more than 200 infants under one every year in the UK?

That’s the controversial claim made by some to support a scheme where new parents are given a free ‘baby box’ containing, at its most basic, a fitted mattress, cover and sheet. It could also include sleepsuits, bibs, creams, ear thermometers and toys.

The NHS in Scotland is already running such a scheme, while a handful of hospitals in England are piloting it.

Some suppliers claim that the boxes can help to reduce infant mortality rates, others wrongly state the cardboard boxes are safer than a Moses basket or cot and campaigners fear parents are being misled when there is no published research to support this.

So why are we even considering the notion of babies sleeping in boxes? The idea has been imported from Finland where, since the late thirties, all new parents have been issued with a free cardboard box for babies to sleep in — packed with clothes, nappies, a mattress and bedding.

They wanted to provide all new mothers, rich or poor, with a dry, comfortable and convenient place for their babies to sleep.

The concept originates from Finland, where new parents are given a cardboard box, which can be used as a bed, filled with baby products and a mattress

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Over the following few decades, the country’s infant mortality rate dropped from the highest in Europe to one of the lowest in the world — from 65 deaths per thousand live births to just two per thousand. In England and Wales, it is 3.6 per thousand.

The baby box, it seemed, was the key, and in recent years, several companies supplying them have sprung up in the UK. 

Are boxes the reason for the mortality decline?

But at around the same time as the boxes, Finland also introduced a national system of maternity and child care, which many experts believe was the real reason for the decline in deaths.

Indeed, critics argue that where modern schemes have been shown to have a benefit in terms of reduced infant mortality, this probably arises from free educational resources — such as online tuition on breastfeeding and safe sleeping positions — that parents get as part of the package.

Most baby boxes sold in the UK are 70cm long, 42cm wide and 27cm deep — though sizes vary slightly. They range in price from around £50 for a basic box to up to £400 for one packed with goodies.

Cot death charity The Lullaby Trust has raised concerns about the safety of so-called ‘baby boxes’

Earlier this year, Scotland’s First Minister Nicola Sturgeon gave the go-ahead for around 58,000 new mothers a year to be issued with a free baby box — each one worth an estimated £160. The scheme, backed by the Royal College of Midwives, is thought to cost almost £9 million a year.

In England, at least nine NHS trusts are piloting similar projects, though the costs are being covered by the firm supplying the boxes. These include three major hospitals in London — North Middlesex University Hospital, The Whittington Hospital and Queen Charlotte’s and Chelsea Hospital — as well others in Colchester, Merseyside, Berkshire and Birmingham.

Are they safer?

One of the main aims was to ensure every parent had a safe place for their baby to sleep, so they did not end up sleeping with them in their bed, which is one of the biggest risk factors for sudden infant death syndrome (SIDS).

In SIDS, the precise cause of death is often unknown, but sleeping with parents in their bed can increase the risk 50-fold.

Putting a baby in a box seems to be safer, but there’s little to suggest it’s any more efficient than a cot or a Moses basket. Yet, according to the British Baby Box website: ‘It can be used as baby’s first bed — and experts say this element has been responsible for helping Finland achieve one of the world’s lowest infant mortality rates.’

One of the firm’s owners recently told a local paper: ‘It might sound odd to tell new mums to put their precious bundle in what is essentially a cardboard box, but studies have shown putting a baby to sleep in a baby box, rather than a cot or Moses basket, can help reduce the causes associated with SIDS.’

A spokeswoman for British Baby Box has since told Good Health the box itself does not reduce mortality risk.

Mary Ross Davie, from the Royal College of Midwives, says although it supports the initiative, parents should not be led to believe that putting their baby in a box is any safer than a Moses basket.

‘The Scottish scheme is not making those claims,’ she adds. ‘When you have companies also selling them, then you will get variations in how the boxes are described.’

But cot death charity The Lullaby Trust now no longer allows its leaflets to be enclosed with baby boxes. It continues to recommend cots or Moses baskets as the ‘safest place’ for a baby to sleep.

‘We need robust academic research in the UK to properly evaluate the use of baby boxes as a safe sleeping product,’ says Francine Bates, the charity’s chief executive.

NHS England said it has no plans to follow Scotland’s example of a nationwide free box scheme.